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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


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Dr.   and  Mrs.    v.'.    Libby 


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PLATE     I. 


HORIZONTAL    SECTION    OF    THE    RIGHT    HUMAN    EYE. 
{Magnified  four  diameters.') 


PRACTICAL    TREATISE 


DISEASES  OF  THE  EYE. 


BY 


WILLIAM  MACKENZIE,  M.  D., 

SUKGEON  OCULIST  IN  SCOTLAND  IN  OEDINAKY  TO  HER  MAJESTY ;   LECTURER  ON  THE  ETE  IN  THE  UMVEESITT 
OF  GLASGOW,  AND  ONE  OF  THE  SURGEONS  TO  THE  GLASGOW  ETE  INFIRMARY. 


TO  WHICH  IS  TREFIXED, 


AIs  ANATOMICAL  INTRODUCTION  EXPLANATORY  OF  A  HORIZONTAL 
SECTION  OF  THE  HUMN  EYEBALL. 


BY 

THOMAS  WHAETOX  JONES,  F.  R.  S., 

PROFESSOR  OF  OPnTHjU,MIC  MEDICINE  AND  SURGERY  IN  UNITERSIIY  COLLEGE,  LONDO.V,  AND 
OPHTHALjnC  SURGEON  TO  THE  HOSPITAL, 

V/ITH  ONE  HUNDP.ED  AND  SEVENTY-FIVE  ILLUSTRATIONS. 

FROM  THE  FOURTH  REVISED  AND  ENLARGED  LONDON  EDITION. 

WITH  NOTES  AND  ADDITIONS, 
BY 

ADDINELL  HEWSON,  A.M.,  M.D., 

ONE  OF  THE  SURGEONS  TO  WILLS  HOSPITAL  FOR>  DISEASES  OP  THE  EYE;   LECTURER  ON  SURGERY  IN  THE 
PHILADELPHIA  ASSOCIATION  FOR  MEDICAL  INSTRUCTION,  ETC.  ETC. 


PHILADELPHIA: 

BLANCHAED    AND    LEA, 

1855. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1855,  by 

BLANCHARD  AND  LEA, 

in  the  Office  of  the  Clerk  of  the  District  Court  of  the  United  States  in  and  for  the 
Eastern  District  of  Pennsylvania. 


nilLADELPHIA: 
T.  K.   AND  P.   G.  COLLINS,   PRINTERS. 


U  \o  w\  CO 
100 


EDITOR'S    PEErACE. 


Notwithstanding  the  very  recent  appearance  of  a  new  American 
edition  of  Mr.  Lawrence's  Treatise  on  Diseases  of  tlie  Eye,  containing 
the  valuable  notes  and  additions  of  its  distinguished  editor,  the  publi- 
cation of  an  American  edition  of  Dr.  Mackenzie's  work  needs  no 
apology,  for  it  indisputably  holds  the  first  place  abroad  amongst  the 
valuable  systematic  treatises  published  there  on  diseases  of  the  eye, 
and  "forms,  in  respect  of  learning  and  research,  an  encyclopasdia 
unequalled  in  extent  by  any  other  work  of  the  kind,  either  English 
or  foreign."^ 

Numerous  new  wood-cuts  have  been  inserted,  and  such  additions 
have  been  made,  as,  it  is  hoped,  will  prove  acceptable  to  the  American 
reader.  They  relate  chiefly  to  matters  of  a  practical  character,  and 
are  embraced  in  brackets,  with  the  initial  H.  appended.  Amongst 
them  will  be  found  a  short  account  of  the  ophthalmoscope,  and  the 
various  conditions  which  have  thus  far  been  revealed  by  its  use,  and 
to  which  the  author  has  scarcely  alluded. 

ADDINELL  HEWSON. 

Philadelphia,  289  Walnut  St. 

'  Dixou  on  Diseases  of  the  Eye,  London,  1855. 


ADYEETISEMENT 


THE     FOURTH     EDITION, 


In  the  present  edition,  a  large  amount  of  new  matter  has  been  added,  and 
an  attempt  made,  as  far  as  the  author's  opportunities  have  served,  to  notice 
every  material  advance  in  the  pathology  and  treatment  of  the  diseases  of  the 
eye,  which  has  been  made  during  the  last  fourteen  years. 

For  most  of  the  additional  wood-cuts  with  which  the  work  is  now  illus- 
trated, the  author  has  been  indebted  to  Dr.  John  Ritchie  Brown. 

In  the  present  edition,  care  has  been  takeu  to  introduce,  under  each  head, 
the  most  remarkable  synonymes  ;  and  to  give  references  to  the  works  where 
the  best  figure  of  each  disease  may  be  found.  The  following  is  a  list  of  the 
authors  chiefly  referred  to,  for  such  illustrations  : — 

Amhon,  Friedrich  August  von,  Klinische  Darstelluugen  der  Krankheiten  und  Bildungs- 
fehler  des  menschliclien  Auges.     3  Theile.     Eerlin,  1838,  1841. 

Beck,  Karl  Joseph,  Abbildungen  von  Ivi-ankheitsform  aua  dem  Gebiete  der  Augenheil- 
kunde.     Heidelberg  und  Leipzig,  1835. 

Beek,  G.  Joseph,  Lehre  von  den  Augenkrankheiten.     2  Biinde.  Wien,  1813,  1817. 

BoYER,  Lucien-A.-H.,  Recherches  sur  I'Op^ration  du  Strabisme.     Paris,  1842,  1844. 

Dalkymple,  John,  Pathology  of  the  Human  Eye.     London,  1852. 

Demours,  a.  p.,  Trait*^  des  Maladies  des  Yeux.     4  Tomes.     Paris,  1818. 

Devergie,  M.  N.,  Clinlque  de  la  Maladie  Syphilitique.  2  Tomes  et  Atlas.  Paris, 
1826,  1833. 

DiEFFENBACH,  J,  F.,  Ucber  das  Schielen  und  die  Hielung  desselben  durch  die  Opera- 
tion.    Berlin,  1842. 

Eble,  Burkard,  Ueber  den  Bau  und  die  Krankheiten  der  Bindehaut  des  Auges.  AVieu, 
1828. 

Geafe,  Carl  Ferdinand,  Die  epidemisch-contagiose  Augenblennorrhcie  Aegyptens  in  den 
Europaischen  Befreiungsheeren.     Berlin,  1823. 

Hooper,  Ptobert,  Morbid  Anatomy  of  the  Human  Brain.     London,  1828. 

Jones,  Thomas  Wharton,  Manual  of  the  Principles  and  Practice  of  Ophthalmic  Medi- 
cine and  Surgery.     London,  1847. 

MiJLLER,  J.  B.,  Die  neuesten  Resultate  iiber  das  Vorkommen,  die  Form  und  Behand- 
lung  einer  ansteckeuden  Augenliederkrankheit  unter  den  Bewohnern  des  Niederrheins. 
Leipzig,  1823. 

Panizza,  Bartolomeo,  Annotazioni  Anatomico-Chirurgiche  sul  Fungo  MidoUare  dell' 
Occhio.     Pavia,  1821,     Sul  Fungo  Midollare  dell'  Occhio,  Appendice.     Pavia,  182G. 


vi  ADVERTISEMENT. 

RiTTEEiCH,  Friedrich  Philipp,  Jllhrliclie  Beitrage  zur  Vervollkommnung  der  Augen- 
heilkunst.     Erster  Band.     Leipzig,  1827. 

Saundees,  John  Cunningham,  Treatise  on  some  Practical  Points  relating  to  the  Dis- 
eases of  the  Eye.     London,  1811. 

ScAEPA,  Antonio,  Trattato  delle  principal!  Malattie  degli  Occhi.  2  Tomi.  Pavia,  1816. 

SiCHEL,  J.,  Iconographie  Ophthalmologique.     Paris,  1852. 

SoEMMEREiNG,  Wilhclm,  Bcobachtungen,  iiber  die  organischen  Verlinderungen  im  Auge 
nach  Staaroperationen.     Frankfurt  am  Main,  1828. 

Travees,  Benjamin,  Synopsis  of  the  Diseases  of  the  Eye.     London,  1820. 

Vetch,  John,  Practical  Treatise  on  Diseases  of  the  Eye.     London,  1820. 

Walton,  H.  Ilaynes,  Treatise  on  Operative  Ophthalmic  Surgery.     London,  1853. 

Waedrop,  James,  Essays  on  the  Morbid  Anatomy  of  the  Human  Eye.  2  vols.  Lon- 
don, 1819,  1818. 

Wellee,  Carolus  Henricus,  Icones  Ophthalmologicse.     Fasciculus  I.     Lipsire,  1824. 

AYiLLis,  Robert,  Illustrations  of  Cutaneous  Diseases.     London,  1841. 

To  the  author  of  a  treatise  on  a  professional  subject,  involving  the  minute 
observation  and  description  of  a  particular  class  of  diseases,  it  must  afford 
no  small  gratification  that  three  large  editions  of  the  original  work  have  been 
exhausted ;  that  it  has  been  reproduced  by  a  transatlantic  press ;  and  has 
been  deemed  worthy  of  being  translated  and  published  in  the  three  best 
known  languages  of  modern  Europe,  German,  French,  and  Italian.  Such  an 
unexpected  reception  affords  assurance  that  the  labor  of  many  years  has  not 
been  altogether  misspent. 

To  the  translation  of  this  work  into  French  by  MM.  Laugier  and  Eichelot, 
from  which  the  Italian  translation  has  been  made,  it  is  necessary  particularly 
to  refer,  on  account  of  what  must  be  regarded  as  an  act  of  injustice  to  the 
numerous  authorities  referred  to  in  the  work,  as  well  as  to  the  readers  of  the 
French  and  Italian  translations,  and  to  the  author  himself.  The  translation 
of  MM.  Laugier  and  E-ichelot  is  executed  with  great  care  and  success  ;  but 
the  bibliographical  references  are  entirely  omitted.  By  this  means,  the 
reader  is  prevented  from  referring  to  the  proper  authorities  for  many  of  the 
facts  stated ;  the  original  authors  who  have  recorded  many  of  these  facts  are 
deprived  of  the -share  of  credit  which  is  justly  due  to  them  ;  and  it  may  hap- 
pen that  many  things  may  be  credited  to  the  author  of  these  pages,  by  the 
French  and  Italian  readers,  which  in  the  original  English  works  are  faithfully 
ascribed  to  those  from  whose  works  the  facts  have  been  taken. 


Glasgow,  27th  September,  1854. 


CONTEjN^TS. 


Anatomical  Inteoduction,  Explanatory  of  a  Horizontal  Section  of  th 
Human  Eyeball   ...... 

I.  Protective  Parts  or  Tunics  of  the  Eyeball 
Sclerotica 
Cornea   . 
Choroid 

II.  Parts  Subsidiary  to  the  Perfection  of  the  Eye  as  an  Optical  In 
strument 
Iris 
Pigment  Membrane 

III.  Specially  Sensitive  Parts 

Optic  N^erve 
Retina    . 

IV.  Dioptric  parts,  refractive  media,  or  lenses 

Vitreous  Body    ...... 

Crystalline  Body,  comprising  the  Lens  and  its  Capsule     . 

Ciliary  Zone  and  Canal  of  Petit 

Aqueous  Humor  ..... 

Postscript. 

General  Plan  of  Distribution  of  the  Bloodvessels  of  the  Eyeball 

A  Short  Account  of  the  Ophthalmoscope  .... 


XXlll 

lb. 

ib. 
xxiv 
xxvi 

sxvii 

ib. 
xxix 

ib. 

ib. 

ib. 
xxxi 

ib. 
xxxii 
xxxiii 
xxxiv 

ib. 


DISEASES  OF  THE  EYE. 


Chapter  I.     Diseases  of  the  Orbit         ..... 

I.  Injuries  of  the  Orbit  .  .  .  . 

I  1.   Contusions  on  the  Edge  of  the  Orbit 
§  2.  Fractures  of  the  Edge  of  the  Orbit 
^  3.  Fractures  of  the   Walls  of  the  Orbit,  attending  Fractured 
Skull  ...... 

§  4.  Fractures  of  the   Walls  of  the  Orbit,   attending  Fractured 
Bones  of  the  Face    ..... 

§  5.   Orbit  Fractured  by  a  Blow  on  the  Eye 

^  6.   Counter-Fractures  of  the  Orbit 

§  7.  Penetrating  Wounds  of  the  Walls  of  the  Orbit 

§  8.  Incised  Wounds  of  the  Orbit 

§  9.   Gunshot  Wounds  of  the  Orbit 


49 
ib. 
ib. 
50 

51 

52 
ib. 
ib. 
53 
61 
63 


CONTENTS. 


Osteo-Sarcoma  of  the 


II.  Periostitis,  Ostitis,  Caries,  and  Necrosis  of  the  Orbit 
§  1.  Acute  Periorbitis 
g  2.   Chronic  Periorbitis 
^  3.    Caries  and  Necrosis  of  the  Orbit 

III.  Periostosis,  Hyperostosis,  Exostosis,  and 

Orbit,  and  Cysts  in  its  Parietes 

§  1.  Periostosis 

§  2.  Hyperostosis 

§  3.  Exostosis     . 

^  4.   Ostco-Sarcoma 

§  5.    Cysts  in  the  Parietes  of  the  Orbit 

IV.  Dilatation,  Deformation,  and  Absorption  of  the  Orbit,  from  Pressur 

I  1.  Pressure  on  the  Orbit  from  within  the  Orbit 

§  2.  Pressure  on  the  Orbit  from  the' Nostril 

§  3.  Pressure  on  the  Orbit  from  the  Frontal  Sinus 

^  4.  Pressure  on  the  Orbit  from  the  Maxillary  Sinus 

^  5.  Pressure  on  the  Orbit  from  the  Sphenoid  Sinus 

§  6.   Pressure  on  the  Orbit  from  the  Cavity  of  the  Cranium 

Chaptek  II.     Diseases  of  the  Secreting  Lachrymal  Organs   . 
I.  Injuries  of  the  Lachrymal  Gland  and  Ducts 

II.  Lachrymal  Xeroma  or  Xerophthalmia 

III.  Epiphora    ....... 

IV.  Inflammation  and  Suppuration  of  the  Lachrymal  Gland 

§  1.  Inflammation  and  Suppuration  of  the  Glandulse  Congregate 
§  2.  Inflammation  and  Suppuration  of  the  Proper  Lachrymal  Gland 
V.  Chronic  and  Specific  Enlargements  of  the  Lachrymal  Gland 
§  1.  Uypertrophy  of  the  Glandulse  Congrcgatx   . 
§  2.  Hypertrophy,   Chloroma,  Scirrhus,  and  Medullary  Fungus 
of  the  Lachrymal  Gland 

VI.  Encysted  Tumor  in  the  Lachrymal  Gland 
VII.  Encysted  Tumor  in  the  Vicinity  of  the  Glandulse  Congregatoj 

and  Lachrymal  Ducts     . 
VIII.  True  Lachrymal  Fistula    . 
IX.  Morbid  Tears 
X.  Sanguineous  Lachrymation.  Hemorrhage  from  the  Lachrymal  Gland 
XL  Dacryoliths  or  Lachrymal  Calculi  in  the  Lachrymal  Ducts 

Chapter  HI.     Diseases  of  the  Etebrow  and  Eyelids 
I.  Injuries  of  the  Eyebrow  and  Eyelids 
§  1.   Contusion  andEcchymosis 
§  2.  Poisoned  Wounds    . 
§  3.  Burns  and  Scalds    . 
§  4.  Incised  and  Lacerated  Wounds 
II.  Phlegmonous  Inflammation  of  the  Eyelids 

III.  Erysipelatous  Inflammation  of  the  Eyelids 

IV.  Phlebitis  of  the  Eyelids     . 
V.  Carbuncle  of  the  Eyelids 

VI.  Malignant  Pustule  of  the  Eyelids 

VII.  Syphilitic  Ulceration  of  the  Eyelids 
VIII.  Syphilitic  Eruptions  aS'ecting  the  Eyelids  of  Infants 

IX.  Cancer  of  the  Eyelids        .... 


73 
74 


82 

ib. 

83 

84 

90 

92 

93 

94 

ib. 

96 

100 

115 

116 

121 

ib. 

ib. 
123 
124 

ib. 

ib. 
126 

ib. 

ib. 
135 

139 
140 

ib. 

141 

ib. 

142 

ib. 

ib. 

144 

145 

147 

153 

154 

157 

158 

159 

160 

165 

ib. 


/ 


CONTENTS. 


IX 


of  the 


Eyebrow 


X.  Inflammation  of  the  Edges  of  the  Eyelids,  or  Ophthalmia  Tarsi 
XI.  Herpes  affecting  the  Eyelids 
XII.  Porrigo  Larvalis  affecting  the  Eyelids 

XIII.  Vitiligo  affecting  the  Eyelids 

XIV.  Abscess  of  the  Meibomian  Glands 
XV.  Obstruction  of  the  Meibomian  Apertures 

XVI.  Meibomian  Calculi 
XVII.  Hordeolum  .  ... 

XVIII.  Phlyctenula  and  Milium  of  the  Eyelids    . 
XIX.  Warts  on  the  Eyelids 
XX.  Sycosis  affecting  the  Edge  of  the  Eyelid 
XXI.  Horny  Excrescences  on  the  Eyelids 
XXII.  Tumors  in  the  Eyebrow  and  Eyelids 
§  1.    Chalazion,  or  Fibririoiis  Tianor 
§  2.  Molluscum,  or  Albuminous  Tumor  . 
§  3.  Encysted  Tumor 
§  4.  Fibro-plastic,  or  Sarcomatous  Tumor 

XXIII.  Tylosis,  or  Callosity  of  the  Eyelids 

XXIV.  Ntevus  Maternus,  and  Aneurism  by  Anastomosis 
and  Eyelids        .... 

XXV.  CEdema  of  the  Eyelids      . 
XXVI.  Emphysema  of  the  Eyelids 
XXVII.  Twitching,  or  Quivering  of  the  Eyelids     . 
XXVIII.  Morbid  Nictitation 
XXIX.  Blepharospasm      .... 
XXX.  Palsy  of  the  Orbicularis  Palpebrarum  and  Muscles 
XXXI.  Ptosis,  or  falling  down  of  the  Upper  Eyelid 
^  1.  Ptosis  from  Hypertrophy 
§  2.   Congenital  Ptosis 
g  3.   Traumatic  Ptosis 
^  4.  Atonic  Ptosis 
^  5.  Paralytic  Ptosis 
XXXII.  Lagophthalmos      . 
XXXIII.  Ectropium,  or  Eversion  of  the  Eyelids 

§  1.  Eversion  from  Inflammation  and  Strangulate 
§  2.  Eversion  from  Excoriation 
I  3.  Eversion  from  a  Cicatrice    . 
§  4.  Eversion  from  Caries  of  the  Orbit  . 
Trichiasis  and  Distichiasis 
Entropium,  or  Inversion  of  the  Ej^elids     . 
XXXVI.  Anchyloblepharon 
XXXVII.  Madarosis  .... 

XXXVIII.  Phtheiriasis  of  the  Eyebrow  and  Eyelashes 

Chapter  IV.     Diseases  of  the  Tunica  Conjunctiva 

I.  Foreign  Substances  adhering  to  the  Conjunctiva 

Dacryoliths,  or  Lachrymal  Calculi,  in  the  Sinuses  of  the  Conjunctiva 
Injuries  of  the  Conjunctiva 
^1.  Mechanical  Injuries 
§  2.  Burns  and  other  Chemical  Injuries 
Subconjunctival  Ecchymosis 
Subconjunctival  Emphysema 


XXXIV. 
XXXV. 


of  the 


II. 
III. 


IV. 
V. 


Eyebrow 


CONTENTS. 


VI.  Subconjunctival  Plilegmon 
VII.  Subconjunctival  (Edema    . 
VIII.  Pterygium  .... 

IX.  Pinguecula  .... 

X.  Warts  of  the  Conjunctiva 
XI.  Polypus  of  the  Conjunctiva 
*XII.  Na3vus  Maternus  of  the  Conjunctiva 

XIII.  Fungus  of  the  Conjunctiva 

XIV.  Conjunctival  and  Subconjunctival  Tumors 


Chapter  V.     Diseases  of  the  Semilunar  Membrane,  and  Caeunccla  Lachry- 
MALIS     ........ 

I.  Inflammation  of  the  Semilunar  Membrane  and  Caruncula  Lachry- 

malis      ..... 

II.  Polypus  of  the  Caruncula  Lachrymalis     . 

III.  Nievus  Maternus  of  the  Caruncula  Lachrymalis 

IV.  Encanthis  . 
V.  Lithiasis  of  the  Caruncula  Lachrymalis    . 

Chapter  VI.     Diseases  of  the  Excreting  Lachrymal  Organs 

I.  Injuries  of  the  Excreting' Lachrymal  Organs 

^  1.  Injuries  of  the  runcta  and  Lachrymal  Canals 
§  2.  Injuries  of  the  Lachrymal  Sac 
I  3.  Injuries  of  the  Hasal  Duct 

II.  Acute  Inflammation  of  the  Excreting  Lachrymal  Organs 

III.  Chronic  Inflammation  of  the  Excreting  Lachrymal  Organs 

IV.  Fistula  of  the  Lachrymal  Sac        .... 

V.  Caries  of  the  Bones  around  the  Lachrymal  Sac  and  Nasal  Duct 
VI.  Relaxation  of  the  Lachrymal  Sac  .... 

VII.  Mucocele  of  the  Lachrymal  Sac   .... 

VIII.  Relaxation  of  the  Puncta  Lachrymalia  and  Canaliculi 
IX.  Eversion  of  the  Puncta  Lachrymalia 
X.  Obstruction  of  the  Puncta  Lachrymalia  and  Canaliculi    . 
XI.  Obstruction  of  the  Nasal  Duct      .... 

XII.  Dacryoliths,  or  Lachrymal  Calculi,  in  the  Excreting  Lachrymal 
Passages  ...... 

XIII.  Polypus  of  the  Lachrymal  Sac      .... 

Chapter  VII.     Diseases  of  the  Ocular  Capsule,  and  of  the  Areolar  an 
Adipose  Tissues  of  the  Orbit 

I.  Injuries  of  the  Orbital  Areolar  Tissue 

II.  Eff'usion  of  Blood  into  the  Orbital  Areolar  Tissue 

III.  Phlegmonous  Inflammation  of  the  Orbital  Areolar  Tissue 

IV.  Inflammation  of  the  Ocular  Capsule 
V.  Exophthalmos,  or  Protrusion  of  the  Eye  from  the  Orbit 

^  1.  Simple  Exophthalmos 
§  2.  Anaemic  Exophthalmos 

VI.  Protrusion  of  the  Orbital  Adipose  Substance 

Chapter  VIII.     Intraorbital  Tumors    .... 
I.  Solid  and  Encysted  Tumors  in  the  orbit    . 

II.  Osseous  Tumors  in  the  Orbit 


page 
262 
263 

ib. 
267 

ib. 
268 

ib. 
269 
270 


273 


ib. 
274 

ib. 
275 

ib. 

276 
ib. 
ib. 
277 
ib. 
278 
282 
294 
295 
296 
298 
299 
300 
801 
303 


309 
310 
312 

ib. 
319 
320 

ib. 
323 
325 

326 

ib. 

339 


II. 


III. 

IV. 


CONTENTS. 

Chaptek  IX.     Malignant  Diseases  of  the  Areolar  and  Fibrous  Tissues  of 
THE  Orbit 
I.   Scirrhus  in  the  Orbit 
II.  Fungus  Hojmatodes  in  the  Orbit  . 
III.  Melanosis  in  the  Orbit 

Chapter  X.     Intraorbital  Aneurisms    . 

I.  Aneurism  of  the  Ophthalmic  Artery 
II.  Aneurism  by  Anastomosis  in  the  Orbit 

Chapter  XI.     Diseases  of  the  Muscles  of  the  Eyeball 
I.  Injuries  of  the  Muscles  of  the  Eyeball     . 

AVant  of  Correspondence  in  the  Action  of  the  Muscles  of  the 
Eyeballs 
^  1.  Diplopia 
§  2.  Monoblepsis 
Palsy  of  the  Muscles  of  the  Eyeball 
Strabismus,  or  Movable  Distortion  of  the  Eyeball 
V.  Luscitas,  or  Immovable  Distortion  of  the  Eyeball 
VI.  Tetanus  Oculi        .  .  . 

VII.  Oscillation  of  the  Eyeball 
VIII.  Nystagmus 

Chapter  XII.     Injuries  of  the  Eyeball 
I.  Injuries  of  the  Cornea 

I  1.   Contusion  of  the  Cornea 

§  2,  Foreign  Substances  imbedded  in  the  Cornea 

,  §  3.  Punctured  Wounds  of  the  Cornea 

^  4.  Licised  Wounds  of  the  Cornea 

§  5.  Penetrating   Wounds  of  the  Cornea — Loss  of  the  Aqueous 

Humor — Prolapsus  of  the  Iris — Fistula  of  the  Cornea — 

Opihthalinitis  and  other  Effects  of  Wounds  of  the  Cornea 

II.  Foreign  Bodies  in  the  Aqueous  Chambers 

III.  Injuries  of  the  Iris 

IV.  Injuries  of  the  Crystalline  Lens  and  Capsule 

§  1.   Traumatic  Cataract 

1  2.  Dislocation  of  the  Lens 
V.  V/ounds  of  the  Sclerotica  and  Choroidea 

VI.  Foreign  Bodies  in  the  Vitreous  Humor     . 
VII.  Pressure  and  Blows  on  the  Eye     . 
§  1.  Amaurosis  from  Pressure    . 
§  2.  Amaurosis  from  Plows 
§  3.   Effusion  of  Blood  into  the  Eye  from  Blows 

2  4.  Bursting  of  the  Eye  from  Blows 
VIII.  Gunshot  Wounds  of  the  Eye 

IX.  Dislocation  of  the  Eyeball 
X.  Evulsion  of  the  Eyeball    . 

Chapter  XIII.     The  Opiithalmi^e,  or  Inflammatory  Diseases  of  the  Eyeball 
AND  Conjunctiva  ...... 

I.  The  OphthalmifB  in  general  ..... 

II.  Eemedies  for  the  Ophthalmias       ..... 


XI 

page 

340 

ib. 

342 

343 

344 

ib. 

346 

352 

ib. 

353 

ib. 

354 

ib. 

357 

387 

388 

ib. 

390 

ib. 
391 


394 
ib. 


ib. 
397 
399 
401 

ib. 
402 
408 
409 
410 

ib'. 

ib. 
411 

ib. 
412 
416 
417 

418 

ib. 

428 


Xll 


CONTENTS. 


III.  Objective  and  Subjective  Symptoms  of  the  Ophtlialmite 

§  1.  Arrangements  of  the  Bloodvessels 
§  2.  Kinds  of  Pain 

IV.  Simple  or  Phlegmonous  Conjunctivitis 
V.  Puro-mucous  Conjunctivitis  in  general 

VI.  Catarrhal  Ophthalmia 
VII.  Contagious  Ophthalmia     . 
VIII.  Ophthalmia  of  New-bom  Children 
IX.  Gonorrhoeal  Ophthalmia    . 

I  1.   Gonorrhoeal  Ophthahnia  from  Inoculation 
^  2.    Gonorrhoeal  Ophthalmia  from  Metastasis 
§  3.   Gonorrhoeal  Ophthalmia  ivithout  Inoculation  or  Metastasis 
X.  Aphthous  Ophthalmia 
XI.  Phlyctenular  Ophthalmia 
XII.  Morbillous  and  Scarlatinous  Ophthalmia 

XIII.  Variolous  Ophthalmia 

§  1.   Conjunctivitis  Variolosa 
§  2.  Corneitis  Postvariolosa 

XIV.  Erysipelatous  Ophthalmia 
XV.  Rheumatic  Ophthalmia 

XVI.  Catarrho-rheumatic  Ophthalmia 
XVII.  Scrofulous  Sclerotitis 
XVIII.  Corneitis    . 

^  1.  Scrofulous  Corneitis 
§  2.  Arthritic  Corneitis 
.XIX.  Iritis  in  general     . 
XX.  Idiopathic  or  Rheumatic  Iritis 
XXI.  Syphilitic  Iritis      . 
XXII.  Pseudo-syphilitic  Iritis 

XXIII.  Gonorrhoeal  Iritis 

XXIV.  Scrofulous  Iritis    . 
XXV.  Arthritic  Iritis 

XXVI.  Aquo-capsulitis      . 
XXVII.  Choroiditis 

^  1.  Acute  Choroiditis     . 
§  2.   Chronic  Choroiditis 
XXVIII.  Idiopathic  Retinitis 

§  1.  Acute  Idiopathic  Retinitis 
^  2.    Chronic  Idiopathic  Retinitis 
XXIX.  Retinitis  from  undue  Lactation 
XXX.  Inflammation  of  the  Crystalline  Capsule  and  Lens 
XXXI.  Inflammation  of  the  Hyaloid  Membrane 
XXXII.  Idiopathic  Ophthalmitis     . 

XXXIII.  Phlebitic  Ophthalmitis       . 

XXXIV.  Postfebrile  Ophthalmitis    . 
XXXV.  Compound  Ophthalmias 

XXXVI.  Traumatic  Ophthalmite      . 
XXXVII.  Artificial  Ophthalmiie 
XXXVIII.  Reflex  or  Sympathetic  Ophthalmitis 
XXXIX.  Intermittent  Ophthalmiaj 


PAGE 

433 
ib. 
434 
435 
ib. 
438 
443 
461 
467 
468 
471 
472 
475 
476 
490 
491 
492 
493 
495 
496 
500 
504 
511 
512 
510 
517 
523 
527 
533 
5.34 
538 
541 
546 
549 
550 
553 
555 
556 
557 
559 
560 
563 
565 
571 
579 
585 
586 
588 
590 
599 


CONTENTS. 


Xlll 


Chapter  XIV. 

I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 


Diseases  consequent  to  the  Ophthalmia 
Onyx,  or  Abscess  of  the  Cornea   . 
Hyp  opium  .... 

Ulcers,  Fossula,  Hernia,  and  Fistula  of  the  Cornea ;  and  Hernia 

of  the  Iris  ...... 

Opacities  or  Specks  of  the  Cornea — Nebula,  Albugo,  Leucoma 

Pannus,  or  Vasculo-nebulous  Cornea 

Granular  Conjunctiva        ..... 

Conjunctival  Xeroma  or  Xerophthalmia    . 

Anchyloblepharon  and  Symblepharon 

Synechia    ....... 

Obliteration  of  the  Pupil  .... 

Cataracts,  or  Specks  of  the  Crystalline  Capsule  and  Lens 
Opacities  of  the  Hyaloid  Membrane 
Synchysis,  or  Dissolution  of  the  Vitreous  Humor 
Atrophy  of  the  Eye  ..... 

Staphyloma  ...... 

§  1.  Staphyloma  Uvex,  or  Iridoncosis     . 

§  2.  Staphyloma  of  the  Iris,  or  Staphyloma  racemosum 

§  3.  Staphyloma  of  the  Cornea  and  Iris 

§  4.  Staphyloma  of  the  Choroid  and  Sclerotica   . 
XVI.  Varicosity  of  the  External  and  Internal  Vessels  of  the  Eye 
XVII.  Asthenopia  and  Amaurosis  .... 

XVIII.  Ossification  in  different  parts  of  the  Eye 

^  1.   Ossification  of  the  Cornea   .... 

§  2.   Osseous  Deposit  in  the  Sclerotica 

§  3.   Osseous  Deposit  in  the  Anterior  Chamber     . 

§  4.   Ossification  of  the  Iris         .... 

2  5.   Ossification  of  the  Corpus  Ciliare    . 

§  6.   Ossification  of  the  Choroid 

§  7.   Ossification  between  the  Choroid  and  the  Retina 

§  8.   Ossification  of  the  Hyaloid  Membrane,  Crystalline  Capsule, 
and  Crystalline  Lens 

Chapter  XV.     Adaptation  of  an  Artificial  Eye 

Chapter  XVI.     Partial  and  General  Enlargements  of  the  Eyeball;  Effu- 
sions AND  Tumors  within  its  Coats 
I.  Conical  Cornea 

II.  Hydrophthalmia,  or  Dropsy  of  the  Eye 
I  1.  Dropsy  of  the  Cornea 
I  2.  Dropsy  of  the  Aqueous  Chambers 
§  3.  Sub- Sclerotic  Dropsy 
I  4.  Sub-Choroid  Dropsy 
§  5.  Dropsy  of  the  Vitreous  Body 
§  6.   General  Hydrophthalmia     . 

III.  Sanguineous  Effusion  into  the  Eye 

IV.  Non-malignant  tumors  of  the  Eyeball 

§  1.  Non-malignant  Tumors  of  the  Cornea  and  Sclerotica 
§  2.  Non-malignant  Tumors  of  the  Iris 
§  3.  Non-malignant  Tumors  of  the  Choroid  and  Corpus  Ciliare 
§  4.  Non-malignant  Depositions  or  Tumors  occupying  the  place 
of  the  Vitreous  Humor    ..... 


page 
601 
602 
604 

606 
611 
616 
617 
623 
625 
630 
631 
632 

ih. 

lb. 
633 
634 

ib. 
635 
636 
644 
645 

ib. 

ib. 
647 

ib. 

ib. 

ib. 
648 

ib. 

ib. 

649 

652 

656 

ib. 
660 

ib. 
661 
662 

ib. 
665 
666 
667 
671 
672 

ib. 
674 

675 


CONTENTS. 


Chapter  XVII.     Malignant  Affections  of  the  Eyeball 

I.  Scirrhus  of  the  Eyeball     ..... 
II.  Fungus  Hsematodes,  or  Encephaloid  Tumor  of  the  Eyeball 
III.  Melanosis  of  the  Eyeball  .... 

Chapter  XVIII.     Extirpation  of  the  Eyeball 

Chapter  XIX.     Arcus  Senilis     ...... 

Chapter  XX.     Cataract  ...... 

I.  Definition   and   Diagnosis   of  Cataract;    Method  of   Examining 

Cases  of  this  Disease  ;  Causes  and  Prognosis   . 
II.  Genera  and  Species  of  Cataract    .... 

Class  I.  True  Cataracts  .... 

Genus     I.  Lenticular  Cataract 
Genus   II.  Capsular  Cataract 

Species  1.  Anterior  Capsular  Cataract 
Species  2.  Posterior  Capsular  Cataract 
Genus  III.  Morgagnian  Catai-act   . 
Genus  IV.  Capsulo-Lenticular  Cataract     . 

Species  1.   Central  Capsulo-Lenticular  Cataract 
Species  2.   Common  Capsulo-Lenticular  Cataract 
Species  3.  Siliculose  Capsulo-Lenticular  Cataract 
Species  4.   Cystic  Capsulo-Lenticular  Cataract 
Species  5.  Bursal  Capsulo-Lenticular  Cataract 
Class  II.  Spurious  Cataracts     .... 

Genus     I.  Fibrinous  Cjitaract 

Species  1.  Flocculent  Fibrinous  Cataract 
Species  2.   Clotted  Fibrinous  Cataract  . 
Species  3.   Trabecular  Fibrinous  Cataract 
Genus    II.  Purulent  Cataract 
Genus  III.  Sanguineous  Cataract 
Genus  IV.  Pigmentous  Cataract    . 

III.  Various  additional  Classifications  and  Distinctions  of  Cataract 

§  1.   Consistence  ..... 

i  2.  Size  ...... 

§  3.   Color  ...... 

§  4.  Duration  and  Development  .  .  .     - 

§  5.   Curability  ...... 

IV.  Complications  of  Cataract  .... 
V.  Palliative  Treatment  of  Cataract 

VI.  Medical  Treatment  of  Cataract     .... 

VII.  Preliminary  Questions  regarding  the  Kemoval  of  Cataract  by 
Operation  ...... 

VIII.  Position  of  the  Patient  during  Operations  for  Cataract — Mode 
of  fixing  the  Eye — Use  of  Chloroform 
IX.  General  Account  of  the  Operations  for  Cataract 
X.  Depression  and  Pveclination  .... 

^  1.  Depression  or  Reclination  through  the  Cornea 

§  2.  Depression  or  Reclination  through  the  Sclerotica 

§  3.  Displacement  by  Lateral  Traction  through  the  Sclerotica 


CONTENTS. 


XV 


XL  Extraction  ...... 

^  1.  Extraction  through  a  Semicircular  Incision  of  the  Cornea 
§  2.  Extraction  through  a  Small  Section  of  the  Cornea 
^  3.  Extraction  through  the  Sclerotica 
XII.  Division     ...... 

§  1.  Division  through  the  Sclerotica 
^  2.  Division  through  the  Cornea 

XIII.  Choice  of  an  Operation  for  Cataract;    Indications  and  Contra 

indications  for  the  different  Modes  of  Operating 

XIV.  Congenital  Cataract 
XV.  Secondary  Cataract 

§  1,  Lenticular  Secondary  Cataract 
§  2.   Capsular  Secondary  Cataract 
^  3.  Spurious  Secondary  Cataract 
^  4.  Mixed  Secondary  Cataract  . 
XVI.  Cataract-Glasses   . 

Chapter  XXI.     Artificial  Pupil 

I.  Introductory  View  of  the  Methods  of  forming  an  Artificial  Pupil 
II.  Diseased  States  of  the  Eye  requiring  the  Foi'mation  of  an  Artifi- 
cial Pupil       ....... 

§  1.  Partial  Opacity  of  the  Cornea         .... 

§  2.  Partial  Opacity  of  the  Cornea,  with  partial  Adhesion  of  the 
Iris  to  the  Cornea  ..... 

§  3.  Closure  of  the  Pupil,  the  Lens  and  Capsule  being  presumed 
transparent  ...... 

^  4.  Closure  of  the  Pupil,  with  firm  and  extensive  Adhesion  of 
the  Iris  to  the  Capsule,  or  the  Capsule  or  the  Lens  known 
to  be  Opaque        ...... 

§  5.   Closure  of  the  Pupil  after  an  Operation  for  Cataract 

§  6.  Closure  of  the  Pupil  from  Protrusion  of  the  Iris  after  Ex- 
traction   ....... 

I  7.  Partial  Opacity  of  the  Cornea,  Closure  of  the  Pupil,  Adhe- 
sion of  the  Iris  to  the  Cornea  or  to  the  Capsule,  and  Opacity 
of  the  Capsule  or  Lens     .... 

III.  General  Rules  regarding  Artificial  Pupil 

IV.  Incision,  Excision,  and  Separation  compared.     Conditions  neces 

sary  for  these  Operations 
V.  Artificial  Pupil  by  Incision 

§  1.  Incision  through  the  Sclerotica 

§  2.  Incision  through  the  Cornea 
VI.  Extension  of  the  Pupil  by  Prolapsus 
VII.  Artificial  Pupil  by  Excision 

§  1.  Lateral  Excision 

§  2.   Central  Excision 
VIII.  Artificial  Pupil  by  Separation 

§1.  Separation  througH  the  Sclerotica 

§  2.   Separation  through  the  Cornea 
IX.  Compound  Operations  for  the  Formation  of  an  Artificial  Pupil 
X.  Accidents  occasionally  attending  the  Formation  of  an  Artificial 

Pupil ;  After-  treatment 
XI.  Sclerectomia 


PAGE 

746 
ib. 

764 
767 
770 
ib. 
778 

785 
789 

ib. 

ib. 
790 
793 

ib. 
794 

797 
ib. 

800 
ib. 

801 


ib. 
803 


ib. 
ib. 


810 
811 
812 
817 
818 

ib. 
821 

ib. 

ib. 

ib. 
826 

827 
829 


XVI 


CONTENTS. 


Chapter  XXII.     Abnormal  States  of  the  Iris,  independext  of  Inflammation 
I.  Myosis 
II.  Mydriasis 
HI.  Tremulous  Iris 

Chapter  XXIII.     Glaucoma  and  Cat's  Eye 
I.  Glaucoma 
II.  Cat's  Eye  . 

Chapter  XXIV.     Various  States  of  Abnormal  Vision 

I.  Myopia,  or  Near-Sightedness 
II.  Presbyopia,  or  Far-Sightedness 

III.  Irregular  Refraction 

^  1.   Uniocular  Diplopia 
§  2.  Astigmatism 

IV.  Pliotopsia 
V.  Chrupsia,  or  Colored  Vision 

VI.  Ocular  Hypercesthesia 
VII.  Ocular  Spectra 
VIII.  Insensibility  to  certain  Colors 
IX.  Myodesopia 
X.  Spectral  Illusions 
XI.  Asthenopia 
XII.  Niglit-Blindness     . 

XIII.  Day-Blindness 

XIV.  Hemiopia  . 

Chapter  XXV.     Diseases  of  the  Fifth  Nerve,  affecting  the  Organ  of  Vision 
I.  Painful  Affections  of  the  Fifth  Nerve        . 

§  1.  Neuralgia  of  the  Ocular  and  Orbital  Branches  of  the  Fifth 

Nerve 
§  2.  Ilemicrania 

II.  Ancesthesia,  and  Impeded  Nutrition  of  the  Optic  Apparatus,  from 

Diseases  of  the  Fifth  Nerve 

Chapter  XXVI.     Amaurosis 

I.  General  Account  of  Amaurosis 
§  1.  Definition    . 
\  2.  Seats 
§  3.   Causes 
§  4.  Symptoms   . 
§  5.  Forms,  Stages,  and  Degrees 
^  6.  Diagnosis    . 
§  7.  Prognosis    . 
§  8.   Treatment  . 

II.  Classification  of  the  Amauroses    , 

III.  Illustration  of  some  of  the  Species  of  Amaurosis 

§  1.  Amaurosis  from  Apoplexy  of  the  Retina 
^  2.  Amaurosis  from  Aneurism  of  the  Arteria  Centralis  Retime 
g  3.  Amaurosis  from  Tumors  attached  to,  or  contained  within,  the 
Envelops  of  the  Op>tic  Nerve         .... 
§  4.  Amaurosis  from  Structural  Changes  in  the  Optic  Nerves 


967 
ib. 


CONTENTS. 


§  5.  Amaurosis  from  Fractured  Cranium  with  Depression,  or  from 

Sanguineous  Extravasation  in  consequence  of  Injury  .         968 

§  6.  Amaurosis  from  Morbid  Changes  in  the  Membranes,  or  in 

the  Bones  of  the  Cranium  ....         969 

§  7.  Amaurosis  from  Cerebral  Congestion  .  .  .         972 

^  8.  Amaurosis,  with  Apoplexy,  from  Encephalic  Hemorrhagy,  ^c.        975 
§  9.  Amaurosis  from  Aneurism  of  the  Encephalic  Arteries  ,         977 

I  10.  Amaurosis  from  Enlargememt  of  the  Pituitary  Gland        .         978 
§  11.  Amaurosis  from  Concussion,  or  other  Injury  of  the  Head  980 

§  12.  Amaurosis  from  Congestion  or  Inflammation  of  the  Nervous 
Optic  Apparatus,  brought  on  by  Exposure  of  the  Eyes  to 
Intense  Light,  or  by  Over-exercise  of  the  Sight      .  .         981 

§  13.  Amaurosis  from  Congestion  or  Inflammation  of  the  Nervous 
Optic  Apparatus,  excited  by  the  presence  of  Worms  in  the 
Intestines  ......         982 

§  14.  Amaurosis  from  Congestion  or  Inflammation  of  the  Nervous 

Optic  Apparatus,  consequent  to  Suppression  of  the  Menses  983 

§  15.  Amaurosis  from  Congestion  or  Inflammation  of  the  Nervous 
Optic  Apparatus,  consequent  to  Suppressed  Purulent  Dis- 
charge     .......         984 

§  16.  Amaurosis  from  Congestion  or  Inflammation  of  the  Nervous 

Optic  Apparatus,  consequent  to  Suppressed  Perspiration    .  ib. 

I  17.  Amaurosis  from  Congestion  of  the  Nervous  Optic  Apparatus, 

produced  by  Poisons         .  .  .  .  .         986 

§  18.  Amaurosis  from  Congestion  or  Inflammation  of  the  Nervous 
Optic  Apparatus,  depending  on  Acute  or  Chronic  Disorders 
of  the  Digestive  Organs    .....         989 

^  19.  Amaurosis  from  Congestion  or  Inflammation  of  the  Nervous 
Optic  Apparatus,  arising  from  Continued  Loss  of  the  Fluids 
of  the  Body  ......         993 

§  20.  Amaurosis  from  Albuminuria         ....         997 

§  21.  Amaurosis  from  Irritation  of  the  Branches  of  the  Fifth  Nerv 

§  22.  Hydrocephalic  Amaurosis  ....         998 

§  23.  Amaurosis  from  Inflammation  and  Dropsy  of  the  Brain, 

consequent  to  Scarlatina   .....         999 

^  24.  Amaurosis  from  Morbid  Formations  in  the  Brain  .       1000 

I  25.   Congenital  Amaurosis        .....       1003 


Chapter  XXVII.     Entozoa  in  the  Organ  of  Vision 
^  1.  Echinocnccus  hominis 
^  2.   Cysticercus  telae  cellulosse 
^  3.  Filaria  Medinensis 
§  4.  Filaria  oculi  humani 
^  5,  6.  Monostoma  and  Disioma  ocxdi  humani 
Formulae    ..... 


1006 
ib. 
1007 
1012 
1013 
ib. 
1014 


LIST  OP  ILLUSTRATIONS. 


i.  Diagram  showing  the  relative  diameter  and  curvatures  of  the  eye 
ii*.  Structure  of  cornea.     (From  Bowman.)       .... 

iii*.  Structure  of  conjunctiva  corner.     (From  Bowman.)  . 
iv*.  Vertical  section  of  cornea,  structure  of  membrane  of  Descemet.     (From 
Todd  and  Bowman.)  ...... 

V*.  View   of  choroid   and   iris,  showing   vasa   verticosa,  ciliary  nerves,  &c 

(FromZinn,  copied  in  Todd  and  Bowman.)  ... 

vi*.  Vessels  of  the  choroid,  ciliary  processes,  and  iris ;  inner  surface  after 

Arnold.     (From  Todd  and  Bowman.)      .... 

vii.  Pigment  membrane  of  choroid         ..... 

viii*.  Foramen  retinae  centrali  of  Soemmerring.     (From  Todd  and  Bowman.) 
ix*.  The  stratum  bacillosum         ...... 

X.  Diagram  of  convexities  of  the  lens  .... 

Cells  and  fibres  of  the  lens.     (From  Todd  and  Bowman.)    . 

Lamellated  structure  of  lens.     After  Arnold.     (From  Todd  and  Bowman 

Diagram  of  Helmholtz's  ophthalmoscope      .... 

Diagram  of  concave  mirror  ophthalmoscope 

Caries  of  lower  margin  of  orbit,  producing  ectropion  of  lower  lid  . 
Caries  just  within  cavity  of  orbit,  followed  by  ectropion  and  lagophthalmos 
of  upper  lid  .  .  .  .... 

Caries  of  fossa  lachrymalis,  attended  with  ectropion  and  lagophthalmos  of 
upper  lid  ....... 

Lagophthalmos  from  caries  of  orbit  .... 

Elevation  of  lower  lid,  produced  by  winking  in  such  cases  . 
Exostosis  of  orbit.     (From  Baillie.)  .... 

Expansion  of  all  the  bones  of  face,  and  obliteration  of  orbits  from  growth 
of  tumor  in  maxillary  sinus  (side  view)  .... 

Same  (front  view)     ....... 

Epithelial  cancer  of  eyelids  ..... 

Chalazion,  external  appearance  of  lid  affected  with 
Chalazion,  internal  surface  of  lids  affected  with 
Desmarres's  ringed  forceps ;  Wilde's  modification    . 

Diagram  of  method  of  strangulating  ntevus,  by  double  ligature  at  right 
angles        ........ 

14.  Diagrams  of  Mr.  Luke's  method  of  applying  ligature  to  nsevus  by  means  of 
three  needles        ....... 


xii*. 
xiii*. 
xiv*. 

1. 

2. 


9. 
10. 
11. 
12. 
13. 


PAGE 

xxiii 
xxiv 

XXV 


ib. 
xxix 

XXX 

ib. 

xxxii 
ib. 

xxxiii 
xl 
xli 
76 

ib. 

ib. 
81 
ib. 


109 
ib. 

167 

183 
ib. 

186 

195 
ib. 


*  The  additional  wood-cuts  of  the  American  edition. 


XX 


LIST   OF   ILLUSTRATIONS. 


15.  Diagram  of  ligature  passed  subcutaneously  around  the  base  of  a  ntevus 

of  the  lid  ........ 

16.  Diagram  of  ligature  passed  beneath,  and  subcutaneously  around,  a  noBTUS 

17.  Himly's  entropi'on  or  ptosis  forceps    .... 

18.  Wharton  Jones's  operation  for  ectropion  of  upper  lid 

19.  Result  of  AVharton  Jones's  operation  for  ectropion  of  upper  lid 

20.  Sir  AVm.  Adams's  operation  for  ectropion  in  lower  lid 
21*.  Dieffenbach's  operation  for  ectropion.     (From  Lawrence.) 
22*.  "  "  "  " 
23*. 
24*. 
25*. 
26. 
27. 
28. 
29. 
30. 


Dieffenbach's  operation  of  transplanting  for  same.     (From  Lawrence.) 
,  Ammon's  operation  for  new  lid.     (From  Lawrence.) 
.  Result  of  same.     (From  Lawrence.) 

Jiingken's  operation  of  transplantation  from  temple  or  cheek  for  ectropion 
Result  of  same 

Brainard's  operation  on  lower  lid 
Distichiasis 
Cilia  forceps   . 

31.  Horn  spatula  . 

32.  Toothed  forceps 

33.  Entropion,  acute 

34.  Chronic  entropion 

35.  Silver  spatula  for  the  removal  of  foreign  substances  adhering  to  conjunctiv 

36.  Pterygium  tcnue         ..... 

37.  Trichosis  bulbi  ..... 
38*.  Encanthis.     (From  Miller.) 

39*.  Operation  of  opening  lachrymal  sac.     (Wharton  Jones.) 
40*.  Fistula  lachrymalis.    (From  ^Miller.) 

41.  Nail-head  style  ..... 

42.  Same,  slightly  raised  after  introduction  for  the  purpose  of  cleansing  it. 

43.  Dupuytren's  tube  for  nasal  duct 
44*.  Wathen's  tube  for  same         .... 
45.  Stylet  for  introduction  of  tube 
40.  Bifurcated  stylet  (closed)  for  introduction  of  tube    . 

47.  Bifurcated  stylet  (blades  separated)  for  extraction  of  tube 

48.  Encysted  tumor  in  the  orbit  .... 
49*.  Aneurism  by  anastomosis  in  the  orbit.     (From  AValton.) 
50*.  Illustrating  Macdonald's  experiment  for  detection  of  strabismus.     (From 

Med.  Times) 
51*. 

52*.  " 

53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
61. 
62, 
63. 
64, 


Wire  speculum  ....... 

Operation  for  strabismus        ...... 

False  pupil  (traumatic),  by  separation  of  iris  from  choroid  . 
Detachment  of  greater  part  of  iris  from  injury 

Laceration  of  iris  from  its  ciliary  to  its  pupillary  edge  from  a  blow 
Detachment  of  iris  with  cataract  from  a  penetrating  wound 
Separation  of  iris,  with  subconjunctival  dislocation  of  lens  . 
Fistulous  opening  through  the  sclerotic,  from  gunshot  wound 
Reticular  arrangement  of  bloodvessels  in  the  ophthalmiae 
Zonular  arrangement  in  the  ophthalmia        .... 

Fascicular  arrangement  in  ophthalmiae  .... 

Varicose  arrangement  in  ophthalmiae  .... 


LIST   or  ILLUSTRATIONS. 


FIG. 

65.  Synechia  anterior,  ■with  central  leucoma 

66.  Sclerotico-choroid  staphyloma  .         .  .  .  . 

67.  Staphyloma  of  cornea,  sclerotic,  and  choroid 

68.  Double  tagging  of  iris  to  capsule,  the  result  of  rheumatic  iritis 

69.  Single  tag  of  iris,  from  rheumatic  iritis 

70.  Arthritic  iritis.     (From  W.  Jones.)    .... 

71.  Anterior  crystalline  capsulitis.     (From  Walther) 

72.  Inflammation  of  posterior  layer  of  capsule.     (From  Walther.) 

73.  Myocephalon,  hernia  of  iris  . 

74.  Granular  conjunctiva 

75.  Symblepharon    .         . 

76.  Staphyloma  uveas.     (From  Klemmer.) 

77.  Staphyloma  racemosum.     (From  Beer.) 

78.  Partial  staphyloma  of  cornea  and  iris 

79.  Hemispherical  total  staphyloma  of  cornea  and  iris 

80.  Staphyloma  of  larger  size,  showing  the  iris  broken,  reticulated,  and  adher 

ent  to  the  pseudo-cornea     ..... 

81.  Specimen  of  staphyloma  of  less  size,  exhibiting  the  iris  entire 

82.  A  general  choroid  staphyloma,  from  traumatic  inflammation 

83.  Ossific  shell  between  choroid  and  retina 

84.  Conical  cornea  .... 

85.  Cyst  of  iris  in  anterior  chamber 

86.  Fungus  haematodes  of  eyeball.     (From  Ammon.) 

87.  Melanosis  of  eyeball 
88*.  Nelaton's  ophthalmostat 

89.  Diagram  illustrating  depression  of  cataract 

90.  Diagram  illustrating  reclination  of  cataract 

91.  Bent  needle  for  displacement  (front  view) 

92.  "  "  "  (side  view) 

93.  Condition  of  capsule  and  iris  after  reclination 

94.  Position  of  lens  in  a  case  where  it  was  depressed  with  its  capsule.     (From 

Soemmerring  ..... 

95.  Diagram  showing  the  incision  of  the  cornea;  too  small 

96.  "  "  "  "        of  proper  size  and  position 

97.  Beer's  cornea  knife    . 

98.  Section  of  the  cornea  for  extraction 

99.  Needle  and  curette  for  division  of  capsule  and  removal  of  lens  in  extraction 

100.  Blunt-pointed  knife  for  enlarging  the  section  of  the  cornea 

101.  Daviel's  scissors  for  the  same 

102.  Sharp  hook  for  taking  out  the  lens    . 

103.  Operation  of  division  through  the  sclerotica 

104.  Straight  needle  for  discission 

105.  Hays's  needle  for  same 

106.  Same  magnified 

107.  Dr.  Jacob's  curved  needle  for  division  through  cornea 

108.  Same  magnified 

109.  Same,  with  sharp  point 

110.  Mode  of  using  it        . 

111.  Canula  scissors  for  secondary  cataract 

112.  Same  closed   .... 

113.  Blades  of  canula  forceps  removed  from  the  canula 

114.  Forceps  closed  .... 


XXll 


LIST   or   ILLUSTRATIONS. 


FIG. 

115.  Spurious  secondary  cataract.     (From  Beer.) 

116.  Cheseldea's  operation  for  artificial  pupil 

117.  Pupil  thus  formed      ..... 

118.  Wenzel's  operation  for  artificial  pupil  by  excision      . 

119.  Scarpa's  operation  by  separation 

120.  Appearance  of  eye  after  an  operation  for  artificial  pupil 

121.  Pupil  in  Sauvages'  eye,  made  by  Demours     . 

122.  Rhomboidal  pupil  the  result  of  the  operation  by  incision 

123.  Adams's  iris  knife       ..... 

124.  Operation  for  artificial  pupil  by  incision  through  cornea.     (From  Walton.) 

125.  Maunoir's  scissors  for  artificial  pupil  (blades  closed) 

126.  Same  opened  ..... 

127.  Diagram  of  the  incisions  in  Maunoir's  operation 

128.  A  quadrilateral  opening  made  by  this  operation 

129.  Maunoir's   operation   by  double   radiating   incision   from   closed  pupil  to 

ciliary  margin         .... 

130.  A  pupil  resulting  from  this  operation 

131.  Partial  synechia  anterior  with  dense  leucoma 

132.  Artificial  pupil  resulting  from  incision  with  canula  scissors  in  this  case 

133.  Tyrrell's  blunt-hook  for  extraction  of  a  portion  of  the  iris 

134.  Leucoma  with  almost  complete  synechia  anterior 

135.  Pupil,  in  this  case,  by  prolapsus  with  Tyrrell's  hook 
136*.  Maunoir's  toothed  forceps  for  excision 
137*.  Fischer's  forceps  for  artificial  pupil 

138.  Reisinger's  double  hook,  closed 

139.  Same  with  blades  separated  . 

140.  Langenbeck's  hook  and  canula 

141.  Schlagintweit's  guarded  book  (hook  exposed) 

142.  "  "  (hook  covered) 

143.  Ordinary  blunt-hook  for  artificial  pupil 

144.  Diagram  showing  manner  of  using  the  hook  in  the  operation  of  separation 

145.  The  guarded  hook  in  the  act  of  being  withdrawn      .... 

146.  Diagram  showing  the  amount  of  refraction  of  light  in  myopia  and  presbyopia 

147.  Diagram  explaining  the  positions  which  muscoo,  either  anterior  or  posterior 

to  the  focal  centre  of  the  eye,  appear  to  assume    . 

148.  Carcinomatous  tumor  of  dura  mater  producing  amaurosis 

149.  Vertical  section  of  same         .... 
160.  Fungus  heematodes  of  thalami 

151.  Mr.  Logan's  case  of  cysticercus  with  the  head  protruding 

152.  Same,  when  head  was  retracted 


ANATOMICAL  INTEODUCTION, 


EXPLANATORY    OF    A 


HORIZONTAL  SECTION  OF  THE  HUMAN  EYEBALL. 

BY  THOMAS  WHARTON  JONES,  F.R.S. 


*.;jj*  The  Numbers  (1)  (2)  (3)  &o..  refer  to  the  horizontal  section,  Plate  I. 


Fig 

.  i. 

V 

^ 

The  human  eyeball  is  nearly  spherical  in  form.     The  antero-posterior  dia- 
meter or  axis  (a  b,  Fig.  i.)  and  the  transverse  diameter 
(c  d),  both  measured  from  the  outside,  are  about  equal ; 
their  average  length  being  Hths  of  an  English  inch. 

The  strong  outer  tunic  of  the  eyeball  consists  of 
the  sclerotica,  vi^hich  is  opaque,  and  the  cornea,  which 
is  transparent.     Though  the   surfaces   of  these   two 
parts  are  not  strictly  spherical,  it  may  be  allowable  to 
state,  in  a  general  way,  that  the  sclerotica  is  a  large 
segment  of  a  larger  sphere,  and  the  cornea  a  small 
segment  of  a  smaller  sphere.      The  diameter  of  the 
sclerotic  sphere,  is  the  same  as  that  above  mentioned 
of  the  eyeball  as  a  whole.     The  radius  of  the  convexity  of  the  cornea  is 
about  Ifths  of  an  inch.     In  order  to  meet  each  other,  the  sclerotica,  at  the 
line  of  junction,  bends  slightly  towards  the  axis  of  the  eyeball;  the  cornea, 
in  an  opposite  direction  (e/). 

The  eyeball  consists  of  four  classes  of  parts  :  1st.  The  protective  parts, 
or  tunics.  2d.  Parts  subsidiary  to  the  perfection  of  the  eye,  as  an  optical 
instrument,  viz  :  the  iris,  which  is  a  diaphragm  for  correcting  the  aberration 
of  sphericity,  and  the  dark  pigment,  which  serves  to  absorb  the  rays  of  light, 
3d.  The  especially  sensitive  parts,  viz  :  the  optic  nerve  and  the  retina.  4th. 
The  dioptric  parts,  refractive  media,  or  lenses. 

I.  Protective  Parts  or  Tunics  op  the  Eyeball. 

In  a  horizontal  section  of  the  eyeball,  |ths  of  the  circumference  are  formed 
by  the  sclerotica  (1),  and  the  remaining  sixth  by  the  cornea  (4). 

Sclerotica. 

The  sclerotica  is  a  strong,  dense,  white,  fibrous  membrane.  Posteriorly, 
[and  about  one-eighth  of  an  inch]  to  the  nasal  side  of  the  axis  of  the  eye- 
ball, it  is  perforated  by  the  optic  nerve  (IT),  and  is  there  continuous  with 
the  sheath  (2)  which  that  nerve  derives  from  the  dura  mater.  Near  the  en- 
trance of  the  optic  nerve  the  sclerotica  is  about  ^oth  of  an  inch  in  thickness  ; 
from  this  it  diminishes  to  about  ^'^th  of  an  inch,  but  becomes  a  little  thicker 
again  in  front,  where  it  is  re-enforced  by  the  tendinous  insertions  of  the  straight 


XXIV 


ANATOMICAL   INTRODUCTION. 


muscles.  The  texture  of  the  sclerotica  consists  of  an  interlacement  of  lon- 
gitudinal and  transverse  fibres  of  the  same  nature  as  those  of  tendon.  [Its 
fibres,  however,  are  straighter  or  less  wavy  than  those  generally  found  in 
common  tendon,  and  the  interlacement  between  the  longitudinal  and  trans- 
Fig,  ii. 


Vertical  section  of  tbe  Sclerotic  and  Cornea,  showing  the  continuity  of  their  tissue  between  the  dotted 
lines,  a.  Cornea,  h.  Sclerotic.  In  the  cornea  the  tubular  spaces  are  seen  cut  through,  and  in  the  sclerotic 
the  irrepiular  areola-.  Cell-nuclei,  as  at  c,  are  seen  scattered  throughout,  rendered  more  plain  by  acetic  acid. 
Magnified  320  diameters.— (From  Bowman.) 

verse  portions  being  at  nearly  right  angles  (Fig.  ii.  h),  makes  this  covering 
a  very  strong  and  unyielding  one,  well  adapted  to  protect  the  form  of  the 
eyeball  from  the  influence  of  external  pressure,  and  from  the  efiects  of  inter- 
nal distension.]  The  sclerotica  is  penetrated  by  small  orifices,  for  the  passage 
of  bloodvessels  into  or  from  the  interior  of  the  eye.  Like  most  other  fibrous 
structures,  however,  it  is  itself  but  little  vascular.  Its  scanty  capillary  net- 
work is  fed  principally  from  the  ciliary  and  muscular  arteries.  Nerves  have 
not  been  unequivocally  traced  into  its  substance,  but  many  pass  through  it 
on  their  way  to  the  interior  parts. 

Coi-nea. 

The  cornea  (4),  at  once  a  part  of  the  outer  tunic  of  the  eyeball  and  of 
the  dioptric  apparatus,  appears  to  the  naked  eye  as  if  framed  into  the  sclero- 
tica, in  the  manner  represented  in  the  section.  The  diameter  of  the  cornea 
measures  about  ^^ih?,  of  an  inch  (e/.  Fig.  i.);  but  this,  the  transverse  dia- 
meter, is  a  little  longer  than  the  vertical ;  because,  in  consequence  of  the 
encroachment  of  the  sclerotica  externally  on  the  upper  and  lower  edges,  the 
circumference  of  the  cornea  appears  actually  oval,  its  small  end  being  towards 
the  temple.  Viewed  from  the  inside,  the  circumference  of  the  cornea  is  more 
nearly  circular.  The  cornea  is  about  ^^  of  an  inch  thick  in  mature  age  ;  in 
early  life,  however,  it  is  somewhat  thicker,  and  in  old  age  thinner. 

The  cornea  comprises  three  principal  layers:  1st.  The  joro/^er  corneal  sub- 
stance in  the  middle  (4).  2d.  The  conjunctiva  cornece  in  front  (4').  3d. 
The  memhrane  of  Descemet  behind  (6). 

The  proper  substance  constitutes  the  principal  thickness  of  the  cornea. 
Microscopical  examination  shows  it  to  consist  of  stratified  bundles  of  fibres. 
There  is,  however,  no  natural  separation  into  distinct  layers.  [But  the 
whole  proper  substance  consists  of  a  mixture  of  yellow  and  white  fibrous 
tissue,  freely  united  so  as  to  form  tubes,  which  are  ])laced  one  on  top  of  the 
other,  and  run  parallel  on  the  same  plane,  or  across  one  another,  occasionally 
in  an  'oblique  manner  ;  a  condition  of  things  very  difi"erent  from  that  which  we 
meet  with  in  the  structure  of  the  sclerotic,  where,  as  we  have  seen,  the  various 
fibres  interlace  at  right  angles,  and  at  much  shorter  intervals.     The  lamel- 


ANATOMICAL  INTRODUCTION. 


XXV 


lated  condition  of  the  cornea  explains  the  greater  facility  with  which  an  in- 
strument can  be  passed  horizontally  than  vertically  through  its  substance. — H.] 
It  is  through  the  medium  of  the  proper  substance,  that  the  cornea  is  joined  to 
the  sclerotica.  The  fibres  of  the  two  structures  interlace,  or  are  continuous 
with  each  other. 

At  its  surfaces,  which  are  invested  respectively  by  the  conjunctiva  cornese 
and  membrane  of  Descemet,  the  proper  substance  of  the  cornea  is  smooth, 
and  of  a  close  texture,  but  can  scarcely  be  said  to  be  formed  of  distinct 
membranes. 

Conjunctiva  cornece,  the  substance  which  is  made  to  peel  off  from  the  ante- 
rior surface  of  the  cornea,  by  the  action  of  boiling  water,  &c.,  and  at  the 
same  time  rendered  opaque,  is  merely  stratified,  tessellated  epithelium. 
[This  epithelial  covering  is  not,  however,  entirely  composed  of  tessellated 


Fis.   iii. 


Vertical  section  of  the  Human  Cornea  near  the  surface,  a.  Ante- 
rior elastic  lamina,  h.  Conjunctival  epithelium,  c.  Lamellated  tis- 
sue, d.  Intervals  between  the  lamella?,  showing  the  position  of  the 
corneal  tubes  collapsed,  c.  One  of  the  nuclei  of  the  lamellated  tissue. 
g.  Fibrous  cordage  sent  down  from  the  anterior  elastic  lamina. — 
Magnified  300  diameters.     (From  Bowman.) 

cells.  The  superficial  ones  are  essentially  such, 
but  those  beneath  them  are  rounded  (Fig.  iii.  h.) 
in  their  form,  and  in  the  most  deeply  seated  layer 
they  are  columnar  and  placed  vertically  to  the 
surface  of  the  cornea.  This  epithelial  layer  has 
interposed  between  it  and  the  proper  substance 
of  the  cornea  a  thin,  structureless  lamina  (Fig. 
iii.  a),  first  described  by  Bowman.  It  is  elastic 
in  its  character,  and  by  sending  down  prolonga- 
tions (which  interlace  with  each  other)  in  the 
proper  substance  of  the  cornea,  serves,  as  he  has 
indicated,  to  brace  and  maintain  it  in  its  right 
configuration. — H.]  This  is  continuous  with  the 
epithelium  of  the  sclerotic  conjunctiva,  and  is  the 
sole  constituent  of  most  part  of  the  conjunctiva 
cornece  ;  the  cellulo-vascular  basis  of  the  sclerotic 
conjunctiva  extending  only  a  little  way  over  the 
marii'in  of  the  cornea. 


Fie;,  iv. 


^■^'hyWr\rH&rf^<i 


A.  vertical  section  of  the  Human 
Cornea,  a.  Conjunctival  epithelium. 
h.  Anterior  elastic  lamina,  from 
which  there  pass  off  a  number  of 
fibres  into  c,  the  layers  of  the  cor- 
nea proper,  among  which  the  nu- 
clei are  apparent.  d.  Posterior 
elastic  lamina,  e.  Posterior  epithe- 
lium.— ilagnified  SO  diameters. 

B.  The  posterior  Epithelium,  o, 
seen  in  section;  p,  seen  in  face. — 
Magnified  300  diameters.  (From 
Bowman  ) 


XXVI 


ANATOMICAL   INTRODUCTION. 


The  menibrane  of  Descemet  (6)  lines  the  whole  posterior  surface  of  the 
cornea.  When  peeled  off  with  a  fine  forceps,  the  fragment  cnrls  forwards 
into  a  roll.  Spread  out  and  examined  under  the  microscope,'  it  appears  a 
homogeneous  transparent  substance,  invested  on  its  posterior  surface  with  a 
single  layer  of  tessellated  epithelium.     (Fig.  iv.  B.) 

Except  in  the  early  stage  of  development,  no  bloodvessels  are  visible  in 
the  cornea  beyoud  its  margin.  The  nutritive  plasma  with  which  the  Hiter- 
stices  of  the  cornea  are  filled,  is  i-eceived  by  transudation  from  the  blood  cir- 
culating in  the  vessels  of  the  neighboring  parts.  In  inflammation,  however, 
the  cornea  may  become  vascular  from  the  development  of  new  vessels.  In 
this  case,  the  vessels  of  the  conjunctiva  cornere  are  continuous  with  those  of 
the  sclerotic  conjunctiva,  while  the  vessels  in  the  proper  substance  appear  to 
be  fed  from  the  minute  vessels,  which  are  at  the  same  time  seen  forming  the 
pink-colored  zone  of  the  sclerotica  around  the  cornea. 

Branches  of  the  ciliary  nerves  are  distributed  to  the  cornea. 

Choroid. 

The  choroid  coat  Ql),  situated  within  the  sclerotica,  is  a  membrane  com- 
posed chiefly  of  bloodvessels  and  pigment  cells.  The  arteries  are  the  short  or 
posterior  ciliaries,  twenty  or  thirty  in  number,  which  enter  the  eye  through 
the  sclerotica,  near  the  optic  nerve.  The  veins,  called,  from  the  peculiarity 
of  their  course,  vasa  vorticosa,  gather  chiefly  into  four  trunks,  which  pass 
out  through  the  sclerotica  midway  between  the  cornea  and  optic  nerve,  and 


Fig.  v. 


Fin;,  vi. 


Choroid  and  Iris,  exposed  by  turning  aside  the  sclerotica : — 
C,  c.  Ciliary  nerves  branching  in  the  iris.  d.  Smaller  ciliary 
nerve,  e,  e.  Vasa  vorticosa.  h.  Ciliary  ligament  and  muscle. 
k.  Converging  fibres  of  the  greater  circle  of  the  iris.  I.  Looped 
and  knotted  form  of  these  near  the  pupil,  with  the  converging 
fibres  of  the  lesser  circle  of  the  iris  within  them.  o.  The  optic 
nerve.  —  (From  Zinn.) 


Vessels  of  the  choroid  Ciliary  pro- 
cesses and  Iris,  inner  surface,  a. 
Portion  of  the  capillary  network  or 
tunica  Rwjschiana.  h.  Ciliary  pro- 
cesses, c.  Portion  of  the  iris. — From 
an  infant.  Maguified  14  diam. — (Af- 
ter Arnold.) 


at  equal  distances  all  round.     The  capillary  network,  which  is  very  close,  is 
disposed  on  the  inner  surface  of  the  choroid.     The  arteries,  therefore,  enter 


ANATOMICAL   INTRODUCTION.  XXVU 

it  from  without  inwards,  whilst  the  veins  proceed  from  it  in  the  opposite 
direction. 

The  ciliary  nerves,  which  pierce  the  sclei'otica  behind,  pass  forward 
between  the  latter  and  the  choroid,  on  their  way  to  the  annulus  albidus 
and  iris. 

Towards  the  place  where  the  sclerotica  joins  the  cornea,  the  choroid  coat, 
for  tnfe  breadth  of  about  ^th  of  an  inch  on  the  temporal  side  of  the  eyeball, 
but  less  on  the  nasal  side,  presents  a  peculiar  plicated  structure  internally. 
The  folds,  seventy  in  number,  and  called  ciliary  jyrocesses,  are  little  elevated 
posteriorly  (10'),  but  very  prominent  anteriorly  (10).  They  are  extremely 
vascular,  and  are  supplied  from  the  same  sources  as  the  choroid. 

This  plicated  anterior  part  of  the  choroid  is  called  ciliary  hody  (10,  10'). 
Externally,  it  is  encircled  by  a  band  of  grayish  white  tissue,  named  annulus 
albidus  (8),  about  ith  of  an  inch  broad,  thick  anteriorly  and  thin  pos- 
teriorly, a  process  of  which  {ciliary  ligament  (9))  is  attached  all  round  to 
the  sclerotica  where  the  latter  joins  the  cornea.  The  annidus  albidus,  long 
conjectured,  on  physiological  grounds,  to  be  muscular,  has  of  late  years  been 
proved  to  be  so  by  microscopical  observation.  The  fibres  are  of  the  un- 
striped  kind,  and  are  disposed  in  orbicular  and  radiating  fasciculi.  The 
ciliary  nerves,  on  their  way  to  the  iris,  pass  through  and  supply  the  muscular 
substance  of  the  annulus  albidus. 

Interposed  between  the  outer  surface  of  the  choroid  and  the  inner  surface 
of  the  sclerotica,  is  a  fine  cellular  tissue  interspersed  with  irregularly  shaped 
pigment  cells.  This  is  the  structure  known  by  the  name  of  lamina  fusca  or 
arachnoidea  oculi  (5). 

II.   Parts  subsidiary  to  the  Perfection  op  the  Eye,  as  an  Optical 

Instrument. 

Iris. 

So  far  as  regards  position,  the  iris  (12)  may  be  said  to  bear  a  relation  to 
the  choroid,  somewhat  similar  to  that  which  the  cornea  bears  to  the  sclerotica. 
It  is  a  disk,  or  circular  membrane,  perforated  by  an  aperture,  called  the 
pupil  (13),  continuous  by  its  circumference  with  the  choroid  through  the 
medium  of  the  ciliary  body  and  annulus  albidus.  The  iris  is  extended  in  a 
plane  behind  the  cornea,  dividing  the  aqueous  cavity  into  two  unequally-sized 
compartments,  called  the  chambers  of  the  aqueous  humor  (30,  31).  The 
pupil,  through  which  these  compartments  communicate,  is  situated,  not 
exactly  in  the  centre  of  the  iris,  but  a  little  towards  the  nasal  and  upper 
side  ;  its  boundary,  which  is  free  in  the  aqueous  humor,  is  called  the 
pupillary  edge  of  the  iris.  The  anterior  surface  of  the  membrane  presents  a 
radiating  streaked  appearance,  produced  by  whitish  tendinous-like  fibres. 
At  the  distance  of  about  ^oth  of  an  inch  from  the  pupillary  margin,  these 
fibres  run  into  irregular  knots  all  round,  whence,  collected  into  larger 
bundles,  they  radiate  towards  the  circumference.  The  portion  of  iris 
between  the  circumference  and  the  corona  of  knots  just  mentioned,  is  named 
the  outer  or  larger  ring ;  and  that  between  the  corona  of  knots  and  the 
pupillary  margin,  the  inner  or  smaller  ring. 

The  color  of  the  iris,  which  is  different  in  different  persons,  depends, 
partly  on  pigment  cells  which,  like  an  epithelium,  are  dispersed  on  its 
anterior  surface,  and  partly  on  the  presence  of  pigment  deposits  in  its  sub- 
stance, the  tint  being  deepened  by  the  uvea  or  dark  pigment  behind.  On 
the  removal  of  the  uvea,  the  posterior  surface  of  the  iris  is  seen  to  be 


XXVIU  ANATOMICAL   INTRODUCTION. 

marked  with  ridges,  converging  from  the  connection  of  the  iris  with  the 
ciliary  body,  towards  the  pupil. 

In  its  structure,  the  iris  comprises  unstriped  muscular  fibres,  nerves,  and 
bloodvessels,  with  cellular  tissue.  The  muscular  fibres  are  disposed  in  two 
difiTerent  directions ;  the  one  set  situated  in  the  larger  ring,  and  disposed  in 
a  somewhat  radiating  direction  ;  the  other  situated  in  the  smaller  ring,  and 
disposed  circularly  round  the  pupil.  It  is  by  the  action  of  these  antagonistic 
sets  of  muscular  fibres  that  the  well-known  variation  in  the  size  of  the  pupil 
is  produced  ;  the  radiating  fibres,  by  their  contraction,  dilating  the  pupil ; 
the  circular  fibres,  by  theirs,  contracting  it.  The  state  of  relaxation  of  the 
iris  is  that  in  which  the  pupil  is  neither  much  contracted  nor  much  dilated  ; 
a  medium  state,  in  which  the  pupil  always  is  some  time  after  death,  and  to 
which,  in  consequence  of  an  elasticity  which  the  tissue  of  the  iris  at  the 
same  time  possesses,  it  has  a  constant  tendency  to  return  after  the  dilating  or 
contracting  force  has  ceased  to  act. 

The  iris,  like  the  choroid,  is  rich  in  bloodvessels.  Its  arteries  are  the 
long  posterior  ciliaries,  branches  from  the  short  posterior  ciliaries  ramifying  in 
the  ciliary  processes,  and  branches  from  the  anterior  ciliaries.  These  dif- 
ferent vessels  form  a  vascular  anastomosis  at  the  circumference  of  the  iris, 
from  which  branches  proceed  towards  its  pupillary  edge,  near  which  they 
form  another  finer  vascular  network,  whence  capillary  loops  extend  to  the 
pupillary  margin.  The  long  posterior  ciliaries  perforate  the  sclerotica,  a 
little  further  from  the  optic  nerve  than  the  short  posterior  ciliaries  do  ;  and 
proceed  on  the  outer  surface  of  the  choroid  towards  the  iris,  one  on  the  tem- 
poral, the  other  on  the  nasal  side  of  the  eye,  in  a  line  corresponding  to  the 
equator  of  the  ball.  Each  of  these  arteries  divides  at  some  distance  from 
the  ciliary  margin  of  the  iris,  about  ^th  of  an  inch  on  the  temporal  side,  less 
on  the  nasal  side,  at  an  acute  angle,  into  two  branches — an  upper  and  a 
lower.  The  upper  branches  of  the  two  arteries  inosculate  above,  and  the 
lower,  below,  in  the  substance  of  the  annulus  albidus,  from  whence  their 
ramifications  proceed  to  open  into  the  first  vascular  circle  above  mentioned. 
There  are  veins  corresponding  to  the  posterior  ciliary  arteries.  The  veins 
corresponding  to  the  anterior  ciliaries  have  a  communication  with  the  si7ius 
circularis  iridis  (3)  [canal  of  Fontana]  ;  a  canal  of  a  size  to  admit  a  hair, 
which  is  lodged  in  a  groove  on  the  inner  surface  of  the  sclerotica  all  round, 
where  the  latter  joins  the  cornea  and  receives  the  insertion  of  the  ciliary 
ligament. 

The  ciliary  nerves,  which  arise  in  the  orbit  from  the  lenticular  ganglion 
and  nasal  branch  of  the  fifth,  and,  as  above  mentioned,  enter  the  eye  through 
the  sclerotica  behind,  to  pass  forward  on  the  outer  surface  of  the  choroid 
and  supply  the  muscular  substance  of  the  annulus  albidus,  at  last  reach  the 
iris,  where  they  are  distributed  to  its  muscular  fibres. 

Of  the  fibrils  of  the  ciliary  nerves,  those  wliich  govern  the  circular  muscle 
of  the  iris  are  originally  derived  from  the  third  nerve:  and  those  which 
govern  the  radiating  muscle,  from  the  spinal  and  sympathetic  in  the  neck. 

To  return  to  the  membrane  of  Descemet  (6)  :  from  the  cornea  it  is  con- 
tinued, to  a  very  limited  extent,  upon  the  inner  surface  of  the  sclerotica,  at  its 
juncture  with  the  cornea,  and  thence  upon  the  ciliary  ligament,  from  which, 
becoming  modified  in  texture,  it  is  reflected  on  the  anterior  surface  of  the 
iris  at  its  circumference. 

[The  modification  in  texture  which  it  here  undergoes  is,  as  was  first  pointed 
out  by  Bowman,  the  conversion  from  a  homogeneous  and  structureless  tissue 
into  a  network  of  fine  fibres,  which  become  blended  with  the  substance  of 
the  iris  at  its  circumference  ;  and  hence  this  membrane  of  Descemet  does  not 
terminate  in  a  free  border,  as  was  once  supposed,  but  is  lost  in  the  tissue  of 


ANATOMICAL   INTRODUCTION.  XXIX 

the  iris  itself.  Kblliker  describes  tlie  anterior  surface  of  tlie  iris  as  covered 
by  a  layer  of  "  simple  epithelium  of  rounded  and  much  flattened  cells  ;"  but 
this  is  altogether  denied  by  Bowman,  who  says  that  the  epithelium  covering 
the  membrane  of  Desceraet  "  must  cease  with  (that)  elastic  lamina,  since  there 
is  no  longer  any  stratum  upon  which  it  can  rest." — H.] 

Pigment  Membrane. 

The  inner  surface  of  the  choroid  and  ciliary  body,  and  the  posterior  surface 
of  the  iris,  are  lined  with  the  pigment  membrane  (14).     Though  called  hlach, 
the  color  in  the  human  eye  is  brown ;  lighter  in  shade  on  the  choroid,  darker 
on  the  ciliary  body  and  iris.     If  a  shred  of  the  pigment  membrane  from  the 
choroid  be  examined  under   the  microscope,  it  is  seen  to  be 
composed  of  flat  six-sided  nucleated  cells,  about  yo'oijth  of  an         Fig-  vii. 
inch  in  diameter,  joined  together  at  their  edge,  by  intercellular 
substance,  in  a  single  layer,  like  Mosaic  work  (Fig.  vii.).    The 
coloring  matter  consists  of  very  minute  granules,  which  consti- 
tute  the   contents  of  the  cells,  and  are  most  accumulated  at 
their  circumference,  leaving  the  clear  nucleus  distinctly  seen  in 
the  centre.     In  albinoes,  the  cells  contain  no  colored  granules.     Their  nuclei 
then  appear  very  prominently.     In  those  animals  in  which  there  is,  on  the 
inner  surface  of  the  choroid,  what  is  called  the  tapetum  lucidum,  the  mem- 
brane,   immediately  over  the   most   brilliant  part,  is  also,  as   in   albinoes, 
destitute  of  pigment  granules. 

The  cells  of  the  part  of  the  pigment  membrane  lining  the  ciliary  body  are 
round,  and  irregularly  heaped  together,  so  that  the  membrane  here  does  not 
present  the  beautiful  Mosaic  work  appearance  which  it  does  on  the  inner 
surface  of  the  choroid. 

The  pigment  on  the  posterior  surface  of  the  iris,  called  iivea  (a  name 
applied,  however,  sometimes  to  the  choroid,  and  frequently  to  the  whole  of 
the  iris),  is  composed  of  incompletely  formed  cells,  i.  e.  aggregations  of  pig- 
ment granules  with  nuclei  in  their  centre,  but  destitute  of  cell-wall.  The 
pigment  granules,  thus  loosely  deposited,  are  prevented  from  mingling  with 
the  aqueous  humor  by  a  very  delicate  membrane,  called  the  membrane  of  the 
posterior  chamber  of  the  aqueous  humor,  with  which  the  posterior  surface  of 
the  uvea  is  invested  (15). 

III.    Specially  Sensitive  Parts. 
Optic  Nerve. 

The  fibres  (1*7)  of  the  optic  nerve  visible  to  the  naked  eye,  are  fasciculi  of 
microscopical  primitive  fibrils,  enclosed  in  a  neurilemma  or  cellular  sheath, 
and  the  whole  enveloped  in  a  general  neurilemma.  The  neurilemmata  of  the 
fibres  cease  as  the  nerve  penetrates  the  sclerotica,  whence  arises  the  constric- 
tion of  the  nerve  at  that  place,  and  the  appearance  commonly  described 
under  the  name  of  cribriform  lamina  of  the  sclerotica.  There,  free  from 
neurilemma,  the  optic  nerve  passes  through  a  well-defined  opening  in  the 
choroid,  to  join  the  retina.  About  the  third  of  an  inch  frpm  the  sclerotica, 
the  optic  nerve  is  perforated  obliquely  from  below,  by  the  central  artery  and 
vein  of  the  retina  (18),  which  run, in  a  canal  in. the  axis  of  the  nerve,  to 
gain  the  interior  of  the  eye. 

Retina. 

The  retina  (20)  is  a  transparent  expansion  of  nervous  substance,  situated 
within  the  pigment  membrane  lining  the  choroid,  continuous  behind  with  the 


XXX  ANATOMICAL  INTKODUCTION. 

optic  nerve,  which,  at  the  place  of  junction,  forms  a  slight  prominence  (19), 

called  papilla  conica,  and  terminating  anteriorly  at  the  ora  serrata,  or  place 

of  transition  of  the  choroid  into  the  ciliary  body. 

At  the  place  corresponding  to  the  antero-posterior  axis  of  the  eyeball,  and 

ith  of  an  inch  on  the  temporal  side  of  the  entrance  of  the  optic  nerve,  the 
retina  presents  a  transparent  point  (21),  and  is,  for  the 
Fig.  viii.  extent  of  -^-^ih  of  an  inch  all  round,  of  a  yellow  color. 

These  appearances,  which  are  found  only  in  the  eye  of 
man  and  the  monkey  tribe,  were  discovered  in  1191,  by 
S.  T.  Soeramerring,  who,  supposing  the  transparent  point 
to  be  actually  a  perforation  of  the  retina,  called  it 
foramen  retince  centrale,  and  the  yellow  border,  limbus 
luteus  foraminis  centralis.  In  this  situation  the  retina  is, 
on  dissection,  always  found  raised  into  a  small  fold,  which 
extends  from  near  the  temporal  side  of  the  optic  nerve, 

retina ocrapying  the  axis    trausverscly  outwards  for  about  |th  or  1th  of  an  inch. 

?r?nreonhe'o°pUcDerve;    The  bloodvcsscls  of  the   retina,  usually  quite  distinctly 

■with  the  arteria  centralis    sccu,  are  ramificatious  of  the  Central  artery  and  accom- 

retinae  on  the  Inner  side 

of  the  axis.-After  Soem-      pauyiUg  VCin. 

^erring.  The  retina  is  of  very  complex  intimate  structure.     Ac- 

cording to  the  latest  researches,  it  comprises  five  different 
kinds  of  elements,  disposed  in  successive  strata,  viz :  proceeding  from  without 
inwards,  1.  stratum  bacillosum,  2.  stratum  granulosum,  3.  stratum  gangliosum, 
4.  stratum  fibrillosum,  and  5.  stratum  limitans. 

The  stratum  bacillosum  consists  of  columnar  bodies,  of  a  peculiarly  clear 
substance,  about  jjo^th  of  an  inch  long  and  jjloo^'^  ^^  ^^^  i"^'^  thick,  ar- 
ranged side  by  side,  and  vertically  to  the  surface  of  the  retina ;  so  that  if  a 
bit  of  the  retina,  together  with  the  corresponding  portion  of  the  vitreous  body, 
be  carefully  removed  from  the  eye,  disposed  on  a  glass  plate  with  the  outer 
surface  of  the  retina  uppermost,  and  examined  with  the  microscope,  the  outer 
and  thicker  ends  of  the  columnar  bodies  are  seen  arranged  like  minute  tessel- 
lated work.     Interspersed  through  this  tessellated-looking  surface  at  intervals, 
the  wider  the  further  forward  the  part  of  the  retina  which  is  ex- 
amined, we  observe  spots,  as  if  two  or  three  columns  were  wanting 
(Fig.  ix.).    These  spots  are  owing  to  the  presence  of  thicker  but 
shorter  columns,  which,  towards  the  subjacent  stratum,  are  swollen 
out  into  fusiform  or  spigot-shaped  bodies.    From  the  inner  ends  of 
these  fusiform  dilatations  of  the  thicker,  as  well  as  from  the  inner 
ends  of  the  thinner  columns,  delicate  filamentary  prolongations  are 
said  to  extend  through  the  other  strata  of  the  retina  towards  its 
inner  surface. 
By  the  action  of  water  the  structure  of  the  stratum  bacillosum,  both  as  a 
whole  and  in  its  component  columns,  is  speedily  and  remarkably  altered.    The 
change  of  the  stratum  as  a  whole,  consists  in  its  detachment  from  the  rest  of 
the  retina,  and  that  in  a  continuous  film,  but  of  much  greater  superficial  ex- 
tent than  the  surface  from  which  it  has  separated.     In  this  state,  it  constitutes 
what  was  first  observed  and  described  by  Dr.  Jacob,  and  has  since  been  usually 
.  demonstrated  under  the  name  of  memhrana  Jacohi. 

In  regard  to  the  change  in  its  component  parts,  we  observe,  that  the  columns 
readily  become  variously  distorted,  and  at  last  acquire  the  form  and  appear- 
ance of  very  pale  globules,  held  together  by  the  same  uniting  medium  as  that 
by  which  the  rods  are  in  their  natural  state  held  together.  It  is  to  this  change 
that  the  great  increase  of  superficial  extent  is  owing,  which  the  stratum  bacil- 
losum, now  altered  into  Jacob's  membrane,  presents. 

Its  natural  condition  above  described,  was  first  discovered  by  Dr.  Hannover, 


ANATOMICAL   INTRODUCTION.  XXXI 

of  Copenhagen.  The  prolongations  of  its  component  columns,  through  the 
subjacent  strata,  towards  the  inner  surface  of  the  retina,  were  subsequently 
pointed  out  by  Dr.  H.  Mtiller,  and  confirmed  by  Dr.  Kolliker,  in  the  human 

eye. 

To  the  stratum  bacillosum  succeeds  a  layer  of  nuclear-like  bodies,  stratum 
granulosum,  connected  with  the  inward  prolongations  of  the  columnar  bodies. 
The  bodies  of  which  this  layer  consists,  measure  from  3  oVotl"^  to  4  oVotli  of  an 
inch  in  diameter. 

After  this  comes  a  layer  of  ganglionic  corpuscles,  with  filamentary  processes 
{stratum  gangliosum).  Then  we  have  the  layer  composed  of  the  primitive 
fibrils  of  the  optic  nerve  {stratum  jihrillosum).  These  fibrils,  which  are  very 
delicate,  spread  out  in  a  radiating  direction  from  the  entrance  of  the  optic 
nerve.  The  fibrils  are  at  first  collected  in  fasciculi,  which  by  frequent  inter- 
change of  fibres  form  plexuses  with  much-elongated  meshes.  In  proceeding 
forward,  the  meshes  gradually  become  wider,  and  the  fibres  more  dispersed. 
The  mode  of  termination  of  the  fibrils  has  not  been  with  certainty  deter- 
mined. [They  seem  to  consist  of  the  gray  nerve  matter  alone;  and  it  is 
probable,  as  Todd  and  Bowman  observe,  that  none  of  the  white  substance  of 
Schwann  enters  into  the  component  parts  of  the  retina. — H.] 

Lastly,  a  homogeneous  membrane  forms  the  inner  superficial  boundary  of 
the  retina  {memirana  Umitans). 

In  regard  to  the  disposition  of  the  above  elements  of  the  retina  at  the  cen- 
tral point  and  limbus  luteus  :  At  the  central  point  the  stratum  granulosum 
is  absent.  In  the  situation  of  the  yellow  spot  the  smaller  columnar  bodies 
are  wanting,  the  large  spigot-like  bodies  alone  form  this  part  of  the  stratum 
bacillosum.  Here,  also,  the  optic  fibrils  are  few,  and  form  no  continuous 
layer  between  the  ganglionic  stratum  and  membrana  limitans. 

The  capillary  network  of  the  retina,  is  seated  partly  in  the  fibrillous  stra- 
tum, but  chiefly  in  the  ganglionic.  The  branches  of  the  central  artery  and 
vein  of  the  retina,  proceeding  to  and  from  the  capillary  network,  are  seated 
under  the  membrana  limitans. 


lY.  Dioptric  Parts,  Refractive  Media,  or  Lenses. 

Vitreous  Body. 

The  vitreous  body  (22)  is  a  transparent  gelatiniform  mass,  situated  imme- 
diately within  the  retina,  and  filling  the  middle  and  back  part  of  the  interior 
of  the  eyeball.  It  presents  a  concavity  in  front,  called  fossa  hyalotdea,  into 
which  the  crystalline  body  is  received.  The  vitreous  body  consists  of  a  very 
delicate  and  transparent  enclosing  membrane,  called  the  hyaloid  (23) ;  nu- 
merous processes  of  which  are  considered  to  extend  into  the  interior,  like  the 
sectors  of  an  orange  according  to  Dr.  Hannover,  enclosing  spaces  in  which 
a  watery  fluid,  called  the  vitreous  humor,  is  contained.  This  fluid  slowly 
drains  away  when  the  vitreous  body  is  punctured,  and  is  found,  under  the 
microscope,  to  contain  a  few  colorless  cells.  In  old  age  the  membranous  septa 
tend  to  disappear,  so  that,  in  operations  for  the  extraction  of  cataract  for 
example,  a  more  or  less  considerable  quantity  of  vitreous  humor  is  apt  to  be 
suddenly  evacuated. 

[Brucke's  view  was  that  the  vitreous  body  resembled  an  onion,  and  was 
composed  of  concentric  lamellte,  separated  from  each  other  by  a  gelatiniform 
fluid,  but  the  reagent  he  employed  to  develop  these  lamella  (solut.  of  acetate 
of  lead)  Bowman  has  proved  could  produce  the  same  appearance,  no  matter 
in  what  direction  the  section  was  made,  and  yet  no  true  lamella  could  be  de- 
tected.    The  same  objection  will  also  hold  good,  in  part  at  least,  against 


XXXU  ANATOMICAL   INTRODUCTION. 

Hannover's  view ;  for  although  Bowman  has  confirmed  his  observations  in 
the  foetal  vitreous  humor,  he  has  not  been  able  to,  in  the  adult  eye  ;  for  there 
the  septa  formed  by  Hannover's  reagent  (chromic  acid)  cannot  be  proved  to 
be  true  membranes.  It  is  possible,  however,  that  as  these  septa  tend  to  dis- 
appear in  advanced  life,  that  the  specimens  examined  by  Bowman  were  not 
such  as  to  allow  us  to  draw  any  positive  inference  as  to  the  total  absence  of 
such  a  structure  at  any  period  in  adult  life.  KoUiker's  view  is,  that  in  early 
life  it  presents  a  condition  of  things  analogous  to  embryonic  cellular  tissue, 
but  that  subsequently  all  traces  of  such  development  entirely  disappear  and 
it  becomes  a  kind  of  mucus,  more  or  less  consistent  in  its  character.  The  crys- 
talline body  varies  very  much  in  form,  consistency,  transparency,  and  color, 
at  different  periods  of  life.  In  the  foetal  state  it  approaches  in  form  a  sphere, 
is  quite  soft,  pinkish  in  color,  and  not  entirely  transparent.  In  adult,  it  pre- 
sents the  conditions  described  above,  but  in  old  age  it  becomes  flattened,  dull, 
or  less  transparent,  tough  and  dense  in  structure,  and  of  a  yellowish  hue. — H.] 


Crystalline  Body,  comprising  the  Lens  and  its   Capside. 


Fi{ 


The  crystalline  body  (27,  28,  29),  as  above  said,  lies  in 
the  hyaloid  fossa  of  the  vitreous  body.  It  is  a  double 
convex  lens  about  /o^hs  of  an  inch  in  diameter,  and  half  as 
much  in  thickness  at  its  axis.  Its  anterior  surface  is  less 
convex  than  its  posterior,  the  radius  of  the  convexity  of  the 
former  (a.  Fig.  x.),  being  much  the  same  as  that  of  the 
•  !       cornea,  i.  e.  {lihs  of  an  inch;  the  radius  of  the  convexity 

of  the  latter  {b,  Fig.  x.),  ^^o^^^s  of  ^^  ^"^h.     At  its  cir- 
'^..^       ,,-''         cumference  it  is  thick  and  rounded,  as  is  represented  in  the 

section. 
The  axis  of  the  crystalline  body  does  not  lie  exactly  in  that  of  the  eyeball, 
but  a  little  to  the  nasal  side,  corresponding  to  the  middle  of  the  pupil. 
The  crystalline  body  comprehends  the  lens  (27)  and  capsule  (28,  29). 
The  capsule  of  the  lens  is  a  transparent,  elastic,  but  easily  lacerable,  homo- 
geneous membrane,  somewhat  resembling  the  membrane  of  Descemet.     Its 
anterior  wall  (28)  is  thicker  than  its  posterior  (29).     The  posterior  wall  lies 
close  upon  the  vitreous  mass,  and  the  union  between  them  is  intimate,  though 
capable  of  being  dissolved  by  maceration.     On  the  inner  surface  of  the  ante- 
rior wall  there  is  a  layer  of  tessellated  epithelium,  first  demonstrated  by  Dr. 
Werneck,  of  Salzburg. 

The  lens,  which  increases  in  consistence  from  without  inwards,  is  composed 

of  tubular  fibres  (i),  filled  with 
a  clear  viscid  substance  [albu- 
minous in  its  character,  readily 
coagulated  by  nitric  acid,  and 
speedily  dissolved  in  caustic  al- 
kalies— H.]  They  are  flat, 
being  about  3^)00^^  ^^  ^^  ^^^^ 
broad  and  jH^ooth  of  ^d  i^ch 
thick,  and  their  transverse  sec- 
tion is  hexagonal.  This  is  just 
such  a  form  as  tubular  fibres, 
closely  aggregated  together  and 
stratified,  necessarily  assume. 
[In  the  lens  of  the  ox  these  fibres 
present  a  finely  serrated  edge, 
and  in  the  codfish  lens  this 
serration  is  still  more  marked, 


Fisr.  xi. 


a.  Cells  connecUng  the  body  of  the  lens  to  its  capsule  (hu- 
man). 6.  Fibres  of  the  lens,  with  slightly  sinuous  edges  (hu- 
man), c.  Ditto  from  the  Ox,  with  finely  serrated  edges,  d. 
Ditto  from  the  Cod ;  the  teeth  much  coarser. — Magnified  Z2Q 
diameters. 


ANATOMICAL   INTRODUCTION.  XXXIU 

(c,  d,  Fig.  xi) — H.]  The  fibres,  thus  aggregated  together,  are  so  arranged 
and  disposed  that  they  extend,  say  from  about  the  middle  of  the  anterior 
surface,  turning  round  the  circumferential  edge,  towards  the  middle  of  the 
posterior  surface ;  in  fact,  something  like  the  lines  of  longitude  in  the  maps 
of  the  world.  It  is  to  be  remarked,  that  the  fibres  do  not  converge  to  points 
on  the  anterior  and  posterior  surfaces,  but  to 
radiating  clefts,  filled  with  a  transparent   homo-  Fig.  xii. 

geneous-like  substance.  Though  there  are  no 
actually  distinct  layers,  the  fibrous  structure  is 
separable  by  dissection  in  concentric  strata,  which 
are  denser  the  nearer  they  are  to  the  centre  of  the 
lens  (Fig.  xii.  a). 

Betwixt  the  lens  and  capsule,  a  fluid  called  liquor 
Morgagni,  has  been  said  to  exist ;  and  indeed,  if  the 
capsule  of  the  lens  of  a  sheep's  eye,  a  day  or  two 
after  death,  be  punctured,  a  liquid  escapes  ;  but 
this  is  a  post-viortem  accumulation,  arising  from 
the  aqueous  humor  having  passed  through  the  cap-  p,^tian/Sd^ion/?b"Cee 
sule  by  endosmosis,  and  mixed  with  the  detached     iutenor  planes,  as  weii  as  into 

.,,     T.  c  J.^  1  1        fi         i  i      lamella'. — Macnifiecl SJ diameters. 

inner  epithelium  ot  the  capsule  and  soft  outermost     After  Arnow. 
part  of  the  lens. 

Ciliary  Zone  and  Canal  of  Petit. 

Around  the  circumference  of  the  crystalline,  as  it  lies  embedded  in  the 
vitreous  body,  the  hyaloid  membrane  is,  for  the  breadth  of  ]th  of  an  inch, 
raised  up  into  radiating  folds.  This  is  what  is  called  the  zonula  ciliaris,  or 
zonula  Zinnii  (25).  It  is  the  counterpart  of  the  ciliary  body  of  the  choroid, 
with  which  it  is  dovetailed,  the  folds  and  intervening  clepressions  of  the  two 
structures  being  received  into  each  other.  At  the  place  where  the  ciliary 
body  of  the  choroid  and  ciliary  zone  of  the  hyaloid  begin  posteriorly  to  be 
thus  dovetailed  with  each  other,  the  retina  terminates  in  a  serrated  edge  ;  but 
branches  of  the  retinal  bloodvessels  extend  forward.  In  separating  the  ciliary 
body  from  the  ciliary  zone,  some  fragments  of  the  pigment  membrane  of  the 
former  generally  remain  adherent  to  the  latter,  and  hence  the  ciliary  zone  has 
been  considered  merely  as  an  impression  of  the  ciliary  body,  and  called  halo 
signatus.  Besides  the  folds  of  the  hyaloid,  the  ciliary  zone  comprises  in  its 
sti'ucture  peculiar  fibres,  something  like  those  of  elastic  tissue,  which  extend 
from  its  posterior  margin  to  the  capsule  of  the  lens.  To  the  corona  formed 
by  the  aggregate  of  these  fibres,  the  name  orbiculus  capsulo-ciliaris  has  been 
given. 

The  united  folds  of  the  ciliary  zone  and  ciliary  processes,  overlap  the  cir- 
cumference of  the  lens  in  front,  but  do  not  adhere  to  it,  there  being  betwixt 
them  a  ring  of  transparent  hyaloid,  called  zonida  lucida,  broader  on  the  tem- 
poral than  on  the  nasal  side. 

Around  the  circumference  of  the  crystalline  body  there  is  a  space  which 
may  be  inflated  into  the  form  of  a  beaded  ring,  by  blowing  through  a  punc- 
ture in  the  zonula.  This  is  the  canal  of  Petit  (26),.  which  is  usually  consi- 
dered as  being  formed  by  a  separation  of  the  hyaloid  into  two  layers,  one  pass- 
ing behind  the  capsule  of  the  lens,  adhering  to  it  and  lining  the  hyaloid  fossa ; 
the  other,  that  which  forms  the  ciliary  zone,  being  inserted  into  the  circum- 
ferential part  of  the  capsule  of  the  lens. 


ANATOMICAL   INTRODUCTION. 


Aqueous  Humor. 


This  watery  fluid,  examined  under  the  microscope,  is  found  to  contain  in 
suspension,  a  few  colorless  cells.  The  form  of  the  aqueous  humor  is  deter- 
mined by  that  of  the  compartment  in  which  it  is  contained  (30,  31).  This 
compartment  is  bounded  in  front  by  the  cornea,  behind  by  the  crystalline 
body,  and  at  its  circumference  by  the  ciliary  processes  and  ligament ;  and  is 
subdivided  by  the  iris  into  the  anterior  (31)  and  posterior  (30)  chambers  of 
the  aqueous  humor,  communicating  with  each  other  through  the  pupil  (13). 
The  depth  of  the  whole  aqueous  humor,  from  the  posterior  surface  of  the 
cornea,  through  the  pupil,  to  the  anterior  surface  of  the  crystalline,  is  rather 
more  than  j^th  of  an  inch. 

From  the  membrane  above  referred  to,  as  investing  the  uvea  or  the  pos- 
terior surface  of  the  iris,  a  continuous  surface  may  be  traced  over  the  free 
extremities  of  the  ciliary  processes,  and  from  them  to  the  circumference  of  the 
capsule  (15). 

[The  whole  chamber  of  the  aqueous  humor  has  been  supposed  by  many  to 
be  lined  by  a  continuous,  a  true  serous,  membrane,  and  called  by  them  the 
membrane  of  the  aqueous  humor,  but  no  such  structure  has  yet  been  detected 
by  the  microscope.  The  existence  of  a  membrane  passing  over  the  anterior 
surface  of  the  iris  to  connect  the  membrane  of  Descemet  with  the  pigment 
membrane  of  the  uvea  has  not  been  demonstrated  ;  neither  has  the  presence 
of  any  such  structure  on  the  anterior  surface  of  the  capsule  of  the  lens;  and 
Bowman,  as  was  observed  before,  even  denies  the  existence  of  an  epithelial 
layer  on  the  anterior  surface  of  the  iris,  though  this  is  disi)uted  by  Kolliker, 
who  describes,  very  minutely,  the  structure  of  such  a  covering.  It  seems 
impossible  to  reconcile  the  dilfereuce  between  these  two  eminent  Anatomists 
and  Microscopists ;  one  states  he  has  never  been  able  to  detect  such  a  struc- 
ture :  the  other,  an  equally  high  authority,  not  only  asserts  its  existence,  but 
has  described  its  character. — H.] 

In  the  preceding  sketch,  the  curvatures  of  the  refractive  media  have  been 
spoken  of  as  if  spherical,  but  they  are  in  reality  not  so.  The  curvature  of 
the  cornea  appears  to  be  ellipsoidal,  with  the  long  axis  not  exactly  in  the 
direction  of  the  incident  rays,  but  slightly  inclined  from  before  backwards  and 
to  the  temporal  side.  Tiie  curvatures  of  the  aqueous  humor  which,  as  a 
whole,  has  something  of  the  form  of  a  meniscus,  depend  on  those  of  the  pos- 
terior surface  of  the  cornea  and  anterior  surface  of  the  lens.  As  to  the  curva- 
tures of  the  lens,  that  of  its  anterior  surface  is  ellipsoidal,  with  the  lesser 
axis  in  the  direction  of  the  incident  rays,  while  that  of  its  posterior  surface 
appears  to  be  hyperbolical.  The  curvature  of  the  hyaloid  fossa  of  the  vitreous 
body  corresponds  with  that  of  the  posterior  surface  of  the  crystalline,  while 
the  posterior  curvature  of  the  vitreous  body  corresponds  with  the  concavity 
of  the  retina,  which  is  probably  ellipsoidal. 

Postscript. 

General  Plan  of  Distribution  of  the  Bloodvessels  of  the  Eyeball. 

To  give  a  correct  idea  of  the  distribution  of  the  bloodvessels  of  the  eye- 
ball, it  would  be  necessary  to  make  a  few  preliminary  observations  on  its 
development. 

Of  the  different  constituents  of  the  eyeball,  the  retina,  which,  along  with 
the  vitreous  body,  is  the  fundamental  part  of  the  posterior  segment,  origin- 
ally a  diverticulum  from  the  brain.  These  parts  receive  their  supply  of  blood 
from  the  central  vessels  of  the  retina. 


ANATOMICAL   INTRODUCTION.  XXXV 

The  central  artery  of  the  rethia,  as  already  said,  enters  the  eyeball  through 
the  substance  of  the  optic  nerve,  and  divides  into  two  sets  of  branches ;  one 
set,  which  is  a  persistent  one,  to  the  retina,  as  already  explained ;  another 
set,  to  the  vitreous  body,  as  well  as  to  a  structui'e  which  exists  in  front  of 
the  vitreous  body,  in  the  early  stage  of  formation  ;  namely,  the  vascular  cap- 
sule of  the  lens  presently  to  be  described. 

The  latter  set  of  branches  has  merely  a  temporary  existence.  Their  trunk, 
which  is  the  third  branch  of  the  central  artery  of  the  retina,  and  called  the 
central  artery  of  the  vitreous  body,  divides,  on  entering  the  hyaloid  canal 
(24)  of  that  body,  into  the  central  artery,  properly  so  called,  and  circumfer- 
ential branches. 

The  ramifications  of  these  vessels  are  dispersed  throughout  the  vitreous 
body,  anastomosing  with  each  other. 

The  central  artery  having  given  off  its  ramifications,  passes  out  from  the 
vitreous  body,  at  the  middle  part  of  the  hyaloid  fossa,  in  which  the  crystalline 
body  is  seated.  There  the  artery  enters  and  ramifies  in  a  capsule  enclosing 
the  crystalline  body,  not  the  capsule  of  the  lens,  formerly  described  as  struc- 
tureless, transparent,  and  non-vascular,  but  the  vascular  capsule  just  now 
referred  to  as  having  a  temporary  existence  only. 

This  vascular  capsule  appears  to  be  originally  an  involution  of  the  skin. 

From  the  point  where  the  artery  enters  the  middle  of  this  capsule,  it  radi- 
ates towards  its  circumference  and  from  thence  turns  round  to  its  anterior 
wall.  At  the  circumference  corresponding  to  the  zonula  ciliaris,  these  vessels 
anastomose  with  the  vessels  of  the  zonula ;  these  again,  being  in  connection 
with,  or  derived  from  the  retinal  vessels  and  the  circumferential  branches  of 
the  vitreous  body,  perhaps  also  in  connection  with  the  vessels  of  the  ciliary  body. 

With  the  development  of  the  eye,  the  vascular  capsule  of  the  ci'ystalline 
body  grows  in  a  greater  ratio  than  does  the  crystalline  body  itself;  its  ante- 
rior part  coming  to  line,  though  not  adhering  to  the  walls  of  the  aqueous 
chamber.  The  iris  not  having  yet  been  developed,  the  aqueous  chamber  is 
not  hitherto  divided  into  anterior  and  posterior  chambers. 

When,  however,  the  iris  does  sprout  out,  it  soon  comes  into  contact  with, 
and  adheres  to  this  vascular  capsule  of  the  crystalline,  in  such  a  way  that 
the  anterior  wall  of  the  capsule  closes  to  the  pupil,  constituting  what  is  known 
by  the  name  of  the  pupillari/  membrane ;  the  rest  of  the  capsule  constituting 
what  is  called  the  capsido-pupillary  membrane,  extending  backwards  from 
the  pupil  through  the  posterior  chamber,  to  be  continued  into  the  posterior 
wall,  which  still  lies  between  the  hyaloid  fossa  and  the  crystalline  body.  The 
iris  having  joined  the  vascular  capsule  of  the  crystalline  in  the  manner  now 
explained,  its  vessels  shoot  into  that  membrane,  and  anastomose  with  its 
original  vessels. 

The  iris  continuing  to  grow,  its  pupillary  or  small  ring  shoots  forth  beyond 
the  point  where  the  first  formed  part  of  the  iris,  or  the  ciliary  ring,  joined 
the  vascular  capsule  of  the  crystalline ;  and  this  in  such  a  way  that  the  point 
of  the  junction  in  question  comes  to  be  on  the  anterior  surface  of  the  iris 
where  the  ciliary  joins  the  pupillary  ring  ;  the  edge  of  the  pupil  thus  exists 
quite  free.  Such  is  the  vascular  distribution  of  the  retina  and  humors,  in 
the  early  stage  of  the  formation  of  the  eye.  The  vascular  distribution  in 
the  choroid  is  the  same  as  we  have  already  described  it  to  be  in  the  fully 
formed  condition. 

In  regard  to  the  cornea,  it  owes  its  vascularity  to  ramifications  from  the 
anterior  ciliary  and  conjunctival  vessels. 

It  is  thus  perceived  that  the  parts  of  the  eyeball,  through  which,  when  the 
organ  is  fully  formed  and  called  into  use,  the  rays  of  light  have  to  pass  on 
their  way  to  the  retina,  are  in  the.  early  stage  of  formation  interwoven  with 


XXXVl  ANATOMICAL   INTRODUCTION. 

bloodvessels.  These  bloodvessels  are  necessary  for  the  full  development  of 
the  organ ;  but  this  having  been  accomplished,  a  smaller  number  of  vessels 
is  sufficient  to  minister  to  its  nutrition,  and  these  are  dispersed  in  parts  of  it 
through  which  the  rays  of  light  are  not  required  to  pass. 

"Vessels  which  are  distributed  in  parts  through  which  the  rays  of  light  are 
required  to  pass  on  their  way  to  the  retina,  become  obliterated  ;  the  cornea 
thus  ceases  to  be  vascular ;  the  pupillary  membrane,  contingently  with  the 
obliteration  of  its  vessels,  disappears.  This  disappearance  usually  occurs 
before  birth,  or  about  the  eighth  month.  Coincident  with  this,  the  pupillary 
ring  of  the  iris,  which  was  before  small,  acquires  its  full  development.  The 
capsulo-pupillary  membrane,  the  other  part  of  the  vascular  capsule  of  the  crys- 
talline body,  has  in  like  manner  disappeared ;  this  disappearance  having 
occurred  before  that  of  the  pupillary  membrane,  no  traces  of  it  remaining. 

As  is  the  case  with  regard  to  the  cornea,  the  bloodvessels  of  the  vitreous 
body  become  obliterated,  the  body  itself  remaining  and  drawing  the  materials 
for  its  nutrition  from  the  bloodvessels  of  the  neighboring  parts. 

Thus  the  cornea,  in  its  fully  formed  state,  is  nourished  from  the  vessels  of 
the  neighboring  parts  of  the  conjunctiva  and  sclerotica. 

The  aqueous  humor  ap])ears  to  be  supplied  by  transudation  from  the  vessels 
of  the  ciliary  processes.  The  lens  never  was  vascular,  but  at  first  surrounded 
by  a  vascular  membrane,  and  it  continues  to  receive  nourishment  from  the 
vascular  network  of  the  zonula  Zinnii. 

The  whole  posterior  surface  of  the  vitreous  body  being  in  contact  with  the 
vascular  layer  of  the  retina,  the  vessels  of  which  are  persistent,  is  from  it 
supplied  with  nourishment,  as  also  from  the  ciliary  zone  on  its  lateral  part, 
anteriorly. 

The  non-vascular  layers  of  the  retina  are  nourished  from  the  vascular  layer. 
The  non-vascular  membrane  of  the  pigment  has  its  supply  from  the  capillary 
network  on  the  inner  surface  of  the  choroid. 


Scale  of  the  English  inch  and 
division  into  tenths. 


Scale  of  the  Parisian  inch  and  its  division 
into  twelfths  or  lines. 

2  / 


DESCRIPTION  OP  THE  PLATES. 


REFERENCES  TO  THE  HORIZONTAL  SECTION,  PLATE  I. 

1.  Sclerotica. 

2.  Sheath  of  the  optic  nerve,  a  continuation  of  the  dura  mater. 

3.  Circular  venous  sinus  of  the  iris. 

4.  Pi'oper  substance  of  the  cornea. 

4'.  Conjunctiva  extending  over  the  cornea. 

5.  Membrana  fusca  or  arachnoidea  oculi. 

6.  Membrane  of  the  anterior  chamber  of  the  aqueous  humor.  Of  the  two 
dotted  lines,  the  short  one  points  to  the  membrane  of  Descemet,  the  long  to 
the  supposed  continuation  of  that  membrane  over  the  anterior  surface  of  the 
iris. 

7.  Choroid. 

8.  Aunulus  albidus,  or  ciliary  muscle. 

9.  Ciliary  ligament. 

10.  10'.  Ciliary  body,  consisting  of  (10')  a  pars  non-plicata,  and  (10)  a 
pars  plicata  formed  by  the  ciliary  processes. 

11.  Ora  serrata  of  the  ciliary  body,  and  anterior  limit  of  retina. 

12.  Iris. 

13.  Pupil. 

14.  Membrane  of  the  pigment. 

15.  Delicate  membrane  lining  the  posterior  chamber  of  the  aqueous  humor. 

16.  Stratum  bacillosum  of  retina,  or  membrane  of  Jacob. 

17.  The  optic  nerve  surrounded  by  its  general  neurilemma. 

1*7'.  The  fibres  of  the   optic  nerve,  consisting  of  fasciculi  of  primitive 
tubules. 

18.  Central  artery  of  the  retina. 

19.  Papilla  conica  of  the  optic  nerve. 

20.  Retina.     The  situation  of  its  membrana  limitans  is  indicated  by  a 
dotted  line. 

21.  Central  transparent  point  of  the  retina,  or  foramen  centrale  of  Soem- 
merring. 

22.  Yitreous  body. 

23.  Hyaloid  membrane. 

24.  Canalis  hyaloideus. 

25.  Zonula  ciliaris. 

26.  Canal  of  Petit. 

27.  Crystalline  lens. 

28.  Anterior  wall  of  the  capsule  of  the  lens. 

29.  Posterior  wall  of  the  capsule  of  the  lens. 

30.  Posterior  chamber  of  the  aqueous  humor. 

31.  Anterior  chamber  of  the  aqueous  humor. 

3* 


DESCRIPTION   OF   THE  PLATES. 


EXPLANATION  OF  PLATE  11. 

Fig.  L  Crystalline  capsule,  extracted  entire.     See  p.  191. 

2.  Glaucomatous  lens,  as  seen  by  transmitted  light.     See  p.  84L 

3.  Four  varieties  of  entobyaloid  spectra  ;  a.  pearly  spectra ;  h.  watery 
spectra ;  c.  obscurely  defined  insulo-globular  spectra ;  d.  sharply  defined 
insulo-globular  spectra.     See  p.  888. 

4.  Cysticercus  cellulosoe  in  anterior  chamber.  See  Case  423,  p. 
1010. 

5.  Cysticercus  cellulosoe  in  anterior  chamber.  See  Case  424,  p. 
1011. 

6.  Cysticercus  cellulosjs,  removed  from  the  eye  in  Case  423,  magnified 
about  six  diameters. 

1.  Neck  and  head  of  cysticercus  cellulosa3,  removed  from  the  eye  in 
Case  424,  magnified  about  twelve  diameters. 


PLATE     II. 


Fig.  4. 


Fig.  5. 


Fig.  1. 


Fig.  3. 


Fig.  2. 


Fig.  7. 


A  SHORT  ACCOUNT 


OPHTHALMOSCOPE 


[When  we  look  into  an  eye  which  is  healthy,  and  particularly  that  of  a  young 
person,  the  pupil  presents  a  dark  appearance,  as  though  the  bottom  of  the 
eye  was  black.  This  evidently  does  not  arise  from  the  color  of  the  tissues 
themselves  in  that  part,  for  the  retina  is  grayish  white  and  quite  transparent, 
and  beneath  it  is  the  choroid,  a  bright  vascular  tissue,  covered  with  brown 
pigment  cells,  whose  color  is,  however,  too  light  to  produce  the  phenomenon 
in  question.  How,  then,  can  we  explain  this  dark  appearance  of  the  bottom 
of  the  eye  ? 

In  the  beginning  of  the  last  century,  Mery,  having  accidentally  immersed 
a  cat  in  water,  observed,  whilst  the  animal  was  in  that  condition,  he  could 
very  readily  perceive  the  bottom  of  its  eye,  and  even  the  bloodvessels  of  its 
retina  and  choroid.  But  he  gave  no  explanation  of  what  he  observed.  Five 
years  afterwards,  Lattere  repeated  the  experiment,  and  showed  that  our 
inability  to  perceive  the  bottom  of  the  eye,  arose  from  the  refractive  power 
of  the  cornea  and  lens,  and  that  in  this  experiment  of  Mery,  the  refraction  of 
the  water  neutralized  this  power,  and  caused  the  rays  of  light  reflected  from 
the  cat's  retina,  to  come  to  a  focus,  and  produce  an  image  on  the  retina  of 
the  experimenter's  eye. 

About  ten  years  since,  Kussmaul  demonstrated  by  dissection,  that  our 
inability  to  see  the  bottom  of  the  eye  was  due  to  refraction.  He  took  a 
sheep's  eye,  and  on  removing  the  cornea,  found  that  the  bottom  of  the  eye 
still  appeared  black,  but  when  he  removed  the  lens,  he  had  no  difiiculty  in 
observing  the  retina.  Here  is  positive  proof  of  the  influence  of  the  lens  ;  but 
that  the  cornea  also  exerts  an  influence  on  the  phenomenon  in  question,  is 
evident  from  the  fact  that  the  bottom  of  the  eye  still  appears  black  in  cases 
where  the  lens  has  been  removed,  as  in  the  operation  for  cataract. 

Although  the  retina  is  transparent,  it  is  also  brilliant  and  capable  of  reflect- 
ing, and  does  reflect  some  of  the  rays  of  light  which  impinge  upon  it ;  and 
these  rays,  on  being  reflected,  pass  out  through  the  crystalline  and  cornea  in 
precisely  the  same  direction  as  that  in  which  the  incident  rays  enter;  they  are 
subjected  to  the  same  refraction,  and  finally  come  to  a  focus  at  the  point  of 
origin  of  the  incident  rays.  "From  this,"  as  Dr.  Williams  observes,  "it 
follows  that  we  could  see  the  retina  of  an  individual  only  when  he  looked 
attentively  at  our  own  eye,  which,  in  this  case,  would  be  the  luminous  point. 
But  it  is  clear  that  the  quantity  of  light  which  our  own  eye  can  project,  is 
too  feeble  to  illuminate  the  bottom  of  the  eye  explored,  and  in  attempting  to 
look  into  the  interior  of  that  eye  by  the  aid  of  ordinary  daylight,  we  should 


xl 


A  SHORT   ACCOUNT   OF   THE   OPHTHALMOSCOPE. 


E 


Fio;.  xiii. 


only  intercept  with  our  head  the  rays  which  should  illuminate  the  cavity. 
Placed  in  this  manner  in  the  shade,  the  pupil  will  naturally  appear  black." 

To  Prof.  Helmholtz,  of  Kcenigsberg,  is  due  the  credit  of  first  devising  an 
instrument,  by  which  a  sufficient  amount  of  light  can  be  thrown  into  the  eye 
to  enable  us  to  see  clearly  its  interior  structures.  His  eye  speculum  consists, 
essentially,  of  a  tube,  with  one  end  bevelled  to  an  angle  of  50°  to  its  axis,  on 
which  is  fastened  the  reflector  of  four  parallel  and  highly  polished  slips  of 
glass ;  the  other  end  is-  cut  square  to  the  axis,  and  has  adapted  to  it  an  eye- 
piece, containing  a  biconcave  lens  and  diaphragm. 

An  accident  suggested  this  invention  to  Helmholtz.  His  friend,  Yon 
Erlach,  who  wore  spectacles,  observed  one  day,  whilst  conversing  with  an 
acquaintance,  that  the  eye  of  the  latter  became  illuminated  when  the  rays  of 
the  light  from  a  neighboring  window  were  reflected  by  his  glasses  into  this 
person's  eye — hence  the  probable  reason  of  Helmholtz  using  plate  glass  as 
the  reflector  in  his  ophthalmoscope. 

The  accompanying  diagram  will  ex- 
plain the  principle  of  his  instrument. 
The  luminous  rays  emanating  from  the 
light  at  A,  impinge  on  the  reflector  of 
glass  B — they  are  (some  of  them)  re- 
flected by  it  into  the  eye,  and,  by  the 
refractive  power  of  the  cornea  and  lens, 
come  to  a  focus,  and  illuminate  the 
retina.  The  retina  reflects  some  of  them 
back,  and  these  passing  out  in  precisely 
the  same  direction  in  which  they  en- 
tered, meet  the  reflector,  which  some  of 
them  penetrate,  and  would  converge  to 
a  focus  at  D,  and  thus  produce  no  dis- 
tinct image  of  the  patient's  retina  on 
that  of  the  observer.  Hence  the  neces- 
sity, in  this  instrument,  of  the  biconcave 
lens,  which  will  bring  them  to  a  focus 
at  E,  the  retina  of  the  observer. 
Since  Helraholtz's  instrument  was  first  made  known  in  1851,  Coccius 
Meyerstein,  Follin  Epkens,  and  many  others,  have  invented  instruments  but 
little  difi'erent  from  it  in  principle.  In  some  a  plain  mirror,  with  a  hole  in  it, 
has  been  substituted  for  the  reflector  of  plate  glass  ;  in  others,  a  biconvex 
lens  has  been  added,  to  condense  the  light  as  it  falls  on  the  reflector  ;  in 
others,  the  same  means  has  been  employed  when  either  the  eye  of  the  observer 
or  that  of  the  patient  was  short-sighted,  to  converge  the  rays  as  they  enter 
or  pass  from  the  latter. 

The  simplest  form  of  eye  speculum  yet  proposed,  is  that  described  and 
claimed  as  original  by  Anagnostakis.  Although,  on  the  authority  of  an 
informant  of  Mr.  Dixon,  we  learn  that  Prof.  Graeff  showed  this  very  instru- 
ment, or  one  precisely  like  it,  to  Dr.  Anagnostakis,  when  he  was  in  Berlin,  in 
1853,  some  time  before  the  publication  of  his  paper  on  this  subject.  It  con- 
sists of  a  small  concave  mirror,  about  2  inches  in  diameter,  with  a  focal  dis- 
tance of  four  and  a  half  inches.  In  the  centre  of  this  mirror  there  is  a  small 
hole,  of  a  quarter  of  an  inch  in  diameter.  This  mirror,  mounted  on  a  handle, 
and  protected  on  its  plated  surface  by  a  sheet  of  blackened  copper,  consti- 
tutes the  apparatus  described  by  Anagnostakis,  but  except  in  persons  who 
^  are  short-sighted,  a  distinct  view  of  the  deep  seated  structures  of  the  eye  can- 
not be  obtained  by  it,  without  the  aid  of  a  biconvex  lens  of  two  and  a  half 
inch  focus. 


A   SHORT   ACCOUNT   OF   THE   OPHTHALMOSCOPE. 


xli 


Ruete's  Ophthalmoscope  consists  of  a  mirror  analogous  to  the  one  just 
described,  but  of  ten  inch  focus,  and  a  biconvex  lens,  placed  before  the 
patient's  eye,  to  increase  the  convergence  of  the  rays  reflected  from  the  mirror. 

Mr.  Dixon  has  proposed  to  fix  the  mirror  into  a  spectacle  frame,  to  be 
worn  by  the  observer,  so  that  both  his  hands  may  be  free,  and  enabled,  with- 
out assistance,  to  command  the  movements  of  the  patient's  lids  with  one  hand, 
whilst  with  the  other  he  can  use  the  magnifying  glass.  He  also  suggests 
the  use  of  mirrors  of  a  focus  corresponding  to  the  distance  of  distinct  vision 
of  the  observer. 

We  have,  on  these  suggestions  of  Mr.  Dixon,  made  for  ourselves  an  extempore 
instrument,  at  a  very  trifling  cost,  by  plating  with  tin-foil  and  mercury  one  side 
of  a  common  bi-convex  lens,  having  selected  for  the  purpose  a  lens  of  such  con- 
vexity as  would,  when  plated,  produce  a  mirror  of  a  focus  to  suit  our  own  eye. 
This  mirror  we  covered  with  dark  paper  through  which  and  the  plating  we  made 
a  hole  of  about  the  fifth  of  an  inch  in  diameter,  and  then  mounted  the  mirror 
in  one  side  of  a  common  iron  spectacle  frame,  having  placed  in  the  other  a 
plane  glaiss,  so  that  the  instrument 
would  balance  itself  on  the  nose.  fig.  xiv. 

The  principle  of  these  forms  of  the 
Ophthalmoscope  can  be  perceived 
at  a  glance  by  reference  to  the  dia- 
gram (Fig.  xiv.).  The  rays  of  light 
divergent  from  A,  impinge  on  the 
mirror,  B  G,  which  is  to  be  so 
placed  before  the  eye,  D,  to  be  ob- 
served, as  to  reflect  them,  in  a  con- 
vergent manner,  into  its  interior, 
and  illuminate  the  structures  there. 
This  illumination  can  be  readily  appreciated  through  the  hole  in  the  mirror  at  E. 

The  original  instrument  of  Helmholtz  has  not  proved  as  efficient  a  one 
as  is  desirable  in  examining  the  retina  ;  its  illumination  is  not  sufficient  to 
give  a  clear  view  of  the  parts  it  is  intended  to  expose.  This  objection  can 
not,  however,  be  urged  against  some  of  the  improved  forms  of  the  instru- 
ment, particularly  those  of  Jiiger  and  Meyerstein  ;  but  these,  in  common  with 
many  others,  are  so  complicated  in  their  construction,  that  we  give  a  decided 
preference  for  the  simple  mirror  and  lens  over  all  of  them. 

The  mode  of  using  the  instrument All  examinations  with  the  eye  specu- 
lum require  to  be  conducted  in  a  dark  room,  and  it  is  also  necessary  that  the 
pupil  of  the  eye  to  be  examined  should  be  well  dilated  by  the  solution  of 
atropia.  A  steady-burning,  broad-flamed  lamp  will  be  found  to  be  the  best 
means  of  illuminating  the  reflector.  Some  recommend  that  the  light  should 
be  placed  to  one  side  of  the  patient's  face,  and  on  the  same  plane  with  his 
and  the  observer's  eye.  This  may  undoubtedly  be  the  best  position  for  it  in 
some  instruments  of  a  fixed  angle  of  reflection,  and  may  be  even  essential  for 
their  proper  adjustment,  but  is  not  necessary  where  the  simple  concave  mirror 
is  employed.  In  using  this  we  would  decidedly  prefer  the  lamp  placed  behind 
the  patient's  head,  and  so  elevated  that  its  rays  will  just  clear  his  forehead  to 
reach  the  observer's  eye  ;  for  no  matter  where  the  light  may  be,  we  must,  to 
throw  the  reflected  rays  into  the  patient's  eye,  compensate  for  the  obliquity  of 
the  rays  incident  on  the  mirror,  by  giving  a  corresponding  obliquity  to  the 
position  of  this  reflecting  surface.  Hence,  when  the  light  is  in  the  position 
we  advocate,  by  elevating  ourselves  above  the  horizontal  plane  of  the  patient's 
eye,  we  will  approach  nearer  the  horizontal  plane  of  the  lamp,  and  thus  dimi- 
nish the  angle  of  the  incident  rays,  and  this  position  will  require  much  less 


Xlii  A   SHORT   ACCOUNT   OF   THE   OPHTHALMOSCOPE. 

obliquity  of  the  reflector  to  illuminate  the  eye  to  be  observed  than  is  necessary 
where  the  light  is  at  the  side. 

The  next  step  after  arranging  the  position  of  the  patient  and  the  source  of 
illumination,  is  to  throw  the  reflection  on  the  eye  to  be  explored.  This  is 
done  by  turning  the  reflecting  surface  to  the  light,  and  then  gradually  changing 
its  position  until  its  reflection  appears  on  the  eye  to  be  observed. 

The  observer  is  now  to  apply  his  eye  close  to  the  orifice  of  the  speculum 
(if  he  has  not  been  looking  through  it  before),  and  watching  carefully  the 
reflection,  he  is  to  move  his  head  with  the  instrument  back  or  forward,  until 
the  reflecting  light  appears  about  the  size  of  the  reflecting  surface.  The 
patient  is  then  to  be  directed  to  keep  his  eye  slightly  inverted,  perfectly  steady, 
and  wide  open  ;  its  interior  will  then  present  a  reddish  hue,  but  none  of  the 
deep-seated  structures  will  probably  be  recognizable.  It  is  evident,  then,  that 
the  proper  focal  adjustment  has  not  yet  been  obtained.  By  slightly  moving 
the  head  and  instrument,  or  by  interposing  a  biconvex  lens,  this  will  be  rec- 
tified. We  prefer  introducing  the  lens  here,  as  it  has  afterwards  to  be  used. 
If  this  does  not  make  apparent  the  deep-seated  structures,  the  head  and  re- 
flector are  not  yet  in  their  proper  position,  and  must  be  moved  nearer  to,  or 
furtlier  from,  the  patient's  eye,  until  the  observer  can  distinctly  detect  red  ves- 
sels on  the  yellowish-red  ground  of  the  retina  and  choroid.  If  the  patient's 
eye  is  inverted,  as  we  said  it  should  be  when  the  lens  and  speculum  are  pro- 
perly adjusted,  the  light  will,  in  all  probability,  fall  on  a  brilliant  white  circle 
which  is  the  entrance  of  the  optic  nerve,  and  from  the  centre  of  this  circle 
there  will  be  readily  seen  two  larger  vessels,  an  artery  and  vein,  passing  up 
over  the  surface  of  the  retina,  and  a  similar  set  passing  downwards  over  the 
same  structure.  This  white  circle  has  a  diameter  of  one-fourth  of  an  inch, 
and  the  contrast  between  it  and  the  bright  choroid  shining  through  the  retina 
surrounding  it,  is  very  striking.  It  is  important  that  the  whereabouts  of  this 
entrance  of  the  optic  nerve  should  be  sought  for  at  the  very  first,  as  it  is  a 
valuable  landmark,  and  its  detection  aff"ords  great  facility  in  investigating 
the  other  parts  ;  for  here  the  illumination  is  brighter,  being  on  a  white  surface, 
and  the  bloodvessels  are  larger  and  more  readily  detected.  Consequently,  the 
observer  becoming  familiar  with  their  appearance,  will  have  much  less  diffi- 
culty in  detecting  them  in  situations  not  so  favorable  for  their  observation. 
Should  the  patient's  eye  be  too  much  or  not  at  all  inverted,  the  light  will  fall 
on  the  surface  of  the  retina,  and  the  appearance  presented  will  be  that  of  a 
yellowish-red  surface  marked  with  streaks  of  darker  red.  Those  dark  streaks 
are  the  larger  bloodvessels,  and  by  following  them  in  the  direction  in  which 
they  increase  in  diameter,  in  other  words,  towards  their  origin,  the  observer 
will  readily  reach  this  landmark  of  the  entrance  of  the  optic  nerve.  Some 
have  spoken  of  the  facility  with  which  they  could,  with  the  ophthalmoscope, 
see  the  pulsation  in  the  larger  arteries  of  the  retina.  The  ability  to  detect 
such  a  phenomenon  seems  to  us,  however,  rather  doubtful.  We  believe  the 
only  mode  of  distinguishing  the  artery  from  the  vein  is  by  the  darker  color  of 
the  latter.  To  follow  up  one  of  these  vessels  in  order  to  reach  the  entrance 
of  the  optic  nerve,  it  is  much  better  that  the  observer  should  move  the  instru- 
ment, the  lens,  and  his  own  eye,  rather  than  keeping  these  fixed  to  direct  the 
patient  to  change  the  position  of  the  eye  under  observation,  for  the  latter 
cannot  appreciate  the  character  or  exact  amount  of  motion  required  to  throw 
the  light  on  the  point  sought  after,  and  in  attempting  to  do  so,  he  will  not 
unfrequently  disturb  completely  the  whole  adjustment.  Sometimes  it  will  be 
only  necessary  to  change  the  position  of  the  convex  lens  to  bring  distinctly  into 
view  the  parts  we  wish  to  observe.  We  need  but  remind  the  beginner  of  the 
fact,  that  the  lens,  from  its  peculiar  property,  must  be  moved  in  the  opposite 


A   SHORT   ACCOUNT   OP   THE   OPHTHALMOSCOPE.  xliii 

direction  to  that  in  whicli  the  part  is,  which  he  desires  to  bring  into  proper 
focus,  precisely  as  the  microscopist  has  to  move  an  object  which  he  wishes  to 
trace  under  the  field  of  his  instrument. 

The  vessels  coming  out  from  the  optic  centre  were  stated  to  consist  of  two 
pairs.  One,  an  artery  and  vein,  passing  upwards  in  a  more  or  less  vertical 
direction ;  the  other  similar  in  character,  but  passing  downwards.  This  is 
the  course  they  generally  take  ;  they  will  sometimes  be  found  to  vary.  It  is 
exceedingly  difficult  to  trace  them  very  far,  from  the  fact  that  the  red- 
dened surface  over  which  they  run  makes  it  impossible  to  distinguish  their 
minuter  branches ;  and  the  iris  completely  intercepts  the  view  of  their  final 
distribution. 

The  bottom  of  a  healthy  eye  presents,  as  was  just  observed,  a  yellowish 
red  color  ;  this  color  is  brighter  in  the  immediate  vicinity  of  the  optic  centre 
than  on  the  periphery  of  the  retina.  The  tint  will  also  be  found  to  vary  in 
diiferent  eyes — being  lighter  (more  yellowish)  in  those  who  are  fair  than  in 
those  who  are  dark  and  florid;  showing  that  the  intensity  and  character  of 
the  color  are  influenced  by  the  pigment  layer  of  the  choroid. 

Close  to  the  inner  side  or  the  entrance  of  the  optic  nerve,  the  color  will  be 
observed  to  be  darker  at  one  point.  This  Helmholtz  attributes  to  the  shadow 
of  the  semilunar  fold  of  the  retina. 

When  the  patient  looks  directly  at  the  eye  of  the  observer,  and  thus  brings 
the  axis  of  the  two  eyes  in  the  same  line,  the  yellow  spot  of  Soemmerring  will 
come  into  view ;  the  retina  here  is  of  a  grayish  yellow  color,  entirely  free 
from  any  admixture  of  red ;  and  has  no  bloodvessels  on  its  surface. 

As  regards  the  value  of  the  ophthalmoscope  in  the  diagnosis  of  deep- 
seated  disease  of  the  eye,  it  might  justly  be  supposed,  from  what  has  been 
said  of  this  instrument,  that  it  would  not  only  be  indispensable  in  the  inves- 
tigation of  all  such  diseases,  but  that  with  it  there  should  be  no  difficulty  in 
detecting  the  slightest  pathological  change  in  any  of  these  structures,  and  in 
determining  the  exact  character  of  the  disease  present,  without  any  regard  to 
its  subjective  symptoms.  A  great  deal  more,  however,  has  been  expected  of, 
and  claimed  for  the  instrument,  than  it  is  capable  of  accomplishing,  in  the 
present  state  of  its  construction. 

In  the  first  place,  the  great  concentration  of  light  which  it  produces  in  the 
eye,  renders  its  employment  highly  injurious,  even  for  a  few  moments  of  time, 
in  the  incipient  stages  of  disease.  In  cases  where  it  can  be  endured,  its  em- 
ployment for  any  length  of  time  sufficient  to  detect  all  the  changes  which  have 
taken  place,  produces  an  excited  and  unnatural  condition  of  the  structures 
which  are  the  subject  of  investigation,  and  might  readily  lead  the  observer 
astray  in  his  diagnosis. 

In  cases  of  more  confirmed  disease,  it  might  not  give  rise  to  such  annoy- 
ances and  serious  consequences  ;  but  would  the  investigation  be  of  any  value 
in  such  cases  ?  Are  they  not  generally  incurable  ?  Granting  such  to  be  the 
case,  here  will  be  found  the  great  value  of  the  instrument ;  for  it,  and  it  alone, 
will  often  enable  us  to  set  aside,  as  Mr.  Dixon  justly  observes,  "as  positively 
hopeless,  a  large  number  of  cases  formerly  termed  '  amaurotic,''  or  'nervous,'' 
which  were  assumed  to  be  still  curable,  because  their  real  nature  could  not  be 
demonstrated." 

"  We  now  know,"  he  says,  "that  total  disintegration  of  the  vitreous  body, 
detachment  of  the  retina  from  its  connection  with  the  choroid,  and  other 
equally  hopeless  conditions  of  structures  essential  to  vision,  may  exist  without 
any  alterations  being  produced  in  the  outward  appearance  of  the  eye.  In 
enabling  us,  therefore,  to  appreciate  these  conditions,  the  ophthalmoscope  has 
proved  of  immense  value." 


Xliv  A    SHORT   ACCOUNT   OF   THE   OPHTHALMOSCOPE. 

We  would  refer  those  who  wish  to  study  the  subject  more  fully  than  the 
limits  of  the  present  work  will  admit  of,  to  the  following  : — 

Helmholtz — Beschreibung  eines  Augenspiegel  zur  Untersuchung  tier  Netzhaut  ine 
lebendea  Auge.     Berlin,  1851. 

RuETE — Der  Augenspiegel  und  das  Optometer.     Gottingen,  1852. 

Coccius — Ueber  die  Anwendung  des  Augenspiegel  nebst  Angabe  eines  neuen  Instru- 
mentes.     Leipzig,  1853. 

Anagnostakis — Essai  sur  I'Exploration  de  la  Ratine  et  des  Milieux  de  I'CEil  sur  la 
Tivant  a  moyen  d'une  nouvelle  Ophthalmoscope.     Paris,  1854. 

Van  Trigt — Der  Augenspiegel,  seine  Anwendung  und  Modificationen  nebst  Beitragen 
zur  Diagnostik  inneren  Augenkrankheiten.  Nach  dem  Hollatidischen  mit  Zusiitzen  bear- 
beitet  von  Dr.  C.  H.  Schauenberg,  Docenten  au  der  Universitilt  zur  Bonn.     Lahr,  1854. 

Ed.  Jager — Ueber  Staar  und  Staaroperationen  nebst  anderen  Beobachtungen  und 
Erfah  nungen  aus  seines  Vaters,  Dr.  Friedrich  Jiiger,  K.  K.  Prof.  &c.  und  aus  der 
eigcuen  Ophthalmologischen  Praxis.     AVien,  1854. 

RtJETE — Physikalische  Untersuchung  des  Auges  on  Dr.  C.  G.  Theodor  Ruete.  Tab. 
viii.     Leipzig,  1854. 

T.  Wharton  Jones — Report  on  the  Ophthalmoscope.  British  and  Foreign  Med.- 
Chirurg.  Review,  for  Oct.,  1854,  p.  549. 

E.  Williams,  M.D. — The  Ophthalmoscope.  Med.  Times  and  Gazette,  July  1,  1854, 
p.  7. 

J.  Hays's  edition  of  Lawrence  on  Diseases  of  the  Eye.     Blanchard  &  Lea.  1854. 

C.  Badf.r,  M.D.  and  Bransby  Roberts,  Esq. — On  the  Means  of  Diagnosing  the  In- 
ternal Diseases  of  the  Eye.  Aug.,  1854.  British  and  Foreign  Medico-Chirur.  Rev.,  for 
April,  1855,  p.  501. 

J.'VMES  DixoN — A  Guide  to  the  Practical  Study  of  Diseases  of  the  Eye.  London,  1855, 
p.  7. 

Christopher  Johnston,  M.  D. — Report  to  the  Medical  and  Chirurgical  Faculty  of 
Maryland,  published  in  the  proceedings  of  that  Society  for  1854,  p.  45.  Baltimore, 
1855.— H.] 


I 


PRACTICAL  TREATISE 


DISEASES    OF    THE    EYE. 


CHAPTER     I. 
DISEASES   or  THE   ORBIT. 

SECTION  r. — INJURIES  OF  THE  ORBIT. 

In  considering  the  injuries  of  the  orbit,  it  is  impossible  to  avoid  noticing 
the  effects  produced  on  the  investments  and  contents  of  this  cavity ;  or,  in 
treating  of  wounds  penetrating  the  walls  of  the  orbit,  to  pass  over  in  silence 
the  injuries  which,  in  this  way,  the  brain  and  other  surrounding  organs  may 
sustain.  Cases  occur,  indeed,  in  which  it  is  doubtful,  to  the  injury  of  what 
particular  part,  without,  within,  or  beyond  the  orbit,  the  effects  which  arise 
ought  to  be  attributed.  Amaurosis,  for  example,  one  of  the  chief  conse- 
quences to  be  apprehended  from  wounds  of  the  orbit,  appears  sometimes  to 
be  owing  to  injury  of  the  branches  of  the  fifth  nerve  exterior  to  that  cavity ; 
in  other  cases,  to  injury  of  the  optic  or  other  nerves  withiu  the  oi'bit,  or  of 
the  eye  itself;  and,  in  other  cases,  to  injury  of  the  brain. 

§   1.    Contusions  on  the  Edge  of  the  Orbit. 

Blows,  falls,  and  similar  accidents  are  apt,  especially  in  scrofulous  children, 
as  I  shall  explain  more  fully  in  the  next  section,  to  excite  inflammation, 
running  into  suppuration,  and  affecting  the  periosteum,  and  even  the  sub* 
stance  of  the  bones  forming  the  edge  of  the  orbit. 

From  blows  on  the  edge  of  the  orbit,  particularly  its  upper  edge,  we  must 
be  prepared,  however,  to  meet  occasionally  with  still  more  serious  conse- 
quences than  an  affection  of  the  bone  or  its  periosteum.  Effusion  of  blood 
within  the  cranium,  concussion  of  the  brain,  or  inflammation  of  its  substance, 
or  of  its  membranes,  may  be  excited  by  such  an  injury;  and,  while  we  are 
perhaps  confining  our  fears  to  the  state  of  the  bone,  or  of  the  soft  parts 
which  cover  it,  changes  may  be  going  on  within,  which  shall  suddenly  prove 
fatal . 

Case  1. — Henry  II.,  King  of  France,  Avas  struck,  in  a  tilting-matcli,  above  the  right 
eyebrow.  The  skin  was  torn  across  the  foreliead  to  the  external  angle  of  the  left  eye,  in 
the  substance  of  which  there  stuck  several  small  bits  of  the  shivered  lance.  There  was 
no  fracture.  The  injury  proved  mortal  on  the  11th  day.  On  opening  the  head,  Pare 
found  a  quantity  of  blood  effused  betAveen  the  dura  and  the  pia  mater,  under  the  middle 
4 


50  FRACTURES  OF  THE  EDGE  OF  THE  ORBIT. 

of  the  occipital  bone ;  and  the  substance  of  the  brain  at  that  place  changed  in  color  and 
consistence.' 

Case  2. — Mr.  Dease^  was  called  to  a  woman  who  had  been  struck  with  a  pewter  quart 
over  the  left  eye,  and  had  thus  received  a  wound  about  an  inch  and  a  half  long,  laying 
bare  the  bone.  She  died  on  the  26th  day  from  the  receipt  of  the  injury.  On  dissection, 
the  dura  mater  under  the  wound  was  found  detached,  and  slightly  spotted  with  matter, 
the  anterior  part  of  the  left  hemisphere  of  tlie  brain  in  a  state  of  suppuration,  and  some 
fluid  matter  lying  on  the  anterior  and  left  fossa  cerebri. 

Case  ">. — A  man  received  a  wound  18  lines  long,  above  the  right  eyebrow.  On  the 
third  or  fourtli  day,  fever  and  sleeplessness  came  on ;  the  edges  of  the  wound  became 
tender  and  swollen  ;  the  patient  vomited  bile  ;  he  fell  into  a  state  of  delirium  ;  bis  abdo- 
men was  painful,  e.'^pecially  the  right  hypochondrinm.  The  symptoms  grew  speedily 
worse,  locked-jaw  supervened,  and  the  man  died  on  the  7th  day.  A  large  quantity  of 
pus  was  found  beneath  the  pericranium,  in  contact  with  the  fals,  and  on  the  tentorinm ; 
the  surface  of  the  brain  was  highly  injected,  and  of  a  darker  color  than  natural ;  the 
liver  large,  and  its  peritoneal  covering  thickened  ;  the  intestines  contracted,  and  present- 
ing here  and  there  spots  of  purulent  exudation. ^ 

Consequences  not  less  serious  have  been  known  to  result  from  injuries  of 
a  similar  sort,  received  at  the  lower  edge  of  the  orbit.  Thus  Petit  relates  a 
case  of  palsy  of  the  left  side,  and  death,  from  suppuration  in  the  right  hemi- 
sphere of  the  brain,  consequent  to  a  wound  at  the  lower  edge  of  the  right 
orbit,  close  to  the  exit  of  the  infra-orbitary  nerve,  which,  however,  did  not 
appear  to  have  been  injured.* 

Contusion  of  its  teui))oral  edge  has  been  sometimes  followed  by  the  growth 
of  encysted  and  other  tumors  within  the  orbit.  These  efiFects,  ho^NSver,  as 
well  as  inflammation  of  the  various  parts  contained  within  that  cavity,  and 
the  formation  of  exostoses,  excited  by  the  same  cause,  will  require  separate 
consideration  hereafter. 

§  2.  Fractures  of  the  Edge  of  the  Orhit. 

The  only  recent  instance  of  this  injury  I  recollect  to  have  seen,  was  from  a 
blow  with  the  end  of  a  long  piece  of  wood,  which  struck  the  lower  edge  of 
the  orbit,  and  separated  a  fragment,  which  I  concluded  to  be  the  anterior 
angle  of  the  malar  bone.  The  fractured  piece  moved  at  first  easily  under  the 
finger,  in  different  directions,  but  became  united  in  the  course  of  a  few  weeks. 
No  bandage  was  applied  ;  but  cases  may  occur  in  which,  the  eyelids  being 
])reviously  closed,  compresses  might  be  judiciously  employed,  with  a  roller 
round  the  head,  to  keep  the  fractured  portion  of  the  edge  of  the  orbit  in 
contact  with  the  bone  from  which  it  had  been  separated,  till  the  process  of 
reunion  should  be  completed. 

Case  4. — A  butcher  was  leaping  from  a  barrel  to  the  ground,  and  not  observing  a  flesh- 
hook  which  hung  close  by  him,  it  caught  him  by  the  middle  of  the  left  orbitary  arch,  and 
f;iirly  took  the  piece  of  bone  with  it,  tearing,  of  course,  the  integuments  and  the  eyebrow. 
The  wound  healed  in  such  a  wny  as  to  leave  the  lid  peaked  up  in  the  middle,  so  that  the 
patient  could  not  completely  close  the  eye,  which  consequently  was  exposed  to  frequent 
attacks  of  inflammation.  During  one  of  these  he  consulted  nie,  several  years  after  the 
acci<lent.  The  deficiency  of  the  bone  was  very  perceptible,  and  added  to  the  deformity 
produced  by  the  lagophthalmos.  The  ophthalmia  was  puro-mucous,  and  soon  subsided 
under  the  use  of  a  solution  of  nitrate  of  silver. 

Cafe  5. — Dr.  Scott  relates*  that  a  soldier,  riding  into  the  town  of  Douglas,  Isle  of  Man, 
in  a  December  night,  was  caught  by  the  hook  of  an  iron  lamp-supporter,  which,  fixing 
beneath  the  superciliary  ridge  of  the  right  orbit,  tore  away  that  part  of  the  bone,  and 
wounded  the  brain.     He  recovered  perfectly  in  about  four  weeks. 

Case  6. — Biermayer^  records  the  case  of  a  boy  who,  being  struck  with  a  stone  at  the 
inner  angle  of  the  eye,  was,  on  the  5th  dnj-  after  the  injury,  seized  with  tetanus,  and 
died  in  a  few  hours.  On  dissection,  a  small  portion  of  the  nasal  process  of  the  superior 
maxillary  bone  was  found  lying  loose  in  the  abscess  at  the  seat  of  the  injury,  and  in  con- 
tact with  one  of  the  branches  of  the  infra-orbitary  nerve. 

Of  fractures  of  the  edge  of  the  orbit  extending  into  the  frontal  or  maxil- 
lary sinus,  or  into  the  ethmoid  cells,  the  consequence  sometimes  is  that,  on 


SKULL   AND    ORBIT   FRACTURED.  51 

blowing  the  nose,  air,  passing  through  the  fracture,  is  introduced  into  the 
celhilar  membrane  of  the  eyelids,  which  suddenly  become  swollen,  and  crepi- 
tate under  pressure.  In  such  cases,  of  which  I  shall  have  occasion  again  to 
speak  under  the  head  of  Emphysema  of  the  Eyelids,  it  is  scarcely  necessary 
to  open  the  integuments  with  the  lancet,  to  let  the  air  escape.  Its  presence 
is  of  no  moment;  but  the  patient  should  avoid  blowing  his  nose  till  the 
fracture  is  consolidated. 

§  3.  Fractures  of  the  Walls  of  the  Orhit,  attending  Fractured  Skull. 

Fractures  of  the  skull  not  unfrequently  penetrate  into  one  or  both  of  the 
orbits ;  and  it  is  worthy  of  observation  that,  if  the  roof  of  the  orbit  be  broken 
in  this  way,  it  is  apt  to  be  attended  by  laceration  of  the  dura  mater,  and 
injury  of  the  anterior  lobes  of  the  cerebrum,  which  rest  upon  the  orbits. 
Suppose  that  this  is  the  case,  while  at  the  same  time  a  fracture  with  depres- 
sion is  present,  we  shall  say  on  the  temple,  and  that  this  fractured  piece  of 
the  skull  is  raised  into  its  place  by  the  operation  of  trepan,  the  patient  will, 
in  all  probability,  not  be  relieved ;  the  symptoms  of  pressure  on  the  brain, 
or  of  inflammation  within  the  head,  will  most  likely  remain  as  before,  and 
death  follow,  contrary,  perhaps,  to  what  might  have  been  expected,  if  the 
fractured  temple  had  been  the  sole  injury.  It  will  probably  be  only  on  dis- 
section that,  in  such  a  case,  the  cause  of  death  will  be  discovered. 

Case  7  — Sir  George  BallingalF  has  recorded  a  case  of  compound  fracture  of  the  os 
frontis,  in  which,  after  the  depressed  pieces  of  bone  -were  removed,  the  patient  instantly 
recovered  his  senses,  and  answered  questions  rationally.  He  soon  lapsed,  however,  into 
a  comatose  state,  and  died  within  48  hours  of  the  receipt  of  the  injury.  On  dissection, 
the  fracture  was  found  to  extend  backwards,  through  both  orbitary  plates  of  the  frontal 
bone,  and  to  pass  across  the  ethmoid  behind  the  crista  galli.  Opposite  to  the  fissures  in 
the  roof  of  each  orbit,  the  dura  mater  was  found  lacerated  to  a  considerable  extent,  and 
portions  of  brain  protruding.  The  anterior  lobes  of  the  brain  were  disorganized  and 
broken  down  ;  and  there  was  a  distinct  appearance  of  purulent  matter  upon  the  tunica 
arachnoidea  covering  each  hemisphere  of  the  brain,  although  the  patient  had  survived 
the  accident  for  so  short  a  time,  lost  a  considerable  quantity  of  blood  from  the  wound, 
and  manifested  no  inflammatory  symptoms. 

In  cases  of  fractured  skull  extending  to  the  orbit,  it  sometimes  happens 
that  portions  of  the  walls  of  this  cavity  are  so  completely  separated,  that  they 
easily  come  away,  either  in  dressing  the  wound,  or  in  raising  the  depressed 
pieces  of  the  skull.  The  mere  circumstance  of  a  portion  of  bone  being  loose, 
is  not  sufficient  ground  for  removing  it ;  for,  if  its  surfaces  are  still  attached 
to  the  membranes  with  which  they  are  naturally  in  connection,  it  may  be 
susceptible  of  reunion  ;  but  if  the  bone  be  extremely  shattered,  and  pressed 
partly  through  the  dura  mater,  w^e  are  warranted  in  extracting  the  loose 
pieces. 

Case  8. — Cheselden^  communicates  a  case  of  this  kind,  which  occurred  in  the  practice 
of  Mr.  Cagua,  in  which  five  splinters  of  the  cranium,  depressed  into  the  substance  of  the 
brain,  were  extracted,  the  largest  piece  comprehending  part  of  the  orbitary  plate  of  the 
frontal,  of  the  great  wing  of  the  sphenoid,  and  of  the  suture  which  connects  the  external' 
angular  process  of  the  frontal  to  the  superior  angle  of  the  malar  bone.  Pieces  of  the 
substance  of  the  brain  followed  the  removal  of  this  splinter;  yet  the  patient,  a  boy  of 
ten  years  of  age,  perfectly  recovered. 

Case  9.— A  similar  case,  also  terminating  favorably,  is  recorded^  by  Dr.  Klein,  in 
which  several  large  portions  of  the  frontal  bone  were  removed  ;  the  roof  of  one  of  the 
orbits  was  completely  loose;  a  wide  hiatus,  separating  the  ethmoid  from  the  nei;:hboring 
bones,  ran  down  towai'ds  the  basis  of  the  skull ;  and  considerable  portions  of  brain  were 
discharged. 

Case  10. — I  was  consulted,  in  October  1842,  by  a  man  whose  right  eye  was  totally 
amaurotic,  and  lay  depressed  and  everted  in  its  orbit.  On  passing  the  hand  over  the 
forehead,  the  right  portion  of  the  frontal  bone  presented  a  triangular  elevation,  showing 
the  seat  of  a  former  fracture.  Six  months  before,  he  had  received  a  severe  blow  on  the 
right  temple,  but  no  fracture  was  then  detected.     He  lay  insensible  for  14  days  after  the 


52  FRACTURES   OF   THE   ORBIT. 

accident.  The  bone  yras  exposed  to  the  extent  of  an  inch.  All  the  symptoms  of  con- 
cussion of  the  brain  followed.  The  right  eye  projected  considerably,  as  if  from  the 
pressure  of  effused  blood  within  the  orbit.  Now  it  had  retreated.  I  considered  it  likely 
that  there  had  been  fracture  of  the  orbit. 

§  4.   Fractures  of  the  Walls  of  the  Orbit,  attending  Fractured  Bones  of  the 

Face. 

Of  this  sort  of  accident  it  may  be  sufficient  to  give  the  following  illustra- 
tion : — 

Case  11. — John  Lewis,  aged  11,  had  his  face  crushed  by  the  wheel  of  a  carriage,  and 
the  bones  of  the  nose  and  cheek  fractured.  He  lay  with  little  appearance  of  sensibility, 
but  understood  and  replied  to  questions  when  roused.  He  had  no  paralysis  ;  but  it  was 
thought  that  some  convulsive  twitches  occasionally  took  place  on  the  left  side.  There 
■was  ecchymosis  about  both  eyes,  and  some  laceration  under  the  left,  and  about  the  nose. 
He  died  on  the  6th  day  after  the  injury. 

On  removing  the  scalp,  several  patches  of  ecchymosis  were  seen  between  it  and  the 
calvaria  ;  the  largest  of  these  was  situated  at  the  posterior  part  of  the  head.  At  these 
spots,  the  scalp  scarcely  adhered  to  the  calvaria,  but  elsewhere  it  did  so  with  consider- 
able firmness.  The  internal  surface  of  the  dura  mater  was  of  a  light  red ;  between  it 
and  the  arachnoid,  on  the  left  side,  there  was  a  pretty  generally  diffused  layer  of  puri- 
form  lymph  of  a  light  yellow  color  with  a  tinge  of  green,  which  adhered  partly  to  the 
dura  mater,  and  partly  to  the  arachnoid.  It  dipped  down  between  the  hemispheres,  but 
was  wholly  confined  to  the  left  side  of  the  falx.  At  the  under  part  of  the  left  anterior 
lobe,  a  portion  of  brain  of  about  the  size  of  a  shilling  was  softened  to  the  depth  of  about 
half  an  inch  ;  and  a  few  minute  ecchymosed  spots,  such  as  are  usually  met  with  in  lace- 
rated brain,  were  visible  at  this  part.  There  was  very  little  laceration  of  the  dura  mater, 
but  a  portion  of  the  left  orbitary  plate  of  the  os  frontis  appeared  to  have  been  pushed 
inwards,  so  as  to  bruise  the  brain  at  the  part  above  mentioned.  The  fracture  was  con- 
tinued through  the  sphenoid  bone  by  the  side  of  the  left  cavernous  sinus,  and  at  this 
part  there  was  a  considerable  quantity  of  exti-avasated  and  coagulated  blood  beneath  the 
dura  mater.  "* 

§  5.    Orbit  Fractured  by  a  Blow  on  the  Eye. 

The  following  case,  related"  by  Duverney,  has  sometimes  been  referred  to 
as  an  example  of  this  sort  of  injury  ;  but  it  may  fairly  be  doubted  if,  in  this 
instance,  the  fracture  of  the  orbit  was  actually  produced  through  the  medium 
of  the  eyeball. 

Case  12. — .\.  gentleman  had  his  left  eye  crushed  to  pieces  by  a  blow  from  a  stone,  and 
the  orbit  beaten  in  upon  the  brain.  ,\fter  the  first  shock  till  his  death,  which  liappened 
on  the  7th  day,  his  faculties  remained  entirely  unimpaired,  insomuch  that  some  of  his 
medical  attendants  pronounced  it  impossible  the  brain  should  be  injured.  On  dissection, 
the  cranium  was  found  filled  with  brain  in  a  softened  state,  mixed  with  fragments  of 
bone.  The  whole  substance  of  the  brain,  even  to  the  cerebellum,  was  changed  by  dis- 
ease.    The  anterior  part  of  the  sella  Turcica  was  found  broken. 

§  6.    Counter-Fractures  of  the  Orbit. 

Fractures  of  the  orbit  sometimes  take  place,  by  what  the  French  call 
contre-coup,^^  in  consequence  of  blows  or  falls  on  the  forehead,  or  even  on  the 
occiput. 

Case  13. — Bohnius'^  opened  the  body  of  a  man  who  died  in  consequence  of  a  blow  with 
a  stick,  close  to  the  right  eyebrow.  At  the  part  struck  there  was  an  ecchymosis,  but  no 
wound  ;  beneath  the  ecchymosis,  the  bone  was  sound  and  entire  ;  but  in  the  roof  of  the 
orbit  there  was  a  fissure,  an  inch  and  a  half  long,  running  towards  the  sella  Turcica,  and 
the  corresponding  portion  of  the  dura  mater  was  ruptured. 

After  a  fall  or  blow  on  the  head,  should  an  extravasation  of  blood  appear 
in  the  upper  eyelid,  without  its  having  received  any  contusion,  it  may  be 
suspected  that  a  counter-fracture  of  the  upper  wall  of  the  orbit  has  taken 
place  ;  if  in  the  lower  eyelid,  that  the  floor  of  the  orbit  is  broken.**  It  can 
be  but  seldom,  if  ever,  that  such  fractures  can  be  positively  pronounced  to 
exist,  till  after  death.     Indeed,  it  is  of  comparatively  little  importance  to 


PENETRATING  WOUNDS  OP  THE  ORBIT. — EXTERNAL  WOUNDS.       53 

know  of  their  existence  during  life,  as  they  do  not  admit  of  any  particular 
treatment,  and  as  our  attention  will  be  directed  chiefly  to  the  concussion, 
and  consequent  inflammation  of  the  brain,  by  which  counter-fractures  are 
attended. 

§  "T.  Penetrating  Wounds  of  the  Walls  of  the  Orbit. 

The  smoothness  and  mobility  of  the  eyeball,  together  with  its  sraallness, 
compared  with  the  size  of  the  cavity  in  which  it  is  placed,  and  its  firm  resist- 
ance, compared  with  the  looseness  of  the  parts  interposed  between  it  and  the 
orbit,  serve  to  explain  how  pointed  bodies,  thrust  against  this  organ,  are 
very  apt  to  leave  the  eyeball  uninjured,  and  to  penetrate  deep  into  the  orbit, 
or  even  passing  through  its  walls,  to  enter  one  or  other  of  the  neighboring 
cavities.  The  nasal  and  cranial  sides  of  the  orbit,  from  their  situation  and 
extreme  thinness,  are  especially  liable  to  be  thus  injured.  Perforation  of  the 
orbitary  plate  of  the  frontal  bone,  in  particular,  is  an  accident  to  which  the 
attention  of  the  surgical  student  is  early  and  forcibly  drawn.  The  thinness 
and  fragility  of  that  plate,  the  readiness  with  which  the  brain  maybe  reached 
through  it,  and  the  instantaneousuess  with  which  death  has  been  known  to 
follow,  are  among  the  earliest  points  impressed  on  the  mind  of  the  young 
anatomist.  Thus  Mr.  John  Bell,  after  attributing  the  thinness  of  the  orbit- 
ary plate  to  "the  continual  rolling  of  the  eye,"  with  which  that  plate  never 
comes  into  contact,  and  by  which,  therefore,  it  cannot  be  thinned,  tells  us 
that  "it  is  the  aim  of  the  fencer ;  and  we  have  known  in  this  country,"  adds 
he,  "a  young  man  killed  by  the  push  of  a  foil,  which  had  lost  its  guard. "*' 

Various  effects  may  follow  a  penetrating  wound  of  the  orbit,  and  we  may 
find  the  patient  in  one  or  other  of  very  different  states.  The  weapon  may 
have  been  immediately  withdrawn  after  the  injury  was  inflicted ;  or  the 
foreign  body  may  still  be  fixed  in  the  wound,  and  is  to  be  extracted ;  or  it 
may  have  sunk  so  deep  that  it  cannot  be  laid  hold  of.  As  for  the  effects 
of  the  injury,  they  may  be  slight  and  transient,  or  violent  and  immediately 
dangerous,  or  prolonged  for  a  length  of  time.  It  is  evident,  that  a  dagger, 
or  other  weapon,  directed  outwards,  so  as  to  break  through  the  suture 
between  the  malar  and  sphenoid  bones  into  the  temporal  fossa,  or  directed 
downwards,  so  as  to  shatter  the  floor  of  the  orbit,  and  enter  the  maxillary 
sinus,  will  not  be  productive  of  the  same  amount  of  dangerous  consequences 
as  when  the  instrument  of  injury  traverses  the  os  planum  of  the  ethmoid,  or 
the  orbitary  plate  of  the  frontal,  or  fractures  the  sphenoid  where  it  gives 
passage  to  the  optic  nerve.  I  shall  treat  of  gunshot  wounds  of  the  orbit 
separately ;  but  I  may  here  remark,  that  their  effects  correspond  so  far  at 
least  with  those  of  common  penetrating  wounds,  that  from  both  we  may 
occasionally  expect  hemorrhage,  extravasation  of  blood,  blindness,  strabis- 
mus, syncope,  vomiting,  coma,  convulsions,  palsy,  and  even  death,  as  imme- 
diate effects  ;  and,  as  remote  effects,  fever,  delirium,  suppuration,  caries, 
exfoliation  of  bone,  and  the  like.  In  all  such  injuries,  paralytic  symptoms 
are  most  likely  to  arise  from  hemorrhage  into  the  cavity  of  the  cranium  ; 
fever  and  delirium  indicate  inflammation  of  the  membranes  ;  rigors,  suppura- 
tion ;  coma,  convulsions,  and  dilated  pupils,  abscess  of  the  brain. 

1.  Trifling  appearance  of  external  wound. — A  weapon,  penetrating  through 
the  orbit,  may  strike  deep  into  the  brain,  and  yet  so  small  an  external  wound 
be  present  as  shall  be  apt  to  excite  little  or  no  suspicion  of  danger. 

Case  14. — Ruysch  relates  the  case  of  a  man  who  was  wounded  in  the  left  orbit,  with 
the  end  of  a  stick,  not  particularly  sharp.  The  injury  appeared  of  little  importance; 
yet  the  patient  died  soon  after  receiving  the  wound.  The  magistrates  appointed  Ruysch 
to  examine  the  body,  in  order  to  discover  the  cause  of  the  sudden  death.  Externally, 
he  observed  a  slight  degree  of  ecchymosis  at  the  upper  part  of  the  eye;  but  on  removing 


54  SITUATION  AND  EXTENT   OF  FRACTURED   ORBIT. 

the  calvaria,  he  found  that  the  wound  had  penetrated  to  a  considerable  depth  into  the 
brain.  '^ 

Case  15. — Peter  Borel  mentions  a  still  more  remarkable  case,  of  a  man  -who  was 
wounded  with  a  sword  in  the  left  orbit.  Thinking  that  the  wound  had  not  penetrated 
deep,  he  merely  covered  it  with  a  plaster ;  after  which  he  walked  two  leagues,  and  ate 
and  drank  heartily  with  his  companions,  exactly  as  if  he  had  been  well,  being  aifected 
with  no  pain.  Next  morning  he  was  found  dead.  The  skull  was  opened,  when  the 
wound  was  found  to  have  penetrated  to  the  cerebellum. '" 

Such  cases^^  sufficiently  show  how  carefully  our  examination  ought  to  be 
conducted,  and  how  cautiously  our  prognosis  delivered,  when  a  wound 
appears  to  have  penetrated  towards  the  roof  of  the  orbit. 

In  the  following  case,  symptoms  of  danger  supervened  early,  and  were 
treated  with  the  appropriate  remedies,  although  unfortunately  without 
success : — 

Case  IG. — A  man  was  brought  into  the  London  Hospital,  12th  April,  1832,  with  a  lace- 
rated wound  of  the  right  upper  eyelid.  He  stated  that,  while  working  on  board  a  ship 
discharging  coals,  a  hook  used  for  raising  the  coals  caught  him  by  the  eye,  so  that  he 
was  elevated  to  the  height  of  several  feet.  His  companions,  observing  what  had  hap- 
pened, suddenly  let  go  the  rope,  so  that  the  poor  fellow  fell  heavily  on  the  deck.  He 
immediately  withdrew  the  hook  himself.  On  his  admission  to  the  hospital,  he  did  not 
appear  to  be  suffering  from  any  serious  injury.  The  eyeball  was  uninjured,  and  no 
fracture  could  be  detected.  His  respiration  was  natural;  his  pulse  76,  full,  but  not 
more  than  might  have  been  expected  in  a  robust  man;  pupils  obedient  to  the  light;  no 
pain  in  the  head. 

He  was  bled  to  the  extent  of  twenty  ounces  ;  a  cold  lotion  was  applied  to  the  forehead  ; 
and  two  grains  of  calomel  were  ordered  to  be  given  every  second  hour.  He  passed  a 
quiet  night.  Next  morning,  his  pulse  was  74,  full,  but  free  from  hardness.  He  had 
very  little  pain  in  the  head.  His  bowels  had  been  opened  three  times.  Twelve  leeches 
were  applied  to  the  forehead,  and  the  calomel  continued.  Symptoms  of  compression  of 
the  brain  came  on  very  suddenly  at  six  in  the  evening.  His  breathing  became  stertorous; 
pupils  contracted,  and  insensible  to  the  stimulus  of  light;  pul.'^e  52,  and  laboring ;  he 
could  not  be  roused  by  any  noise.  At  this  time,  a  quantity  of  blood,  mixed  apparently 
with  cerebral  substance,  to  the  amount  of  about  two  ounces,  escaped  from  the  wound. 
He  was  again  bled  to  the  extent  of  twenty  ounces ;  the  blood  cupped  and  butfy.  Twelve 
leeches  were  applied  to  the  temple.  He  lingered  in  this  state  until  two  o'clock  next 
morning,  when  he  died. 

The  orbitary  plate  of  the  frontal  bone  was  found  to  be  completely  smashed,  and  a  con- 
siderable portion  of  the  anterior  lobe  of  the  right  hemisphere  of  the  brain  wanting,  it 
having  escaped  through  the  wound. '^ 

2.  Differences  in  situation  and  extent  of  fractured  orbit. — -'It  is  worthy  of 
remark,  that  it  is  not  the  orbitary  plate  of  the  frontal  bone  alone  which  is  apt 
to  be  fractured,  when  the  weapon  is  directed  towards  the  roof  of  the  orbit; 
and  that  we  are  in  some  degree  enabled  to  judge  of  the  violence  employed  by 
the  hand  which  held  the  weapon,  even  by  the  mere  situation  of  the  fracture, 
which,  in  fatal  cases,  is  detected  on  dissection. 

The  following  case  of  fatal  wound  of  the  brain  through  the  orbit  and 
ethmoid  bone,  is  quoted  by  Bonetus : — 

Case  17. — .\  countrj-man,  about  55  years  of  age,  was  asked  by  one  who  met  him  to 
step  out  of  the  way ;  but,  as  he  was  carrying  a  heavy  burden  at  the  time,  he  could  not 
do  so,  and  therefore  refused.  The  other,  provoked  at  this,  struck  the  countryman  vio- 
lently over  the  shoulders  with  a  whip  ;  and,  when  the  whip  broke,  thrust  the  sliarp  end 
of  the  broken  shaft  of  the  whip  in  the  countryman's  face.  Not  apprehending  any  dan- 
gerous effects  from  the  blows  which  he  had  received,  the  countryman,  with  his  burden 
on  his  back,  trudged  along  after  his  cart,  which  was  loaded  with  wood,  for  nearly  a 
quarter  of  a  mile,  till  he  arrived  at  the  wood  market,  when  he  instantly  dropped  down 
dead. 

Schmid  was  appointed  to  inspect  the  body.  On  examining  the  head  externally,  he 
found  that  the  sharp  end  of  the  stick  had  penetrated  at  the  inner  canthus  of  the  right 
eye.  He  endeavored  to  ascertain  with  the  probe  whether  the  wound  had  reached  the 
brain  ;  but  he  could  not,  on  account  of  the  narrowness  of  the  wound.  Having  opened 
the  cranium,  the  brain  and  its  membranes  at  first  view  appeared  sound  ;  but,  on  raising 
the  anterior  part  of  the  cerebrum,  the  nasal  extremity  of  the  falx  was  observed  to  be 


SITUATION. AND   EXTENT   OF   FRACTURED   ORBIT.  55 

injured,  and  it  was  found  that  tbe  wound  had  penetrated  into  the  third  ventricle,  in  which 
lay  a  considerable  quantity  of  clotted  blood. ^ 

Case  18. — A  man,  standing  at  the  head  of  a  horse  which  had  fallen  in  the  street,  was 
suddenly  struck  in  the  face,  upon  the  animal  raising  itself  unexpectedly.  The  blow  was 
so  violent  that  he  was  thrown  down  by  it,  but  not  stunned.  He  was  of  opinion  that  it 
was  not  the  head  of  the  horse,  but  some  part  of  the  harness  that  had  struck  him.  There 
was  a  bleeding  wound  between  the  left  eye  and  the  nose,  about  an  inch  long,  dividing  the 
lachrymal  canal  and  palpebral  tendon.  A  probe  was  introduced  to  the  depth  of  three- 
quarters  of  .an  inch  into  the  wound,  in  the  direction  of  the  inner  wall  of  the  orbit,  but 
■without  the  bone  being  felt.  The  left  eye  was  uninjured.  The  right  eye,  without  any 
perceptible  injury,  had  entirely  lost  the  power  of  vision.  Its  pupil  was  dilated  to  the 
utmost ;  and,  although  its  common  sensibility,  as  well  as  its  different  motions,  was  per- 
fect, a  lighted  candle  held  close  before  it  caused  no  contraction  of  the  pupil,  nor  any 
sensation  of  light.  The  patient  answered  questions  promptly  and  clearly,  and  evinced  no 
symptom  of  injury  extending  to  the  brain,  except  that  he  complained  of  a  little  headache. 
The  bones  of  the  nose  were  examined,  but  no  crepitus  could  be  felt ;  neither  was  there 
any  eechymosis  to  indicate  injury  on  the  right  side.  Delirium,  however,  and  stupor 
supervened  on  the  following  day ;  and,  as  these  symptoms  were  attiibuted  to  meningitis, 
the  patient  was  bled,  purged,  and  treated  with  repeated  doses  of  calomel  and  antimony. 
In  the  evening,  convulsions  came  on ;  the  left  arm  and  leg  were  stiff  and  contracted, 
while  the  right  extremities  were  in  constant  motion;  the  pupil  of  the  right  eye  was  now 
found  to  be  contracted.  As  the  patient  could  no  longer  swallow  pills,  calomel  was  laid 
on  the  tongue ;  a  blister  also  was  applied  to  the  nape  of  the  neck.  The  left  side  and 
extremities  became  subsequently  paralytic,  while  the  right  were  tranquil.  He  died  con- 
vulsed on  the  5  th  day  after  the  accident. 

On  dissection,  the  brain  and  its  membranes  were  found  loaded  with  vessels,  and  there 
was  a  copious  deposit  of  lymph  between  the  arachnoid  and  the  pia  mater,  over  both 
hemispheres.  A  large  accumulation  of  serum,  with  purulent  matter  diffused  in  it,  was 
present  in  both  lateral  ventricles.  The  whole  lower  surface  of  the  anterior  lobes  was 
adherent  to  the  dura  mater,  by  means  of  coagulable  lymph.  The  optic  nerves  being 
exposed,  the  right  was  seen  to  be  torn  completely  through,  or  its  ends  joined  only  by 
delicate  membrane,  close  to  the  foramen  opticum.  The  base  of  the  brain,  from  the 
medulla  oblongata  to  the  chiasma,  was  thickly  covered  with  a  layer  of  lymph,  which 
obscured  the  roots  of  the  nerves.  In  the  postei-ior  part  of  the  right  anterior  lobe,  close 
to  the  injured  part  of  the  optic  nerve,  and  approaching  to  the  anterior  cornu  of  the  late- 
ral ventricle,  the  brain  was  bruised,  softened,  and  ecchymosed.  The  cause  of  the  lacera- 
tion of  the  brain  and  tearing  across  of  the  optic  nerve  was  found  to  be  a  fracture  of  the 
cerebral  plate  of  the  ethmoid  bone,  with  part  of  the  sphenoid  forming  the  roof  of  the 
foramen  opticum.  The  fractured  fragment  of  bone  was  found  loosely  attached  by  dura 
mater  to  the  fore  part  of  the  sella  Turcica,  above  the  right  cavernous  sinus.  On  intro- 
ducing a  probe  into  the  external  wound,  it  could  be  made  to  pass,  by  a  slight  degree  of 
management,  into  the  crushed  part  of  the  ethmoid,  and  to  appear  within  the  skull.  It 
was  evident,  therefore,  that  the  object  by  which  the  blow  was  inflicted,  must  have  been 
pointed ;  that  it  enteretl  the  orbit,  so  as  to  strike  the  os  planum,  and  force  it  inwards ; 
and  that  the  force  being  communicated  at  the  same  time  upwards,  the  blow  had  the  effect 
of  fracturing  the  cerebral  plate  of  the  ethmoid,  and  lacerating  the  optic  nerve  on  the 
opposite  side. 2' 

Case  19. — On  the  20th  December,  1819,  I  assisted  at  the  examination  of  the  body  of  a 
man  who,  the  evening  before,  had  instantaneously  dropped  down  dead  in  a  scuffle  on  the 
street,  after  receiving  a  penetrating  wound  of  the  orbit,  with  the  pointed  end  of  an 
umbrella.  Considerable  bleeding  had  taken  place  from  the  nose  and  mouth.  The  upper 
eyelid  was  swollen  and  livid,  and  the  conjunctiva  elevated  by  extravasated  blood.  Just 
over  the  tendon  of  the  orbicularis  palpebrarum,  a  penetrating  wound  easily  admitted  the 
little  finger  to  the  bottom  of  the  orbit,  between  its  nasal  side  and  the  eyeball.  A  frac- 
ture of  the  orbit  was  felt  with  the  end  of  the  finger.  On  opening  the  head,  much  dark 
fluid  blood  was  found  effused  into  the  cavity  of  the  tunica  arachnoidea,  and  some  between 
it  and  the  pia  mater.  The  dura  mater  was  seen  to  be  perforated  by  a  lacerated  wound, 
just  under  the  edge  of  the  boundary  of  the  middle  fossae  of  the  basis  of  the  cranium, 
formed  by  the  little  wing  of  the  sphenoid  bone.  The  brain  behind  the  wound  of  the  dura 
mater  was  lacerated,  and  a  small  portion  of  it  separated  from  the  rest.  On  removing 
the  dura  mater,  the  fracture,  which  had  been  seen,  indeed,  immediately  on  lifting  the 
brain,  was  displayed  completely  to  view.  The  little  wing  of  the  sphenoid  was  separated 
by  the  fracture  from  the  frontal  bone,  in  the  course  of  the  sphenoidal  suture.  The  frac- 
ture extended  through  the  orbitary  plate  of  the  frontal  from  behind  forward  for  about 
half  its  length ;  but  what  was  much  more  remarkable,  the  comparatively  thick  and 
strong  portion  of  the  sphenoid,  which  completes  the  posterior  part  of  the  roof  of  the 


56  HEMORRHAGE — SUPPURATION  —  CONVULSIONS. 

orbit,  was  broken  across  at  its  inner  extremity ;  proving,  along  with  the  state  of  the  dura 
mater  and  brain,  the  great  degree  of  force  with  which  the  instrument  of  death  had  been 
driven  against  the  hapless  victim  of  a  drunkard's  fury.  I  may  mention,  that  the  optic 
nerve  and  eyeball  were  entire,  the  cornea  clear,  and  the  humors  and  retina  uninjured. ^^ 

3.  Hemorrhage. — Although  hemorrhage,  more  or  less  profuse,  must  attend 
all  accidents  of  the  kind  now  under  consideration,  I  know  only  of  one 
recorded  case,  in  which  a  fatal  result  was  to  be  ascribed  entirely  to  the  loss 
of  blood. 

Case  20. — In  a  scuffle,  a  nailer  drew  a  red-hot  iron  nail-rod  from  the  fire,  and  thrust  it 
against  the  eye  of  a  man,  aged  28  years,  who  immediately  fell  heavily,  and  remained  in- 
sensible for  a  short  time ;  but,  after  having  been  carried  home,  became  quite  conscious, 
and  vomited  a  large  quantity  of  blood.  Wlien  Dr.  Little  saw  him  next  morning,  he  found 
a  trifling  wound  of  the  left  upper  lid,  immediately  under  the  internal  orbital  angle  of  the 
frontal  bone,  not  presenting  any  of  the  characters  of  a  recent  burn,  and  already  united. 
The  lid  was  swollen  and  black  from  ecchymosis,  and  was  closed  over  the  eye,  which  was 
intact  and  uninflamed.  The  face  was  pale,  voice  weak,  and  general  aspect  that  of  a 
person  who  had  lost  a  large  quantity  of  blood.  Pulse  50,  full,  soft,  and  regular.  His 
intellect  continued  unaffected,  and  he  had  a  desire  for  food.  Pupils  regular  and  con- 
tractile. He  was  purged,  and  on  the  second  day  after  the  accident  was  bled  at  the  arm 
on  account  of  headache.  On  the  fourth  day,  he  began  to  void  his  urine  in  bed,  and  lost 
the  power  of  his  left  leg,  and  partially  of  his  left  arm.  Till  the  fourteenth  day,  he  seemed 
to  improve  ;  his  pulse  steadily  at  50;  he  was  free  from  pain ;  his  mind  active  ;  his  ap- 
petite keen  ;  but  still  passing  urine  involuntarily,  and  his  left  extremities  paralytic.  On 
that  day,  he  was  seized  with  a  violent  and  sudden  epistaxis,  evidently  arterial,  immedi- 
ately after  which  coma  supervened,  and  in  three  hours  he  was  dead. 

The  dura  mater  and  subjacent  arachnoid  were  perfectly  normal.  No  serum  in  the 
ventricles.  On  raising  the  anterior  lobes  of  the  cerebrum,  a  large  clot  of  blood,  about 
three  ounces  in  weight,  was  found  lying  on  the  orbital  plate  of  the  frontal  bone.  On  re- 
moving this  coagulum,  an  oval  breach,  with  sharp  and  ragged  edges,  and  about  half  an 
inch  in  its  longest  diameter,  was  exposed,  involving  the  orbital  plate  of  the  frontal  bone 
and  cribriform  plate  of  the  ethmoid,  and  terminating  at  the  side  of  the  crista  galli.  Not 
a  drop  of  matter  had  been  formed,  either  within  the  skull  or  in  the  course  of  the  wound, 
which  had  quite  healed  externally.  The  vessel  from  which  the  fatal  hemorrhage  had 
issued  could  not  be  discovered.  Dr.  Little  thought  it  probable,  that  it  had  been  the  an- 
terior artery  of  the  cerebrum,  and  considered  that  the  same  vessel  had  given  origin  to 
the  blood  which  the  patient  had  swallowed  and  afterwards  vomited,  and,  either  hy  the 
separation  of  a  slough  or  the  disengagement  of  a  coagulum  from  its  orifice,  had  finally 
caused  death. 

There  are  many  remarkable  circumstances  about  this  case  The  permanent  pulse  of 
oO ;  the  occurrence  of  paralysis  on  the  5th  day,  without  any  new  symptoms  directly  af- 
fecting the  head  ;  the  contemporaneous  improvement  in  the  general  state  of  the  patient 
up  to  the  day  of  his  death  ;  the  freedom  of  the  brain  from  injury;  the  absence  of  in- 
flammation ;  and  the  cause  of  pressure,  as  detected  on  dii-ection,  existing  on  the  same 
bide  as  the  paralysis ;  all  deserve  particular  attention.** 

4.  Suppuration — Comndsions. — The  eases  which  I  am  now  about  to 
quote,  serve  at  once  to  confirm  what  is  proved  by  some  of  the  preceding 
ones,  namely,  that  at  the  first  there  may  be  nothing  alarming,  except  the 
suspicious  situation  of  the  wound ;  exemplify  a  symptom  which  has  ever 
been  regarded  as  an  exceedingly  dangerous,  if  not  fatal,  one  in  injuries  of 
the  brain,  namely,  convulsions  ;  and  illustrate,  in  accidents  of  this  kind,  both 
the  date  and  the  effects  of  suppuration.  The  earliness  with  which  matter  is 
formed  by  the  tunica  arachnoidea,  in  cases  of  wounded  brain,  is  strikingly 
proved  by  the  case  already  quoted  from  Sir  Gr.  Ballingall's  Clinical  Lecture. 

With  regard  to  the  convulsions  arising  from  irritation  of  the  brain,  and 
which  not  unfrequently  appear  immediately  or  very  soon  after  a  severe  in- 
jury of  the  head,  it  may  be  observed,  that  they  are  probably  the  effect  rather 
of  pressure  from  fractured  pieces  of  bone  or  effused  blood  than  of  any  change 
in  the  cerebral  structure,  and  are  attended  with  comparatively  less  danger 
than  those  caused  by  disorganization  consequent  on  inflammation.  The 
latter  usually  occur  along  with  strabismus  and  coma,  some  time  after  the 


\ 


PALSY.  5t 

setting  in  of  the  symptoms  called  secondary,  from  their  occurring  days  or 
weeks  after  the  injury,  and  are  almost  invariably  the  forerunners  of  death. 

Case  21. — A  soldier  was  brought  to  the  hospital  at  Brest,  at  eleven  o'clock  in  the  even- 
ing, having  been  wounded  with  a  pitclifork,  at  the  middle  of  the  left  upper  eyelid.  The 
wound  was  oblique,  about  three  lines  in  length,  and  appeared  to  implicate  only  the  skin 
and  orbicularis  palpebrarum  ;  there  was  very  little  blood  discharged  ;  the  eyelid  was  dis- 
tended, and  the  conjunctiva  inflamed.  The  apparent  simplicity  of  the  wound,  the  good- 
ness of  the  pulse,  and  the  free  exercise  of  all  the  functions,  led  to  a  favorable  prognosis ; 
the  patient  asserted  that  he  had  experienced  nothing  particular  at  the  moment  of  the  in- 
jury, and  had  scarcely  been  stupefied  by  it.  Compresses  dipped  in  brandy  and  water 
were  applied  over  the  wound.  The  patient  rested  during  the  night ;  next  day,  he  was 
quite  livelj%  walking  about  in  the  wards,  complaining  only  of  slight  pain  in  the  wound, 
and  even  eating  with  appetite.  The  same  day,  at  seven  in  the  evening,  he  was  seized 
with  convulsions,  which  were  supposed  by  his  attendants  to  be  epileptic.  The  day  after, 
he  was  kept  from  food,  and  bled  at  the  arm  ;  the  convulsions  returned,  and  he  was  bled 
at  the  foot.  Vomiting,  uneasiness,  agitation,  and  delirium  came  on ;  the  pulse  became 
small  and  contracted ;  cold  sweats  succeeded,  and  the  patient  died  at  two  o'clock  next 
morning. 

On  dissection,  the  eyelids  were  found  oedematous,  and  the  wound  had  already  closed. 
On  cutting  through  the  upper  eyelid  and  orbicularis  palpebrarum,  a  circumscribed  collec- 
tion of  pus  was  found  in  the  orbit,  between  its  roof  and  the  levator  palpebrae  superioris. 
This  collection  of  pus  communicated  with  the  cranium,  through  the  orbitary  plate  of  the 
frontal  bone,  which  had  been  penetrated  by  one  of  the  prongs  of  the  fork.  After  remov- 
ing the  eyeball,  the  inferior  wall  of  the  orbit  was  found  fractured,  and  depressed  almost 
completely  into  the  maxillary  sinus.  This  fracture  is  compared  by  M.  Massot,  the  nar- 
rator of  the  case,  to  the  depression  which  might  be  produced  on  the  surface  of  an  egg, 
by  pressing  it  inwards  with  the  thumb.  On  removing  the  calvaria,  the  dura  mater  was 
seen  to  be  penetrated  over  the  hole  made  by  the  fork  in  the  roof  of  the  orbit.  The  dura 
mater  appeared  in  a  morbid  state  at  that  place,  the  anterior  fossa3  of  the  basis  of  the 
cranium  were  covered  with  pus,  the  anterior  lobes  of  the  cerebrum  were  in  a  state  of 
suppuration,  and  the  rest  of  the  brain  healthy.  M.  Massot  thinks  it  probable  that,  when 
the  fork  was  jjushed  through  the  orbit  into  the  cranium,  the  eyeball  being  fixed  and  vio- 
lently pressed  between  the  fork  and  the  floor  of  the  orbit,  the  thin  plate  of  the  superior 
maxilhiry  bone  could  not  resist  this  pressure,  but  sunk  by  the  continued  action  of  the 
fork  upon  the  eyeball.^* 

5.  Palsy. — Wounds  penetrating  the  upper  or  inner  side  of  the  orbit  are 
sometimes  productive  of  paralytic  affections,  from  the  effusions  of  blood 
within  the  cranium  to  which  they  give  rise.  The  palsy  is  generally,  but  not 
always,  on  the  opposite  side  of  the  body  to  that  which  has  been  injured. 
The  upper  and  lower  extremity,  and  the  sphincter  of  the  bladder,  are  most 
apt  to  be  paralyzed.  The  paralytic  affection  sometimes  occurs  instantly 
after  the  injury  ;  in  other  cases,  not  for  several  days.  The  effusion  of  blood 
ceasing,  the  patient  may  survive;  and  slowly,  as  the  blood  is  absorbed,  the 
palsy  may  disappear.  The  effusion  continuing,  or  being  renewed,  after 
having  ceased  for  a  time,  coma  and  death  are  likely  to  supervene. 

Case  22. — The  son  of  Gen.  E.,  a  student  at  the  Polytechnic  School  in  Paris,  received, 
in  fencing,  the  end  of  the  foil  through  the  roof  of  the  orbit,  and  became  hemiplegic  on 
the  opposite  side  of  the  body.     The  eye  was  saved. ^^ 

Case  23. — Thomas  Hale,  aged  35,  was  assisting  in  hay-making.  A  scaffolding  had  been 
erected  at  the  side  of  the  hayrick ;  and  while  his  companion,  a  man  named  Joslyn,  was  in 
the  act  of  throwing  some  hay  upon  it,  the  pitchfork  missed  the  hay,  and  struck  Hale  in 
the  right  eyebrow.  Instead  of  drawing  the  pitchfork  out,  .Joslyn,  under  the  impression 
that  he  had  caught  the  hay,  thrust  it  further  in,  the  one  prong  entering  Hale's  orbit,  while 
the  other  glanced  over  the  outside  of  his  head. 

When  the  prong  was  withdrawn,  which  was  accomplished  with  difficulty,  Hale  turned 
to  leave  the  field,  having  the  impression  that  his  eye  had  been  driven  out  of  his  head ;  but 
.'6  had  not  proceeded  more  than  five  or  six  yards  before  he  fell,  his  left  side  crippling 
under  him.  In  other  respects  he  recovered ;  but  the  palsy  continued,  the  fingers  of  the 
left  hand  being  contracted,  and  the  left  foot  swinging  about,  although  he  became  able,  in 
the  course  of  some  months,  to  walk  at  the  rate  of  a  mile  in  30  minutes.  Dr.  Roe,  who 
published^  the  case,  had  given  a  trial  to  strychnia  internally,  and  to  electro-magnetism, 
without  any  ytr^  striking  improvement.  Hale  continued  to  taste,  smell,  and  see  as  well 
as  ever. 


58  FOREIGN  BODY   STILL  IN  THE   ORBIT. 

Case  24. — A  case  of  this  kind  is  also  recorded  by  Mr.  Geach.^  He  does  not,  indeed, 
say  that  the  wound  penetrated  into  the  brain,  but  merely  that  the  instrument  of  injury 
struck  against  the  inner  side  of  the  orbit;  leaving  it  a  matter  of  doubt  whether  the  para- 
lytic symptoms  which  followed,  were  attributable  to  effusion  within  the  cranium,  or  to  a 
still  more  direct  injury  of  the  brain.  The  instantaneousness  with  which  the  patient,  in 
this  case,  fell  on  receiving  the  injury,  looks  very  like  the  effect  of  a  wound  of  the  brain ; 
while,  on  the  other  hand,  the  slowness  of  the  pulse  and  the  hemiplegia,  are  more  the 
symptoms  of  pressure  from  effused  blood.  Even,  however,  on  the  supposition  that  the 
small  sword  with  which  the  wound  was  inflicted,  had  not  penetrated  through  the  ethmoid 
bone  into  the  brain,  the  case  becomes  only  the  more  remarkable  ;  as  it  would  lead  us  to 
conclude,  that  a  wound  of  the  bones  of  the  orbit,  without  perforation,  might  be  attended 
by  rupture  of  vessels  within  the  cranium,  and  consequently  with  pressui-e  on  the  brain, 
and  paralysis.  At  the  time  when  Mr.  Geacb  drew  up  his  account  of  the  case,  the  para- 
lytic arm  and  thigh  were  recovering,  but  slowly,  their  power  of  flexion  and  extension. 

6.  Foreign  body  still  in  the  orbit. — In  all  the  instances  to  which  I  have 
hitherto  referred,  the  weapon,  whatever  it  was,  was  instantly  withdrawn  on 
the  injury  beint?  inflicted ;  but  we  must  be  prepared  to  meet  with  cases  where 
the  foreign  body  which  has  been  driven  through  the  walls  of  the  orbit,  still 
remains  in  the  wound. 

In  such  cases,  we  instantly  proceed  to  its  removal ;  for  there  very  soon 
follows  such  a  degree  of  sweliing  as  might  prevent  us  from  accomplishing  the 
extraction  without  great  difliculty,  if  at  all :  and  were  the  weapon  left,  what 
could  we  expect  but  destructive  inflammation  of  the  eyeball,  of  the  orbit,  of 
the  surrounding  parts,  and,  among  these,  of  the  brain  ? 

Crt.se  25. — A  laborer  thrust  a  long  lath,  with  great  violence,  into  the  inner  canthus  of 
the  left  eye  of  another  laborer.  It  broke  off  quite  short,  so  that  a  piece  nearly  two  inches 
and  a  half  long,  balf  an  inch  wide,  and  above  a  quarter  of  an  inch  thick,  remained  in  his 
head,  and  was  so  deeply  buried  that  it  could  scarcely  be  seen  or  laid  hold  of.  He  rode 
with  the  piece  of  lath  in  him  above  a  mile,  to  Barnet,  where  Mr.  Morse  extracted  it  with 
difficulty;  it  sticking  so  hard,  that  others  had  been  baffled  in  attempting  to  remove  it. 
The  man  continued  dangerously  ill  for  a  long  time:  at  last  he  recovered  entirely,  with  the 
sight  of  the  eye  and  the  use  of  its  muscles ;  but  even  after  he  seemed  well,  upon  leaning 
forwards,  he  felt  great  pain  in  bis  hcad.^ 

In  the  days  when  javelins  and  arrows  formed  principal  weapons  of  war, 
many  difficult  cases  of  this  sort  must  have  occurred.  Albucasis  shortly  relates 
two  which  had  come  under  his  care.  In  the  one,  an  arrow  entered  at  the 
nasal  side  of  the  orbit,  and  was  extracted  under  the  ear.  The  patient  re- 
covered, without  any  permanent  injury  of  the  eye.  In  the  other  case,  a  Jew 
was  struck  with  a  large  unbarbed  arrow  from  a  Turkish  bow,  under  the  lower 
eyelid.  It  had  sunk  so  deep  that  Albucasis  reached  with  difficulty  the  end 
of  the  iron,  where  it  stuck  upon  the  shaft.  This  patient  also  recovered  with- 
out any  serious  effect.*-' 

Very  great  force  may  sometimes  be  necessary  for  extracting  a  foreign  body, 
which  has  been  driven  through  the  walls  of  the  orbit.  Fare's  successful  case'*" 
is  well  known,  in  which  he  was  obliged,  with  a  pair  of  farrier's  pincers,  to 
tear  away  from  the  Duke  of  Guise  the  broken  end  of  a  lance,  which,  entering 
above  the  right  eye,  and  towards  the  root  of  the  nose,  penetrated  as  far  as 
the  space  between  the  ear  and  the  nape  of  the  neck,  tearing  and  destroying 
vessels  and  nerves  in  its  course,  as  well  as  fracturing  the  bones. 

Case  26. — Percy  had  under  his  care  a  fencing-master,  who  in  an  assault  received  so 
furious  a  thrust  from  a  foil  on  the  right  eye,  that  the  weapon  penetrated  nearly  half  a  foot 
into  the  head,  and  broke  short.  The  man  fell  down  in  a  state  of  insensibility,  and  very 
soon  the  supervening  swelling  was  so  great  as  to  conceal  the  foreign  body.  In  order  to 
lay  hold  of  it,  Percy  opened  and  evacuated  the  contents  of  the  ej'eball.  His  forceps  not 
being  strong  enough,  he  sent  to  a  clock-maker  in  the  neighborhood,  and  borrowed  from 
him  a  pair  of  screw-pincers,  with  which  he  laid  hold  of  the  broken  end  of  the  foil,  and 
thus  succeeded  in  extracting  it.  The  fencing-master  died  some  weeks  after,  more  from 
the  consequence  of  intemperance  than  of  the  injury.*' 

Commenting  on  this  case,  Percy  recommends,  that  we  should  rather  re- 


DANGERS  AFTER   FOREIGN  BODY  IS  REMOVED.  59 

move  the  eyeball,  than  leave  large  foreign  bodies  in  such  a  situation  ;  and 
refers,  in  support  of  this  practice,  to  a  case  related  by  Bidloo,  in  which  a 
splinter  of  wood  was  left  to  come  away  from  the  orbit  by  suppuration.  The 
eye  burst  at  last,  after  the  most  dreadful  pain  and  after  the  other  eye  had 
been  threatened  with  destructive  sympathetic  inflammation. 

Case  27. —  Sabatier  notices^^  an  instance  of  wound  with  a  knife,  through  the  upper  eye- 
lid, -with  injury  of  the  neighboring  edge  of  the  frontal  bone.  It  was  not,  he  says,  till 
after  four  hours'  work,  that  the  surgeon  succeeded,  by  means  of  a  hand- vice,  in  tearing 
away  the  portion  of  the  knife-blade  which  remained  in  the  orbit,  on  account  of  its  pro- 
jecting so  little  from  the  wound.  The  patient  complained  of  severe  pain,  as  if  one  had  been 
tearing  out  his  eye.  No  ill  consequence  followed  ;  the  cure  was  speedy,  and  without  any 
affection  of  sight. 

t.  Dangers  after  foreign  body  is  removed. — We  must  not  imagine  that,  on 
withdrawing  the  foreign  body  from  the  orbit,  the  danger  is  over.  Destructive 
inflammation  of  the  eye,  or  even  fatal  inflammation  of  the  brain,  may  follow, 
as  in  the  case  I  have  just  quoted  from  Percy  :  nay,  the  patient  has  been  known 
suddenly  to  expire,  immediately  after  the  foreign  body  was  removed. 

Case  28. — A  laborer,  aged  51  years,  while  cutting  wood  in  a  forest,  stumViled  over  the 
root  of  a  tree,  and  with  the  whole  weight  of  his  body  drove  the  end  of  a  file,  which  he  held 
in  his  hand,  against  his  left  eye.  The  file  broke  across,  and  a  portion  of  it  remained  in 
the  orbit.  The  patient  was  carried,  in  a  state  of  insensibility,  to  a  small  town  some  nules 
off,  where  three  surgeons  tried  by  turns,  but  in  vain,  to  extract  the  foreign  body,  which, 
Avith  the  probe  and  the  forceps,  they  felt  distinctly,  through  the  wound,  beneath  the  mid- 
dle of  the  eyebrow.  They  enlarged  the  wound  with  the  knife,  and  during  three  days  made 
reiterated  attempts  at  extraction ;  but  the  foreign  body  continued  immovable. 

On  the  4th  day,  the  patient  was  brought  to  the  surgical  clinic  at  Prague.  The  eyelid 
was  greatly  swollen,  and  in  the  middle  of  it  there  was  a  triangular  wound,  with  inverted 
edges.  The  eyeball  was  motionless,  and  was  so  pushed  downwards  and  outwards  that  it 
almost  lay  on  the  cheek,  carrying  the  lower  eyelid  before  it.  The  cornea  presented  a 
Diore  than  ordinary  degree  of  lustre.     The  patient  was  nearly  comatose. 

Fritz  endeavored,  by  means  of  strong  pincers  and  polypus-forceps,  to  withdraw  the 
foreign  hoAj,  but  these  instruments  bent  under  the  pressure.  At  last,  with  a  pair  of 
small  but  very  strong  lithotomj'-forceps,  which  he  grasped  with  both  his  hands,  he  suc- 
ceeded in  extracting  the  piece  of  the  file.  It  was  triangular,  measured  an  inch  and  a  half 
in  length,  and  was  denticulated  to  its  point,  which  was  blunt. 

The  patient  answered  questions  very  slowly,  or  not  all ;  his  face  was  pale  and  sunk,  his 
eyes  were  shut,  and  he  lay  motionless,  except  that  he  often  raised  his  left  hand  to  the  left 
side  of  his  head.  Respiration  slow  ;  pulse  oppressed  and  hard.  The  wound  gaped  widely ; 
the  eyelid,  almost  completely  divided  into  lateral  halves,  was  of  a  dark  red  color,  and  so 
much  swollen  as  to  allow  only  a  small  portion  of  the  displaced  eyeball  to  be  seen. 

Notwithstanding  the  repeated  use  of  venesection  and  of  leeches,  and  constant  cold 
applications  to  the  eyes,  the  cornea  filled  with  pus,  and  giving  way  about  the  12th  day, 
allowed  the  iris  to  protrude.  The  cornea  was  ultimately  left  in  an  opaque  and  atrophied 
state.  The  wound  suppurated  abundantly,  and  for  some  time  a  probe  could  be  passed 
along  it,  in  a  direction  backwards  and  inwards,  beneath  and  through  the  orbitary  por- 
tion of  the  frontal  bone,  to  the  depth  of  five  inches,  without  causing  pain.  At  length  the 
wound  closed,  the  upper  eyelid  remaining  palsied.  The  patient's  general  health  was  per- 
fectly restored.*^ 

Cas^e  29. — A  girl,  10  years  of  age,  playing  along  with  other  children,  near  a  cotton- 
spinning  machine,  fell  upon  one  of  the  pointed  iron  spikes,  5  or  6  inches  long,  on  which 
the  bobbin  is  placed.  This  instrument  penetrated  to  the  depth  of  about  2  inches  into  the 
orbit,  between  the  inner  wall  and  globe  of  the  eye,  and  then  broke  across,  so  that  2  or  3 
lines'  length  of  it  projected  above  the  level  of  the  skin.  Attempts  were  made  to  remove 
it ;  but  so  much  difficulty  was  experienced,  that  these  attempts  were  not  persisted  in.  Ten 
days  afterwards  the  piece  of  iron  was  found  protruded  to  the  length  of  9  or  10  lines ;  a 
month  afterwards,  it  was  still  more  protruded  ;  in  fact,  it  now  held  apparently  so  slightly, 
that  it  was  laid  hold  of  with  the  fingers  and  extracted.  Scarcely  had  this  been  done, 
when  the  child  was  seized  with  convulsions,  and  died  in  a  quarter  of  an  hour.  The  sight 
had  not  been  affected  during  the  residence  of  the  foreign  body  in  the  orbit,  nor  had  its 
presence  there  excited  any  very  marked  symptoms.  The  child  had  always  been  able  to 
go  about. 3* 

8.  Eyehall  dislocated. — It  is  important  to  observe  that  mention  is  made  by 
different  surgical  authors,  of  the  eyeball  being  dislocated,  or  pushed  out  of  its 


60  UNDETECTED   WOUNDS   OF   ORBIT. 

socket  by  a  foreign  body  thrust  into  the  cavity,  or  traversing  the  sides  of  the 
orbit.  Now,  in  such  cases,  it  is  necessary  not  only  to  remove  the  foreign 
body,  but  to  reduce  the  eye.  This  has  sometimes  been  done  with  complete 
restoration  of  vision. 

By  being  dislocated,  or  pushed  out  of  its  socket,  is  to  be  understood,  that 
the  eyeball  is  extruded  beyond  the  fibrous  layer  of  the  eyelids;  that  layer 
which  is  a  continuation  of  the  periosteum,  and  lies  beneath  the  orbicularis 
palpebrarum.  Of  course,  the  optic  nerve  must  be  put  on  the  stretch  by  such 
an  accident,  and  the  eyelids  can  no  longer  be  made  to  close  upon  the  pro- 
truded eyeball. 

Case  30. — Mr.  B.  Bell  relates  a  case,  in  -which  the  eye  was  almost  completely  turned 
out  of  its  socket,  by  a  sharp  pointed  piece  of  iron  pushed  in  beneath  it.  The  iron  passed 
through  a  portion  of  the  orbit,  and  remained  firmly  fixed  for  tlie  space  of  a  quarter  of  an 
hour,  during  which  period  the  patient  suffered  exquisite  pain.  He  saw  none  with  the 
dislocated  eye  ;  and  the  protrusion  being  so  great  as  to  lead  to  the  suspicion  that  the  optic 
nerve  was  ruptured,  Mr.  Bell  doubted  whether  it  would  answer  any  purpose  to  replace  it. 
He  found,  however,  on  removing  the  wedge  of  iron,  which,  being  driven  to  the  head,  was 
done  with  difficulty,  that  the  power  of  vision  instantly  returned,  even  before  the  eye  was 
replaced.  The  eye  was  now  easily  reduced  to  its  original  situation;  inflammation  was 
guarded  against,  and  the  patient  enjoyed  perfect  vision. ss 

9.  Undetected  wounds  of  orbit — Foreign  body  not  removed. — The  foreign 
body,  by  which  a  wound  of  the  orbit  has  been  inflicted,  has  in  some  cases 
been  left  unremoved,  from  the  fact  of  its  presence  not  having  been  suspected, 
or  from  the  surgeon  not  having  instituted  a  sufficiently  strict  examination  of 
the  wound  with  the  probe;  while,  in  other  cases,  it  has  been  left  in  the  orbit, 
or  within  the  cavity  of  the  cranium,  from  an  impossibility  of  removing  it 
with  safety. 

The  recorded  instances  of  foreign  bodies,  driven  through  the  orbit  by  mere 
manual  force,  and  left  within  the  cavity  of  the  cranium,  are  but  few.  Nu- 
merous cases  of  gunshot  wounds,  however,  in  which  the  ball  or  other  foreign 
body  was  left  within  that  cavity  are  recorded ;  and  it  is  evident  that  the 
effects,  so  far  as  the  mere  presence  of  the  foreign  body  is  concerned,  must  be 
much  the  same,  whether  it  has  passed  through  the  orbit  into  the  brain  by 
manual  or  by  explosive  force.  Death,  under  such  circumstances,  is  almost 
certain  to  be  the  result,  either  immediately  or  in  the  course  of  a  few  days ; 
although  some  remarkable  cases  have  happened,  of  extraneous  bodies  lying 
for  years  in  the  very  brain  itself,  without  causing  any  apparent  inconve- 
nience.^^ 

Ca^e  31. — A  lieutenant  in  a  Highland  regiment,  running  in  a  dark  night  to  escape  a 
shower  of  rain,  came  in  contact  with  an  irritable  old  man,  who  made  a  thrust  at  him  with 
an  umbrella,  the  point  of  which  struck  him  immediately  beneath  the  left  eyebrow.  The 
wound  was  attended  with  so  little  pain  or  shock  to  the  system,  that  the  gentleman  walked 
a  distance  of  at  least  half  a  mile,  to  Sir  Philip  Crampton's  house;  and  having  mentioned 
the  occurrence  as  one  to  which,  however,  he  attached  no  importance,  begged  Sir  P.  to 
look  at  the  wound  on  the  eyelid,  which  still  continued  to  bleed  slightly. 

Sir  P.  found  a  wound  of  about  three-fourths  of  an  inch  in  length  in  the  upper  eyelid, 
exactly  in  the  seat  of  the  fold  formed  in  this  part  by  the  action  of  opening  the  eye,  and 
looking  up.  When  the  eyeball  was  so  turned,  there  was  no  appearance  of  wound ;  but 
when  the  eyelid  was  drawn  downwards,  the  wound  gaped  and  showed  the  conjunctiva, 
which  still  completely  covered  the  upper  portion  of  the  ball  of  the  eye.  Vision  was  quite 
unimpaired.  The  wound  having  been  united  by  two  points  of  suture,  the  patient  took  his 
leave  and  walked  home.  Sir  P.  called  on  him  next  morning,  and  found  him  at  breakfast, 
making  no  complaint,  but  of  some  stiffness  in  the  eyelid.  Next  morning  at  seven  o'clock, 
Sir  P.  was  called  to  him  in  a  hurry,  and  found  him  in  so  strong  convulsions,  that  it  was 
with  difficulty  two  persons  were  able  to  keep  him  from  working  himself  out  of  bed.  The 
convulsions  continued,  with  short  intervals  of  coma,  till  eight  or  nine  o'clock  in  the  even- 
ing, when  he  expired. 

At  the  post-mortem  examination,  it  was  found,  that  the  brass  ferrule  of  the  umbrella, 
nearly  two  inches  long,  had  penetrated  the  orbital  plate  of  the  frontal  bone,  and  was 
lodged  in  the  substance  of  the  left  hemisphere  of  the  brain;  it  was  imbedded  in  a  thin 


INCISED   WOUNDS   OF  THE   ORBIT.  61 

coagulum  of  blood,  -which  extended  into  the  left  lateral  ventricle;  both  ventricles  contained 
a  small  quantity  of  bloody  serosity.^^ 

As  to  foreign  bodies  which  have  not  touched  the  brain,  but  merely  passed 
through  one  or  other  of  the  sides  of  the  orbit,  and  are  left  remaining,  they  give 
rise  to  more  or  less  irritation,  destroy  the  bones  more  or  less  extensively,  take 
different  routes  for  their  escape,  but,  in  most  instances,  appear  to  pass  either 
through  the  maxillary  sinus,  or  by  the  spheno-maxillary  fissure  into  the  fauces, 
and  are  discharged  in  very  various  spaces  of  time. 

Case  32. — Marchetti  had  under  his  care  a  beggar,  -who,  asking  charity  rather  importu- 
nately one  summer's  day  from  a  Paduan  nobleman,  this  testy  personage  struck  the  beggar 
with  the  handle  of  his  fan,  in  the  inner  angle  of  the  eye,  and  with  so  much  force,  that  a 
portion  of  the  fan,  three  inches  long,  broke  through  the  orbit,  and  sunk  out  of  sight  in  the 
direction  of  the  palate.  When  the  man  came  to  the  hospital,  Marchetti  removed  some 
small  bits,  which  he  found  sticking  in  the  angle  of  the  eye,  combated  the  inflamma- 
tion, allowed  the  wound  to  close,  and  dismissed  the  patient  as  cured.  In  three  months 
he  returned  with  a  large  swelling  in  the  palate,  which,  when  Marchetti  cut  into,  his  knife 
struck  upon  the  handle  of  the  fan,  which  he  immediately  extracted  with  a  pair  of  forceps. 
The  patient  speedily  recovered. ^^ 

Case  33. — .Mr.  White  relates  the  case  of  a  person,  to  whom  it  happened  that,  as  he  sat 
in  company,  the  small  end  of  a  tobacco-pipe  was  thrust  through  the  middle  of  the  lower 
ej^elid.  It  passed  between  the  globe  of  the  eye  and  the  inferior  and  external  circumfer- 
ence of  the  orbit,  and  was  forced  through  that  portion  of  the  os  maxillare  which  consti- 
tutes the  lower  and  internal  part  of  the  orbit.  The  pipe  was  broken  in  the  wound,  and 
the  part  broken  off,  which,  from  the  examination  of  the  remainder,  appeared  to  be  above 
three  inches,  was  quite  out  of  sight  or  feeling,  nor  could  the  patient  give  any  account  of 
what  had  become  of  it.  The  eje  was  dislocated  upwards,  pressing  the  upper  eyelid  against 
the  superior  part  of  the  orbit ;  the  pupil  pointed  perpendicularly  upwards,  the  depressor 
ocull  was  upon  the  full  stretch,  and  the  patient  could  see  none  with  that  eye.  Mr.  White 
applied  one  thumb  above  and  the  other  below  the  eye,  and  after  a  few  attempts  at  reduc- 
tion, it  suddenly  slipped  into  its  socket.  The  man  instantly  recovered  perfect  sight,  and 
suffered  no  other  inconvenience  than  that  of  a  constant  smell  of  tobacco  smoke  in  his 
nose  for  a  longtime  after;  for,  as  he  informed  Mr.  AVhite,  the  pipe  had  just  been  used 
before  the  accident.  About  two  years  afterwards,  he  called  upon  Mr.  White,  to  acquaint 
him  that  he  had,  that  morning,  in  a  fit  of  coughing,  thrown  out  of  his  throat  a  piece  of 
tobacco-pipe,  measuring  two  inches,  which  was  discharged  with  such  violence,  as  to  be 
thrown  seven  yards  from  the  place  where  he  stood.  In  about  six  weeks  he  threw  out  an- 
other piece,  measuring  an  inch,  in  the  same  manner,  and  never  afterwards  felt  the  least 
inconvenience. ''^ 

In  illustration  of  the  length  of  time  which  a  foreign  body  may  take  in 
this  way  to  escape,  I  may  notice  the  following  case,  related  in  a  letter  to 
Horstius  : — 

Case  34. — A  boy  of  14  years  of  age  was  struck  by  an  arrow,  while  amusing  himself  in 
his  play-ground.  It  stuck  fast  in  the  orbit ;  but  the  boy  pulled  it  out,  and  threw  it  on 
the  ground.  A  surgeon  an-ived,  to  whom  the  playfellows  of  the  boy  who  was  wounded 
showed  the  arrow,  deprived  of  its  iron  point.  With  a  probe  the  surgeon  attempted  to 
examine  the  wound;  but,  on  the  boy  fainting,  he  desisted,  so  that  the  iron  point  was  left 
in  the  orbit.  The  external  wound  healed,  and  the  boy  recovered ;  the  eye  remained  clear 
and  movable,  but  deprived  of  sight.  This  happened  in  the  beginning  of  August  1594, 
and  nothiug  more  was  heard  of  the  iron  point,  till  October  1624;  when,  after  an  attack 
of  fever  and  catarrh  with  a  great  deal  of  sneezing,  it  descended  into  the  left  nostril, 
whence,  taking  the  way  of  the  fauces,  it  came  into  the  mouth  and  was  discharged.  Dar- 
ing the  whole  thirty  years  and  three  months  that  it  had  remained  in  the  head,  it  had  not 
been  productive  of  any  pain.'*" 

§  8.  Incised  Wounds  of  the  Orbit. 

Sabre-wounds  of  the  head  have  sometimes  been  attended  by  a  cleaving  of 
the  orbit ;  and,  in  some  rare  instances,  the  orbit  has  been  laid  open,  by  an 
entire  separation  of  part  of  its  parietes,  so  as  to  expose  its  contents  to  view. 
The  following  cases  illustrate  this  class  of  injuries  of  the  orbit : — 

Case  35. — Marchetti  shortly  states  the  case  of  a  German  soldier,  who  wns  wounded  in 
the  forehead,  with  a  broad  and  heavy  sword.     The  frontal  bone  and  the  brain  were 


62  INCISED   WOUNDS   OF   THE   ORBIT. 

divided,  down  to  the  eyes,  and  the  patient  was  immediately  deprived  of  sight.     In  two 
months,  he  recovered  from  the  wound,  but  continued  blind,  with  the  pupils  clear.'" 

Case  36. — Edward  Power  received  a  desperate  wound  with  a  backsword,  extending 
from  the  top  of  the  frontal  bone  to  the  orbit  of  the  left  side,  forming  an  extended  and 
frightful  chasm,  in  which  were  included  the  bone,  membranes,  and  brain.  The  wound 
bled  considerably,  and  was  for  nearly  three  hours  exposed  to  the  open  air,  the  patient 
not  having  so  much  as  a  rag  to  cover  it.  Fever  and  inflammation  of  the  brain  might 
have  been  apprehended  ;  yet  by  a  couple  of  bleedings,  and  some  other  antiphlogistics, 
the  man  was  completelj'  cured  in  five  weeks,  without  exfoliation,  or  the  slightest  ope- 
ration.''^ 

The  following  case  shows  the  propriety  of  attempting  union  by  the  first 
intention,  even  when  part  of  the  osseous  parietes  of  the  orbit  is  completely 
separated  by  an  incised  wound  : — 

Case  37. — A  young  man  received  a  wound  with  a  cutting  instrument,  extending  ob- 
liquely from  the  upper  part  of  the  left  temporal  fossa,  across  the  root  of  the  nose,  to  the 
right  fossa  canina.  This  wound  divided  the  skin,  the  temporal  branches  of  the  portio 
dura,  the  anterior  auricular  muscle,  part  of  the  temporal  muscle,  orbicularis  palpebra- 
rum, and  corrugator  supercilii,  the  frontal  branch  of  the  ophthalmic  nerve,  and  the 
superciliary  artery.  These  parts  hanging  over  on  the  cheek,  formed  a  flap,  in  which 
were  also  present  a  portion  of  the  orbitary  arch  of  the  frontal  bone  and  its  external  an- 
gular process,  so  that  a  portion  of  the  cavity  of  the  cranium  was  laid  open,  as  well  as  the 
cavity  of  the  orbit,  exposing  to  view  the  globe  of  the  eye,  and  the  motion  of  the  brain. 
The  nasal  nerve  and  artery,  the  pyramidal  muscles,  and,  to  a  small  extent,  the  bones  of 
the  nose,  were  divided  ;  from  the  nose  to  tlie  right  fossa  canina,  only  the  skin  was 
divided.  The  portion  of  brain  laid  bare  appeared  unhurt;  the  eye  also  seemed  perfectly 
sound,  none  of  its  parts  having  been  touched,  except  the  levator  palpcbrse  superioris, 
which,  having  been  cut  across  in  the  middle,  presented  its  anterior  half  in  a  state  of  re- 
laxation, and  dragged  downwards  and  forwards  by  the  flap  which  lay  upon  the  cheek. 

The  patient  had  neither  experienced  any  concussion,  nor  become  insensible ;  but,  when 
M.  Ribes  saw  him,  was  in  a  state  of  considerable  depression.  A  surgeon,  who  kad  been 
called  before  M.  Ribes  arrived,  had  already  dressed  the  wound.  Perhaps,  in  imitation 
of  Magatus,  who  directs  in  such  cases  that  a  plate  of  gold  or  lead,  drilled  through  with 
holes,  be  applied  over  the  dura  mater,  and  that  the  edges  of  the  wound  be  simply  brought 
together,  without  supporting  them  by  sutures,  this  surgeon  had  placed  between  the  lips 
of  the  wound  a  bit  of  linen  spread  with  cerate  on  both  sides,  in  order  to  give  vent  to  the 
suppuration,  which  no  doubt  would  have  followed;  he  had  then  brought  tJie  flap  into  its 
place,  and  supported  it  by  a  roller.  ]M.  Ribes  removed  the  piece  of  linen,  and  brought 
the  edges  of  the  wound  exactly  together,  retaining  them  by  strips  of  adhesive  plaster. 
In  six  weeks  the  patient  was  cured,  without  fever  or  suppuration. 

The  eye,  however,  which  had  been  exposed,  became  blind,  and  the  upper  eyelid  re- 
mained motionless.  Ten  years  afterwards,  the  eye  still  preserved  its  form  and  transpa- 
rency', but  liad  shrunk  in  size.  M.  Ribes  is  of  opiiiion,  that  the  blindness  in  this  cnse 
was  a  sympathetic  effect,  produced  upon  the  retina  by  the  division  of  the  branches  of  the 
fifth  pair.  lie  regards  tiie  retina,  not  as  a  mere  expansion  of  the  optic  nerve,  but  as  a 
nervous  membrane  into  which  enter  brandies  of  the  great  sympathetic,  and  of  the  ciliary 
or  iridal  nerves,  as  well  as  the  fibrils  of  the  optic  nerve;  whence  injuries  of  the  great 
sympathetic,  or  of  the  fifth  pair,  may,  he  thinks,  produce  blindness,  although  in  the  first 
instance  the  optic  nerve  has  not  been  affected.'''' 

Although  the  separated  piece  of  the  orbit  appears  to  have  united  in  this 
case,  it  sometimes  happens  that  only  the  soft  parts  unite,  while  the  bones 
continue  divided.  Of  this,  we  have  an  example  in  the  following  case,  related 
by  Dr.  llennen  : — 

Case  38. — An  officer  received,  at  the  battle  of  Waterloo,  a  sabre-wound  across  the 
eyes,  cutting  obliquely  inwards  and  downwards  to  such  a  depth  as  to  admit  of  a  view  of 
the  pharynx.  One  eye  was  destroyed;  and  the  hiatus  was  so  great,  that  it  was  neces- 
sary to  support  the  upper  jaw  by  morsels  of  cork  put  into  the  mouth  in  such  a  way  as  to 
act  as  fulcra,  but  admitting  the  passage  of  liquid  nourishment.  After  the  wound  was 
dressed  on  the  field,  the  patient  was  sent  to  Brussels,  where  he  fell  into  the  hands  of  a 
Belgian  barber,  who  stupidly  cut  out  the  ligatures,  removed  the  straps  by  which  the 
lower  portion  of  the  face  wns  kept  in  position,  and  stuffed  the  parts  with  charpie.  This 
was  not  removed  for  several  days,  after  which  the  parts  were  again  brought  into  apposi- 
tion by  straps  and  bandages,  but  with  great  pain  and  consequent  delirium.  The  patient 
recovered,  granulations  .sprouting  up  at  all  points,  and  the  soft  parts  uniting,  but  not  the 
bones.''* 


DIRECTIONS   or   PROJECTILES   THROUGH   THE   ORBIT,  63 

§  9.    Gunshot  Wounds  of  the  Orhit. 

Gunshot  wounds  of  the  orbit,  and  wounds  caused  by  other  explosions, 
present  much  greater  variety  in  their  direction  than  any  other  wounds  of 
this  part.  They  also  vary  much  in  the  depth,  extent,  and  effects  of  the  in- 
jury which  they  produce. 

1.  Exterior  parts  of  orhit  uninjured.' — The  superciliary  ridge,  and  the  other 
exterior  parts  of  the  orbit,  are  often  the  seat  of  gunshot  injuries. 

Sometimes  a  ball  traverses  the  outer  wall  of  the  orbit.  In  other  cases,  the 
person  bending  forward  at  the  moment  of  receiving  the  wound,  the  ball  passes 
through  the  superciliary  ridge,  whence  it  generally  descends  through  the  floor 
of  the  orbit  into  the  maxillary  sinus,  or  into  the  nostril,  destroying  the  eye- 
ball in  its  course. 

The  frontal  sinus,  when  much  developed,  separates  the  two  tables  of  the 
orbitary  plate  of  the  frontal  bone,  so  as  to  form  a  cavity  in  which  musket-balls 
have  frequently  been  known  to  lodge.  This  is  generally  attended  by  depres- 
sion of  the  inner  table,  so  as  to  render  necessary  the  operation  of  trepan.** 
The  surgeons  of  former  days  refrained  from  trepanning  these  sinuses,  partly 
from  fear  of  an  incurable  fistula  following  the  operation,  partly  from  the  diffi- 
culty of  sawing  through  two  plates  of  bone  placed  obliquely  in  regard  to  each 
other,  without  wounding  the  dura  mater  ;  but  the  fear  of  a  fistula  is  now  laid 
aside,  and  the  second  difficulty  is  in  some  degree  obviated,  by  employing  two 
trephines,  a  large  one  for  the  external,  and  a  smaller  one  for  the  internal 
table.  In  this  way,  a  depression  may  be  raised,  or  a  ball,  fixed  perhaps  in 
the  internal  table,  or  in  the  roof  of  the  orbit,  may  be  removed. 

Sometimes  a  ball  has  been  left  in  the  frontal  sinus,  whence  it  has  slowly 
made  its  way. 

Case  39. — The  French  General  T.  received  a  ball  in  the  left  orbit,  at  Waterloo.  After 
lacerating  the  eyeball,  it  traversed  the  superior  internal  wall  of  the  orbit,  and  lodged  in 
the  frontal  sinus.  It  remained  there  for  12  years,  without  producing  any  remarkable 
effects,  after  which  time  the  patient  awoke  one  night  with  the  sensation  of  something 
falling  into  his  gullet.     It  was  the  ball,  which  he  immediately  coughed  out.''^ 

2.  Bones  of  orhit  suscejttihle  of  reunion. — The  bones  of  the  orbit,  shattered 
by  a  ball,  are  still,  in  some  cases,  susceptible  of  reunion,  and  ought  not, 
therefore,  to  be  hastily  removed,  although  they  are  felt  to  be  loose  after  an 
injury  of  this  kind.  The  copiousness  with  which  all  the  parts  of  the  face  are 
supplied  with  blood,  communicates  to  its  bones  a  power  of  recovery,  greater 
than  that  usually  found  in  the  osseous  system. 

Case  40. — Poneyes  had  under  his  care  a  soldier,  in  whom  a  musket-ball  had  shattered 
the  anterior  part  of  the  frontal  sinuses,  the  upper  part  of  the  bones  of  the  nose,  and  the 
right  orbit  towards  the  inner  angle.  He  fell  instantly  on  receiving  the  wound,  vomited 
soon  after,  became  insensible,  and  bled  at  the  nose.  Poneyes  removed  the  portion  of  bone 
forming  the  frontal  sinuses,  leaving  the  bones  of  the  nose  and  the  injured  portion  of  the 
orbit  loose.  The  posterior  part  of  the  frontal  sinuses  was  not  fractured.  Delirium  came 
on  with  drowsiness ;  but  after  the  patient  was  repeatedly  bled,  those  symptoms  ceased. 
The  loose  pieces  of  bone  reunited,  and  cure  was  completed  in  two  months  and  a  half.'''' 

3.  Different  directions  of  projectiles  through  the  orhit. — Balls  passing  di- 
rectly backwards  through  the  orbit,  are  generally  fatal,  from  entering  the 
brain  ;  whereas,  those  which  enter  the  orbit  obliquely,  though  generally  de- 
structive of  vision,  either  by  striking  the  eyeball,  or  dividing  the  optic  nerve, 
very  frequently  leaving  the  brain  untouched.  A  ball  passing  transversely, 
or  with  only  a  slight  degree  of  obliquity,  through  one  or  both  orbits,  proves 
fatal,  if  the  cribriform  plate  of  the  ethmoid  is  fractured,  the  shock  communi- 
cated by  the  crista  galli  to  the  brain  and  its  membranes  being  followed  by 
cerebritis  and  meningitis. 

Dr.  John  Thompson  mentions  a  case,  in  which  the  ball  entered  nearly  in 


64  BALLS  TRAVERSING   BOTH   ORBITS. 

the  middle,  between  the  frontal  sinuses,  passed  across  the  left  sinus,  and  seemed 
to  lodge  in  the  cavity  of  the  orbit,  producing  blindness,  with  great  swelling 
of  the  eye,  and  of  the  parts  surrounding  it.  In  another  case,  where  the  bullet 
entered  the  face  on  the  upper  and  left  side  of  the  nose,  and  passed  out  anterior 
to  the  right  ear,  the  patient  was  affected  with  amaurosis  of  the  right  eye. 
The  left  eye  was  similarly  affected,  in  a  case  where  the  ball  entered  the  right 
side  of  the  nose,  and  came  out  in  front  of  the  left  ear.  In  one  case,  the  ball 
entered  at  the  inner  angle  of  the  left  eye,  and  passed  out  in  front  of  the  left 
ear.  In  another,  the  ball  entered  above  the  inner  angle  of  the  right  eye,  and 
passed  out  of  the  right  ear.  In  both  these  cases,  the  eye  of  the  side  on  which 
the  ball  passed  was  destroyed.  In  one  case,  in  which  the  ball  entered  the 
right  eye,  and  passed  out  midway  between  the  left  eye  and  ear,  the  left  eye 
was  affected  with  amaurosis.** 

Case  41. — WepfeH^  has  recorded  the  case  of  a  person,  accidentally  shot  by  his  fellow- 
traveller,  while  resting  on  the  ground.  The  ball  entered  a  little  below  tiie  lobe  of  the 
right  ear,  and  passing  behind  the  angle  of  the  jaw,  above  the  roof  of  the  palate,  and  behind 
the  root  of  the  nose,  traversed  the  left  orbit,  and  made  its  exit  through  the  upper  eyelid. 
The  eyeball  was  forced  from  its  place,  so  that  it  hung  out  of  its  socket,  with  the  cornea 
in  a  state  of  laceration  ;  and  at  the  same  time  a  portion  of  the  frontal  bone  was  separated 
from  the  rest  of  the  orbit.  Blood  was  discharged  from  both  apertures  of  the  wound,  and 
from  the  nostrils  and  mouth  ;  and  for  some  days  it  flowed  whenever  the  patient  made  any 
exertiou.  In  the  course  of  the  cure,  no  pus  came  from  the  nose  or  moutli.  The  patient 
had  no  convulsions.  He  was  always  able  to  swallow,  although  at  first  lie  found  it  difficult 
to  masticate,  or  to  oi)en  his  mouth.  The  right  eye  and  the  neighboring  parts  were 
ecchymosed  for  a  number  of  days. 

From  the  aperture  caused  by  the  exit  of  the  ball,  laudable  pus  was  copiously  discharged; 
an  abscess  forming  above  the  inner  angle  of  the  eye,  an  incision  was  made  into  it,  above 
an  inch  in  length,  and  kept  open  until  some  loose  fragments  of  the  frontal  bone  came 
away;  after  this  it  closed.  At  first  the  eyeball  was  not  only  extruded  from  the  orbit;  but 
the  muscles,  lachrymal  gland,  and  fatty  cellular  substance  were  exposed  to  view.  Pus  was 
discharged,  but  not  very  copiously,  from  the  orbit;  the  eye  retreated  into  its  place  ;  and 
a  thick  fold  of  conjunctiva  being  removed  with  the  scissors,  the  parts  healed.  Purulent 
matter  was  copiously  discharged  from  the  aperture  near  the  angle  of  the  jaw,  which  was 
kept  open  for  18  weeks,  till  some  fragments  of  bone  came  away;  after  which  the  patient 
perfectly  recovered,  but  with  tlie  loss  of  his  eye. 

Case  42. — .\t  the  battle  of  Pultusk,  a  cannon-ball  striking  and  giving  impetus  to  a 
bayonet,  the  latter  penetrated  the  right  temple  of  a  soldier,  at  the  distance  of  two  fingers' 
breadth  behind,  and  a  little  above  the  orbit;  and  taking  a  direction  forwards  and  down- 
wards, traversed  the  left  maxillary  sinus,  whence  it  protruded  to  the  length  of  5  inches. 
The  surgeon,  on  the  field  of  battle,  tried  in  vain  to  extract  the  bayonet;  but  a  comrade, 
making  him  sit  down  on  the  snow,  and  putting  his  foot  on  the  wounded  man's  head,  drew 
it  out  with  both  his  hands.  The  patient  recovered  in  three  months,  with  the  loss  of  the 
right  ej'C.^ 

4.  Balls  traversing  both  orbits. — Many  instances  are  recorded  of  balls  passing 
through  the  orbits  from  temple  to  temple. 

Case  43. — Heister  relates^'  a  case  of  this  sort.  The  person  recovered;  only  he  became 
blind  the  very  moment  he  received  the  shot,  and  remained  so  ever  after.  The  entrance 
and  exit  of  the  ball  were  exactly  in  the  angle  which  the  zygoma  makes  with  the  process 
of  the  malar  bone  going  up  to  join  the  frontal,  and  of  course  the  ball  must  have  passed 
through  the  posterior  part  of  each  orbit,  probably  dividing  the  optic  nerve  and  the  muscles 
of  both  eyes,  without  wounding  either  the  eyeballs  or  the  brain.  The  eyes  appeared  quite 
clear,  and  without  inflammation,  but  fixed,  and  totally  deprived  of  sight. 

In  such  wounds,  many  different  parts  are  exposed  to  injury;  and  by  the 
subsequent  effects  we  may  sometimes  determine  what  structures  have  actually 
suffered.  The  outer  and  inner  walls  of  the  orbit  will  be  reduced  to  splinters, 
and,  perhaps,  the  cribriform  plate  of  the  ethmoid ;  the  temporal  muscle  and 
its  aponeurosis,  numerous  nervous  filaments  from  the  portio  dura,  and  from 
the  three  divisions  of  the  fifth  nerve,  and  numerous  branches  of  the  external 
and  internal  maxillary  artery,  will  be  divided;  while  the  nerves  within  the 


BALLS   TRAVERSING   BOTH   ORBITS,  65 

orbit,  as  well  as  the  muscles  of  the  eye  and  the  branches  of  the  ophthalmic 
artery,  will  suffer  more  or  less  severely. 

A  gunshot  wound  which  traverses  both  orbits,  must  be  regarded  as  less 
dangerous  than  one  in  which  the  ball  does  not  pass  so  directly  across  from 
one  side  of  the  head  to  the  other;  but  either  from  being  directed  backwards 
in  its  course,  enters  the  brain,  or  from  its  force  being  partially  spent,  lodges 
among  the  bones.  Speaking  of  the  wounded  before  Mons,  in  1709,  Heister 
states  that,  for  the  most  part,  those  who  had  received  a  wound  only  in  one 
temple,  died  either  immediately,  or  soon  after. 

Dr.  Thomson  tells  us  that  he  saw  from  eight  to  ten  patients,  after  the  battle 
of  Waterloo,  in  whom  musket-balls  had  passed  behind  the  eyes  from  temple 
to  temple.  In  all  of  them,  there  was  great  swelling,  pain,  and  tension  of  the 
head  and  face.  He  mentions,  that  a  careless  examination  would  have  led 
one  to  suppose  that,  in  these  cases,  the  balls  had  entered  the  cavity  of  the 
cranium;  and  remarks,  that  cases  of  this  kind  are  recorded,  in  which  the 
blindness  which  followed  is  supposed  to  have  been  produced  by  the  balls  in- 
juring the  inferior  part  of  the  anterior  lobes  of  the  brain ;  but  that,  most 
probably,  in  such  cases  the  brain  is  untouched. 

In  one  case  observed  by  Dr.  Thomson,  where  the  ball  had  passed  behind 
the  eyes  from  temple  to  temple,  one  eye  was  destroyed  Ijy  inflammation,  and 
the  other  affected  by  amaurosis.  In  another  case,  where  the  ball  had  taken  pre- 
cisely the  same  direction,  both  eyes  were  affected  with  amaurosis,  without  any 
inflammation  being  produced.  He  remarks  that,  in  some  of  the  patients  in 
whom  amaurosis  had  followed,  there  was  reason  to  believe,  from  the  course 
which  the  balls  had  taken,  that  the  optic  nerves  were  divided;  but  that  in  a 
considerable  proportion  of  those  so  affected,  it  was  obvious  that  the  balls 
had  not  come  into  contact  with  those  nerves.  Various  instances  also  occurred, 
in  which  the  bullet,  penetrating  through  both  eyeballs,  had  passed  behind 
the  bridge  of  the  nose,  and  left  it  unbroken.  In  one  of  the  cases,  in  which 
the  ball  had  passed  below  and  behind  the  eyes,  the  patient  was  affected,  at 
the  end  of  some  weeks,  with  painful  spasms  in  the  face,  which,  in  their  severity 
and  mode  of  attack,  bore  a  resemblance  to  tic  douloureux. -^"^ 

Ca&e  44. — A  case  by  Valleriola  is  often  quoted, ^^  of  a  soldier  through  ■whose  head  a  ball 
passed  from  temple  to  temple,  entering  by  the  left,  and  coming  out  a  little  higher  on  the 
right  side.  Apoplectic  symptoms  followed,  from  vhich  he  recovered ;  but  he  remained 
blind  and  deaf. 

Case  45. — In  one  of  the  engagements  between  the  French  and  the  Algerines,  in  1830,  a 
French  corporal  received  a  ball  through  the  orbits.  It  entered  an  inch  behind  and  six 
lines  above  the  external  angular  process  on  the  right  side,  and  came  out  at  the  point 
diametrically  opposite.  The  patient  presented  symptoms  of  concussion  of  the  brain,  and 
Dr.  Baudens^''  "was  of  opinion  that  the  anterior  and  inferior  surface  of  the  cerebrum  was 
injured.  Although  gunshot  wounds  are  not  in  general  attended  by  much  hemorrhage,  the 
patient,  in  this  instance,  was  covered  with  blood,  which  flowed  from  the  temples,  and  still 
more  from  the  nostrils.  AVhen  he  arrived  at  the  ambulance,  he  was  in  a  state  of  sjncope, 
which  served  to  arrest  the  bleeding.  The  face  was  considerably  swollen,  and  especially  the 
naso-orbitary  region. 

The  splinters  were  removed;  tlie  wounds  were  washed,  dressed,  and  covered  with  large 
compresses  wrung  out  of  cold  water.  These  were  continued  for  six  days,  as  well  with  the 
view  of  preventing  inflammation  within  the  head,  as  of  retarding  the  flow  of  blood.  Dr. 
Baudens  did  not  wish  to  arrest  the  bleeding  altogether,  as  it  contributed,  he  thought,  to 
the  safety  of  the  patient.  During  the  first  fifteen  days,  there  was  occasional  delirium  ; 
btit  this  symptom  was  moderated  by  cold  applications  to  the  head,  along  with  the  abstrac- 
tion of  blood  b^'  cupping  between  the  shoulders.  A  multitude  of  small  maggots  formed 
in  the  orbits  and  nostrils.  Feai-ing  they  might  penetrate  to  the  brain.  Dr.  Baudens  de- 
stroyed them  by  a  weak  solution  of  corrosive  sublimate. 

Among  the  effects  of  this  injury,  the  following  are  particularized  by  Dr.  Baudens.  A 
feather  pushed  into  the  nostrils  produced  no  sensation ;  but  any  sharp  body  was  distinctly 
felt.  This  organ,  although  not  entirely  deprived  of  sensibility,  was  not  affected  by  any 
annoying  itchiness  from  the  presence  of  the  maggots.     The  corner  became  opaque,  and 

5 


66  BALLS  LEFT   WITHIN  THE   CRANIUM. 

■were  destroyed,  so  that  the  eyes  sunk.  The  sense  of  smell  was  lost,  and  the  sensibility 
of  the  palate  was  blunted.  The  intellect  was  weakened.  The  patient  preserved  the 
memory  of  what  had  happened  to  him  previously  to  the  injury ;  but,  after  this,  not  even 
the  incidents  of  the  evening  could  be  recalled  on  the  following  morning.  He  was  not 
aware  of  the  extent  of  his  misfortune,  and  still  cherished  the  hope  of  being  restored  to 
sight.     The  wounds  were  cicatrized  two  months  after  the  receipt  of  the  injury. 

5.  Balls  sometimes  extracted  from  the  orhit;  in  other  cases  left  unremoved. — 
A  ball  which  has  penetrated  through  one  or  other  of  the  sides  of  the  orbit 
may,  in  some  cases,  be  detected  and  extracted.  In  other  cases,  it  cannot  be 
extracted,  nor  its  course  ascertained;  so  that,  if  the  individual  survives,  it 
must  be  left  to  make  its  way  out  by  the  fauces,  or  by  some  other  route. 

Even  grains  of  small  shot,  traversing  the  walls  of  the  orbit,  or  fixing  in 
them,  should  be  traced,  and,  if  possible,  extracted.  Left  in  the  substance  of 
the  bones,  they  are  apt  to  give  rise  to  exostoses.  In  those  cases  in  which  a 
rausket-ball  is  left,  we  must  lay  our  account  with  long-continued  and  severe 
pain,  caries,  exfoliation  of  the  bones,  deep-seated  formations  of  matter, 
sloughing  of  the  mucous  membranes,  puify  swellings  on  the  surface  towards 
which  the  ball  is  approaching,  and  a  very  tedious  recovery.  Sinuses  form,  in 
such  cases,  before  the  ball  makes  its  exit,  and  continue  after  it  has  escaped; 
and  to  dry  them  up  is  generally  attended  with  danger.  We  must  wait  till 
the  parts  within  have  become  healthy,  and  then  the  sinuses  will  close  of 
themselves. 

Case  46. — Dr.  Hennen  mentions*  the  case  of  a  soldier,  who  was  brought  to  him  some 
weeks  after  being  wounded,  for  the  purpose  of  having  a  ball  extracted,  which  gave  him 
excessive  pain,  impeded  his  respiration  and  deglutition,  prevented  his  speaking  distinctly, 
and  kept  up  an  irritation  in  his  fauces,  attended  with  a  constant  flow  of  saliva,  and  a  very 
frequent  inclination  to  vomit.  On  examination,  it  was  found  to  be  lodged  in  the  posterior 
part  of  the  fauces,  forming  a  tumor  behind,  and  nearly  in  contact  with  the  velum  pendu- 
lum. It  had  passed  in  at  the  internal  canthus  of  the  eye,  fracturing  the  bone.  Although 
blindness  was  the  instant  effect,  the  globe  of  the  eye  was  not  destroyed ;  and  the  remaining 
cicatrice,  and  the  very  intlamed  state  of  the  organ,  were  the  only  proofs  that  an  extra- 
neous body  had  passed  near  it. 

Case  47. — One  of  the  most  remarkable  cases  of  a  ball  penetrating  through  the  orbit, 
and  making  its  way  out  of  the  head,  is  that  of  Dr.  Fielding,  who  was  shot  at  the  battle  of 
Newlierry,  in  the  time  of  the  Civil  Wars.  The  ball  entered  by  the  right  orbit  and  passed 
inwards.  After  30  years'  residence  in  the  parts,  and  a  variety  of  exfoliations  from  the 
wound,  nose,  and  mouth,  and  the  formation  of  several  swellings  about  the  jaw,  it  was  at 
last  cut  out  near  the  pomum  Adami.^ 

Case  48. — A  soldier  of  one  of  Napoleon's  armies  was  struck  just  above  the  left  orbit 
by  a  musket-ball ;  but,  as  a  fellow  soldier  fell  dead  at  the  same  time  by  his  side,  he  be- 
lieved the  ball  had  rebounded  from  his  own  head  and  killed  his  comrade.  For  more  than 
24  years  he  was  subject  to  violent  pains  in  the  left  eye,  and  in  the  head;  and  this  eye 
projected  much  from  the  orbit.  The  surgeons  under  whose  care  he  was  placed  from  time 
to  time,  believing  his  story  of  the  rebounding  of  the  ball,  aflForded  him  little  or  no  relief. 
In  1837,  he  came  to  the  hospital  at  Verona,  when  Dr.  De  Borsa,  on  examining  the  case, 
came  to  the  conclusion,  that  the  projection  of  the  eye,  which  commenced  soon  after  the 
accident,  could  be  caused  only  by  the  persistence  of  the  foreign  body  in  the  orbit,  as  any 
exfoliation  of  bone  which  the  blow  might  have  occasioned,  would,  in  the  course  of  so 
many  years,  have  been  discharged  or  absorbed. 

A  portion  of  bone  was,  therefore,  removed  from  the  orbit  by  the  trephine.  The  track 
of  the  ball  was  found  ossified,  excepting  at  a  small  aperture,  whence  issued  from  time  to 
time  a  little  fluid.  After  the  bone  was  removed,  the  ball  was  felt,  by  means  of  a  probe, 
at  the  back  of  the  orbit,  and  extracted  by  means  of  a  forceps.  The  eye  now  retreated 
into  the  orbit,  and,  after  some  weeks,  became  atrophic.  The  violent  pains  were  quite  re- 
lieved, and  the  patient  lived  for  five  years,  to  die  then  of  pleuro-pneumonia.  On  examina- 
tion, it  was  found  that  the  cranial  cavity  had  not  been  penetrated  by  the  trephine  ;  but 
opposite  to  where  the  bone  had  been  removed,  was  a  deposit  of  osseous  substance. ^^ 

6.  Balls  or  other  foreign  bodies,  passing  through  the  orbit,  left  tvithin  the 
cranium. — Although  it  generally  happens  that  gunshot  wounds  of  the  orbit, 
penetrating  into  the  brain,  prove  immediately  mortal,  yet,  in  some  rare  cases, 


BALLS  TRAVERSING  THE  BRAIN.  67 

the  ball  or  other  foreign  body  has  been  known  to  remain  within  the  cranium 
for  a  length  of  time,  without  producing  much  disturbance. 

Ca.se  49. — Petit  related  in  his  lectures  the  case  of  a  soldier,  who  received  a  musket- 
Bhot  in  the  inner  angle  of  the  eye.  It  seemed  a  very  simple  Tvound,  and  healed  under 
the  common  hospital  treatment.  The  man  thinking  himself  cured,  determined  to  leave 
the  hospital,  although  advised  by  the  surgeon  to  remain  some  time  longer.  Scarce  had 
he  reached  the  door  when  he  was  seized  with  rigors,  obliged  to  return,  and  died  in  two 
days.  On  dissection,  the  ball  was  found  lodged  under  the  sella  Turcica  and  optic  fora- 
mina.    An  abscess  was  present  in  the  brain. ^* 

Case  50. — Dr.  Hennen  mentions^*  the  case  of  a  French  soldier,  wounded  at  Waterloo. 
The  ball  entered  the  right  eye ;  the  left,  though  not  in  the  slightest  degree  injured  to  ap- 
pearance, became  completely  blind.  Dr.  H.  felt  under  the  zygoma,  and  all  along  the 
neighborhood  of  the  wound,  but  in  the  puflFy  state  of  the  parts  could  not  detect  the  course 
of  the  ball.  The  patient  himself  was  confident  it  had  gone  into  his  brain.  He  returned 
to  France  convalescent. 

In  contrast  to  the  cases  in  which  a  very  small  injury  of  the  brain,  through 
the  orbit,  has  been  followed  by  instant  death,  may  well  be  placed  those  in 
which  such  a  substance  as  the  breech  of  a  gun,  a  piece  of  iron  measuring  up- 
wards of  three  inches  in  length,  and  weighing  more  than  three  ounces,  has 
been  projected  through  the  frontal  bone  into  the  brain,  and  been  extracted, 
in  one  case,  two  months,  and  in  another  twenty-seven  days  after  the  accident. 
In  the  first  of  the  cases  referred  to,  Mr.  Waldon's,  the  roof  of  the  orbit  seems 
to  have  been  destroyed ;  as  through  it  one  of  the  screw-pins  of  the  lock  was 
extracted.  The  patient  died  three  days  after  the  extraction  of  the  breech 
from  the  brain.""  In  the  second  case.  Dr.  Rogers's,  the  patient  recovered 
with  the  loss  of  an  eye." 

7.  Balls  or  other  foreign  bodies  passing  through  the  orbit,  and  at  the  same 
time  traversing  the  brain;  loss  of  substance  of  the  brain,  in  gunshot  and  other 
wounds  of  the  orbit. — The  effects  of  such  wounds  must,  in  general,  be  similar 
to  those  described  in  the  following  case  by  Wepfer,  in  which  it  is  surprising 
that  death  did  not  ensue  more  speedily.  Still  more  remarkable  are  those  in- 
stances, in  which  gunshot  and  other  explosive  wounds,  traversing  the  orbit 
and  the  brain,  have  been  followed  by  recovery. 

Case  51. — A  huntsman,  says  Wepfer,^^  holding  the  upper  end  of  his  gun  with  his  hand, 
accidentally  touched  the  trigger  with  his  foot.  The  piece  went  off,  and  two  balls  enter- 
ing by  the  right  side  of  the  lower  jaw,  traversed  the  left  orbit,  and  made  their  exit 
through  the  left  parietal  bone,  near  the  lambdoid  suture.  The  left  eye  was  driven  from 
its  orbit.  The  patient's  mind  seemed  entire,  and  he  moved  all  his  limbs  till  the  close  of 
the  4th  day.  At  that  time  he  began  to  sing ;  but  an  hour  or  two  before  death  his  speech 
became  indistinct,  although  he  still  testified  by  nods  that  he  understood  what  was  said  to 
him.  He  began  to  toss  about  his  arms,  as  if  in  pain  ;  short  fits  of  a  convulsive  kind 
came  on ;  he  raved  during  the  niglit;  and  died  on  the  5th  day.  During  life,  a  copious 
ichorous  discharge  took  place  from  the  aperture  in  the  jaw.  On  dissection,  the  course  of 
the  ball  through  the  brain  was  traced  from  the  parietal  bone  to  the  neck  of  the  orbit, 
and  was  observed  to  be  filled  with  the  same  sort  of  ichor  as  had  flowed  from  the  jaw 
during  life. 

The  following  case  of  recovery  from  a  gunshot  wound  traversing  the  orbit 
and  the  cranium,  in  several  respects  resembles  Mr.  Cagua's  case  of  fractured 
orbit,  referred  to  at  page  51 : — 

Case  52. — A  lad  of  17  years  of  age  was  wounded  by  a  musket-ball,  which,  passing  from 
below  upwards,  penetrated  through  the  upper  lip,  the  right  nostril,  and  the  roof  of  the 
•  orbit  into  the  cranium,  whence  it  escaped  at  the  upper  part  of  the  frontal  bone  near  to 
the  sagittal  suture,  where  it  made  a  large  wound  of  the  integuments,  with  loss  of  sub- 
stance.    Such  a  degree  of  swelling  came  on  as  made  the  head  frightful. 

An  incision  was  made  over  the  wounded  part  of  the  orbit,  whence,  at  the  first  dressing, 
there  came  out  a  portion  of  both  substances  of  the  brain,  in  bulk  about  the  size  of  a 
small  hen-egg.  The  eye  was  exceedingly  swollen,  especially  the  upper  eyelid,  into  which 
an  incision  was  made,  to  give  issue  to  the  blood  which  was  supposed  to  be  there  extrava- 
Fated ;  but,  instead  of  blood,  there  came  out  a  splinter  of  bone  and  a  portion  of  both 
substances  of  the  brain,  nearly  equal  to  a  third  of  the  portion  which  had  formerly  come 


68  PART   OF  THE   OEBIT  SHOT   AWAY. 

away.  The  wounds  were  dressed  lightly,  and  the  patient  was  repeatedly  bled.  Some 
small  portion  of  brain  was  again  discharged.  On  the  4th  day,  the  brain  appeared  to  be 
in  a  state  of  suppuration ;  on  the  5th,  the  discharge  became  very  considerable.  From 
the  time  that  he  had  been  bled,  the  patient  continued  pretty  well  till  the  11th  day.  Next 
day  he  was  more  feeble.  On  the  13th  day,  the  matter  from  the  brain  which  had  been 
discharged  both  from  the  wound  above  and  from  that  below,  was  in  part  retained,  and 
the  patient  fell  into  a  state  of  drowsiness  and  general  depression. 

M.  Bagieu,  who  treated  the  case,  having  anew  examined  the  wounds  with  minute  atten- 
tion, removed  a  large  piece  of  loose  bone  from  the  upper  part  of  the  skull.  The  patient  did 
not  appear  to  be  relieved  by  this,  but  became  worse  till  the  15th  day,  when  every  one  ex- 
pected him  to  die.  M.  Bagieu  remarked,  that  on  pressing  the  skin  where  he  had  removed 
the  piece  of  bone,  pus  oozed  out,  which  made  him  suspect  that  there  was  an  accumulation 
of  matter  at  that  place.  Led  by  this  idea,  he  removed  the  skin,  and  some  portions  of 
dura  mater,  so  as  freely  to  re-establish  the  discharge.  The  pulse  rose,  the  patient  was 
next  day  able  to  speak,  and  afterwards  the  suppuration  slowly  subsided.  About  the  19th 
day,  the  fleshy  parts  began  to  granulate,  and  the  wound  on  the  upper  part  of  the  head 
was  soon  covered  over.  It  was  otherwise  with  that  of  the  eyelid,  where  supervened  a 
considerable  fungus,  occasioned  by  the  splinters  separating  from  the  neighboring  bone. 
In  spite  of  cutting  and  burning  this  fungus,  it  was  found  necessary  to  wait  patiently  till 
all  these  splinters  had  come  away ;  after  which  the  excrescence  was  easily  destroyed,  the 
wound  closed,  and  the  patient  recovered  completely.*'' 

Still  more  remarkable,  in  some  respects,  are  the  two  following  successful 
cases :  — 

Case  53. —  Nicholas  Joseph  Brune,  aged  17,  wishing  to  unload  a  musket,  began  by  ex- 
tracting the  balls  with  the  common  screw  used  for  that  purpose,  but  was  foiled  in  at- 
tempting to  remove  the  paper  and  tlie  powder.  He  tried  in  vain  to  make  the  piece  go 
off,  priming  it  repeatedly  for  that  purpose.  At  last,  he  resolved  to  bring  the  thick  end 
of  the  ramrod  to  a  strong  heat,  and  introduce  it  into  the  barrel  of  the  gun.  The  instant 
this  was  done  the  powder  exploded,  and  the  ramrod  was  driven  against  the  inner  part  of 
Bruue's  right  orbit,  where  the  os  unguis  is  united  to  the  nasal  process  of  the  superior 
maxillary  bone.  Directing  its  course  upwards  and  backwards,  it  came  out  by  the  right 
side  of  the  superior  angle  of  the  occipital  bone,  to  the  length  of  ten  inches. 

On  hearing  the  explosion,  the  father  in  terror  ran  to  the  assistance  of  his  son,  who  had 
fallen  to  the  ground.  He  instantly  raised  him,  and,  seizing  the  thick  end  of  the  ramrod 
with  both  his  hands,  drew  it  out  of  his  head.  About  two  ounces  of  blood  flowed  from 
the  two  openings,  whence  escaped  also  some  portions  of  brain.  A  suj-geon  dressed  the 
wounds,  enjoined  abstinence,  but  did  not  bleed.  No  bad  sj-mptoms  occurred,  except  that 
the  right  eye  became  violently  inflamed,  and  was  lost.  A  considerable  quantity  of  pus 
came  from  the  wounds,  and  between  the  3Gth  and  52d  days,  some  small  exfoliations  were 
discharged.     Three  months  after  the  accident,  the  cicatrization  was  complete. 

Professor  Ansiaux  afterwards  repeatedly  examined  the  patient,  and  exhibited  him  to 
his  pupils.     His  health  was  perfect,  and  he  was  able  to  labor  at  hard  work." 

Cane  54. —  Phineas  P.  Gage,  25  years  of  age,  was  charging  with  powder  a  hole  drilled 
in  a  rock,  for  the  purpose  of  blasting.  It  is  customary  when  filling  the  hole  to  cover  the 
powder  with  sand.  The  charge  Laving  been  adjusted.  Gage  directed  his  assistant  to  pour 
in  the  sand  ;  and  at  the  interval  of  a  few  seconds,  his  head  being  averted,  and  supposing 
the  sand  to  have  been  properly  placed,  he  dropped  the  iron  bar  as  usual  upon  the  chjirge, 
to  consolidate  it.  The  assistant  had  failed  to  obey  the  order;  and  the  iron  striking  fire 
upon  the  rock,  the  uncovered  powder  was  ignited,  and  an  explosion  took  place.  Gage 
was  at  this  time  standing  above  the  hole,  leaning  forward,  with  his  face  slightly  averted  ; 
and  the  bar  of  iron  was  projected  directly  upwards  through  his  head,  and  high  into  the 
air.  The  wound  thus  received,  was  oblique,  traversing  the  cranium  in  a  straight  line 
from  the  angle  of  the  lower  jaw  on  the  left  side  to  the  centre  of  the  frontal  bone  above, 
near  the  sagittal  suture.  The  iron  weighed  13J  lbs. ;  it  was  3  feet  7  inches  in  length,  and 
\\  inch  in  diameter.  The  end  which  entered  first  was  pointed,  the  tapering  part  being 
seven  inches  long,  and  the  diameter  of  the  pointy-  inch  ;  circumstances  to  which,  perhaps, 
the  patient  owed  his  life.  It  was  picked  up  at  a  distance  of  some  rods  from  the  patient, 
smeared  with  brains  and  blood. 

Notwithstamling  considerable  hemorrhage  and  loss  of  cerebral  substance,  the  patient 
recovered  in  the  space  of  about  two  months,  the  left  eye  remaining  amaurotic,  and  inca- 
pable of  being  turned  outwards  or  upwards,  and  the  upper  eyelid  in  a  state  of  ptosis. — 
In  the  course  of  the  cure  there  occurred  no  signs  of  con)pression,  concussion,  nor  inflam- 
mation of  the  brain. 

The  case  was  treated  by  Dr.  Harlow,  and  is  ably  commented  on  by  Professor  Bigelow.** 

8.  Part  of  the  orhit  shot  away. — The  temporal  angle  of  the  orbit  is  pecu- 


INJURIES   OF   THE   ORBIT.  69 

liarly  exposed  to  this  accident.  Occasionally  a  considerable  portion  of  the 
face,  along  with  the  lower  edge,  or  the  floor  of  the  orbit,  is  destroyed ;  and 
yet  recovery  may  follow.  Even  the  roof  has  been  so  shattered,  that  it  re- 
quired to  be  removed  ;  yet  life  has  been  preserved. 

Case  55. — Captain  M.,  aged  38,  a  Freneh  officer  engaged  against  the  Algerines,  was 
wounded  by  a  musket-ball,  on  the  1st  of  April,  1836.  It  entered  at  the  lower  external 
part  of  the  base  of  the  orbit,  and  came  out  behind  the  ear,  carrying  away  the  malar 
bone,  with  the  exception  of  a  part  of  its  superior  surface,  and  of  its  superior  and  infe- 
rior angles,  which,  notwithstanding  their  being  quite  loose.  Dr.  Baudeus^*  did  not  re  - 
move.  All  the  soft  parts,  as  far  as  the  ear,  were  lacerated,  and  presented  a  dreadfully 
contused  wound,  the  bottom  of  which  corresponded  to  the  temporal  fossa. 

By  gently  introducing  his  finger  along  the  groove  of  the  wound.  Dr.  B.  withdrew  some 
small  splinters  of  bone,  mixed  with  large  clots  of  blood.  He  replaced  the  shattered  bones 
which  were  still  adherent,  and  preserved  carefully  the  envelops  of  the  globe  of  the  eye, 
the  humors  of  which  had  been  evacuated,  in  order  to  obtain  a  stump,  movable  by  the 
muscles  of  the  eye,  upon  which  a  glass  eye  might  afterwards  be  placed.  Having  pared 
the  edges  of  the  wound,  he  brought  them  together  by  stitches. 

The  cure  went  on  during  two  months  ;  there  were  no  cerebral  symptoms;  distressing 
tinnitus  aurium  was  removed  by  local  bleedings ;  the  suppuration  was  not  great ;  the 
edges  of  the  wound  united  perfectly,  leaving  a  linear  cicatrice ;  there  was  no  exfoliation. 

Case  56. — Guibon,  aged  30,  on  the  10th  December,  1830,  received  a  wound  by  a  case- 
shot,  on  the  right  inferior  part  of  the  frontal  bone.  The  wound  was  contused  and  rag- 
ged, with  splinters  of  bone  driven  in  above  the  orbitary  arch.  All  the  splinters  were  re- 
moved, and  a  large  portion  of  the  roof  of  the  orbit  was  extracted;  there  was  a  loss  of 
cerebral  substance  ;  but  no  loss  of  feeling,  motion,  or  intellect.  The  cure  was  well  ad- 
vanced by  the  2d  January.^ 

Case  57. — Louis  Vaute  was  struck  obliquely  on  the  face  with  a  cannon-ball,  which  took 
away  almost  the  whole  of  the  lower  jaw,  and  three-fourths  of  the  upper.  The  two  upper 
maxillary  bones,  the  bones  of  the  nose,  the  vomer,  the  ethmoid  bone,  both  malar  bones 
and  zygomata  were  broken  to  pieces  ;  the  soft  parts  corresponding  to  those  osseous  por- 
tions destroyed ;  the  right  eye  burst ;  the  tongue  cut  across  ;  the  fauces,  and  posterior 
apertures  of  the  nostrils  completely  exposed,  as  well  as  one  of  the  glenoid  cavities.  Such 
was  the  state  of  the  wound,  that  the  comrades  of  this  soldier  had  laid  him  in  a  corner  of 
one  of  the  French  hospitals  at  Alexandria,  in  the  belief  that  he  was  dead.  Indeed,  when 
Larrey  first  saw  him,  the  pulse  was  scarcely  to  be  felt,  and  the  body  cold  and  without  the 
appearance  of  motion. 

As  he  had  taken  nothing  for  two  days,  Larrey's  first  care  was  to  administer  to  him,  by 
means  of  an  oesophagus  tube,  some  soup  and  a  little  wine.  His  strength  was  re-ani- 
mated ;  he  raised  himself,  and  testified  by  signs  the  most  lively  gratitude.  Larrey  washed 
the  wound,  removed  the  foreign  substances  which  adhered  to  it,  cut  away  the  soft  parts 
which  were  in  a  state  of  disorganization,  tied  several  vessels  which  had  opened  in  doing 
so,  and  brought  the  flaps  together,  as  much  as  possible,  by  stitches.  He  also  united  by 
stitches  the  two  portions  into  which  the  tongue  had  been  divided.  He  covered  the  whole 
excavation  with  a  piece  of  linen  with  holes  cut  in  it,  and  dipped  in  warm  wine,  and  then 
applied  fine  charpie,  compresses,  and  a  bandage.  Every  three  hours,  a  little  soup  and 
some  spoonfuls  of  wine  were  given  with  the  gum-elastic  tube  and  funnel.  The  dressings 
were  frequently  renewed,  on  account  of  the  flow  of  saliva  and  other  fluids.  Suppuration 
was  established,  the  sloughs  separated,  the  edges  of  the  enormous  wound  approached 
each  other,  and  the  parts  which  were  brought  together  adhered  ;  35  days  after  the  injury, 
the  man  was  in  a  state  to  be  moved,  and  ultimately  cicatrization  was  completed.  After 
having  been  fed  during  the  first  15  days  through  the  tube,  he  was  able  to  take  nourish- 
ment with  a  spoon. 

The  patient  returned  to  France:  and  11  years  afterwards,  when  Larrey  published  his 
work,fis  ^as  alive,  and  in  good  health,  in  the  Hotel  des  Invalides.  He  could  even  speak  so 
as  to  make  himself  understood,  especially  when  the  large  opening  into  his  face  was  co- 
vered with  a  gilt  silver  mask. 

I  have  thus  attempted  to  classify  and  illustrate  the  different  injuries  to 
which  the  orbit  is  liable,  and  the  various  effects  which  those  injuries  are  apt 
to  produce.  There  remain  only  two  topics,  on  which  I  wish  to  say  a  few 
words. 

1.  Prognosis. — It  is  evident,  from  the  cases  which  have  been  passed  in 
review  before  us,  that  although,  in  general,  immediate  death  is  the  conse- 
quence of  an  injury  extending  through  the  orbit  to  the  brain,  yet  this  is  not 


70  INJURIES   OF   THE   ORBIT. 

always  the  case  ;  but  that  in  some  instances  life  has  been  prolonged  for  seve- 
ral days,  and  that  in  others  the  patient  has  completely  recovered. 

Putting  aside  the  important  question,  whether  or  not  large  vessels  have 
been  ruptured  and  blood  extravasated,  it  is  probable,  that  it  is  not  so  much 
the  absolute  amount  of  injury  to  the  brain,  as  the  suddenness  with  which  it  is 
inflicted,  which  renders  wounds  of  the  bi'aiu  so  generally  fatal.  We  have  ex- 
amples of  disorganization  of  very  considerable  portions  of  the  brain  proceed- 
ing slowly,  and  yet  life  prolonged  for  years ;  while  in  perforation  of  the  roof 
of  the  orbit,  the  smallest  wound  of  the  brain  may  prove  immediately  mortal. 
Pathologists  generally  attempt  to  explain  the  sudden  and  fatal  effects  of  such 
wounds  of  the  brain,  by  telling  us,  that  thereby  the  heart,  or  the  organs  of 
respiration,  are  instantly  deprived  of  the  nervous  energy  necessary  for  con- 
tinuing their  functions.  But  how  it  happens  that  death  takes  place  instanta- 
neously in  some  cases  of  this  sort,  while  in  others  the  person  suffers  so  little 
from  sudden  and  severe  injury  of  the  brain,  but  lingers,  like  Mr.  Waldon's 
patient  with  the  gun-breech  in  his  head,  or  recovers,  like  Mr.  Cagua's,  M. 
Bagieu's,  and  Dr.  Harlow's  patients,  we  cannot  teil,  any  more  than  we  can 
explain  how  one  man  shall  have  a  limb  carried  off  or  shattered  to  pieces  by  a 
cannon-ball,  without  exhibiting  the  slightest  symptom  of  mental  or  corporeal 
agitation,  while  deadly  paleness,  violent  vomiting,  profuse  perspiration,  and 
universal  tremor,  shall  seize  another  on  the  receipt  of  a  slight  flesh  wound. 
To  say  that  all  this  depends  on  dififereuces  in  nervous  susceptibility,  is  only 
to  repeat  the  fact  in  other  words,  not  to  explain  it. 

2.  General  Treatment. — In  regard  to  the  general  treatment  of  injuries  of 
the  orbit,  it  is  plain  what  that  ought  to  be ;  namely,  quiet  and  rest ;  a  spare 
diet ;  bloodletting,  if  the  reaction  demands  k ;  o})iates ;  laxatives ;  gentle 
diaphoretics ;  a  mercurial  pill  occasionally,  if  the  liver  becomes  irregular  in 
its  action,  as  from  confinement  it  is  very  apt  to  do  ;  great  cleanliness  in  regard 
to  the  injured  parts  ;  emollient  cataplasms  and  soft  light  dressings,  frequently 
renewed. 

We  must  not  neglect  the  use  of  bloodletting,  but  we  must  beware  of  em- 
ploying this  remedy  too  soon  or  too  profusely.  We  must  not  omit  to  examine 
the  injured  parts  frequently,  in  order,  if  there  be  any  piece  of  exfoliated  bone 
or  foreign  substance  keeping  up  irritation,  that  it  may  bs  withdrawn,  and 
as  soon  as  the  sloughs  have  separated,  and  the  inflammation  diminished, 
we  must  draw  the  edges  of  the  wound  together,  and  keep  them  as  nearly  as 
possible  in  contact  with  one  another ;  but,  on  the  other  hand,  we  must  avoid 
too  much  poking  and  intermeddling,  or  attempting  prematurely  to  close  up 
the  issues,  by  which  matter  and  foreign  substances  may  have  still  to  escape. 
In  some  cases,  it  will  be  necessary  to  divide  the  soft  parts,  or  even  to  apply 
the  trephine,  in  order  to  allow  an  exit  to  extravasated  blood,  evacuate  puru- 
lent matter,  or  remove  depressed  or  detached  pieces  of  bone.  All  other 
things  being  equal,  the  cure  proceeds  more  favorably  when  there  is  a  free 
outlet  to  the  fluids  extravasated  or  secreted  in  consequence  of  the  wound.  A 
simple  fissure,  with  effusion  of  blood,  being  followed  by  inflammation,  is  often 
more  dangerous  than  a  fracture,  with  splinters,  and  even  loss  of  part  of  the 
brain. 


'  (Euvres  d'Ambroise   Parfi  ;  Liv.  x.  cap.  9  ;  Petit,  in  (Euvres  diverses  de  Louis;  Tome  ii.p. 

Paris,  1607.  41;  Paris,  1788. 

^  Observations  on  AVounds  of  the  Head,  p.  '  Duncan's  Annals  of  Medicine,  vol.  i.  p.  358. 

107  ;  London,  1766.  Edinburgh.  1796. 

^  Quoted  from  the  Journal  de  M6decine  do  '  Musaeum  Nosocomii  Vindobonensis,  p.  45 ; 

Corvisart,  Dec,  1808,  by  Ansiaux,  Clinique  Chi-  Vindobonre.  1816. 

rurgieale,  p.  48  ;  Liege.  1829.  ■■  Clinical  Lecture  in  the  Eoyal  Infirmary  of 

*  Nouveau  Systeme  du  Cerveau,  par  F.  P.  du  Edinburgh,  March,  1828,  p.  5. 


INJURIES   OF   THE   ORBIT. 


11 


'  Phildsophioal  Transactions  for  1740;  Vol. 
xH.  Part  ii.  p.  495. 

"  Grate  unci  Walther's  Journal  der  Chirurgie 
und  Augenheilkunde  ;  Vol.  ii.  p.  192  ;  Berlin, 
1821. 

'°  Brigbt's  Report  of  Medical  Cases;  Vol.  ii. 
p.  36;  London,  1831. 

''  Meinoires  de  rAcademie  Royale  des  Sci- 
ences, Annee  1703,  p.  355;  Amsterdam,  1738. 

'*  Chopart,  Memoire  ?ur  les  Lesions  de  la 
Tete  par  Contre-coup,  p.  1;  Paris,  1771. 

"  De  Renunciatione  Vulnerum,  p.  168;  Lip- 
siae,  1755. 

"  See  the  French  translation  of  this  work, 
by  MM.  Laugier  and  Richelot,  p.  vii.  Paris, 
1844. 

"  Bell's  Anatomy,Vol.i.  p.  49;  London,  1811. 
The  thinness  of  the  orbitary  plate,  like  the  thin- 
ness of  the  middle  of  the  os  ilium,  or  scapula, 
must  be  regarded  as  the  natural  constitution  of 
the  bone,  and  not  at  all  as  the  effect  of  pressure 
by  the  brain,  or  rolling  of  the  eye. 

"  Ruyschii  Observationum  Centuria;  Obs. 
54 ;  Amstelodarai,  1691. 

'''  Petri  Borelli  Historiarum  et  Observationum 
Centuria  IL  Obs.  19 ;  Francofurti,  1676. 

"  See  a  similar  case  by  Diemerbroeck,  in  his 
Anatome  Corporis  Humani,  p.  637  ;  Ultrajecti, 
1672. 

"  Lancet,  May  12,  1832,  p.  190. 

*"  Joannis  Schmidii  Miscellanea ;  quoted  by 
Bonetus  in  his  Sepulchretum,  Tom.  iii.  p.  380 ; 
Lugduni,  1700. 

'^  Medical  Gazette,  Vol.  xxvii.  p.  587;  Lon- 
don, 1841. 

^^  See  a  similar  case  in  Bright's  Reports  of 
Medical  Cases,  Vol.  ii.  p.  611;  London,  1831. 

''  Dublin  Quarterly  Journal  of  Medical  Sci- 
ence ;  Vol.  xii.  p.  226  ;  Dublin,  1851. 

''*  Journal  de  Medecine,  Tome  iii.  p.  530 ; 
quoted  in  Dictionnaire  des  Sciences  Medicales, 
Tome  xxxvii.  p.  558.  See  a  case  by  Hewett, 
of  a  child,  in  whom  the  orbit  was  penetrated 
by  a  lead-pencil ;  Medical  Gazette  ;  Vol.  xli. 
p.  553  ;  London.  1848. 

'^^  Traite  Tlieorique  et  Pratique  des  Blessures 
par  Amies  de  Guerre,  redige  d'apres  les  Lemons 
Cliniques  de  Dupuytren,  par  Paillard  et  Marx, 
Tome  ii.  p.  216  ;  Paris,  1834. 

"  Medical  Tirae.s  March  22,  1851.  p.  316. 

"''  Philosophical  Transactions  for  1763;  Vol. 
liii.  p.  234. 

"  Ibid,  for  1748;  Vol.  xlv.  p.  520. 

*'  Albucasis  Methodus  Medendi;  Lib.  ii.  cap. 
xciv.  p.  J  66;  Basileee,  1541. 

'°  Pare,  Apologie  et  Voyages ;  Voyage  de 
Boulogne,  1545. 

''  M;inuel  du  Chirurgien-d'Armee,  p.  Ill; 
Paris.  1792. 

^^  Medecine  Operatoire,  Tomei.  p. 409;  Paris, 
1822. 

^^  Fischer,  Klinischer  Unterricht  in  der  Aug- 
enheilkunde,  p.  32  ;  Prag.  1832. 

"  Demours,  Traite  des  Maladies  des  Yeux, 
Tome  ii.  p.  45;  Paris,  1818. 

*'  Bell's  System  of  Surgery;  Vol.  iv.  p.  162; 
Edinburgh,  1801. 

'*  See  Quesnay  sur  les  Plaies  du  Cerveau, 
Memoires  de  I'Acadeujie  Royale  de  Chirurgie, 
Tome  ii.  p.  131,  12mo. ;  Paris,  1780. 

''  Quarterly  Journal  of  Medical  Science,  Vol. 
xi.  p.  352  ;  Dublin,  1851.  At  p.354of  the  same 
volume,  a  case  is  given  of  a  piece  of  tobacco- 


pipe  passing  through  the  orbit  into  the  brain, 
and  detected  only  on  dissection. 

^*  Petri  de  Marchettis  Observationum  Syl- 
loge;  Obs.  23;  Londini,  1729. 

"  Cases  in  Surgery,  by  Charles  White,  p.  131; 
London,  1770. 

*°  Gregorii  Horstii  Observationum  Lib.  i. ; 
Operum  Tom.  ii.  p.  226  ;  Norimbergie,  1660. 

*'  Op.  cit.     Obs.  17;  Londini,  1729. 

*^  O'Halloran  on  Injuries  of  the  Head,  Trans- 
actions of  the  Royal  Irish  Academy;  Vol.  iv.  p. 
157. 

"  Memoires  de  la  SociSt6  M^dicale  d'Emu- 
lation  ;  Vol.  vii.  p.  86  ;  Paris,  1811. 

**  Hennen's  Observations  on  some  important 
points  in  Military  Surgery,  p.  370  ;  Edinburgh, 
1818. 

■"  Baudens,  Clinique  des  Plaies  d'Armes  i 
feu;  p.  162;  Paris,  1836. 

*'  Ibid.  p.  163. 

*''  Memoires  de  I'Academie  Royale  de  Chi- 
rurgie ;  Tome  vi.  p.  202,  12mo. ;  Paris,  1787. 

*'  Thomson's  Report  of  Observations  in  the 
Military  Hospitals,  after  the  Battle  of  Waterloo ; 
p.  64  ;  Edinburgh,  1816. 

"  De  Affectibus  Capitis  Internis  et  Externis; 
Obs.  11.  p.  27;  Scaphusii,  1727. 

'"  Quoted  from  the  Journal  Generalede  Mede- 
cine, Tome  XXXV.  p.  387:  by  Briot,  in  his  His- 
toire  de  la  Chirurgie  Militaire  en  France,  p. 
Ill;  Paris,  1817. 

' '  Medical, Chirurgical,  and  Anatomical  Cases 
and  observations,  translated  byM'irgman;  Obs. 
Ixxiv.  p.  92;  London,  1755. 

"  Op.  cit.    p.  65. 

"  Memoirs  of  the  Literaryand  Philosophical 
Society  of  Manchester,  vol.  iv.  p.  23;  Manches- 
ter. 1793. 

"  Op.  cit.  p.  127. 

"  Op.  cit.  p.  361. 

"  Philosophical  Transactions,  abridged  by 
Jones,  vol.  v.  p.  203. 

'''  Quoted  from  Bresciani  De  Borsa,  in  the 
Medico-Chirurgical  Review  for  April,  1846,  p. 
358. 

"  Garengeot,  Traite  des  Operations  de  Chi- 
rurgie ;  Tome  iii.;  Obs.  xi.  p.  155;  ParLs,  1731. 

"  Op.  cit.  p.  361. 

'"  Memoirs  of  the  MedicalSociety  of  London; 
Vol.  V.  p.  409;  London,  1799. 

' '  Medico-Chirurgical  Transactions;  Vol.  xiii. 
p.  283:  London,  1827. 

"  Op.  cit.     Obs.  15,  p.  33. 

"  Memoires  de  I'Academie  Royale  de  Chi- 
rurgie; Tome  i.  Partie  ii.  p.  127.  12mo;  Paris, 
1780. 

'*  Clinique  Chirurgieale,  par  N.  Ansiaux;  p. 
276;  Liege,  1829. 

^'  American  Journal  of  the  Medical  Sciences; 
New  Series;  Vol.  xx.  p.  13;  Philadelphia,  1850. 

'•^  Op.  cit.  p.  151. 

''■'  Paillard,  Relation  Chirurgieale  du  Siege 
de  la  Citadelle  d'Anvcrs,  p.  145  :  Paris,  1833. 

**  Larrey,  Memoires  de  Chirurgie  Militaire; 
Tome  ii.  p.  140;  Paris,  1812.  Vaute  survived 
his  wounds  18  years,  and  died  a  violent  death 
in  the  hospital  at  Charenton.  A  sketch  of  his 
appearance  during  life  is  given  in  the  Diction- 
naire des  Sciences  Medicales,  Tome  xxix.  PI. 
2;  and  a  figure  representing  his  cranium  on 
dissection,  in  the  Journal  Complemeucaire  du 
Dictionnaire,  Tome  viii.  p.  119. 


72        PERIOSTITIS,    OSTITIS,    CARIES,    AND  NECROSIS   OP   ORBIT. 


SECTION  II. — PERIOSTITIS,  OSTITIS,  CARIES,  AND  NECROSIS  OP  THE  ORBIT.* 

We  have  hitherto  considered  the  orbit,  merely  as  a  part  exposed  to  a 
variety  of  external  injuries.  We  must  now  turn  our  attention  to  it  as  a  part 
subject  to  inflammation  and  its  consequences. 

The  bones  are  susceptible  of  the  same  disease  as  the  soft  parts  ;  they  in- 
flame, and  when  inflamed  they  redden,  swell,  become  painful,  and  are  the 
seat  of  effusions ;  in  different  stages  of  disease,  or  in  diflerent  circumstances, 
they  harden  or  soften ;  they  suppurate,  ulcerate,  mortify,  and  slough.  On 
account  of  the  mineral  matter  which  they  contain  in  the  proportion  of  about 
2  to  1  of  animal  matter,  although  abundantly  supi)lied  with  bloodvessels, 
the  whole  of  the  processes,  whether  natural  or  morbid,  which  go  on  in  the 
bones,  take  place  with  less  rapidity  than  do  similar  changes  in  the  soft  parts. 
Inflammation  in  particular,  ulceration,  and  mortification,  with  all  their  con- 
comitant phenomena,  proceed  in  general  very  slowly  in  bones.  We  meet, 
indeed,  with  both  acute  and  chronic  inflammation  of  the  bones  ;  but  the 
chronic  is  much  the  more  frequent.  The  periosteum,  with  which  they  are 
everywhere  closely  invested,  possesses  a  much  greater  degree  of  vitality  than 
the  bones  themselves;  and,  as  this  membrane  is  not  merely  adherent  to  their 
surfaces,  but  sends  innumerable  vessels  into  the  continuous  network  of  canals 
and  cancelli  hollowed  out  in  their  substance,  we  find  the  bones  very  apt  to 
sufi"er  when  the  periosteum  is  diseased.  The  periosteum,  however,  may  sepa- 
rate from  a  bone,  without  the  bone  perishing  ;  and  a  bone  may  inflame  and 
become  carious,  while  the  periosteum  adiieres  to  it.  All  inflammatory 
changes,  and  all  malignant  and  non-malignant  growths  in  bone,  have  their 
site  in  the  Haversian  canals. 

The  dura  mater,  making  its  exit  by  the  numerous  foramina  of  the  cranium, 
is  continued  into  the  periosteum.  The  envelop  which  the  optic  nerve  derives 
from  the  dura  mater,  having  reached  the  point  of  origin  of  the  recti  muscles 
of  the  eye,  sjilits  into  two  laminae,  the  exterior  of  which  is  lost  in  the  peri- 
orbita, while  the  interior,  which  is  whiter,  denser,  and  thicker,  forms  a  tubular 
sheath  for  the  nerve,  exterior  to  its  neurilemma,  and  becomes  continuous  with 
the  sclerotica.  Between  these  two  lamin-<o,  a  canal  is  formed  for  the  trans- 
mission of  the  ophthalmic  artery.  It  is  not  by  the  optic  foramen  alone,  how- 
ever, that  the  dura  mater  enters  the  orl)it.  The  dura  mater  closes  in  part 
the  spheno-orbital  fissure,  and  sends  into  the  orbit  by  this  opening  a  pro- 
longation, which  is  also  continued  into  the  periosteum  of  the  orbit.  Tlirough 
this  prolongation,  the  3d  and  4th  nerves,  the  1st  division  of  the  5th,  and  the 
6th,  enter  the  orbit,  and  the  ophthalmic  veins  escape  from  it.  At  the  base 
of  the  orbit,  the  periorbita,  joining  the  periosteum  of  the  face,  is  continued 
into  the  palpebral  fascia  or  fibrous  layer  of  the  eyelids.  The  bones  of  the 
orbit  derive  nourishment  not  from  the  periorbita  alone ;  the  roof  is  supported, 
on  its  upper  surface,  by  the  dura  mater ;  the  floor,  on  its  lower  surface,  and 
the  inner  wall,  on  its  mesial  surface,  by  the  mucous  membrane  of  the  nasal 
cavities ;  and  the  outer  wall,  on  its  outer  surface,  by  the  periosteum  of  the 
temporal  fossa. 

Causes. — Inflammation  of  the  periosteum  and  bones  of  the  orbit  may  result 
from  different  causes  ;  for  example  :  1.  Injuries,  perhaps  producing  fracture; 
2.  Cold,  and  other  common  causes  of  inflammation  ;  3.  Syphilis,  scrofula, 
or  other  diseases  of  a  constitutional  nature,  acting  locally;  and  4.  The  spread 
of  inflammation  from  the  neighboring  parts,  and  especially  from  the  soft 
parts  contained  within  the  orbit.  We  should  call  the  first  three  examples 
primary,  and  the  last  secondary  inflammation  of  the  orbit. 

Inflammation  of  the  periosteum  or  of  the  bones  of  the  orbit,  primarily  or 


ACUTE   PERIORBITIS.  13 

secondarily  excited,  may  terminate  by  resolution.  If  the  periosteum  is  left 
in  a  thickened  state,  the  term  node  or  periostosis  is  applied  to  the  swelling. 
If  an  increased  deposition  of  osseous  matter  is  left  in  the  inflamed  bone,  or 
on  its  surfaces,  hyperostosis  or  hony  node  is  the  term  used.  Periostitis  or 
ostitis  may  terminate  in  the  formation  of  pus,  and  this  may  be  deposited 
either  between  the  periosteum  and  the  bone,  or  in  the  cancelli.  When  the 
disease  proceeds  to  ulcerative  absorption  of  the  bony  substance,  it  is  styled 
caries ;  if  it  ends  in  the  death  of  the  intiaraed  piece  of  bone,  necrosis. 

Arising  from  causes  of  the  first  or  second  set,  above  enumerated,  peri- 
ostitis or  ostitis  of  the  orbit  is  more  apt  to  run  an  acute  course,  and  to  be 
attended  with  severe  pain,  fever,  and  immediate  danger,  than  when  causes  of 
the  third  or  fourth  class  are  in  operation.  When  acute,  pus  is  likely  to  be 
deposited  between  the  periorbita  and  the  bones  ;  the  eyeball  to  be  displaced, 
if  the  disease  is  completely  within  the  orbit ;  and  sympathetic  inflammation 
to  be  excited  in  the  membranes  of  the  brain,  terminating  fatally.  Chronic 
eases,  again,  are  more  likely  to  end  in  thickening  of  the  periosteum,  or  de- 
struction of  the  bones. 

I  do  not  consider  it  necessary  to  describe  further  than  I  have  done,  the 
inflammatory  efiects  of  those  injuries  of  the  orbit,  which  form  the  subject  of 
the  preceding  section.  In  penetrating  wounds  especially,  and  in  gunshot 
wounds  of  the  orbit,  we  must  lay  our  account  with  inflammation  of  the  bones 
and  periosteum,  followed  by  suppurations,  sloughings,  sinuses,  caries,  necrosis, 
and  tedious  exfoliations. 

Demours  speaks"^  of  primary  inflammation  of  the  orbital  periosteum  as  ex- 
tremely common  ;  but  the  symptom  to  which  he  refers,  is  evidently  nothing 
more  than  the  circumorbital  neuralgia,  which,  increasing  every  evening,  and 
relaxing  every  morning,  is  an  attendant  on  some  of  the  internal  ophthalmia?. 
It  seems  more  reasonable  to  refer  the  pain,  in  such  cases,  to  the  branches  of 
the  5th  nerve,  radiating  from  the  orbit,  than  to  the  periosteum. 

The  most  frequent  cause  of  secondary  inflammation  of  the  bones  of  the 
orbit,  is  supposed  to  be  inflammation  of  the  orbital  cellular  substance,  or  of 
the  lachrymal  gland,  going  on  to  suppuration,  and  the  abscess,  either  from 
misapprehension  or  neglect,  not  being  opened  ;  while,  in  some  cases,  severe 
inflammation  of  the  eyeball  spreads,  not  only  to  the  surrounding  soft  parts, 
but  also  to  the  periosteum  and  the  bones.  Orbital  tumors,  running  into 
suppuration,  sometimes  produce  similar  effects. 

Inflammatory  affections  of  the  bones  of  the  orbit  occur  in  various  situa- 
tions, and  in  different  degrees  of  extent.  Its  exterior  margin,  just  within  its 
cavity,  the  fossa  lachrymalis,  the  middle  part  of  one  or  of  several  of  its  pa- 
rietes,  and  the  apex  of  the  orbit,  where  it  communicates  with  the  cranium, 
are  the  several  situations  where  the  bones  have  been  met  with  in  a  diseased 
state. 

§  1.   Acute  Periorhitis. 

The  symptoms  in  acute  inflammation  of  the  periosteum  and  bones  of  the 
orbit,  may  be  gathered  in  some  measure  from  a  case  presently  to  be  quoted. 
A  case  of  a  lady,  related  by  Dr.  Abercrombie,^  in  whom  a  swelling  of  the 
upper  eyelid  being  punctured,  purulent  matter  was  discharged,  and  on  a 
probe  being  introduced  deep  into  the  orbit,  the  bone  was  felt  bare,  bears  also 
in  some  respects  on  our  present  subject.  The  pain  in  the  left  temple,  with 
which  the  patient  was  suddenly  seized  at  the  commencement  of  her  illness, 
appears  attributable  to  inflammation  of  the  periosteum  lining  the  roof  of  the 
orbit,  and  it  may  even  be  doubted,  how  far  the  fatal  inflammation  of  the 
dura  mater  and  tunica  arachnoidea  on  the  right  side,  was  not  a  sympathetic 
effect  arising  from  the  previous  disease  of  the  left  orbit. 


n  CHRONIC   PERIORBITIS. 

Case  58. — A  boy,  aged  15,  had  a  swelling  of  the  right  cheek,  and  pain  of  the  teeth. 
After  some  days,  the  pain  removed  to  the  left  side  of  the  head,  where  it  occupied  en- 
tirely the  eye  and  its  dependencies.  He  then  had  irregular  attacks  of  fevei",  witli  want 
of  sleep  and  loss  of  appetite,  and  about  the  7th  day  considerable  delirium.  On  the  8th 
day  the  eyelid  was  swollen,  so  as  to  close  the  eye ;  and  on  raising  it,  the  eyeball  appeared 
unusually  prominent.  He  had  nausea,  and  severe  headache,  but  was  quite  sensible,  and 
the  fever  was  moderate;  some  delirium  occurred  towards  night,  and  the  swelling  extended 
beyond  the  eyelids  over  the  forehead.  On  the  9th  day  there  was  permanent  delirium; 
on  the  10th,  coma  and  death. 

The  left  eyelid,  and  the  integuments  of  the  left  side  of  the  forehead,  were  imbued  with 
purulent  matter;  the  frontal  bone  was  denuded  and  carious  for  a  considerable  space ;  the 
abscess  j^enetrated  the  orbit,  and  pus  was  found  in  its  upper  and  back  part,  where  the 
bone  was  also  denuded.  The  caries  of  the  frontal  bone  occupied  its  whole  thickness,  and 
extended  in  length  somewhat  beyond  the  roots  of  the  hairs,  and  transversely  from  the 
external  orbitar  process  beyond  the  nose. 

The  dura  mater  was  detached  and  covered  with  pus  over  a  space  corresponding  with 
the  external  disease,  but  it  was  not  detached  from  the  superior  part  of  the  vault  of  the 
orbit.  The  arachnoid  was  covered  with  purulent  matter ;  there  was  very  little  fluid  in 
the  ventricles,  and  the  brain  in  other  respects  was  healthy.* 

In  acute  periorbitis,  however  limited  the  inflammatorv  affection  may  be,  it 
is  evident  that  very  active  antiphlogistic  measures  will  be  required.  The 
division,  also,  of  the  inflamed  periosteum  with  the  knife,  as  soon  as  the 
symptoms  are  sufficiently  indicative  of  the  nature  and  seat  of  the  affection, 
should  be  attempted. 

§  2.    Oironic  Periorhitis. 

Chronic  periorbitis  of  the  orbit  is  generally  the  result  of  syphilis,  or  of  the 
inordinate  use  of  mercury  for  the  cure  of  syphilis.  Our  knowledge  of  the 
symptoms  we  owe  chiefly  to  Mr.  Hamilton  of  Dublin.* 

1.  The  eyelids  are  swollen  and  of  a  pale  red  color,  or  cedematous. 

2.  The  eyeball  is  protruded  from  the  orbit,  and  most  frequently  depressed  ; 
the  conjunctiva  affected  with  pale  chemosis ;  the  patient  sees  double,  the  one 
image  appearing  above  the  other ;  there  is  confusion  of  sight,  the  motions  of 
the  eye  are  impeded,  and  ptosis  sometimes  takes  place. 

3.  There  is  pain  in  the  orbit,  and  pain  above  the  eyebrow,  extending  in 
some  cases  over  the  whole  head,  and  aggravated  at  night.  One  of  the  most 
diagnostic  signs  is  a  shrinking  tenderness,  if  the  edge  or  walls  of  the  orbit  be 
pressed  upon,  or  even  the  forehead  or  temple.  The  pressure  must  be  directed 
perpendicularly  towards  the  bone  ;  upwards,  for  example,  if  the  roof  of  the 
orbit  is  affected.  The  pain  is  always  excited  when  pressure  is  employed  ; 
and  is  not  sometimes  present,  sometimes  absent,  in  the  course  of  the  day  or 
night,  like  the  pain  felt  on  pressing  the  supra-orbitary  nerve  in  neuralgia. 

4.  In  some  cases,  there  is  little  apparent  swelling  of  the  periosteum  ;  in 
others,  a  swelling  is  distinctly  perceived  within  the  margin  of  the  orbit,  and 
is  even  felt  to  fluctuate.  It  may  be  so  great  as  to  prevent  the  upper  eyelid 
from  being  pressed  up,  so  as  to  expose  the  eyeball.  An  abscess  may  form 
in  connection  with  the  diseased  membrane,  and  may  burst  through  the  skin. 

5.  The  disease,  going  on,  involves  the  bone,  causing  caries  of  the  walls 
of  the  orbit.  If  the  roof  is  affected,  the  frontal  sinus  may  be  penetrated,  or 
even  the  cavity  of  the  cranium.  In  the  former  case,  matter  drains  down  the 
nostrils  ;  in  the  latter,  the  dura  mater  inflames,  palsy  of  one  side  of  the  body 
has  been  known  to  happen,  coma  is  likely  to  supervene,  and  the  case  will 
terminate  fatally. 

6.  By  far  the  most  common  situation  of  the  disease  is  the  two  inner  thirds 
of  the  orbital  plate  of  the  frontal,  where  the  bone  is  least  protected  by  soft 
parts. 

7.  Simple  thickening  of  the  periorbita,  effusion  of  thin  fluid  between  it  and 


CARIES   AND   NECROSIS   OF   THE   ORBIT.  (5 

the  bone,  and  deposit  of  pus  in  tlie  same  situation,  or  even  of  cartilage  or 
bone,  are  the  circumstances  which  afford  an  explanation  of  the  symptoms. 

Treatment. — This  consists  :  1.  In  the  internal  and  external  use  of  mercury. 
As  the  mouth  becomes  sore,  the  symptoms  subside  with  remarkable  rapidity. 
Corrosive  sublimate  has  been  especially  recommended  for  internal  use  ;  and 
friction  with  mercurial  ointment  round  the  orbit.  2.  The  iodide  of  potas- 
sium, and  other  preparations  of  iodine,  are  extremely  beneficial.  They  are 
often  used  with  sarsaparilla,  or  with  mercury.  3.  Should  the  symptoms  not 
yield  to  these  remedies,  and  should  fluctuation  be  obscurely  perceived  in  the 
swelling,  an  exploratory  puncture  may  be  made,  followed  up,  if  any  fluid 
escapes,  by  a  larger  opening  with  the  lancet. 

§  3.    Caries  and  Necrosis  of  the  Orbit. 

Whatever  part  of  the  cavity  is  affected,  and  from  whatever  cause  the  dis- 
ease originates,  we  generally  find,  in  caries  or  necrosis  of  the  orbit,  the  eye- 
lids more  or  less  red  and  swollen,  hot  and  painful,  and  often  exceedingly 
cedematous.  At  length,  a  particular  spot  of  the  upper  or  lower  lid  points, 
and  bursts,  the  opening  generally  continuing  for  a  long  time  to  discharge 
thin  purulent  matter  ;  round  the  opening  the  skin  is  depressed,  and  some- 
times extensively  ulcerated,  but  more  frequently  the  aperture  becomes  fistu- 
lous, and  occasionally  it  is  surrounded  by  fungous  granulations.  The  probe, 
passed  along  'the  fistulous  opening,  comes  into  contact  with  bare  rough  bone, 
in  the  state  of  caries  or  of  necrosis  ;  exfoliation  sometimes  takes  place ;  and 
at  last,  after  a  course  of  months  or  years,  the  parts  heal,  the  external  aperture 
closes,  and,  in  doing  so,  the  integuments  adhere  to  the  periosteum,  leaving  a 
deeply  depressed  cicatrice,  with  more  or  less  shortening  of  the  lid,  a  symptom 
termed  lagophthalmos,  and  with  more  or  less  ectropium  or  eversion  of  the 
lid.  There  are  thus  four  stages  in  the  course  of  such  an  affection  of  the 
orbit ;  first,  the  stage  of  pure  inflammation  ;  secondly,  that  of  abscess ; 
thirdly,  that  of  fistula  ;  and  fourthly,  that  of  distortion  of  the  eyelids. 

1.  Caries  of  external  margin  of  the  orbit. — Chronic  inflammation  of  the 
bones  of  the  orbit  occurs  more  frequently  at  the  outer  inferior  angle  of  that 
cavity  than  at  any  other  part  of  its  extent.  The  occasion  of  the  disease  is 
commonly  found  to  have  been  a  fall  or  blow ;  and  the  patients  are  generally 
children  who  have  suffered,  or  are  still  suffering,  from  scrofulous  affections  of 
other  bones,  or  of  other  organs.  Over  the  malar  portion  of  the  edge  of  the 
orbit,  generally  with  pain  and  external  redness,  but  occasionally  without 
either,  a  swelling  makes  its  appearance,  and  by  and  by  is  felt  to  fluctuate. 
One  or  both  lids  generally  become  at  the  same  time  cedematous,  the  conjunc- 
tiva reddens,  the  eye  is  intolerant  of  light,  and  the  patient  is  more  or  less 
feverish.  The  swelling  becomes  dark-red,  and  more  and  more  prominent ; 
it  points  through  the  skin,  breaks,  and  discharges  thin  matter.  The  opening 
thus  formed  is  close  to  the  edge  of  the  orbit.  The  swelling  falls,  but  does 
not  go  entirely  away.  The  external  redness  continues,  with  scrofulo-catarrhal 
inflammation  of  the  conjunctiva.  The  matter  discharged  from  the  opening 
is  generally  thin,  but  sometimes  thick  and  curdy,  and  occasions  excoriation 
of  the  neighboring  skin.  The  edge  around  the  opening  becomes  inverted, 
and  adherent  to  the  periosteum.  On  introducing  a  probe,  the  periosteum 
feels  as  if  swollen  and  loosened  from  its  natural  attachment  to  the  bone,  and, 
in  general,  the  bone  is  bare  and  rough.  *  The  oedema  falls,  and  the  conjunc- 
tivitis subsides,  except  that  a  few  vessels  continue  to  run  towards  the  cornea, 
which  is  often  nebulous.  By  the  sinking  of  the  skin,  the  lid  is  dragged 
towards  the  sinus,  is  much  everted  (Fig.  1),  and  ultimately  adheres  to  the 
periosteum.  The  longer  the  discharge  continues,  with  caries  probably  and 
small  exfoliations,   so  much  the  more   intimate  are  the  adhesions.     On 


•76 


CARIES  AND   NECROSIS   OF   THE   ORBIT. 


Fig.  1. 


Fig.  2. 


dissecting  a  scrofulous  child,  in  whom  an  adhesion  existed  between  the  lower 

lid  and  the  edge  of  the  orbit,  in  consequence 
of  the  caries  of  the  latter,  Dr.  Ammon"  found 
so  intimate  a  union  of  the  bone,  periosteum, 
and  thinned  but  indurated  lid,  that  it  was 
impossible  to  separate  these  several  parts  ; 
they  formed  a  firm,  cartilaginous-like,  fibrous 
mass. 

Caries  of  the  malar  bone  occurs  also  in 
the  adult,  but  follows  a  more  tedious  course, 
sometimes  ending  fatally.^ 

2.  Caries  just  within  the  cavity  of  the 
orhit. — I  have  met  with  several  cases,  in 
which  a  fluctuating  swelling  having  risen 
just  under  the  eyebrow,  generally  about  its 
middle,  and  having  given  way  and  discharged 
matter,  a  fistulous  opening  continued  for  a 
length  of  time,  leading  to  a  rough  and  bare  portion  of  the  roof  of  tlie  orbit. 
Almost  all  the  subjects  of  this  chronic  affection  were  old  people,  unable  to 

assign  any  cause  for  the  inflammation,  which, 
at  first,  wore  the  aspect  of  an  attack  of  ery- 
sipelas. In  one  old  man,  a  patient  at  the 
Glasgow  Eye  Infirmary,  first  the  one  orbit, 
and,  after  it  healed  uj),  the  other  also  became 
aff"ected.  In  one  individual,  considerable 
shortening  of  the  lid  was  produced,  so  much 
so  that  the  eye  being  imperfectly  covered,  it 
inflamed,  and  an  abscess  formed  in  the  cornea. 
I  am  unable  to  say  what  was  the  ultimate  result 
in  this  case  ;  butthf^re  was  reason  to  fear  that 
the  cornea  would  give  way,  and  the  eye  become 
staj)hylomatous.  In  the  greater  number  of 
^^.^  cases  of  this  sort  (Fig.  2)  wliich  I  have  seen,  the 

~"°^  fistulous  opening  has  ultimately  closed,  with- 

out leaving  any  considerable  lagophtlialmos. 

3.  Secondary  caries  of  the  fossa  iachry/na/is. — A  snpimratiou  within  the 
orbit,  close  to  the  external  angular  process  of  the  frontal  bone,  followed  by 

a  fistulous  opening  leading  to  the  fossa 
lachrymalis,  and  ultimately  attended  with  a 
great  degree  of  ectropium  and  lagophtlial- 
mos (Pig.  3),  occurs  not  unfrequently  in 
scrofulous  children,  and  is  generally  re- 
garded as  the  result  of  inflammation  of  the 
lachrymal  gland.  The  inflammation  is  sup- 
posed to  spread  from  the  gland  to  the 
periosteum,  which,  separating  from  its 
natural  connections,  or  secreting  pus  on 
its  internal  surface,  the  bone  takes  on 
inflammation,  falls  into  a  state  of  ulcera- 
tion, or  perishes  to  a  certain  extent  by 
necrosis. 

4.  Deep-seated  secondary  caries  of  the  orbit. — Inflammation  of  the  orbital 
cellular  substance,  going  on  to  suppuration,  may  take  place,  more  or  less 
deeply,  within  the  cavity  of  the  orbit;  between  the  orbitary  plate  of  the 
frontal  bone,  and  the  levator  palpebral  superioris;  or  below  the  eyeball,  be- 


Fig.  3. 


CARIES   OF   THE   ORBIT.  77 

tween  the  rectus  inferior  oeuli,  and  the  floor  of  the  orbit.  Inflammation  and 
suppuration  in  these  situations  are  attended  with  pain  and  fever,  immobility 
and  distortion  of  the  eyeball,  and  much  swelling  of  the  eyelids.  If  the  disease 
be  understood  from  the  first,  and  treated  on  an  active  antiphlogistic  plan, 
suppuration  may  probably  be  prevented ;  if  matter  has  actually  formed,  any 
very  serious  or  extensive  injury  may  still  be  obviated  by  opening  the  abscess 
sufficiently  early ;  but  neglected  or  misunderstood,  an  abscess,  even  when  not 
very  deeply  seated,  but  perhaps  pointing  and  fluctuating  through  one  or 
other  eyelid,  may  spread  its  mischief  to  the  periosteum  and  bones,  or  in- 
sinuate itself  into  some  of  the  neighboring  cavities  ;  into  the  nostril  by  the 
lachrymal  passage,  into  the  zygomatic  fossa  by  the  spheno-maxillary  fissure, 
into  the  maxillary  sinus  through  the  floor  of  the  orbit,  into  the  frontal  sinus, 
or  even  into  the  cavity  of  the  cranium,  through  the  orbitary  plate  of  the 
frontal  bone.  The  matter  will  penetrate  through  the  bones  in  the  last  three 
cases,  by  the  process  technically  called  progressive  absorption ;  a  process  by 
which  the  bones  pressed  upon  are  thinned  and  partially  removed,  but  are 
seldom  left  in  the  state  either  of  caries  or  necrosis.  It  is  where  there  is  no 
perforation  from  the  orbit  into  the  neighboring  cavities,  but  merely  an  ex- 
tension of  inflammation  to  the  periosteum  and  bones,  that  caries  or  necrosis 
is  most  apt  to  take  place. 

Of  a  still  more  dangerous  character  is  inflammation  in  the  back  part  of  the 
orbit,  or  in  the  cellular  membrane  immediately  surrounding  the  optic  nerve. 
Vision  is  always  injured,  and  often  destroyed,  by  suppuration  in  these  situa- 
tions ;  the  eyeball  is  pushed  forward  from  its  natural  place;  not  unfrequently 
exophthahnia  follows  close  upon  this  state  of  exophthalmos  ;  that  is  to  say,  the 
eyeball  is  affected  with  inflammatory  disorganization  as  well  as  protuded  ; 
nay,  I  have  known  deep-seated  abscess  of  the  orbit  to  prove  fatal,  the  patient 
having  for  a  day  or  two  shown  symptoms  of  pressure  on  the  brain,  and  in 
fact  dying  apoplectic.  I  need  scarcely  say  that,  in  such  cases,  the  perios- 
teum and  bones  of  the  orbit  will  be  very  apt  to  suffer,  especially  if  the  dis- 
ease is  prolonged,  and  no  attempt  made  to  evacuate  the  abscess  which  may 
have  formed. 

It  occasionally  happens  that  several  different  portions  of  the  orbit  are 
affected  at  the  same  time,  ending  in  the  formation  of  a  number  of  sinuses, 
passing  through  the  eyelids  in  the  direction  of  the  diseased  pieces  of  bone, 
and  sometimes  opening  in  the  temple.  In  these  cases,  the  integuments  are 
always  puffy  and  greatly  swollen.  Such  a  state  is  commonly  the  result  of 
severe  and  general  inflammation  of  the  orbital  cellular  membrane,  running  on 
into  suppuration.  When  the  floor  or  the  inner  wall  of  the  orbit  is  the  seat 
of  caries  or  necrosis  excited  in  this  way,  we  almost  always  find  that  the  whole 
thickness  of  the  bones  has  to  a  greater  or  less  extent  been  destroyed,  per- 
mitting the  matter  to  drain  from  the  orbit  into  the  nostril  or  into  the  maxil- 
lary sinus.  A  case  of  this  kind  is  related  in  a  desultory  and  tedious  manner, 
by  Demours. 

Case  59. — The  patient  was  a  canon  of  Besan9on,  in  whom  it  would  appear  that  sup- 
puration had  entirely  destroyed  the  cellular  membrane  of  the  orbit,  and  that  a  part  of 
the  upper  lid  had  been  lost  by  gangrene.  The  eyeball  was  destroyed,  the  upper  lid  was 
everted  and  shortened,  and  there  Avere  four  fistulous  openings  into  the  orbit,  two  at  the 
upper  edge,  and  two  at  the  inner  canthus.  Fetid  matter,  mixed  with  curd-like  substance, 
was  discharged,  some  pieces  of  bone  came  away,  and  injections  passed  for  a  time  from 
the  orbit  into  the  maxillary  sinus  and  nostrils;  at  last  the  discharge  ceased,  the  parts 
became  quiet,  the  sinuses  closed,  and  a  glass  eye  was  apphed  to  cover,  as  much  as  pos- 
sible, the  deformity.  The  general  health  does  not  appear  to  have  been  affected.  The 
chief  local  treatment  consisted  in  mild  injections,  frequently  repeated  in  the  course  of  the 
day.^ 

Although  caries  of  the  orbit  is  generally  attended  by  abscess  of  the  soft 


78  CARIES   OP  THE   ORBIT. 

parts  in  its  neighborhood  (if  it  has  not  itself  originated  in  such  abscess), 
the  skin  of  one  or  other  eyelid  inflaming,  and  at  length  giving  way,  and  an 
external  fistula  forming,  yet  cases  may  occur  in  which  the  disease  shall  be 
situated  very  deep  in  the  orbit,  in  the  sphenoid  bone,  for  example,  where  it 
gives  passage  to  the  optic,  or  other  orbital  nerves,  so  that  amaurosis  may  be 
brought  on,  any  suppuration  of  the  soft  parts  lie  long  concealed,  or  even 
death  ensue,  before  any  external  marks  of  the  disease  be  present. 

5.  Syphilitic  caries  of  the  orbit. — When  the  bones  of  the  orbit  inflame 
from  syphilis,  after  pain  in  the  neighborhood  of  the  diseased  part  not  in 
general  acute,  there  appears  a  swelling  of  the  eyelid,  slightly  red  at  first,  and 
but  little  painful  to  the  touch,  but  which  slowly  advances  in  redness,  pain, 
and  prominence,  till  it  is  felt  to  fluctuate,  and  either  bursts  of  itself,  or  is 
opened  with  the  lancet.  It  is  but  rarely  that  an  opportunity  is  afforded  of 
watching  the  invasion  and  progress  of  such  a  case.  Much  more  frequently 
the  patient  applies  for  aid,  only  after  the  abscess  has  burst  and  discharged 
matter  for  a  length  of  time. 

It  is  evidently  impossible  to  decide,  from  a  mere  examination  of  the  dis- 
eased bone,  what  has  been  the  nature  of  the  inflammation  in  which  the  caries 
or  necrosis  has  originated,  whether  syphilitic,  or  scrofulous,  or  of  what  other 
kind.  We  must  refer  to  the  history  of  the  case  and  the  constitutional  symp- 
toms, in  order  to  determine,  if  possible,  this  point. 

In  syphilitic  cases,  we  might  be  led  to  expect  considerable  pain,  aggravated 
during  the  night.  Other  bones,  besides  those  of  the  orbit,  are  likely  in  such 
cases  to  be  aff"ected  with  similar  disease.  The  bones  of  the  nose,  and  the 
frontal  bone  where  it  forms  the  forehead,  are  much  more  apt  to  be  affected 
with  syphilitic  inflammation,  than  are  the  walls  of  the  orbit.  In  a  case  which 
I  saw,  both  orbits  were  affected,  and  it  appeared  that  the  patient  had  had  a 
similar  disease  of  the  right  acromion,  a  painful  node  on  the  left  side  of  the 
forehead,  and  repeated  chancres  and  buboes,  during  the  eighteen  months 
l)receding  the  disease  of  the  orbits.  Such  a  history  naturally  led  to  the  con- 
clusion that  the  disease  of  the  orl)its  was  syphilitic." 

Prognosis. — It  is  evident  that  both  the  prognosis  and  the  treatment  will  be 
diiferent  in  different  cases.  In  a  healthy  adult,  in  whom  the  affection  of  the 
bones  is  the  result  of  an  injury,  the  prognosis  will  be  much  more  favorable, 
and  the  treatment  more  simple,  than  in  a  scrofulous  child,  or  an  individual 
whose  constitution  is  imbued  with  syphilis,  or  impaired  by  frequent  courses 
of  mercury. 

In  respect  to  the  prognosis,  I  may  mention  that  the  eye  is  in  danger,  of 
being  destroyed  in  caries  of  the  orbit,  simply  in  consequence  of  the  lagoph- 
thalmos,  or  incapability  of  closing  the  eye.  In  almost  every  case  of  caries 
of  the  orbit  which  I  have  seen,  there  was  either  eversion,  or  lagophthalmos, 
or  both ;  and  in  consequence  of  the  eyeball  being  but  partially  covered  when 
the  patients  attempted  to  shut  the  eyes,  there  was  always  inflammation  of  the 
conjunctiva,  sometimes  inflammation  and  nebula  of  the  cornea.  In  an  in- 
stance to  which  I  have  already  referred,  in  which  the  lagophthalmos  was  to  a 
great  extent,  the  upper  eyelid  being  permanently  drawn  upwards  and  back- 
wards into  the  orbit,  so  that  a  very  considerable  portion  of  the  eyeball  was 
continually  exposed  to  the  contact  of  the  air  and  of  foreign  particles  floating 
through  it,  there  were  pustule  of  the  cornea  and  onyx.  I  was  consulted  only 
once  in  this  case,  but  I  have  no  doubt  that  the  cornea  would  soon  after  be  so 
much  aff"ected  as  to  give  way,  and  the  eye  be  ultimately  left  staphylomatous 
or  atrophic.  The  caries  alfected  the  roof  of  the  orbit  immediately  behind  the 
middle  of  the  su])ra-orbitary  arch. 

When  the  caries  of  the  orbit  proceeds  unchecked  for  years,  especially  in 
scrofulous  or  syphilitic  cases,  one  or  other  eyelid  may  be  completely  destroyed. 


CARIES   OF   THE   ORBIT.  ^2 

with  the  exception,  perhaps,  of  its  ciliary  edge.  In  this  case,  large  folds  of 
inflamed  conjunctiva  are  permanently  protruded. 

Treatment. — The  treatment  will  vary  according  to  the  different  stages  of 
the  disease.  In  the  Jirst  or  purely  inflammatory  stage,  it  should  be  solely  an- 
tiphlogistic, our  object  being  to  prevent  suppuration.  In  the  second  stage, 
namely,  that  of  abscess,  we  must  endeavor  to  procure  absorption  of  the  mat- 
ter, or  give  it  vent  externally.  In  the  third  stage,  namely,  that  of  fistula,  our 
object  is  to  arrest  the  ulcerative  process  going  on  in  the  bone,  and  to  promote 
exfoliation  of  any  part  of  it  which  may  be  in  the  state  of  necrosis.  In  the 
fourth  stage,  or  that  of  distortion,  the  ends  we  have  in  view  are  to  bring  the 
lid  into  a  natural  position,  and  to  obviate  the  bad  effects  arising  from  the 
exposed  state  of  the  eyeball. 

The  treatment  in  the  first  and  second  stages  is  so  obvious,  that  I  need  not 
enter  into  a  detail  of  particulars.  The  remarks  which  follow,  refer  chiefly  to 
the  treatment  to  be  followed  in  the  third  and  fourth  stages. 

It  is  evident,  then,  that,  in  thejirst  or  inflammatory  stage,  leeches  should  be 
applied  liberally  around  the  orbit.  I  am  the  more  disposed  to  advise  this  in 
all  cases  of  contusion  of  the  edge  of  the  orbit,  from  having  met  with  cases  of 
this  kind  which,  having  been  thought  of  too  lightly,  and  therefore  not  treated 
with  leeches,  ran  the  course  already  described;  but  which,  it  is  probable, 
might  have  been  prevented  from  doing  so,  had  proper  antiphlogistic  means 
been  employed. 

Some  advantage  may  be  obtained  by  the  use  of  counter-irritation.  In  some 
cases,  mercury  cautiously  exhibited,  will  do  good ;  in  a  greater  number, 
iodide  of  potassium. 

Antiphlogistic  and  sorbefacient  means  failing  to  prevent  or  to  dissipate 
suppuration,  the  abscess  which  has  formed  in  the  second  stage  is  to  be  opened 
through  the  conjunctiva,  if  possible ;  but  if  this  cannot  be  accomplished,  then 
through  the  skin,  only  as  far  from  the  edge  of  the  eyelid  as  can  be  conveni- 
ently done,  in  order  to  avoid  the  eversion  which  is  apt  to  follow. 

Case  60. — A  scrofulous  child,  six  years  old,  received  a  blow  on  the  external  inferior 
part  of  the  orbit ;  but  suffered  nothing  afterwards  from  it  for  several  months.  When  Dr. 
Cunier  saw  it  for  the  first  time,  he  found  at  the  external  angle  of  the  eye,  a  fluctuating 
swelling,  which  he  opened  thrcmgh  the  conjunctiva.  An  abundant  quantity  of  pus,  mixed 
with  blood,  escaped.  On  passing  a  probe,  he  found  that  a  portion  of  the  edge  of  the 
orbit  was  loose.  Next  day,  he  succeeded  in  laying  hold  of  it  with  forceps,  and  detaching 
it.  It  measured  4  lines  long  by  2  broad,  and  was  completely  necrosed.  In  seven  days, 
the  wound  of  the  conjunctiva  healed.  Alterative  doses  of  calomel,  followed  by  cod-liver 
oil,  and  baths  impregnated  with  iodine,  were  used;  and  the  patient  perfectly  recovered. 
The  depression  at  the  external  angle,  at  first  considerable,  became  effaced,  so  as  to  leave 
only  a  slight  degree  of  deformity.'" 

It  may  sometimes  happen,  in  cases  of  abscess  over  the  edge  of  the  orbit, 
that  the  bone  is  merely  denuded,  in  which  case  an  early  and  pretty  free  inci- 
sion is  likely  to  prevent  the  bone  from  suff"ering  in  the  way  it  would  certainly 
do  by  delay.  Opening  scrofulous  abscesses  in  this  situation  by  caustic  potass, 
rather  than  the  knife,  has  been  recommended. 

In  the  third  stage,  our  object  is,  if  the  disease  be  caries,  to  arrest  the 
ulcerative  process  going  on  in  the  bone;  if  necrosis,  to  promote  the  separa- 
tion and  expulsion  of  the  portion  which  is  dead. 

It  will  rarely  be  possible  to  decide,  at  first  sight,  whether  the  bone  which 
is  felt  bare  with  the  probe,  is  carious  or  necrosed,  or  whether  both  caries  and 
necrosis  are  present.  The  exact  condition  of  the  diseased  bone  will  become 
evident  only  in  the  course  of  the  cure,  from  the  sensations  communicated 
through  the  medium  of  the  probe,  the  fetor  emitted,  the  appearances  of  the 
discharge,  and  the  te.xture  and  size  of  the  pieces  of  bone  which  come  away. 

We  shall  seldom  be  able  to  assist  in  arresting  the  ulcerating  process,  or  in 


80  •  CARIES   OF   THE   ORBIT. 

promoting  exfoliation,  without  dilating  the  opening  communicating  with  the 
diseased  hone.     This  may  be  done  partly  with  the  knife,  partly  with  tents.  ^ 
The  iistula  may  first  of  all  be  enlarged  by  means  of  a  bistoury  ;  and  then  kept 
open  by  a  dossil  of  lint,  dipped  in  oil,  and  pushed  along  until  it  comes  into 
contact  with  the  diseased  bone. 

In  cases  of  children,  or  of  adults  who  are  afraid  of  the  knife,  we  may  be 
induced  to  dilate  the  fistula  by  sponge-tent,  although  this  is  in  fact  the  more 
painful  method  of  the  two,  so  painful,  indeed,  that  it  sometimes  cannot  be 
borne.  If  there  are  fungous  granulations  round  the  opening  of  the  fistula, 
these  may  first  of  all  be  destroyed  with  lunar  caustic.  A  piece  of  sponge-tent, 
cut  into  the  form  of  a  pencil,  is  then  to  be  introduced,  and  kept  in  for  10  or 
12  hours.  Thicker  and  thicker  pieces  of  sponge-tent  are  then  to  be  employed, 
till  the  opening  becomes  large  enough  to  admit  a  dossil  of  lint,  which  is  to  be 
renewed  daily. 

Some  surgeons  rest  contented  with  soothing  applications.  Others  recom- 
mend various  means  for  cauterizing  the  exposed  bone,  especially  red  precipi- 
tate in  i)0wder,  lunar  caustic,  either  solid  or  in  solution,  the  mineral  acids, 
and  phosphoric  acid.  The  risk  of  such  substances  producing  fresh  attacks  of 
inflammation  in  the  l)one,  and  thus  extending  the  disease,  seems  greater  than 
any  chance  of  benefit  to  be  derived  from  their  use.  In  general,  no  cure  takes 
place,  unless  bone  comes  away.  The  coming  away  of  the  bone  is  not  always 
evident.  It  sometimes  separates  in  minute  scales,  sticking  to  the  dossil  of 
lint,  or  washed  out  by  the  injections  which  are  used;  while,  in  other  cases,  a 
considerable  portion  is  thrown  oft"  at  once,  is  felt  with  the  probe  to  be  loose, 
and  is  to  l)e  extracted  with  a  small  scoop  or  pair  of  forceps.  There  is  no 
stated  time  for  the  necessary  exfoliation  in  such  cases.  It  may  take  place  in 
a  month;  or  many  months  may  elapse  before  the  diseased  bone  is  discharged. 
It  is  in  cases  originating  from  injiuy  that  the  most  extensive  exfoliation  takes 
place.  As  soon  as  we  judge  it  probal>le  that  the  whole  diseased  part  has 
been  removed,  we  lay  aside  the  dossil  of  lint,  and  allow  the  opening  to  close. 

I  do  not  imagine  that,  in  cases  of  caries  or  necrosis  of  the  bones  of  the 
orbit,  there  ever  is  any  considerable  formation  of  new  bone.  All  that  nature 
eJTects  in  such  cases  is,  I  believe,  a  heaping  up  of  the  diseased  part,  a  bony 
cicatrice,  without  any  attempt  to  restore  what  has  been  removed  by  ulcerative 
absorption,  or  by  exfoliation.  Fortunate,  indeed,  must  the  case  be  regarded, 
when  the  former  process  ceases,  or  the  latter  is  completed,  so  that  the  diseased 
bone  may  granulate  and  heal,  and  the  external  wound  be  allowed  to  close, 
and  this  without  any  greater  deformity  than  a  deeply  sunk  cicatrice. 

It  mav  sometimes  happen  that  we  are  deceived  in  regard  to  the  state  of  the 
bone.  The  fistula  may  even  close,  and  yet  the  bone  continue  diseased.  Gra- 
nulations may  fill  up  the  sinus,  without  its  bottom  being  sound.  Perhaps 
some  trifling  exfoliation  has  taken  place,  without  the  whole  diseased  piece  of 
bone  having  come  away;  and  the  surgeon,  misled  by  appearances  and  think- 
ing that  all  is  right,  does  his  best  to  close  up  the  sinus.  Nothing,  however, 
is  gained,  if  the  bone  is  still  left  in  a  state  of  disease.  On  the  contrary,  we 
are  only  obliged  to  go  over  again  the  same  process  of  dilatation,  and  to  wait 
for  renewed  exfoliation.  Perhaps,  to  scrape  the  diseased  surface,  or  scoop  it 
out  with  a  gouge,  may  be  advisable  in  such  a  case. 

The  exfoliation  and  heaping  up  of  diseased  bone  is  throughout  an  organic 
process,  and  may  unquestionably  be  assisted  by  whatever  remedies  tend  to 
support  or  improve  the  general  health.  In  syphilitic  cases,'  mercury,  sarsa- 
parilla,  and  other  anti-venereal  remedies,  are  to  be  employed.  In  scrofulous 
cases,  tonics,  such  as  sulphate  of  quinia,  along  with  a  nourishing  diet  and 
country  air,  will  be  found  of  use.  I  have  no  experience  of  the  power  of 
assafoetida,  and  a  variety  of  other  internal  remedies,  which  have  gained  a 


I 


LAGOPHTHALMOS   FROM   CARIOUS   ORBIT. 


81 


.  reputation  for  promoting  the  exfoliation  and  healing  up  of  bones.  If  they 
act  at  all,  they  probably  do  so  merely  as  stimulants  or  tonics,  without  any  of 
the  specific  power  over  diseased  bone  which  has  been  ascribed  to  them.  In 
many  cases,  iodide  of  potassium  and  cod-liver  oil  will  be  found  advantageous. 

Unless  when  the  separation  of  the  diseased  portion  of  bone  and  the  healing 
up  of  the  sinus  have  been  more  than  commonly  prompt,  it  is  rarely  the  case 
that  recovery  takes  place  without  a  considerable  degree  of  distortion  of  the 
eyelids,  constituting  i\\%  fourth  stage. 

The  lagojihthalmos,  in  such  cases,  is  generally  relieved  in  part  by  a  loosening 
of  the  retracted  eyelid,  effected  slowly  by  the  natural  action  of  the  orbicularis 
palpebrarum.  Should  this  prove  insufficient  to  enable  the  eyelids  to  close, 
the  operations  for  ev^'sion  to  be  afterwards  described,  modified  according  to 
the  circumstances  of  the  case,  might  perhaps  prove  useful. 

Case  61. — la  a  patient  who  was  under  ray  care,  at  the  Glasgow  Eye  Infirmary,  with 
caries  of  the  roof  of  each  orbit,  and  lagophthalmos  of  each  upper  eyelid,  the  eyelids  came 
very  gradually  to  close  more  and  more  upon  the  eyeballs.  For  a  time,  however,  the 
lagophthalmos  was  to  such  a  degree,  as  to  leave  the  conjunctiva  constantly  exposed  to  the 
irritation  of  the  air,  and  the  particles  of  dust  floating  through  it.  The  conjunctivitis  and 
corneitis  thereby  excited,  I  treated  chiefly  by  the  application  of  lunar  caustic  solution, 
till  the  elongation  of  the  eyelids,  produced  by  the  action  of  the  orbicularis  palpebrarum 
in  winking,  rendered  the  lagophthalmos  gradually  less  and  less,  and  served  at  length  to 
permit  the  eyeballs  to  be  almost  completely  covered.  When  this  patient  was  dismissed, 
the  sinuses  had  long  been  healed.  There  still  remained  a  slight  speck  on  one  of  the  cor- 
neas; and  an  evident  deficiency  was  felt  at  the  part  of  each  orbit  which  had  been  the  site 
of  the  caries.  The  solution  of  four  grains  of  lunar  caustic  to  the  ounce  of  distilled  water 
was  of  signal  service  in  this  case,  moderating  the  external  inflammation  of  the  eyeballs, 
brought  on  from  their  state  of  exposure,  and  in  fiict  saving  the  eyes,  till  the  natural 
apparatus  of  protection  was  in  a  great  measure  restored  to  the  exercise  of  its  oflBce. 

In  cases  of  more  considerable  lagophthalmos,  it  is  curious  to  observe  the 
degree  of  accommodation  effected  by  the  lid  which  is  free,  for  supplying  the 
defective  action  of  the  lid  which  is  fixed,  so  as  to  lubricate  the  eyeball  in  the 


Fig.  4. 


Fig.  5. 


From  Am  men. 


From  Ammon. 


act  of  winking,  and  protect  it  from  the  intrusion  of  foreign  particles.  The 
upper  lid,  for  example,  being  fixed  to  the  root  of  the  orbit,  the  appearance, 
when  the  eye  is  open,  is  such  as  is  represented  iu  Fig.  4;  when  the  individual 
winks,  the  upper  lid  not  being  capable  of  descending  over  the  eye,  the  vicari- 
ous lower  lid  is  thrust  up,  as  in  Fig.  5,  so  as  to  meet  the  upper  lid,  and  almost 
to  cover  the  eye.  This  muscular  exertion  is,  unfortunately,  available  only 
while  the  patient  is  awake. 

I  need  scarcely  say  that  it  would  be  folly  to  attempt  the  cure  of  the  eversion 
consequent  to  diseased  orbit,  if  the  fistula  were  still  open,  or  the  bone  unsound. 
Were  we  to  detach  the  eyelid  from  the  edge  of  the  orbit  to  which  it  is  fixed, 
6 


82  PERIOSTOSIS   OF   THE   ORBIT. 

replace  it  in  its  natural  position,  and  endeavor,  by  some  operative  manipula- 
tion, to  make  it  sit  close  upon  the  eyeball,  we  should  merely  lose  our  labor ; 
for  the  disease  of  the  bone  not  being  removed,  the  eyelid  would  very  soon 
return  to  its  former  malposition.  The  operative  means  to  be  adopted  after 
the  bone  is  perfectly  healed,  we  shall  consider  more  fully  in  the  third  chapter, 
under  the  head  of  Ectropium. 


'■  On  Diseases  of  Bone,  consult  Cumin,  Edin-  '  Dublin  Journal  of  Medical  Science;  Vol.  ix. 

burgh  Medical  and  Surgical  Journal ;  Vol.  xxiii.  p.  255  ;  Dublin,  1836.     Ibid.  vol.  xxvii.  p.  385; 

p.  3 ;  Stanley  on  Diseases  of  the  Bones,  Lon-  Dublin,  1845. 

don,  1849:  Goodsir,  Monthly  Journal  of  Medical  '  Zeitschrift  fUr  die  Ophthalmologic  ;  Vol.  i. 

Science  ;  Vol.  x.  p.  H9  ;  Edinburgh,  1850.  p.  41  ;  Dresden,  1830. 

■^  Demours,  Traite  des  Maladies  des  Yeux;  '  Haynes    Walton's    Operative    Ophthalmic 

Tome  i.  p.  91  ;  Paris,  1818.  Surgery,  p.  229;  London,  1853. 

"  Pathological  and  Practical  Kesearches  on  '  Op.  cit.;  Tome  ii.  p.  33.     See  Case  by  St. 

Diseases  of  the  Brain  and  Spinal  Cord;  p.  29;  Yves,  Nouveau  Traite  des  Maladies  des  Yeux, 

Edinburgh,  1829.  p.  SO  ;  Paris,  1722. 

■"  Quoted  by  Dr.  Abercrombie  from  new  series  '  For  cases  of  Syphilitic  Caries  of  the  Orbit, 

of  Journal  de  Medecine  ;  Tome  xi.  p.  623.     See  see  Uawkins,  Msdical  and  Physical  Journal; 

Caseof  Periostitis  of  the  Face,  extending  to  Dura  Vol.  Ivii.  p.  318;  London,  1827  ;  Listen,  Medical 

Mater,    in    a   paper   on    Periostitis,  by  Sir  P.  Gazette,  Vol.  v.  p.  843;  London,  1830. 

Crampton  ;  Dublin  Hospital  Reports ;  Vol.  i.  p.  '°  Annales   d'Oculistique  ;    Tome    vii.  p.  8; 

337  ;  Dublin,  1818.  Bruxelles,  1842. 


SECTION   in. — PERIOSTOSIS,    HYPEROSTOSIS,   EXOSTOSIS,    AND   OSTEO-SARCOMA  OF 
THE  ORBIT,  AND  CYSTS  IN  ITS  PARlETES.* 

Periostosis  signifies  a  thickening  of  the  periosteum  ;  Hyperostosis,  an  in- 
crease of  the  bulk  or  thickness  of  bones ;  exostosis,  a  bony  tumor ;  osteosarcoma, 
a  degeneration  of  bone,  generally  malignant,  in  which  it  is  converted  into  a 
soft  mass,  with  numerous  osseous  spiculae  radiating  through  it.  To  all  these 
diseases,  the  orbit  is  subject ;  as  well  as  to  the  development  of  cysts  in  its 
parietes. 

§   1,  Periostosis. 

A  node,  or  periostosis,  may  form  on  the  surface  of  any  bone  ;  on  the  ex- 
ternal surface  of  the  skull,  or  within  the  orbit.  I  have  seen  a  large  venereal 
node  occupying  the  upper  edge  of  the  orbit.  Exostosis  is  often  combined 
with  greatly  thickened  periosteum, 

A  node  is  not  unfrequently  affected  with  secondary  inflammation  ;  it  then 
becomes  more  swollen,  and  tender  to  the  touch  ;  it  communicates  a  feeling  of 
fluctuation,  and  a  flow  of  matter  is  looked  for  on  dividing  it  with  the  knife. 
Pus  is  sometimes  discharged  under  such  circumstances,  while  in  other  cases 
only  a  reddish  serum  escapes  by  the  incision. 

Periostosis  of  the  orbit,  except  when  syphilitic,  and  brought  under  the  in- 
fluence of  mercury,  or  iodine,  is  not  likely  to  be  either  readily  recognized  or 
successfully  treated.* 

An  incisfon,  down  to  the  bone,  is  certain  to  relieve  the  severe  pain  and 
tension  of  a  node ;  but  as  the  consequences  of  this  practice  are  generally  an 
unhealthy  tedious  suppuration,  perhaps  also  an  exfoliation  of  bone,  and  cer- 
tainly a  very  unseemly  depressed  cicatrice,  repeated  blisters  over  the  part,  and 
the  use  of  mercury  or  iodine  internally,  ought  first  to  be  tried.  These  means 
are  often  successful  in  causing  absorption  of  the  eff'used  fluid,  and  procuring 
adhesion  of  the  periosteum  and  integuments  to  the  surface  of  the  bone,  which 
may  then  present  a  depression  in  place  of  an  elevation.  [The  subcutaneous 
division  of  the  periosteum  to  relieve  the  tension,  and  consequent  pain,  in  a 
node,  or,  in  periostitis,  by  means  of  a  fine  tenotome,  introduced  through  the 


HYPEROSTOSIS   OF   THE   ORBIT.  83 

skin,  at  some  distance  from  the  seat  of  the  disease,  is  the  method  we  should 
always  recommend  in  preference  to  free  incision  by  the  bistoury  or  scalpel. 
For,  by  such  a  procedure,  the  strangulation  of  the  tissue  is  as  readily  relieved 
as  by  the  simple  incision;  and  the  occurrence  of  the  evil  consequences  of  the 
latter  method,  the  unhealthy,  tedious  suppuration,  the  exfoliation,  and  the 
very  unseemly  depressed  cicatrix,  are  entirely  avoided.  "We  think  that  this 
plan  should  have  precedence  of  counter-irritation ;  it  failing  (which  it  will  be 
found  very  rarely  to  do),  then  we  may,  with  great  propriety,  try  the  discussion 
of  the  disease  by  the  means  above  indicated  before  laying  open  the  part  by  a 
free  incision. — H.] 

Other  specific  diseases,  besides  syphilis,  may  cause  thickening  of  the  peri- 
osteum of  the  orbit.' 

§  2.   Hyperostosis.  . 

Inflammation  of  a  bone  being  arrested  before  the  occurrence  of  disorgani- 
zation or  death  of  the  part,  the  consequence  is  sometimes  hyperostosis.  It  is 
a  variety  of  this  process  which,  in  some  cases,  and  these  generally  complicated 
with  atrophy  of  the  brain,  slowly  thickens  the  bones  of  the  cranium,  without, 
perhaps,  exciting  any  suspicion  of  the  existence  of  such  a  state,  till  epilepsy 
or  mania,  and  ultimately  death,  are  produced.  The  bones  of  the  orloit  are 
liable  to  the  same  process;  the  cavity  will  thereby  be  intruded  upon,  its 
contents  pressed  together,  and  the  eyeball  pushed  forward  from  its  natural 
place,  and  at  last  destroyed. 

I  have  now  before  me  the  skull  of  an  Indian  child,  probably  about  six  years 
of  age,  which  was  picked  up  as  it  rolled  down  the  Ganges.  There  has  been 
ostitis  of  the  roof  of  each  orbit ;  but  in  the  left  one  the  affected  bone  is  ele- 
vated into  a  hyperostosis,  and  the  surface  marked  by  numerous  orifices  of  the 
Haversian  canals  greatly  expanded. 

I  have  also  before  me  an  adult  male  Indian  skull,  thickened  and  altered 
from  ostitis.  Although  a  small  skull,  it  weighs,  without  the  lower  jaw,  1 
pound  15^  ounces.  The  bony  palate  has  been  in  a  considerable  measure 
destroyed  by  caries.  The  left  parietal  bone,  and  the  margins  of  both  orbits, 
are  thickened  and  covered  with  osseous  protuberances,  the  fibres  of  which 
present  in  several  places  a  stellated  arrangement. 

In  some  cases,  the  whole  bones  of  the  head  are  affected  with  hypertrophy. 
There  may  be  a  combination  of  hyperostosis  with  exostosis  ;  as  in  the  case 
presently  to  be  quoted  from  Jourdain. 

The  only  treatment  likely  to  be  useful  in  hyperostosis  is  the  employment 
of  alteratives. 

Case  62. — Hyperostosis  of  the  facial  bones  shutting  up  the  orbits.  Jourdain  has  related 
and  figured  a  remarkable  case  of  hyperostosis  of  the  bones  of  the  skull,  and  especially  of 
those  of  the  face.  The  patient  was  the  son  of  a  surgeon  at  Perpignan.  At  the  age  of 
12  years,  he  was  affected  with  a  lachrymal  tumor  at  the  inner  ang^le  of  the  right  eye, 
which  his  father  opened,  and  which  suppurated  for  a  pretty  long  time.  When  the  tumor 
was  opened,  an  eminence  was  observed  growing  from  the  middle  of  the  nasal  process  of 
the  upper  maxillary  bone,  about  the  size  of  a  small  almond.  It  resisted  diffei-ent  local 
applications,  and  grew,  so  that  in  a  short  time  it  was  a  considerable  tumor.  By  the  time 
that  the  patient  was  15,  his  two  upper  maxillary  bones  were  equal,  and  presented  two 
eminences  so  considerable,  that  they  served  to  bury  between  them  the  cartilages  of  the 
nose,  and  so  compressed  the  nostrils  that  the  patient  could  breathe  only  by  the  mouth. 
His  school-fellows  could  not  endure  the  deformity  of  his  face ;  yet  they  loved  him  for  his 
wit  and  talents.  Everything  was  done  by  his  father  which  was  likely  to  remove  the  disease, 
but  all  was  ineffectual.  At  the  age  of  20,  his  appearance  was  monstrous,  so  that  hia 
friends  dissuaded  him  from  thinking  of  the  priesthood,  to  which  he  had  intended  to  attach 
himself.  His  lower  jaw  was  also  affected  with  an  enlargement,  which  augmented  more 
and  more.  Although  his  appearance  was  such  as  to  oblige  those  Avho  met  him  to  turn 
away  from  looking  at  him,  he  was  very  inquisitive,  and  would  visit  everything  which  ex- 
cited attention.     He  ate  and  drank  well,  till,  having  reached  his  44th  year,  he  was  attacked 


84  EXOSTOSIS   OF   THE   ORBIT. 

■with  fever,  during  his  convalescence  from  which  he  became  blind.  As  he  recovered 
strength  be  began  to  see  with  bis  left  eye,  and  go  about  alone ;  but  inflammation  of  the 
chest  supervening,  with  suppuration,  and  bloody  expectoration,  he  died. 

On  dissection,  the  left  lung  was  found  almost  destroyed  by  suppuration.  With  the 
greatest  attention,  it  was  impossible  to  discover  any  of  the  muscles  of  the  face.  The  skin 
was  glued  to  the  periosteum.  The  cranium  and  face  were  entirely  exostosed.  The  malar 
and  superior  maxillary  bones  especially  appear,  from  Jourdain's  figure,  to  have  given 
rise  to  a  large  exostosis  on  each  side  projecting  so  as  to  meet  each  other,  and  covering 
the  nose,  and  in  a  great  measure  the  orbits.  The  lower  jaw  also  is  exceedingly  enlarged. 
The  exostoses  were  as  hard  as  marble.  The  cranium  and  face  weighed  5  French  pounds; 
the  lower  jaw  by  itself  weighed  3  pounds  3  ounces;  the  whole  together,  8  pounds  3 
ounces;  whereas,  an  ordinary  adult  skull,  including  the  lower  jaw,  weighs  generally  about 
1  pound  9  ounces,  or  at  most  1  pound  and  3  quarters;  so  that  taking  the  pound  at  16 
ounces,  the  exostoses  had  augmented  the  weight  of  the  head  6  pounds  7  ounces.  This 
patient  had  never  complained  of  pain  in  his  head  or  in  his  lower  jaw.* 

*  §  3.   Exostosis. 

This  is  a  circumscribed  tumor,  consisting  of  newly  formed  osseous  matter. 
Tumors,  presumed  to  be  exostoses  in  an  incipient  state,  have  been  met  with 
within  the  orbit,  wholly  in  a  cartilaginous  state  ;  in  other  cases,  the  tumor 
has  been  partly  cartilaginous,  partly  osseous.  The  cartilaginous  deposition 
is  supposed  gradually  to  undergo  the  change  which  converts  it  into  bone. 
It  is  by  no  means,  however,  a  necessary  step  in  the  process  by  which  an  exos- 
tosis is  formed,  that  there  shall  be  a  preliminary  deposition  of  cartilage. 
Three  varieties  of  exostosis  have  been  distinguished  ;  the  cellular,  the  craggy, 
and  the  ivory ;  the  first  presenting  an  external  crust,  within  which  are  nume- 
rous bony  partitions,  together  with  a  quantity  of  soft  substance,  and  occa- 
sionally hydatids  ;  the  second  consisting  of  a  mixture  of  osseous  laminae  with 
cartilage,  but  without  any  shell ;  the  third,  white  and  dense  throughout,  like 
ivory.  In  the  last,  and  partly  in  the  first,  the  deposit  consists  of  pretty 
perfect  bone  ;  but  in  the  craggy  exostosis,  the  matter  deposited  is  a  sort  of 
false  bone,  not  perfectly  organized.  The  cellular  exostosis  appears  to  be  one 
of  the  diseases  comprehended  under  the  old  name  spina  ventosa.  It  proceeds 
from  the  periosteum,  is  not  preceded  by  cartilage,  seldom  acquires  a  very 
large  size,  and  often  ceases  to  grow.  Several  such  exostoses  occur  not  un- 
frequently  in  the  same  individual.  The  craggy  is  not  so  common.  It  may 
grow  either  from  the  cancelli  or  from  the  periosteum.  The  tumor  has  a 
cartilaginous  covering,  the  periosteum  being  imperfectly  traceable  over  it, 
and  into  its  substance.  The  centre  of  the  tumor  is  generally  bone  :  some- 
times cartilage.  The  ivory  is  exceedingly  dense,  and  of  high  specific  gravity. 
In  composition,  it  does  not  differ  much  from  ordinary  bone.  It  originates  in 
the  diploe,  pressing  the  compact  tissues  of  the  bone  before  it,  and  forms  a 
round  smooth  tumor.  It  is  the  most  frequent  exostosis  affecting  the  orbit, 
tending  at  the  same  time  to  intrude  on  the  cavity  of  the  cranium. 

Symptoms. — Exostosis  springs  in  some  cases  from  the  edge  of  the  orbit ; 
its  nature  is  recognized  by  the  touch  ;  and  as  it  grows,  it  comes  in  part  to 
cover  and  confine  the  eye.  Although,  in  general,  the  touch  will  serve  to 
discriminate  between  exostosis  in  this  situation,  and  any  other  kind  of  growth, 
I  may  mention  that  I  have  seen  a  case  of  scirrhous  tumor  attached  to  the 
edge  of  the  orbit,  and  partly  within  its  cavity,  so  very  firm  in  its  consistence, 
and  unyielding  in  its  attachment,  as  to  have  been  taken  for  an  exostosis,  pre- 
viously to  dividing  the  skin  for  its  extirpation. 

Exostosis  from  the  edge  of  the  orbit  is  sometimes  combined  with  encysted 
tumor,  of  which  I  had  an  instance  at  the  Glasgow  Eye  Infirmary,  in  a  middle- 
,aged  female.     The  encysted  tumor  had  existed  from  infancy,  and  was  at- 
tended with  exostosis  from  the  edge  of  the  frontal  bone,  preventing  the  pa- 
tient from  raising  the  upper  lid.     After  a  gentle  mercurial  course,  the  exos- 


EXOSTOSIS  OF   THE   ORBIT.  85 

tosis  diminislied  so  much  as  to  permit  the  lid  freely  to  exercise  its  functions. 
The  case  was  probably  in  part  syphilitic,  as  the  patient  afterwards  presented 
herself  with  a  suspicious-looking  sore  on  the  arm,  which  healed  under  the 
use  of  mercury. 

Exostosis  may  spring  from  any  side  of  the  orbit.  We  might  perhaps  sup- 
pose it  more  likely  to  grow  from  the  floor  or  from  the  temporal  wall  of  that 
cavity,  than  from  the  thin  bones  which  form  its  roof  and  nasal  side  ;  but  this 
does  not  appear  to  be  the  case.  The  surface  throwing  out  an  exostosis  is 
generally  thickened.  The  most  remarkable  symptoms  produced  by  an  exos- 
tosis within  the  orbit  are  the  following  :  — 

1.  Exophthalmos. — This  is  one  of  the  earliest  symptoms  of  any  kind  of 
growth  within  the  orbit.  Sometimes  the  eye  is  projected  directly  forwards, 
even  when  the  osseous  tumor  is  afterwards  found  to  arise  not  from  the  apex 
of  the  orbit,  but  from  one  or  other  of  its  sides.  More  frequently  the  eye- 
ball is  pushed  forwards  and  to  one  side,  towards  the  nose  or  temple,  upwards 
or  downwards,  according  to  the  size  of  the  orbit  giving  rise  to  the  exostosis. 
If  the  case  is  left  to  itself,  the  protruded  eye  sometimes  inflames  and  bursts. 

2.  Pain. — This  is  very  variable  ;  nor  is  it  easy  to  explain  how  some  suffer 
so  severely,  even  from  a  small  exostosis  within  the  orbit,  while  others  from 
large  tumors  of  this  sort  suffer  but  little.  The  pain  is  communicated  through 
the  fifth  nerve,  and  is  sometimes  felt  in  the  eyeball,  sometimes  deep  in  the 
orbit,  sometimes  in  the  temple. 

3.  Amaurosis. — The  protrusion  of  the  eye  must  be  attended  with  dragging 
of  the  optic  nerve  ;  and  this,  along  with  the  pressure  caused  by  the  tumor, 
generally  induces  dimness  of  sight,  and  at  length  blindness.  Amaurosis  is 
sometimes  the  earliest  symptom.  It  is  wonderful,  however,  to  observe  how 
much  an  eye  is  in  some  cases  protruded  and  displaced  by  an  exostosis,  and 
yet  vision  retained. 

4.  Change  of  form. — Exostosis  often  increases  to  such  a  size  as  considerably 
to  disfigure  and  intrude  upon  the  orbit.  It  advances  so  as  to  be  felt  between 
the  edge  of  the  orbit  and  the  eyeball,  or  even  form  a  considerable  protu- 
berance beyond  the  basis  of  the  orbit.  It  may  fill  so  much  of  the  orbit,  that 
the  eyeball  is  no  longer  contained  in  this  cavity.  It  may  intrude  upon  the 
nostrils,  upon  the  opposite  orbit,  or  even  upon  the  cavity  of  the  cranium, 
and  thus  prove  fatal. 

Diagnosis. — In  exostosis  of  the  orbit,  it  is  often  impossible  to  decide  re- 
garding the  nature  of  the  disease,  before  proceeding  to  operate,  or  before 
the  death  of  the  patient ;  for  exophthalmos,  pain,  amaurosis,  and  deformity 
of  the  orbit,  are  found  to  arise  from  several  other  diseased  states  of  the  parts 
besides  an  osseous  growth  ;  as  encysted  and  other  tumors,  fungus  of  the 
maxillary  sinus,  &c.  In  advanced  cases  of  fungus  of  the  maxillary  sinus, 
other  symptoms,  no  doubt,  attend  those  already  enumerated,  as  softening  of 
the  palate,  distension  of  the  cheek,  and  obstruction  of  the  nostril,  which 
may  serve  to  distinguish  such  cases  from  any  disease  confined  to  the  cavity 
of  the  orbit.  But  between  an  encysted  orbital  tumor,  not  yet  advanced 
so  as  to  press  upon  the  eyelids,  and  a  deep-seated  exostosis,  it  is  often  totally 
impossible  to  discriminate.  The  eyeball  is  merely  extremely  prominent,  and 
the  patient  deprived  of  the  sight  of  that  eye,  without  any  tumor  being  felt,  or 
any  other  diagnostic  symptom  being  present.  Neither  can  we  pretend  to 
decide  in  cases  of  this  dubious  kind,  whether  thickening  merely  of  the  peri- 
osteum, thickening  of  the  bones,  or  such  a  tumor  as  we  call  exostosis,  be  the 
cause  of  the  exophthalmos. 

Prognosis. — Cellular  exostoses  are  said  to  be  occasionally  destroyed  by 
suppuration  and  caries ;  any  such  change  can  scarcely  be  expected  to  take 
place  in  the  craggy,  and  much  less  in  the  ivory  exostoses.  Nor  will  the  mere 
possibility  of  any  exostosis  being  destroyed  by  inflammation,  ever  withhold 


86 


EXOSTOSIS   or   THE   ORBIT. 


Fig.  6. 


US  from  removing  such  tumor  by  operation  ;  for  its  spontaneous  destruction 
must  be  uncertain  and  tedious.  The  ivory  exostosis  is  much  slower  in  its 
progress  than  the  others,  and  sometimes  it  entirely  ceases  enlarging.  If  the 
surface  of  the  tumor  feels  through  the  integuments  nodulated  or  botryoidal, 
it  may  be  concluded  that  it  is  of  ivory  consistence,  with  a  broad  base,  and 
from  its  excessive  hardness  very  difficult  to  extirpate.  If  the  exostosis  is 
small,  and  does  not  seem  increasing,  it  should  not  be  interfered  with. 

Several  preparations  have  been  described,  showing  the  ultimate  result  of 
exostoses  of  the  orbit.  Thus,  Dr.  Baillie,  in  his  Series  of  Engravings,  Illus- 
trative of  Morbid  Anatomy,  has  given  a  figure  of  a  preparation  of  exostosis 
of  the  orbit,  belonging  to  Mr.  Hunter's  museum.  The  figure  (Fig.  6)  shows 
an  inner  view  of  a  section  of  the  fore  part  of  the  cranium.  The  section  had 
been  made  at  such  a  level,  as  to  include  a  small  part  of  each  orbit.  A  tumor 
is  represented  occupying  the  left  orbit,  which  it  has  considerably  dilated, 
and  shooting  for  some  way  across  into  the  other  orbit,  and  backwards  into 
the  cavity  of  the  cranium.  Dr.  Baillie  mentions  that  the  tumor  was  nodu- 
lated, and  presented  a  compactness  of  texture  exactly  like  that  of  ivory. 
Unfortunately  no  history  of  the  case  appears  to  have  been  preserved.*    A 

frontal  bone,  picked  up  in  Lower  Alsace, 
is  described  and  figured  by  Frank,  in  which 
an  exostosis  fills  both  orbits,  projects  far 
upon  the  face,  and  occupies  a  large  portion 
of  the  cranial  cavity.^  These  two  cases 
bear  a  considerable  resemblance  to  the 
masses  of  bone,  not  unfrequently  found 
within  the  cranium  of  oxen,  and  ignorantly 
taken  for  ossifications  of  the  brain. 

Causes. — Besides  venereal  and  scrofulous 
constitutional  disease,  contusions  and  frac- 
tures of  the  orbit  have  been  known  to  give 
rise  to  exostosis.  Cases  of  partial  hyper- 
trophy of  the  osseous  system  seem  some- 
times to  depend  on  a  depraved  condition  of 
the  digestive  organs,  combined  wnth  a  de- 
ficiency of  saline  matter  in  the  urine. 

Treatment. — This  must  consist  in  atten- 
tion to  the  state  of  the  digestive  organs 
and  general  health,  and  in  the  use  of  anti-venereal  and  anti-scrofulous  reme- 
dies.    In  certain  cases,  an  attempt  should  be  made  to  remove  or  destroy 
exostosis  of  the  orbit  by  operation. 

Leeches  round  the  orbit ;  friction  with  mercurial  ointment,  or  with  a  mix- 
ture of  1  part  of  iodide  of  potassium  to  8  of  mild  mercurial  ointment,  or  of 
10  parts  of  muriate  of  ammonia  to  100  of  the  same  ointment ;  and  mercury 
and  iodine  internally  are  worthy  of  trial,  especially  if  a  syphilitic  taint  is 
supposed  to  be  the  cause  of  the  disease.  Local  depletion,  change  of  air, 
mild  alteratives,  iodine,  and  tonics  of  different  kinds,  may  be  tried  in  scrofu- 
lous cases.  Should  these  means  fail,  and  the  disease  be  so  situated  that  it 
can  be  reached,  the  attending  symptoms  may  demand,  that  we  should  either 
attempt  excision  of  the  morbid  growth,  or  endeavor  to  produce  in  it  an 
artificial  necrosis. 

Being  well  exposed,  by  an  incision,  in  some  cases,  through  the  integu- 
ments, and  between  the  fibres  of  the  orbicularis  palpebrarum  ;  in  other  cases, 
by  dissecting  back  the  lids,  divided  either  at  the  commissure,  or  vertically, 
as  seems  most  suitable  ;  the  tumor  is  to  be  stripped  of  its  periosteum,  and 
removed  with  a  strong  scalpel,  a  small  chisel,  or  a  pair  of  cutting  pliers. 


A.  The  inner  8ur£Eu;e  of  the  anterior  part 
of  the  cranium. 

B.  The  rijrlit  orbit. 

C.  The  exostosis,  resembling  ivory,  filling 
the  left  orbit. 


EXOSTOSIS   OF   THE   OEBIT.  87 

If  it  is  connected  by  a  kind  of  pedicle,  it  will  be  more  easily  removed 
in  this  way ;  with  much  more  difficulty,  if  it  grows  by  a  broad  basis.  The 
gouge  and  hammer,  the  saw,  the  trephine,  and  various  other  instruments, 
may  then  be  required.  In  some  cases,  it  may  be  possible  to  separate  the 
entire  exostosis ;  in  other  cases,  portions  of  it  merely.  It  may  sometimes 
happen  that  it  shall  be  broken  into  pieces,  yet  none  of  these  can  be  got  away 
without  severely  lacerating,  or  extensively  dividing,  the  soft  parts.  If  they 
be  left,  suppuration  will  take  place  round  them,  and  then  they  will  come 
away.  The  operation  must,  of  course,  be  executed  very  cautiously,  lest  the 
thin  bones  of  the  orbit  be  fractured,  or  any  injury  done  to  the  eyeball  or  its 
nerves,  in  the  attempts  to  detach  the  exostosis.  The  wound  made  in  expos- 
ing the  exostosis  is  not  likely  to  heal  without  suppuration. 

In  cases  where  it  is  not  possible  immediately  to  detach  an  exostosis  from 
the  bone  whence  it  grows,  it  has  been  proposed  to  divest  the  tumor  of  its 
periosteal  covering,  and  then  leave  the  new  growth,  thus  deprived  of  its 
nourishment,  to  perish  by  exfoliation.  After  stripping  the  tumor  of  its 
periosteum,  it  may  be  rasped  with  a  file,  or  rubbed  with  caustic,  or  with 
nitric  acid,  so  as  to  render  its  destruction  still  more  probable.  In  conse- 
quence of  this,  a  scale  will  drop  off,  or  perhaps  the  whole  exostosis  may 
separate ;  for  unhealthy  structures  die  more  readily  than  healthy.  Cases  are 
recorded  in  which,  after  the  application  of  caustic  to  an  exostosis  of  the 
orbit,  the  tumor  has  in  this  way  mortified,  and  been  thrown  off.  Yet  we 
must  regard  this  as  a  practice  to  be  followed  only  when  immediate  detach- 
ment of  the  diseased  growth  appears  impracticable.  It  is  a  mode  of  cure 
attended  with  much  more  pain,  and  is  much  less  manageable  than  the  use  of 
the  chisel  or  the  cutting  pliers  ;  and,  as  the  tumor  is  very  likely  to  be 
nourished  by  vessels  entering  its  internal,  as  well  as  its  external  surface,  it 
may  fail  altogether.  Ivory  exostoses,  however,  are  so  hard  that  even  a  saw 
makes  little  impression  on  them.  Mr.  Hawkins  thinks  it  better,  therefore,  to 
scrape  them,  and  touch  them  with  nitric  acid  or  pure  potass.'' 

Orbital  exostoses  have  sometimes  been  removed  while  in  the  cartilaginous 
state,  lying  under  the  periosteum.  Mr.  Travers  had  seen  several  cases  of 
this  description  ;  the  tumor  presenting  at  the  nasal  side,  and  appearing  to 
exteud  to  the  bottom  of  the  orbit,  its  anterior  edge  thin  and  bound  down  by 
the  orbital  circumference.  From  its  compressing  the  eye  to  blindness,  and 
pushing  it  out  of  the  orbit,  he  inferred  that  the  tumor  probably  possessed 
considerable  bulk.  He  once  removed,  he  tells  us,  a  tumor  of  this  kind,  on 
the  nasal  side  of  the  orbit,  scraping  it  clean  away  from  the  bone.  It  was  of 
the  hardness  of  cartilage,  and  of  great  extent.  He  is  unable  to  say  whether 
the  disease  returned,  having  lost  sight  of  the  patient  soon  after  the  opei-ation. 
The  impression  he  had  of  the  case  was  unfavorable,  from  the  character  as 
well  as  the  extent  and  connections  of  the  tumor.^ 

Under  certain  circumstances,  it  may  be  advisable  to  remove  the  protruded 
eyeball  in  cases  of  exostosis  of  the  orbit ;  namely,  when  vision  is  destroyed, 
the  pain  distressing,  and  the  osseous  tumor  probably  so  far  back  in  the 
orbit  that  it  could  not  be  extirpated.  The  removal  of  the  protruded  eyeball 
has  also  sometimes  been  resorted  to,  in  cases  of  exostosis  of  the  orbit,  when 
the  symptoms  were  too  obscure  to  lead  to  any  decided  diagnosis. 

Cases. — Although  cases  of  exostosis  of  the  orbit,  minutely  related,  are  not 
very  numerous,  my  limits  prevent  me  from  quoting  except  a  few  of  the  most 
remarkable,  each  serving  to  illustrate  one  or  more  points  of  importance. 

Case  63. — Exostosis  of  roof  of  orbit,  removed  by  operation.  A  female,  between  20  and  80 
years  of  age,  in  good  health,  applied  at  the  Royal  Westminster  Ophthalmic  Hospital,  and 
stated  that,  seven  months  previously,  she  had  noticed  her  right  eye  begin  to  protrude  ; 
the  projection  was  steadily  on  the  increase,  and  the  oi'gan  was  now  directed  downwards. 


88  EXOSTOSIS   OF  THE   ORBIT. 

No  pain  was  felt ;  vision  was  perfect ;  but  the  disfigurement  was  so  detrimental  to  her  as 
a  servant,  that  she  was  anxious  for  its  removal.  On  examination,  it  was  found  that, 
besides  the  symptoms  mentioned,  the  orbital  ridge  was  increased  in  thickness,  and  a  hard 
tumor,  continuous  with  it,  passed  downwards  and  deeply  backwards  into  the  orbit,  so  as 
to  press  upon  the  upper  and  back  part  of  the  eye,  causing  its  projection.  Mr.  Canton, 
having  put  the  patient  under  the  influence  of  chloroform,  made  an  incision  from  the 
external  to  the  internal  angular  process  of  the  frontal  bone,  immediately  below  the  eye- 
brow. The  integuments,  orbicularis  muscle,  and  palpebral  fascia  having  been  cut 
through,  the  dissection  was  continued  into  the  orbit  and  around  the  tumor,  so  as  to  free 
the  latter  from  the  neighboring  and  adherent  soft  parts.  A  small  chisel  was  then  applied 
to  the  accessible  parts  of  the  base  of  the  tumor,  which  by  degrees  became  detached  from 
the  orbital  plate,  and  was  withdrawn  from  between  the  latter  and  the  upper  and  lateral 
part  of  the  eye.  Sutures,  plaster  and  water-dressing  were  applied,  and  the  patient 
recovered  in  a  week,  not  having  had  a  bad  symptom.  Vision  on  the  affected  side  con- 
tinued nearly  as  perfect  as  the  sound  one.  The  exostosis  was  about  the  size  of  a  walnut, 
very  heavy,  formed  externally  of  compact  bone,  while  its  structure  within  presented  a 
close  reticular  character.^ 

Case  64. — Orbital  exostosis  removed  by  operation.  A  carter,  40  years  of  age,  was  admit- 
ted under  Mr.  Haynes  Walton's  care,  at  St.  Mary's  Hospital,  with  an  exostosis  growing 
from  the  upper  edge  of  the  orbit ;  it  had  a  very  broad  base,  was  flattened,  and  its  great- 
est point  of  projection  measured  two  inches.  The  upper  edge  was  covered  by  the  eye- 
brow, which  was  considerably  elevated  ;  the  lower  edge  dipped  into  the  orbit,  touched 
the  globe  of  the  eye,  and,  thrusting  it  downwards  and  outwards,  protruded  it  about  half 
an  inch  beyond  its  fellow,  thereby  nearly  destroying  vision.  The  inner  and  outer  bound- 
aries were  less  marked.  The  surface  was  tuberculated,  and  as  hard  as  stone  ;  the  skin 
was  movable,  and  traversed  by  a  few  vessels. 

When  quite  a  lad,  he  had  fallen  down  stairs,  and  pitched  on  the  front  of  his  head;  two 
months  afterwards,  a  little  swelling  appeared  on  the  orbital  ridge,  and  gradually  increased 
to  the  extent  described.  There  was  no  doubt  as  to  its  true  nature ;  hardness,  immobility, 
slow  growth,  continuity  with  the  bone,  and  absence  of  pain  and  inflammation,  suf&ciently 
marked  the  case. 

Chloroform  having  been  administered,  Mr.  Haynes  Walton  made  an  incision  in  the  line 
of  the  eyebrow,  which  had  been  previou.sly  shaved,  along  the  entire  superior  edge  of  the 
tumor ;  a  second,  from  the  inner  extremity  of  that  to  the  root  of  the  nose ;  and  a  third, 
from  the  outer  extremity  to  a  little  below  the  level  of  the  outer  corner  of  the  lid.  The 
flap  thus  formed  was  then  dissected  down  till  the  lower  part  of  the  tumor  was  reached, 
when  Mr.  Haynes  Walton  passed  a  narrow  saw  between  it  and  the  eyeball,  and  sawed 
from  below  upwards,  endeavoring  to  follow  the  natural  line  of  the  brow.  The  texture  of 
the  mass  was  like  ivory,  and  a  very  long  time  was  occupied  in  getting  through  it.  The 
integuments  were  brought  together  by  suture  ;  union  by  the  first  intention  followed, 
except  at  a  central  spot  of  the  transverse  cut,  through  which  healthy  pus  was  discharged 
for  eight  weeks.  Ultimately,  the  eye  was  restored  to  its  place,  sight  returned,  and  very 
little  indication  existed  of  what  had  been  done.  The  eyebrow,  which  concealed  much  of 
the  scar,  descended  to  its  proper  level,  and  the  lid  could  be  raised  nearly  to  the  extent  of 
its  fellow.'" 

Case  65. — Exostosis  of  the  orbit,  consequent  to  an  injury,  remolded  u-ith  difficulty  by  an 
operation.  A  girl,  about  17  years  of  age,  received  a  blow  with  a  rake,  the  handle  of  which 
entered  the  left  orbit.  She  immediately  fell  down  insensible,  but  soon  recovered  her 
senses ;  and,  on  examination,  a  deep  wound  was  found  between  the  upper  wall  of  the 
orbit  and  the  eye,  the  upper  eyelid  having  been  lacerated.  There  was  not  much  bleed- 
ing. The  eyelid  did  not  become  affected,  and  remained  free  from  inflammation  during 
the  healing  of  the  wound,  which  took  place  in  a  short  time,  and  without  any  particular 
treatment.  About  eighteen  months  after  the  accident,  the  girl  felt  a  tumor  forming 
behind  the  upper  eyelid  ;  but,  as  it  was  not  accompanied  by  pain,  or  any  other  inconve- 
nience, she  did  nothing  for  it  till  it  had  acquired  a  large  size.  At  the  time  when  Dr. 
Salzer  saw  her,  four  years  had  elapsed  from  the  occurrence  of  the  accident.  The  tumor, 
by  this  time,  was  very  hard,  immovable,  and  protruding  from  the  orbit,  but  still  com- 
pletely covered  by  the  eyelid ;  the  globe  of  the  eye  was  forcibly  pushed  aside,  and  down- 
wards, so  as  almost  to  touch  the  left  nostril ;  sight  was  not  completely  destroyed. 

The  upper  eyelid  was  divided,  and  the  tumor,  having  been  laid  bare  in  its  whole 
breadth,  was  found  of  osseous  texture,  and  attached  to  the  orbit,  not  (as  was  anticipated) 
by  a  pedicle,  but  by  a  broad  base.  The  substance  of  the  morbid  growth  was  so  dense, 
that  it  was  necessary  to  attack  it  with  the  chisel  and  hammer,  and  even  in  this  way  only 
portions  of  it  could  be  removed.  Towards  the  end  of  the  operation,  which  lasted  several 
hours,  it  appeared  that  a  large  piece  of  bone  was  loose ;  but  this  could  not  be  extracted, 
though  several  attempts  were  made  to  do  so.     The  patient  was  bled,  and  had  ice  applied 


EXOSTOSIS   OF   THE   ORBIT.  89 

over  the  forehead ;  she  complained  of  violent  pain,  apparently  from  the  pressure  ■which 
the  loose  pieces  of  bone  exerted  on  the  eye ;  for  as  soon  as  by  a  proper  apparatus  this 
pressure  was  lessened,  the  pain  and  inflammatory  symptoms  subsided.  The  osseous  frag- 
ment, and  what  remained  of  the  exostosis,  having  been  subsequently  removed  by  the  ap- 
plication of  the  trephine,  the  muscles  and  vessels  of  the  eye  were  found  so  much  flattened, 
as  almost  to  resemble  ligaments  ;  however,  after  some  time  the  globe  began  gradually  to 
reascend  into  the  orbit,  and  in  six  weeks  after  the  operation,  recovered  its  natural  posi- 
tion. The  sight  had  not  suffered  at  all.  The  quantity  of  bone  removed  weighed  about 
2  ounces,  after  having  been  dried." 

Case  ijij. — Exostosis  of  the  orbit  destroyed  hy  inflammation  excited  by  the  use  of  caustic. 
Brassant's  case  is  often  referred  to.  The  patient  was  a  woman,  30  years  of  age,  who  had 
fruitlessly  undergone  the  operation  for  fistula  lachrymalis.  Fifteen  years  afterwards,  the 
OS  planum  and  the  internal  angular  process  of  the  frontal  bone  presented  an  exostosis  of 
the  size  of  an  egg.  The  globe  of  the  eye,  compressed  laterally,  was  thrust  out  of  the 
orbit,  and  hung  in  some  measure  on  the  cheek  at  the  temporal  angle  Brassant  attacked 
the  exostosis  with  caustic.  It  suppurated,  and  within  the  space  of  from  three  to  four 
months,  exfoliation  of  a  considerable  portion  of  the  bony  growth  took  place.  The  eye 
returned  to  its  natural  situation,  and  the  cure  was  ultimately  perfect  '^ 

Case  67. — Exostosis  exfoliates  after  repeated  operations.  Professor  Sporing  has  recorded 
a  case  of  osseous  excrescence,  which  grew  from  the  bone  in  the  immediate  vicinity  of  the 
internal  canthus.  The  patient  was  a  man  of  35  years  of  age.  The  excrescence  grew  to 
the  size  of  a  very  large  walnut,  pushing  the  eye  nearly  out  of  its  socket,  and  impairing 
vision.  A  surgeon  tried  to  remove  it  by  promoting  exfoliation ;  but  the  wound  bled  so 
freely,  that  he  was  happy  to  close  it  up  again.  Some  time  afterwards,  a  peasant  was  al- 
lowed to  try  his  skill  upon  it.  He  began  with  an  incision  round  the  bone,  which  caused 
a  great  effusion  of  blood.  He  afterwards  applied  to  it  some  secret  remedy,  which  pro- 
duced intolerable  pain  for  12  days,  attended  with  faintings.  Several  months  afterwards, 
however,  the  patient  bad  the  courage  to  undergo  the  operation  again.  In  the  following 
spring,  the  entire  exostosis  dropped  out,  the  eye  returned  to  its  situation  in  the  orbit,  and 
vision  was  restored."' 

The  difficulty  of  making  any  impression  on  an  ivory  exostosis,  with  a  saw 
or  trephine,  is  so  great,  that  in  several  cases  the  operation  has  been  aban- 
doned, without  being  finished.  Into  an  exostosis  of  this  kind,  producing 
protrusion  of  the  eye,  Mr.  Keate  made  a  perpendicular  cut  with  iv  trephine, 
but  was  obliged  to  desist  from  its  hardness.  The  patient  continued  to  attend 
at  St.  George's  Hospital  for  several  years,  and  had  various  caustics  applied. 
Ultimately,  a  large  piece  exfoliated,  in  which,  owing  to  its  extreme  density, 
so  little  change  had  been  produced,  that  the  hole  made  by  the  trephine  was 
as  distinct  as  when  the  man  left  the  operating-room. 

Both  in  this  case,  and  in  another,  in  which  Sir  A.  Cooper  had  tried  in 
vain  to  saw  off  an  ivory  exostosis  from  the  frontal  bone,  just  at  the  edge  of 
the  orbit,  but  which  ultimately  exfoliated  after  repeated  applications  of  caus- 
tic by  Sir  B.  Brodie,  Mr.  Hawkins  remarks  that  the  hollow  left  by  the  sepa- 
ration of  the  tumors  produced  so  odd  an  expression  of  countenance,  that  he 
doubts  if  the  patients  thought  themselves  much  improved  by  the  cure,  though 
it  of  course  prevented  the  mischief  that  would  have  ensued  if  the  disease  had 
continued  to  increase.'* 

Cr/.sc  68.  —  Operation  on  an  ivory  exostosis,  abandoned  on  account  of  its  excessive  hardness. 
In  1843,  I  had  an  opportunity  of  witnessing  a  case  somewhat  similar  in  its  result  to  those 
of  Mr.  Keate  and  Sir  A.  Cooper.  A  laborer  was  admitted  into  the  Royal  Infirmary  of 
Glasgow,  under  the  care  of  Mr.  Lyon,  presenting  an  exostosis,  about  the  size  of  a  pigeon's 
egg,  growing  from  the  roof  of  the  right  orbit.  The  supra-orbital  ridge  appeared  as  if 
forced  up  by  it,  while  the  eye  was  displaced  downwards  and  forwards.  The  tumor  was 
exposed  by  an  incision  parallel  to  the  fibres  of  the  orbicularis,  and  the  finger  was  passed 
below  and  behind  the  tumor,  which  felt  distinctly  defined.  Gouge,  cutting  pliers,  rasp, 
and  paring-knife  were  tried  on  its  surface,  without  any  effect.  A  chain-saw  was  passed 
behind  and  around  the  tumor,  but  would  not  work.  Hey's  saw  being  applied  in  front, 
after  considerable  perseverance,  a  cut  to  the  depth  of  three-quarters  of  an  inch  was  made 
into  the  exostosis  in  the  plane  of  the  roof  of  the  orbit.  A  lever  was  passed  into  the  track 
of  the  saw,  but  the  tumor  did  not  yield  to  such  degree  of  force  as  the  fear  of  breaking  up 
the  orbital  plate,  and  injuring  the  brain,  permitted  to  be  used.  The  portion  of  the  exos- 
tosis projecting  anteriorly,  between  the  track  of  the  saw  and  the  eyeball,  was  after  some 


§0  OSTEO-SARCOMA  OF  THE   ORBIT. 

diflBculty  sawn  off,  and  the  wound  closed,  in  the  hope  that  what  the  operation  had  com- 
menced, would  be  finished  by  necrosis. 

Ten  years  have  now  elapsed  since  the  operation.  The  exostosis  still  remains  exposed 
through  the  wound,  and  bears  the  mark  of  the  saw,  as  if  the  operation  had  been  done 
but  yesterday.  The  portion  of  the  frontal  bone  to  which  it  is  attached  feels  somewhat 
loose.  The  eyeball  is  entirely  extruded  from  the  orbit,  and  the  cornea  has  become 
opaque. 

[Mr.  Maisonneuve  recently  presented  to  the  French  Academy  of  Medicine,  a  young  man 
from  whom  he  had  a  short  time  befi)re  removed  a  large  and  hard  ivory  exostosis,  involving 
the  whole  os  planum  of  the  ethmoid  bone  on  the  right  side ;  the  whole  tumor  was  as  large 
as  an  egg.  its  antero-posterior  diameter  measuring  nearly  two  inches,  its  transverse  and 
vertical  each  one  and  a  half  inches. 

It  projected  equally  into  the  orbit,  and  in  towards  the  nose.  It  filled  more  than  two- 
thirds  of  the  former,  and  was  continuous  with  its  superior  and  inferior  walls.  The  eye 
was  completely  extruded  from  tlie  orbit  and  thrust  towards  the  temple,  the  lids  could  not 
close  over  it,  and  the  conjunctiva  was  inflamed.  The  sight,  though  impaired,  was  not 
wholly  lost.  The  tumor  was  so  deeply  seated  as  to  preclude  the  possibility  of  embracing 
it,  and  was  so  hard  as  not  to  be  even  marked  by  the  blades  of  a  pair  of  Leston's  pliers ; 
indeed,  twice  these  powerful  instruments  broke  under  the  united  force  of  the  surgeon  and 
his  assistants.  They  even  broke  a  third  pair  of  forceps,  furnished  by  Charriere,  who  was 
present,  without  making  any  impression  on  it.  Mr.  M.  at  last  resorted  to  the  chisel  and 
mallet,  and  by  violent  efforts,  succeeded  in  detaching  the  whole  growth,  en  masse,  without 
doing  any  injury  to  the  brain,  deep  seated  parts  of  the  face,  or  even  to  the  eye  itself, 
which  was  not  so  much  as  pressed  upon  during  the  whole  operation,  which  lasted  one  hour 
and  a  lialf.  The  tumor,  when  extracted,  weighed  nearly  one  ounce,  avoirdupois.  The 
wound  healed  up  kindly,  and  the  patient  got  well  without  one  untoward  symptom.  The 
function  of  the  eye  was  entirely  restored,  and  when  the  patient  was  pi-esented  to  the  Aca- 
demy, it  was  difficult  to  say  on  which  side  the  disease  had  been.  For  a  more  detailed  ac- 
count of  this  interesting  case,  seeBiille/in  Gen.  de  Therapeutique,  vol.  xlv.  p.  177,  1853.' — H.] 

The  basis  of  the  orbit  has  been  found  to  be  occasionally  the  seat  of  exos- 
toses. Sometimes  one  portion  of  it,  and  sometimes  another  has  been  affected ; 
but  the  superior  maxillary  bone  most  frequent!)''.  Cases  of  this  sort  have 
been  descril)ed  as  exostosis  of  the  maxillary  sinus.  These  we  shall  consider 
in  the  next  section.  In  the  following  case,  the  whole  basis  of  the  orbit  seems 
to  have  been  affected  : — 

Case  69. —  Cup-Wee  exostosis  of  the  edge  of  the  orbit.  Acrel  relates  a  case  of  this  sort 
under  the  title  of  spina  ventosa  of  the  right  orbit.  The  bones  forming  that  cavitj',  espe- 
ciall}-  the  frontal  and  superior  maxillary,  were  so  much  protruded,  as  to  present  the  ap- 
pearance of  a  blunt  cone,  four  fingers'  breadth  high,  and  about  the  same  in  diameter  at 
its  basis.  He  compares  it  to  a  small  cup  inverted,  in  the  Ijottom  of  which,  or  end  which 
was  turned  outwards,  was  the  eye.  This  was  not  completely  sound  and  clear,  and  was 
smaller  than  the  left  eye;  it  had  eyelids,  which  were  movable,  and  the  other  parts  be- 
longing to  it,  and  even  served  to  distinguish  large  objects  pretty  well.  Acrel  considered 
the  case  incurable.  He  mentions  that  he  had  seen  another  case  of  the  same  sort,  for 
which  also  he  regarded  it  useless  to  attempt  any  operation.'* 

§  4.    Osteosarcoma. 

Osteo-sarcoma,  by  some  called  fibrous  exostosis,  and  by  Sir  A.  Cooper 
fungous  exostosis  of  the  medullary  membrane,  sometimes  attacks  the  skull,  and 
involves  the  bones  of  the  orbit. 

The  disease  consists  in  the  development  of  a  tumor,  involving  the  sub- 
stance of  a  bone  ;  taking  its  rise  sometimes  from  the  surface,  and  more  fre- 
quently within  the  spongy  tissue  of  the  bone  affected.  The  tumor  gene- 
rally consists  of  a  substance  much  softer  than  ordinary  cartilage,  containing 
numerous  slender  spiculae,  or  thin  osseous  plates,  radiating  through  it,  being 
partly  the  original  bone  expanded  and  separated  into  fibres,  and  partly  new 
unhealthy  bone.  This  disease  depends  on  a  particular  state  of  constitution, 
and  is  generally  regarded  as  malignant.  Mr.  Lawrence,  however,  distin- 
guishes'^ indolent  from  malignant  ogteo-sarcoma ;  the  former  occupying 
years  before  it  attains  a  very  considerable  size,  attended  with  little  pain,  and 
dangerous  only  in  consequence  of  interferiog  with  the  functions  of  parts,  from 


OSTEO-SARCOMA  OF  THE   ORBIT.  91 

the  magnitude  it  attains ;  the  latter  attended  with  pain  from  the  first,  and 
growing  very  rapidly.  A  similar  distinction  is  made  by  other  surgical 
authors,  between  fibro-cartilaginous  and  sarcomato-raedullary  exostosis.  The 
latter,  or  malignant  osteo-sarcoma,  seems  to  be  eneephaloid  cancer  or  fun- 
gus haematodes  occurring  in  bone;  the  former  is  the  osteoid  tumor  of 
M  tiller. 

In  Dr.  Hunter's  Museum,  in  the  University  of  Glasgow,  two  skulls  are 
preserved,  which  have  suffered  greatly  from  osteo-sarcoma.  One  of  them, 
apparently  a  male  skull,  of  which  no  account  is  preserved,  exhibits  the  whole 
left  side  changed  by  the  disease  in  a  most  remarkable  degree,  the  spiculiE 
and  laminsB  of  bone  into  which  it  is  converted  rising  at  least  three-fourths  of 
an  inch  above  the  natural  level  of  the  bones.  The  spiculse  project  also  to- 
wards the  interior  of  the  cranium,  especially  from  the  temporal  bone.  A 
small  part  of  the  floor  of  the  orbit  only  remains  unaifected,  the  three  other 
sides  being  in  a  great  measure  destroyed.  The  other  skull,  a  female  one,  is 
figured  by  Dr.  Baillie,  in  his  Series  of  Engravings  Illustrative  of  Morbid 
Anatomy.*''  Nine  or  ten  different  parts  of  the  cranium  are  afi"ected  in  this 
instance.  The  middle  of  the  os  frontis,  the  right  temporal  bone,  both  pari- 
etals,  and  the  frontal  behind  its  right  external  angular  process,  are  the  prin- 
cipal situations  of  the  disease.  At  the  right  temple,  the  disease  penetrates 
into  the  orbit,  and  affects  in  a  slight  degree  the  interior  of  the  cranium.  In 
each  parietal  region,  the  inside  of  the  skull  is  much  affected,  spiculae  of  half 
an  inch  in  length  projecting  inwards  in  these  situations.  In  each  specimen, 
the  morbid  appearances  are  evidently  the  effects  of  a  disease  springing  up  in 
the  cancelli,  and  destroying  both  tables  of  the  skull. 

Case  (0. — Sir  A.  Cooper'*  has  given  a  sketch  of  an  osteo-sarcomatous  tumor  on  the 
forehead,  extending  close  to  the  edge  of  the  orbit.  Sir  Astley  persuaded  the  subject  of 
this  tumor  to  submit  to  an  operation.  On  removal,  it  was  found  exactly  of  the  character 
above  mentioned,  and  although  partly  formed  of  osseous  spiculte,  v^as  readily  broken 
down  with  the  finger.  The  patient  became  feverish  and  comatose,  and  died  on  the  6th 
day. 

On  dissection,  Sir  Astley  found  that  the  swelling  occupied  the  internal  as  well  as  the 
external  table  of  the  skull,  that  it  extended  through  both,  and  affected  the  dura  mater, 
which  had  several  fungous  projections  proceeding  from  it,  and  that  the  inflammation  ex- 
cited by  the  operation,  had  extended  to  the  membranes  of  the  brain.  The  complaint 
seemed  to  have  originated  in  the  diploe  of  the  os  frontis,  and  to  have  produced  an  effu- 
sion both  between  the  pericranium  and  the  skull,  and  between  the  skull  and  the  dura 
mater.  The  swelling,  upon  the  outer  part  of  the  head,  was,  however,  much  larger  than 
that  which  had  arisen  from  the  inner  table.  It  was  evident,  too,  that  this  case  must  have 
proved  fital,  although  no  operation  had  been  performed. 

Sir  Astley  concludes  this  case  by  observing,  that  an  exostosis  on  the  ex- 
ternal table  of  the  skull,  growing  slowly,  very  little  vascular,  and  unattended 
with  any  considerable  pain,  may  safely  be  made  the  subject  of  an  operation  ; 
but  that  a  swelling  of  more  rapid  growth,  red  upon  its  surface,  showing  signs 
of  considerable  vascularity,  and  attended  with  great  pain  shooting  through 
the  brain,  is  one  for  which  he  should  hesitate  again  to  perform  an  operation. 

These  latter  characters  belong  not  to  simple  exostosis,  but  to  osteo-sar- 
coma. 

Case  71. — Sir  Philip  Crampton  was  consulted  by  a  lady  of  about  55  years  of  age,  on 
account  of  dimness  of  sight  affecting  the  right  eye ;  the  eye  felt  exceedingly  hard  to  the 
touch,  was  affected  with  strabismus,  and  projected  in  some  degree  from  the  orbit ;  the 
pupil  was  immovable,  but  vision  was  not  altogether  destroyed.  She  complained  of  severe 
shooting  pains  in  the  head  and  in  the  right  arm ;  her  general  health  was  much  affected, 
and  her  aspect  almost  cadaverous ;  her  memory  seemed  much  impaired,  and  there  was  a 
general  insensibility  to  external  impressions ;  she  was  depressed  in  her  spirits,  yet  she 
made  but  little  complaint.  On  an  attentive  examination  it  was  plain  that  there  was  some 
fulness  in  the  situation  of  the  temporal  fossa,  but  the  tumor  was  perfectly  indolent  and 
incompressible. 


92  CYSTS   IN   THE   PARIETES   OF   THE   ORBIT. 

Sir  P.  did  not  see  the  lady  again  for  four  or  five  weeks,  ■when  he  found  her  nearly  co- 
matose ;  the  swelling  on  the  temple  had  increased  to  a  considerable  degree,  and  the  eye 
was  still  farther  protruded  from  the  orbit.  She  expired  in  a  few  days,  and  on  the  day 
following  her  death,  the  head  was  examined. 

On  raising  the  aponeurosis  of  the  temporal  muscle,  the  temporal  fossa  was  found  to  be 
occupied  by  a  grayish-colored  substance,  of  the  consistence  of  brain ;  the  muscle  itself 
had  completely  disappeared;  numerous  osseous  spiculte  proceeding  from  the  frontal  and 
temporal  bones,  passed  into  the  tumor,  of  which  they  constituted  a  considerable  part. 
On  opening  the  head,  a  tumor  of  precisely  the  same  description,  beset  in  the  same  man- 
ner by  bony  spiculaj,  was  found  lodged  between  the  dura  mater  and  the  internal  orbital 
process  of  the  frontal  bone. 

On  macerating  the  bone,  it  exhibited  the  most  perfect  specimen  Sir  Philip  had  seen  of 
fibrous  exostosis.  The  spiculsB  proceeding  both  from  the  outer  and  from  the  inner  table 
of  the  cranium  were  each  about  as  thick  as  a  hog's  bristle,  and  three-fourths  of  an  inch 
in  length;  they  were  set  as  closely  together  as  the  hairs  of  a  brush,  and  extended  in  an 
undulating  line  over  a  space  of  about  two  square  inches  in  extent.  The  tables  of  the 
skull  were  slightly  separated  from  each  other  in  the  part  corresponding  to  the  exostosis, 
and  the  diploe  seemed  to  contain  some  of  the  same  brain-like  matter  which  formed  the 
bulk  of  the  tumor. 

Sir  P.  thinks  it  impossible  to  decide  whether  the  disease  commenced  in  the  soft  parts, 
or  in  the  bone;  although  it  seemed  probable  that  it  commenced  in  the  bone,  because  the 
spiculae  were  furnished  by  the  bone  itself,  and  not  by  the  periosteum  or  dura  mater, 
which  were  separated  by  the  tumor  to  the  distance  of  nearly  an  inch  from  the  outer  and 
inner  tables  of  the  skull  respectively.'^ 

Sir  P.  observes  that,  in  maliprnant  osteo-sarcoma,  it  is  more  usual  to  find 
a  deficiency  than  an  excess  of  bony  matter ;  for  although  spiculae  of  bone  are 
interspersed  through  the  brain-like  substance  which  forms  the  bulk  of  the 
tumor,  the  bone  itself  is  usually  divested  of  its  earthy  basis,  and  is  converted 
into  a  steatomatous  or  cartilaginous  substance.  Sometimes,  however,  the 
tendency  to  secrete  phosphate  of  lime  is  surprisingly  increased,  and  then 
large  and  singularly  shaped  masses  of  bony  matter  are  thrown  out  from  the 
surface  of  the  diseased  bone.  The  presence  or  absence  of  bony  matter  in  an 
osteo-sarcomatous  tumor  will  probably  depend,  Sir  Philip  thinks,  on  the 
relative  activity  of  the  secreting  and  absorbing  systems  in  the  diseased  bone. 
He  is  also  of  opinion,  that  the  varieties  which  are  met  with  in  the  character 
and  nature  of  osseous  tumors,  depend  greatly  on  the  kind  of  constitution  of 
the  patient,  whether  that  be  healthy,  cachectic,  or  scrofulous. 

Case  72. — Dr.  Schott  operated  in  a  case,  in  which  the  eye  was  pushed  out  of  the  orbit 
by  a  fungous  growth,  arising  from  the  diploe  of  the  great  wing  of  the  sphenoid,  the  outer 
half  of  the  pars  orbitalis,  planum  semicirculare  and  z_ygomatic  process  of  the  frontal,  as 
well  as  the  angulus  sphenoidalis  of  the  parietal  and  anterior  half  of  the  squamous  portion 
of  the  temporal.  The  growth  had  pushed  itself  not  merely  into  the  orbit  and  temporal 
fossa,  but  into  the  cavity  of  the  cranium.  The  operation  removed  the  diseased  mass  from 
the  orbit  and  temporal  fossa.     The  patient  died  in  12  hours. ^^ 

It  is  scarcely  necessary  to  add,  that  in  cases  of  osteo-sarcom^  of  the  orbit, 
the  less  that  is  done  the  better. ^^ 

§  5.    Cysts  in  the  Parietes  of  the  Orbit. 

The  bones  are  subject  to  two  kinds  of  encysted  tumors,  viz :  the  hydatid- 
encysted,  containing  echinococci  similar  to  those  met  with  in  the  liver,  and 
the  serous-encysted.  These  tumors  are  developed  in  the  cancellated  structure, 
and  expand  the  affected  bones  often  to  a  great  size.  The  frontal  and  the 
upper  maxillary  bones  have  not  unfrequently  been  found  the  seat  of  such  dis- 
eases; in  the  latter  situation,  connected  sometimes  with  the  fangs  of  the 
teeth. 

A  remarkable  example  of  hydatid-encysted  tumor  of  the  frontal  bone  is 
related  by  Mr.  Keate.  The  tumor  projected  from  the  forehead,  chiefly  over 
the  left  orbit,  and  presented  the  shape  and  size  of  three-fourths  of  a  large 


DILATATION,    DEFORMATION,    AND   ABSORPTION   OF   THE   ORBIT.      93 


orange.     The  tumor  was  laid  open,  and,  ultimately,  about  28  hydatids  came 
away.     Twenty  years  after  the  last  operation,  the  patient  continued  well.-=^ 

In  both  kinds  of  encysted  tumor,  the  bone  covering  the  cyst  must  be  freely 
laid  open,  and  the  cyst  thoroughly  extirpated. 


'  On  tumors  of  the  bones,  consult  Hawkins' 
Clinical  Lectures,  Medical  Gazette,  Vol.  xxiii. ; 
London,  1838,  1839. 

*  Dublin  Journal  of  Medical  Science;  Vol. 
ix.  p.  255  ;  Dublin,  1836. 

^  Medical  Gazette ;  Vol.  xv.  p.  265 ;  London, 
1835. 

■*  Jourdain,  Traite  des  Maladies  de  la  Bouche; 
Tome  i.  p.  289;  Paris,  1778. 

'  Baillie's  Series  of  Engravings,  Fasciculus 
X.  Plate  i. ;  also  his  Morbid  Anatomy,  p.  446; 
London,  1812. 

*  J.  P.  Frank,  Opuscula  Posthuma,  p.  77, 
Tab.  iv.  V.  vi.     Pavia,  1825. 

■"  Op.  cit.  p.  500. 

'  Travers'  Synopsis  of  the  Diseases  of  the 
Eye,  p.  227:  London,  1820. 

'Medical  Times;  Vol.  xxiii.  p.  494;  Lon- 
don, 1851. 

"  Ilaynes  Walton's  Operative  Ophthalmic 
Surgery;  p.  345;  London,  1853. 

"  Quoted  from  the  Neue  Zeitschrift  fiir  Na- 
tur-  und  Heilkunde,  in  the  Lancet  for  1831  ; 
Vol.  i.  p.  671. 

'^  Memoires  de  TAcademie  P>,oyale  de  Chi- 
rurgie  ;   Tome  xiii.  p.  277,  12ino. ;  Paris,  1774. 

''^  Quoted  from  Haller  by  Mr.  B.  Bell,  in  his 


Treatise  on  the  Diseases  of  the  Bones,  p.  121 ; 
Edin.  1828.  Referred  to  also  by  Acrel.  I  have 
not  been  able  to  find  the  original  account  of 
the  case. 

'*  Op.  cit.  p.  500. 

"  Acrel.  Chirurgische  Vorfalle,  ubersetzt  von 
Murray  ;  Vol.  i.  p.  102  ;  Gottingen,  1777. 

'*  Lectures  on  Surgery,  Medical  Gazette;  Vol. 
vi.  p.  454;  London.  1830. 

"  Fasciculus  X.  Plate  i. ;  London,  1799. 

'*  Surgical  Essays,  by  Cooper  and  Travers; 
vol  i.  p.  212;  London,  1818. 

"  Dublin  Hospital  Reports  ;  Vol.  iv.  p.  554. 
Dublin,  1827. 

*"  Controverse  liber  die  Nerven  des  Nabel- 
strangs;  advertisement  at  the  end;  Frankfurt 
am  Main,  1836. 

^'  The  reader  will  find  a  remarkable  case  of 
degeneration  of  the  bones  of  the  cranium  and 
face,  involving  the  orbit,  related  and  figured  by 
Cruveilhier,  Anatomie  Pathologique  ;  Tome  i. 
Livraison  21.  He  considered  the  affection  as 
cancerous. 

^^  Medico-Chirurgical  Transactions;  Vol.  x. 
p.  278;  London,  1819:  Hawkins,  Op.  cit.  p. 
471. 


SECTION   IV.  —  DILATATION,    DEFORMATION,    AND    ABSORPTION    OF    THE    ORBIT, 

FROM  PRESSURE. 

When  an  abscess  or  a  tumor  forms  within  any  of  the  osseous  cavities  of  the 
body,  pressure  slowly  dilates  even  the  bones,  thins  them,  softens  them,  and 
forces  them  to  give  way.  The  bones  of  the  cranium  are  not  exempt  from 
these  changes,  and  have  been  known  to  allow  a  tumor  of  the  bi'ain  to  protrude 
externally.  Dr.  Donald  Munro  has  related  a  case  of  this  kind,  in  which  a 
tumor  of  the  brain  protruded  through  the  os  frontis  ;*  and  Mr.  Hunter  has 
noticed  a  case  in  terms  so  exactly  similar,  that  it  is  likely  it  was  the  very  same 
which  was  seen  by  Dr.  Munro.  Mr.  Hnnter  thinks  that  the  tumor  had  prob- 
ably formed  in  the  pia  mater.  It  was  oblong,  above  an  inch  thick,  and  two 
or  more  inches  long.  It  was  sunk  nearly  its  whole  length  into  the  brain, 
seemingly  by  the  simple  effects  of  pressure;  but  the  outer  end  of  it,  by  press- 
ing against  the  dura  mater,  had  produced  the  entire  absorption  of  this  mem- 
brane at  the  part  pressed  upon.  The  same  irritation  had  been  communicated 
to  the  skull,  which  was  also  absorbed;  after  which,  the  same  disposition  was 
continued  on  to  the  scalp.  As  these  respective  parts  gave  way,  the  tumor 
was  pushed  farther  and  farther  out,  so  that  its  outer  end  came  to  be  in  the 
passage  which  the  absorbents  were  making  for  it  in  the  scalp,  by  which  it 
probably  would  have  been  discharged  in  time,  if  the  man  had  lived;  btit  it 
was  so  connected  with  the  vital  parts,  that  the  man  died  before  the  parts 
could  relieve  themselves.  While  all  these  exterior  parts  were  undergoing 
absorption,  the  internal  parts  which  pressed  upon  the  inner  end  of  the  tumor, 
and  which  pressure  was  sufficient  to  push  it  out,  did  not  in  the  least  ulcerate, 
nor  did  the  tumor  itself,  which  was  pressed  upon  on  all  sides,  in  the  least  give 


94  PRESSURE   ON   THE   ORBIT. 

way  in  its  substance.  No  matter  had  been  formed,  neither  by  the  dura  mater, 
the  edge  of  the  bones  of  the  skull,  nor  that  part  of  the  scalp  which  had  given 
way.  The  general  effect,  however,  was  similar  to  the  progress  of  an  abscess, 
insomuch  that  it  was  on  the  side  nearest  to  the  external  surface  of  the  body 
that  the  irritation  for  absorption  had  taken  place. ^ 

The  process  by  which  an  abscess  or  a  tumor  is  thus  brought  to  the  surface 
of  the  body,  Mr.  Hunter  regarded  as  a  combination  of  interstitial  and  pro- 
gressive absorption — interstitial,  because  particles  from  the  interstices  only  of 
the  part  are  for  a  time  removed,  the  part  still  remaining — progressive,  on 
account  of  the  tending  to  the  surface,  till  at  length  the  surface  gives  way,  and 
the  abscess  or  the  tumor  finishes  its  progress  by  being  exposed  or  evacuated. 
By  the  process  in  question  the  internal  parts  of  the  body  are,  to  a  certain 
extent,  protected  from  the  intrusion  of  such  diseases,  and  in  many  cases  a 
cure  is  effected  by  the  discharge  of  the  morbid  accumulation  or  growth. 
Hence,  Mr.  Hunter  called  interstitial  and  progressive  absorption  the  natural 
surgeon,^ 

If,  then,  the  thick  bones  of  the  cranium  are  forced  to  yield,  how  much  more 
readily  will  the  bones  of  the  orbit  suffer  from  the  same  process,  excited  either 
from  within  that  cavity,  or  without,  from  the  surrounding  cavities,  the  nostril, 
the  frontal,  maxillary,  and  sphenoid  sinuses,  or  the  cranium  I 

§  1.  Pressure  on  the  Orhit  from  within  the  Orbit. 

Various  causes  within  the  orbit  may,  by  pressure,  produce  dilatation  and 
absorption  of  its  walls.  I  have  seen  the  orbit  slowly  enlarged  by  the  growth 
and  pressure  of  a  diseased  lachrymal  gland,  till  it  was  of  size  sufficient  to  con- 
tain the  fist,  and  at  several  points  had  given  way.  Effused  blood,  collections 
of  matter,  aneurisms,  enlargements  of  the  eyeball,  encysted  and  other  tumors, 
are  all  capable  of  producing  such  effects. 

If  pressure  from  within  the  orbit  is  sudden,  it  will  in  some  cases  produce 
inflammation  of  the  bones,  and  caries;  but  if  carried  on  slowly,  perhaps 
during  the  course  of  many  years,  dilatation  and  absorption,  without  any  form- 
ation of  matter,  and  even  without  inflammation,  will  be  the  effect.  It  some- 
times happens,  however,  that  after  the  orbit  has  been  slowly  dilated,  and 
perhaps  partly  absorbed,  in  consequence  of  the  pressure  of  a  morbid  growth 
within  it,  the  tumor  begins  to  inflame  and  form  matter,  and  this  action, 
spreading  to  the  surrounding  parts,  brings  on  caries.  If  it  is  the  roof  of  the 
orbit  which  becomes  affected  in  this  way,  the  dura  mater  inflames  and  se- 
cretes pus ;  the  brain  participates  in  the  disease ;  to  fever,  there  are  added 
delirium  and  coma  ;  and  death  follo\\s  more  or  less  speedily. 

§  2.  Pressure  on  the  Orhit  from  the  Nostril. 

1.  Nasal  polypus. — The  nostril  communicates  with  the  orbit  by  the  lachry- 
mal passage.  The  os  unguis  and  os  planum  of  the  ethmoid  form  a  thin  par- 
tition between  these  cavities  ;  a  partition  which,  but  for  the  tendency  already 
referred  to,  which  morbid  growths  have  towards  the  external  surface,  would 
often  be  broken  through  by  nasal  polypus.  This  tumor,  after  filling  the 
nostril  in  which  it  has  originated,  dilates  it  at  its  anterior  opening,  pushes 
itself  backwards,  so  as  to  appear  behind  the  veil  of  the  palate,  and  presses 
the  septum  narium  aside,  so  as  to  amplify  the  cavity  of  the  one  nostril  at  the 
expense  of  the  other.  It  is  not,  in  general,  till  the  nostril  is  in  this  way 
greatly  dilated,  and  of  course  the  face  much  disfigured,  that  the  polypus 
pushes  itself  through  the  os  unguis,  and  projects,  covered  by  the  inflamed  in- 
teguments, in  the  situation  of  the  lachrymal  sac  Previously  to  this,  however, 
the  passage  for  the  tears  is  obstructed,  and  a  painful  feeling  of  i)ressure  ex- 


EXOSTOSIS  BETWEEN  NOSTRIL  AND   ORBIT.  95 

perienced  in  the  orbit  and  through  the  head.  If  the  polypus  continues  to 
advance,  the  nasal  bones  will  be  separated  from  the  superior  maxillary,  the 
orbit  will  be  still  more  intruded  upon,  the  eyeball  displaced,  vision  lost,  and 
at  last  even  the  cavity  of  the  cranium  giving  way,  the  morbid  growth  may 
come  into  contact  with  the  brain. 

Nasal,  much  more  rarely  than  antral,  polypus  is  the  cause  of  deformation 
of  the  orbit,  and  of  such  destructive  effects  as  I  have  just  now  enumerated. 
Antral  is  apt  to  be  taken  for  nasal  polypus  ;  and  I  strongly  suspect  that,  in 
several  recorded  cases,  this  mistake  has  been  committed.  In  all  cases  of  ex- 
ophthalmos, or  protrusion  of  the  eye,  it  is  necessary  carefully  to  examine  the 
nostril  with  the  finger  and  the  probe,  lest  polypus  of  the  nose  or  of  the  an- 
trum be  the  cause.  Antral  polypus,  having  by  pressure  destroyed  the  bones 
and  mucous  membrane  which  separate  the  antrum  from  the  nose,  sometimes 
pushes  its  way  into  the  nostril,  and  imitates  a  nasal  polypus ;  nay,  I  have 
known  a  polypus  of  the  antrum  to  traverse  both  nostrils,  and  project  at  the 
inner  angle  of  each  orbit. 

I  do  not  conceive  it  necessary  to  enlarge  on  the  treatment  of  nasal  polypus. 
Early  extirpation  ought  to  be  practised. 

2.  Exostosis  between  nostril  and  orbit. — In  the  following  case,  the  orbit 
was  displaced  by  an  osseous  tumor,  which  was  i:|||timately  removed  by  spon- 
taneous separation.  This  case,  and  one  of  osseous  tumor  in  the  orbit,  to  be 
noticed,  along  with  other  orbital  tumors,  in  a  following  chapter,  appear  to 
have  been  exostoses,  growing  by  narrow  necks,  which  at  length  giving  way, 
left  the  tumors  free.  It  is  a  fact  of  much  practical  importance,  that  the 
surface  of  the  attachment  of  an  exostosis  scarcely  ever  extends,  but  that  the 
increase  of  the  tumor  takes  place  chiefly  or  only  upon  its  periphery.* 

Case  73. — When  Thomas  Moore  was  about  13  years  of  age,  a  little  pimple,  like  a  wart, 
appeared  under  his  left  eye,  close  to  his  nose.  He  scratched  off  the  head  of  this  pimple, 
which  formed  a  scab.  This  was  followed  by  a  tumor,  which  grew  for  23  years.  The 
tumor,  although  slow  in  its  progress  and  free  from  pain,  gradually  became  more  conspicu- 
ous, and  at  last  produced  great  disfigurement  of  the  face.  The  septum  nasi  was  pushed 
towards  the  right  side,  so  as  nearly  to  obliterate  the  right  nostril ;  the  turbinated  and 
cellular  apparatus  on  the  left  side  of  the  nose  was  destroyed ;  and  the  left  orbit  was 
thrust  outwards. 

After  a  time,  the  tumor  displaced  the  inner  wall  of  the  orbit ;  and  the  globe  of  the  eye, 
being  thus  subjected  to  pressure,  became  the  seat  of  most  excruciating  pain,  though 
vision  was  very  little  impaired.  When  the  patient  was  about  the  age  of  19,  the  eye, 
yielding  to  the  pressure,  burst,  and  discharged  its  fluid  contents.  In  less  than  an  hour 
after  this  took  place,  the  patient,  who  had  been  deprived  of  rest  during  several  weeks, 
was  buried  in  profound  sleep.  He  awoke  nearly  free  from  pain;  and  this  comparative 
ease  continued. 

When  he  had  reached  the  age  of  30,  the  tumor  was  observed  to  be  somewhat  loosened, 
and  to  be  becoming  detached  by  ulceration  of  the  surrounding  soft  parts.  The  process  of 
detachment  was  alleviated  by  copious  suppuration,  and  occasionally  by  profuse  hemor- 
rhagy  from  the  vessels  of  the  adjacent  structures.  For  a  time,  the  tumor  was  retained 
merely  by  bands  of  integument,  which  it  would  have  been  easy  to  divide.  At  length, 
several  small  irregular  portions  of  bone  came  away ;  but  the  large  mass  continued  to  be 
maintained  in  its  situation  until  the  transverse  bands  were  divided  by  ulceration,  when  to 
the  patient's  astonishment,  the  whole  tumor  fell  from  his  face.  Neither  pain  nor  bleeding 
attended  this  separation ;  but  a  large  chasm  was  left  between  the  nose  and  the  orbit, 
bounded  below  by  the  nasal  surface  of  the  hard  palate,  and  the  floor  of  the  left  antrum, 
above  by  the  left  frontal  sinus  and  left  half  of  the  cribriform  plate  of  the  ethmoid  bone, 
internally  by  the  septum  nasi,  which  presented  a  concave  surface,  with  a  small  opening 
through  its  lower  part,  communicating  with  the  right  nostril,  and  externally  by  the  left 
orbit.     Posteriorly,  the  chasm  opened  into  the  pharynx. 

When  Mr.  Hilton  drew  up  his  account  of  the  case,  the  roof,  the  outer  wall,  and  part  of 
the  inner  wall,  were  covered  with  granulations.  On  comparing  the  distances  from  the 
median  line  of  the  face  to  the  malar  edge  of  each  orbit,  that  on  the  leftside  was  found  to 
be  nearly  an  inch  greater  than  that  on  the  right.  The  left  eyebrow  was  elongated  in  the 
same  direction  for  about  half  an  inch  ;  and  the  cerebral  cavity  appeared  to  be  encroached 
upon  by  the  pressure  of  the  tumor  upwiirds. 


96  PRESSURE   ON   THE   ORBIT   FROM   THE   FRONTAL   SINUS. 

The  tumor  weighed  14|  oz.  Its  specific  gravity  was  1.80.  Its  greatest  circumference 
measured  rather  more  than  1 1  inches,  and  its  least  9  inches.  Externally  it  was  undulated, 
and  its  postei-ior  surface  concave.  A  section  of  it  presented  a  very  hard  surface  resem- 
bling that  of  ivory,  with  lines,  to  the  number  of  fifty,  arranged  in  concentric  curves,  en- 
larging as  they  proceeded  from  the  posterior  part  of  the  tumor.* 

I  3.   Pressure  on  the  Orhit  from  the  Frontal  Sinus. 

If  we  consider  that  when  the  frontal  sinus  is  large,  independently  of  dis- 
ease, it  separates  the  orbitary  plate  of  the  frontal  bone  into  two  laminte,  as 
may  not  unfrequently  be  observed  in  the  skulls  of  old  persons,  and  some- 
times in  the  young,  it  will  not  appear  strange,  that  the  pressure  of  a  diseased 
and  dilated  frontal  sinus  should  deform  the  orbit,  displace  the  eyeball,  destroy 
vision,  and  ultimately  disorganize  the  bones  upon  which  the  pressure  is  ex- 
ercised. 

The  frontal  sinus,  like  the  maxillary,  is  liable  to  several  different  kinds  of 
disease ;  namely,  1st.  Inflammation  of  its  lining  membrane,  ending  in  a  col- 
lection of  matter,  which  may  be  either  thin,  or  thick  and  curdy ;  2d.  En- 
cysted tumors,  or  what  some  have  chosen  to  call  hydatids ;  3d.  Tumors,  more 
or  less  solid,  which  are  considered  to  be  of  the  nature  of  fungus  or  polypus ; 
4th.  Exostosis. 

1.  Injiammation  of  the  ffontal  sinus ,  ending  in  a  collection  of  matter. — The 
frontal  sinus,  on  each  side,  is  lined  by  a  thin  fibro-mucous  membrane,  a  con- 
tinuation of  that  which  lines  the  nostrils.  The  two  sinuses  are  separated  by 
a  bony  partition,  which  rarely  runs  in  the  course  of  the  middle  line ;  so  that, 
in  general,  the  one  sinus  is  larger,  and,  in  many  instances,  much  larger,  than 
the  other.  Each  sinus  communicates  with  the  middle  meatus  of  the  nostril, 
through  the  medium  of  the  anterior  ethmoid  cells.  The  communication  is 
narrow  and  indirect.  Whether  the  diseases  of  the  frontal  sinuses  are  mainly, 
or  frequently,  or  at  all,  to  be  attributed  to  accidental  closure  of  this  commu- 
nication, I  shall  not  pretend  to  say.  Beer  has  mentioned  sudden  suppression 
of  severe  catarrh,  as  a  cause  of  matter  collecting  within  the  sinuses.  It  is 
known,  that  in  cases  of  wounds  penetrating  into  these  cavities,  their  lining 
membrane  inflames,  and  secretes  a  white  puriform  mucus,  which  has  some- 
times been  mistaken  for  the  substance  of  the  brain.  Cold,  and  the  other 
causes  which  give  rise  to  the  inflammation  of  mucous  surfaces,  may  also  affect 
the  lining  membrane  of  these  cavities  ;  and  in  scrofulous  constitutions,  curdy 
pus  will  be  apt  to  collect  there,  as  it  often  does  in  the  maxillary  sinuses. 

Suppression  of  the  natural  discharge  of  the  Schueiderian  membrane,  or  of 
that  discharge  when  increased  by  disease,  seems  occasionally  to  be  the  cause 
of  amaurosis;"  probably  through  the  medium  of  cerebral  congestion. 

It  is  scarcely  necessary  for  me  to  quote  examples  of  simple  suppuration  of 
the  frontal  sinuses ;  I  shall  refer  the  reader  to  the  cases  related  by  Runge'' 
and  Ilichter.*  One  of  these  recovered  after  the  diseased  cavity  was  opened 
externally  ;  another,  after  bursting  of  the  matter  into  the  nostril ;  while  a 
third  proved  fatal  after  spontaneous  discharge  of  the  matter  through  the  ex- 
ternal table  of  the  frontal  bone,  and  through  the  middle  of  the  upper  eyelid. 

In  the  early  stage  of  inflammation  of  the  frontal  sinuses,  the  obscurity  of 
the  symptoms  will  rarely  permit  any  decided  judgment  to  be  formed  of  the 
case,  or  any  active  treatment  to  be  adopted.  In  all  the  three  cases  to  which 
I  have  referred,  the  disease  had  advanced,  either  to  a  considerable  protrusion 
of  the  outer  wall  of  the  affected  sinus,  or  even  to  the  giving  way  of  the  cavity, 
and  the  evacuation  of  the  contained  matter,  before  any  suspicion  seems  to 
have  been  excited.  Leeches  to  the  inside  of  the  nostrils,  and  other  anti- 
})hlogistic  means  would,  of  course,  be  adopted,  were  we  called  in  early  enough, 
and  did  the  pain,  and  other  symptoms,  appear  to  indicate  inflammation  of 
the  lining  membrane  of  the  sinus.     Emollient,  and  afterwards,  stimulating 


PRESSURE   ON   THE   ORBIT   FROM   THE   FRONTAL   SINUS.  91 

vapors  drawn  up  into  the  nostrils,  might  be  tried.  If  they  succeeded  in  ex- 
citing a  considerable  discharge  from  the  Schneiderian  membrane,  this  might 
tend  to  relieve  the  inflamed  state  of  the  sinuses.^ 

In  the  suppurative  stage,  perhaps  counter-irritation,  and  a  variety  of  other 
measures,  might  prove  useful. 

The  last  stage,  in  which  the  frontal  bone  becomes  deformed,  thinned, 
softened,  so  that  it  yields  to  external  pressure,  like  a  piece  of  elastic  cartilage, 
or  is  even  perforated  by  absorption  or  by  caries,  can  scarcely  be  mistaken. 
The  opening,  however,  which  is  formed  in  the  bone,  and  ultimately  in  the 
integuments,  is  not  above,  or  on  a  level  with,  the  eyebrow,  where  a  careless 
examination  of  the  anatomy  of  the  frontal  sinuses  might  lead  us  to  expect  it, 
but  close  to  the  inner  canthus,  or  beneath  the  middle  of  the  superciliary 
arch  ;  so  that,  sometimes,  the  case  might  be  mistaken  for  a  disease  of  the 
lachrymal  sac,  till  the  probe,  taking  a  direction  upwards  and  backwards, 
showed  the  true  nature  of  the  case.  In  a  patient  of  the  Glasgow  Eye  In- 
firmary, the  first  symptom  which  attracted  notice  was  the  abscess  pointing 
under  the  skin,  immediately  above  the  tendon  of  the  orbicularis  palpebrarum. 
No  pain  had  attended  the  first  stage  of  the  disease.  A  large  quantity  of 
thick  pus  was  discharged  for  a  length  of  time.     The  eye  was  not  aff'ected. 

In  this  stage  there  cannot  exist  any  doubt  about  the  propriety  of  exten- 
sively laying  open  the  sinus,  either  with  a  strong  curved  knife,  or  a  small 
trephine,  evacuating  its  contents,  endeavoring  to  improve  the  state  of  its 
lining  membrane,  by  lunar  caustic  injections  and  the  like,  and  then  allowing 
the  parts  to  granulate  and  heal. 

In  one  instance  in  which  Beer  trepanned  the  sinus,  not  merely  was  that 
cavity  restored  completely  to  its  natural  state,  but  the  eyeball  returned  to  its 
proper  place  in  the  orbit,  and  vision  was  recovered.  In  a  second  case,  in 
which  the  external  appearances  were  not  nearly  so  alarming  as  in  the  former, 
after  opening  the  outer  table,  he  found,  on  examining  cautiously  with  the 
probe,  that  the  inner  was  softened,  and  even  drilled  through;  in  this  case  the 
eye  was  totally  blind,  and  Beer  endeavored  merely  to  check  the  progress  of 
the  disease,  by  making  a  counter-opening  through  the  conjunctiva,  above  the 
eyeball.  In  a  third  case,  the  symptoms  were  decidedly  those  of  a  collection 
of  puriform  mucus  in  the  sinus,  but  the  patient  would  hear  of  no  operation. 
Five  weeks  after  Beer's  first  visit,  the  outer  wall  of  the  sinus  gave  way  of 
itself;  and  in  the  course  of  two  weeks  more  the  eye  was  lost,  and  a  great 
portion  of  the  orbit  and  of  the  nose  destroyed  by  caries.  The  other  eye 
remained  completely  amaurotic.'" 

2.  Encysted  tumors,  or  hydatids,  of  the  frontal  sinus. — Professor  Langen- 
beck  has  published  two  cases  of  pressure  on  the  orbit  from  disease  in  the 
frontal  sinus.  He  speaks  of  them  as  cases  of  hydatid  ;  a  term  much  mis- 
applied by  some  of  the  German  pathologists.  Runge  would  have  probaljly 
regarded  them  as  cystic  or  encysted  tumors  ;  perhaps  the  one  was  nothing 
more  than  a  collection  of  mucus,  and  the  other  of  thick  matter.  The  situa- 
tions of  the  protrusion  of  the  outer  table  of  the  bone,  are  amongst  the  most 
remarkable  circumstances  of  these  cases. 

Case  74. — F.  Eeingarten,  aged  17,  enjoyed  perfect  health  till  she  was  8  years  of  age, 
■when  Iiaviiig  fallen  into  the  water  one  hot  day  in  1802.  she  was  seized  next  day  with 
couvulsionti,  followed  some  da^-s  after  by  an  eruption.  This  was  probably  niea.sle.-,  l)nt 
they  ran  an  irregular  course.  In  the  autumn  of  the  same  year,  she  fell,  so  that  her  right 
temple  struck  against  tlie  sharp  corner  of  a  table,  soon  after  which  a  hard  swelling  ap- 
peared in  the  region  of  the  right  frontal  sinus.  Devoid  of  pain,  it  gradually  extended 
towards  the  right  temple,  and  involved  the  whole  right  side  of  the  frontal  bone.  The 
right  eye  speedily  became  displaced  by  the  swelling,  in  a  direction  outwards  and  down- 
wards, and  tlie  power  of  vision  gradually  decreased. 

In  November,  1818,  when  the  patient  applied  at  the  Surgical  Hospital  of  Gottingen, 

7 


98  PRESSURE   ON  THE  ORBIT   FROM  THE  FRONTAL   SINUS. 

the  swelling  extended  upwards  as  far  as  the  coronal  suture.  The  orbital  edge  of  the 
frontal  bone,  the  eyeball,  and  the  orbit  were  pressed  downwards.  The  eye  was  covered 
by  the  eyelids,  and  not  pressed  out  of  the  orbit,  so  that  properly  no  exophthalmos  ex- 
isted ;  but  the  orbit  rather,  along  with  the  eye,  was  pressed  forwards,  outwards,  and 
downwards,  so  that  the  eye  was  in  a  line  with  the  point  of  the  nose,  The  fissura  palpe- 
brarum had  a  crescentic  form.  The  eyeball  could  with  difficulty  be  moved  a  little  towards 
the  nose  ;  it  preserved  its  natural  form,  and  was  not  atrophic,  but  completely  amaurotic. 
Although  the  swelling  was  on  the  whole  hard,  yet  in  the  temporal  region,  and  above  the 
eye,  it  yielded  to  the  pressure  of  the  fingers,  and  immediately  rose  again,  when  the  pres- 
sure was  relaxed,  as  if  one  were  pressing  the  lid  of  a  tin  box.  The  swelling  was  entireW 
free  of  pain,  except  when  one  pressed  hard  on  it,  above  the  nose.  That  the  swelling  did 
not  extend  in  the  direction  of  the  brain  was  evident  from  there  being  no  sign  of  any  dis- 
turbance in  the  cerebral  functions.  There  was  no  headache,  vomiting,  vertigo,  insensi- 
bility, or  coma,  and  the  general  health  was  good.  From  its  situation,  its  hardness,  and 
the  circumstance  that  at  certain  points  a  thin  lamina  of  bone  could  be  depressed  with  the 
finger,  and  from  the  brain  being  free  from  suffering,  it  was  concluded  that  the  swelling 
depended  on  the  frontal  sinus  being  dilated,  and  filled  with  some  morbid  product. 

Langenbeck  proceeded  to  open  the  swelling  on  the  2d  December,  1818.  At  the  place 
where  the  tumor  yielded  to  pressure,  he  divided  the  integuments  by  a  crucial  incision. 
The  outer  table  of  the  frontal  bone  was  next  penetrated  by  a  perforator ;  and  through  the 
aperture  thus  made,  a  pair  of  forceps  was  applied  so  as  to  break  away  some  pieces  of  the 
outer  table.  Through  the  opening  there  was  discharged  a  clear  ropy  lymphatic  fluid,  es- 
caping from  a  white  shining  cyst,  which  filled  the  whole  frontal  sinus,  and  which  had  been 
penetrated  by  the  perforator.  The  cyst,  or  hydatid  as  the  narrator  of  the  case  styles  it, 
was  laid  hold  of  with  the  forceps  and  partially  extracted. 

In  order  to  ascertain  the  dimensions  of  the  cavity,  a  measure  was  introduced.  From 
the  opening  to  the  orbitary  process  of  the  frontal  bone,  it  measured  three  inches ;  to  the 
frontal  sinus  of  the  opposite  side,  and  to  the  posterior  wall  of  the  cavity,  three  inches 
and  a  half.  With  the  finger  the  posterior  wall  of  the  sinus  was  distinctly  felt.  The  an- 
terior wall  was  thin  and  spongy.  The  cyst  was  thick,  and  where  it  had  been  attached, 
almost  cartilaginous.     Internally  it  formed  several  lobes,  containing  a  yellowish  fluid. 

The  sinus  was  filled  with  lint,  and  after  some  days  discharged  a  quantity  of  thin  ichor- 
ous matter,  for  which  injections  of  willow-bark  decoction,  with  myrrh,  were  employed. 
After  a  time  injections  containing  corrosive  sublimate  were  used;  but,  bringing  on  sali- 
vation, they  were  omitted.  The  internal  treatment  was  at  first  antiphlogistic ;  but  when 
the  ichorous  discharge  came  on,  bark  was  given.  The  swelling  subsided  only  in  an  incon- 
siderable degree  when  the  patient  left  the  hospital.  In  winter  1819-1820,  she  returned, 
with  the  swelling  in  the  same  state,  and  the  discharge  of  matter  still  as  abundant.  Lan- 
genbeck now  passed  two  setons  through  the  sinus,  by  which  means  the  discharge  and  the 
swelling  diminished." 

Case  75. — A  ploughboy,  20  years  of  age,  11  years  before  his  admission  into  the  hos- 
pital, had,  while  playing  at  tennis,  received  a  stroke  with  a  racket  on  the  left  side  of  the 
nose,  and  on  the  left  eye,  the  consequence  of  which  was  a  great  degree  of  swelling,  which, 
after  a  time,  completely  disappeared.  Two  years  afterwards,  he  began  to  feel  pain  in 
the  part,  and  observed  a  protuberance  at  the  inner  angle  of  the  eye. 

When  the  patient  came  to  the  hospital,  Langenbeck  found  the  eyeball  natural  in  form, 
the  power  of  vision  not  affected,  and  the  pupil  lively.  The  eyeball,  however,  was  pressed 
outwards  and  downwards,  by  a  considerable  swelling  at  the  inner  angle  of  the  eye.  The 
swelling  had  exactly  the  appearance  and  the  situation  of  a  greatly  distended  lachrymal 
sac,  but  was  considerably  bigger  than  we  almost  ever  find  the  sac,  even  in  its  state  of 
greatest  enlargement.  That  this  swelling  did  not  consist  in  an  enlarged  lachrymal  sac, 
Langenbeck  concluded  from  his  not  being  able  to  empty  it,  no  mucus  or  tears  being  evac- 
uated from  the  puncta  on  pressure,  and  the  tears  being  duly  conveyed  into  the  nostril, 
without  dropping  upon  the  cheek.  The  patient's  voice  was  similarly  affected  as  that  of 
one  with  polypus  in  the  nose.  The  swelling  communicated  an  obscure  impression  of 
fluctuation.  At  the  inner  side  of  the  swelling,  or  towards  the  nose,  it  was  bounded  by  a 
sharp  edge  of  bone,  which  was  felt  exactly  where  the  nasal  process  of  the  upper  maxil- 
lary bone  rises  by  the  inner  side  of  the  orbit.  As  the  surface  of  the  swelling  was  not 
covered  by  any  layer  of  bone,  but  felt  soft  and  fluctuating,  it  was  not  easy  to  form  a 
proper  judgment  regarding  its  seat,  and  one  might  have  readily  fallen  into  the  error  of 
supposing  it  to  be  an  enlarged  lachrymal  sac.  Against  such  a  supposition,  no  doubt,  there 
was  the  remarkable  displacement  of  the  eye  outwards  and  downwards.  As  the  swelling 
also  extended  from  the  inner  angle  upwards  and  towards  the  frontal  sinus,  Langenbeck 
concluded  that  that  cavity  was  the  seat  of  the  disease. 

An  incision  being  made  from  above  downwards,  close  to  the  sharp  edge  of  bone 
which  was  felt  at  the  inner  side  of  the  swelling,  and  in  such  a  way  as  to  avoid  both  the 


PRESSURE   ON  THE   ORBIT   FROM  THE   FRONTAL   SINUS.  99 

Inchrymal  sac  and  lachrymal  canals,  after  the  soft  parts  were  sufBciently  divided,  a  -white 
glistening  sac  came  into  view.  On  touching  this  with  the  finger,  it  was  evident  that  it 
contained  a  soft  mass.  Langenbeck  separated  the  swelling  as  much  as  possible  ;  but  as 
he  found  that  it  extended  deep  in  the  nostril,  he  opened  it,  whereupon  there  issued  from 
it  a  grayish-white  tenacious  substance.  He  cut  away  with  the  scissors  as  much  as  he 
could  of  the  sac,  and  introduced  his  finger  into  its  cavity.  Its  depth  extended  to  3  inches. 
With  the  point  of  his  finger  he  reached  as  far  as  the  floor  of  the  nostril.  He  could  not 
reach  the  orbit,  nor  touch  the  eyeball.  He  felt  from  the  diseased  cavity  the  inner  wall  of 
the  orbit,  formed  by  the  os  planum  of  the  ethmoid,  a  part  of  the  orbitury  plate  of  the 
frontal,  and  the  os  unguis.  This  wall  of  the  orbit,  along  with  the  lachrymal  sac  and  nasal 
duct,  was  pressed  outwards;  hence  arose  the  displacement  of  the  eyeball,  while  the  pas- 
sage of  the  tears  into  the  nose  continued  uninterrupted.  Langenbeck  introduced  his 
forefinger  up  into  the  frontal  sinus.  He  decided,  therefore,  that  the  disease  had  origin- 
ated there,  and  had  descended  by  the  side  of  the  nostril.  He  could  now  see  into  a  large 
cavity  filled  with  a  grayish-white  tenacious  mass,  which  he  removed  with  his  finger  and  a 
pair  of  forceps.  This  substance  was  contained  in  a  shut  sac,  distinct  from  the  mucous 
membrane  of  the  sinus  ;  and  had  it  not  been  so,  bethinks  the  substance  in  question  would 
have  made  its  way  into  the  nostril.  As  has  already  been  mentioned,  the  swelling  was  not 
covered  by  bone  at  the  inner  angle  of  the  eye.  It  must,  therefore,  he  thinks,  have  made 
its  way,  either  between  the  os  unguis  and  nasal  process  of  the  superior  maxillary  bone, 
or  it  must  have  prodviced  the  absorption  of  the  latter.  This  is  the  more  probable  con- 
jecture, as  the  edge  of  the  nasal  process  felt  so  sharp.  The  tenacious  substance,  which 
was  extracted,  was  enough  to  fill  a  tea-cup. '^ 

3.  Polypus  of  the  frontal  sinus. — Polypus  has  been  found  in  the  frontal 
sinuses,  the  same  disease  existing  in  the  neighboring  cavities  at  the  same 
time.  It  is  quite  conceivable,  however,  that  a  polypus  might  occupy  one  or 
other  of  the  frontal  sinuses,  without  any  tumor  of  the  same  sort  existing  in 
the  nostrils  or  maxillary  sinuses  ;  and  that  slowly  dilating  the  cavity  in  which 
it  took  its  origin,  it  might  displace  the  eyeball,  and  attenuate  and  soften  the 
external  table  of  the  frontal  bone.  Under  such  circumstances,  the  sinus 
should  be  opened  ;  and  as  polypus  is  often  attached  by  a  narrow  neck  to  the 
mucous  membrane  which  gives  it  birth,  the  tumor  might  probably  be  extir- 
pated with  success. 

Case  76. — A  boy,  aged  10,  was  put  under  Dr.  Wuth's  care,  on  account  of  a  disease  of 
the  left  eye,  under  which  he  had  labored  9  years.  The  eye  was  so  entirely  pushed  out 
of  the  orbit,  that  it  lay  on  a  level  with  the  back  of  the  nose.  Its  lateral  displacement 
projected  it  so  much  over  the  cheek-bone  that,  viewed  in  front,  it  hid  the  neighboring 
side  of  the  face.  Its  displacement  downwards  brought  it  into  a  line  with  the  point  of  tlie 
nose.  For  the  last  three  years,  it  had  closed  less  and  less  completely,  and  the  lids  now 
covered  it  so  imperfectly  that  the  cornea,  with  a  circumference  of  sclerotica  four  lines 
broad,  remained  constantly  exposed.  A  large,  deep  ulcer  of  the  cornea  threatened  a 
speedy  disorganization  of  the  eyeball. 

The  regions  of  the  frontal  and  nasal  bones  were  greatly  protruded.  The  eyeball  had 
gradually  quitted  its  natural  place,  in  proportion  as  the  orbit  had  become  contracted  hy 
tlie  pressure  exercised  upon  its  constituent  bones.  The  left  side  of  the  nose  formed  one 
flat  surface  with  the  back  of  it,  and  a  firm  obstacle  presented  itself  to  the  finger  passed 
into  the  left  nostril.  From  the  stretching  of  the  skin,  the  left  eyebrow  was  separated 
widely  from  the  right,  and  dragged  downwards.  The  skin  itself  was  thickened  and  doughy 
to  the  touch,  while  at  the  outer  under  part  of  the  eyebrow  was  a  small  opening,  from 
which,  on  pressing  the  surrounding  region,  a  whitish  mucus  welled  out. 

Dr.  Wuth,  being  of  opinion  that  a  large  polypus  occupied  the  frontal  ^nus,  proceeded 
to  remove  it  by  making  first  a  vertical  incision,  2  inches  long,  from  the  root  of  the  nose 
upwards  through  the  soft  parts ;  and  then  a  horizontal  one,  also  2  inches  long,  close 
above  the  eyebrow.  He  next  dissected  back  the  triangular  flap  thus  formed,  so  far  as  to 
permit  the  frontal  sinus  to  be  trepanned.  In  the  middle  of  the  superciliary  arch  was  a 
small  hole  in  the  bone,  opening  into  the  sinus,  and  explaining  the  source  of  the  fluid 
already  mentioned.  In  consequence  of  the  great  dilatation  of  the  sinus,  it  was  necessary 
to  make  two  openings  into  it  with  a  small  trephine,  whereupon  an  immense  quantity  of 
polypi  protruded,  and  were  removed.  The  cavity  in  which  they  were  contained  would 
have  held  three  hen-eggs. 

The  healing  of  the  parts  occupied  twelve  months,  the  frontal  sinus  being  by  that  time 
considerably  lessened  in  all  directions,  and  the  eye  having  partially  retreated  into  the 
orbit.     The  ulcer  of  the  coi-nea  soon  cicatrized.     From  the  first  night  after  the  operation, 


100       PRESSURE   ON  THE   ORBIT   FROM  THE   MAXILLARY   SINUS. 

the  patient  enjoyed  sleep,  such  as  he  had  not  had  for  years,  and  he  speedily  improved  in 
health. '» 

4.  Exostosis  of  the  fro7ital  sinus. — I  know  of  no  recorded  case  of  this  sort. 
By  chance,  I  possess  two  preparations,  each  showing  a  small  exostosis  in  the 
frontal  sinus. 

§  4.   Pressure  on  the  Orhit  from  the  3f axillary  Sinus. 

The  diseases  of  the  maxillary  are  upon  the  whole  analogous  to  those  of 
the  frontal  sinus.  They  are  more  frequent,  more  variable,  and  generally 
more  easily  recognized.  They  dilate  the  cavity  of  the  sinus,  thin  by  pressui-e 
the  bones  which  form  its  walls,  and  force  them  at  last  to  give  way.  They 
disfigure  the  face,  displace  the  eyeball,  and,  if  neglected,  prove  fatal.** 

1.  OoUections  of  tmictis  or  of  pus  within  the  maxillary  sinus. — A  thin  con- 
tinuation of  the  Schueiderian  meralirane  passes  from  the  upper  part  of  the 
middle  meatus  of  the  nostril,  through  a  narrow  aperture,  into  the  maxillary 
sinus,  and  forms  its  lining  membrane.  The  fluid  secreted  by  this  membrane 
is  in  health  discharged  into  the  nostril,  as  one  lies  on  the  opposite  side ;  but 
is  apt  to  accumulate,  constituting  what  some  have  called  dropsy  of  the  sinus; 
in  other  cases,  this  cavity  is  filled  with  thin  puriform  mucus,  or  with  thick 
curdy  pus.  Obstruction  of  the  communication  between  the  sinus  and  the 
nostril,  cold,  blows,  aflections  of  the  teeth,  smallpox,  and  various  other 
causes,  have  been  mentioned  as  giving  rise  to  these  diseased  accumulations, 
which  have  often  been  known  to  increase  so  much  as  greatly  to  dilate  the 
sinus,  elevate  the  floor  of  the  orl)it,  and  foi'ce  the  eyeball  forwards  from  its 
place.  The  matter  may  be  discharged  by  the  alveoli,  or  into  the  orbit,  or 
by  an  opening  which  it  makes  for  itself  through  the  fossa  canina.  As  an 
important  diagnostic  sign  it  may  be  mentioned,  that  in  cases  of  mucous  or 
purulent  collection  within  the  sinus,  or  of  accumulation  of  fluid  in  a  cyst  de- 
veloped in  the  substance  of  the  bone,  the  external  bony  shell  generally 
becomes  so  thin  as  to  yield  and  crackle  under  pressure,  like  the  lid  of  a  tin 
box.  This  symptom  is  wanting  in  exostosis,  and  also  generally  in  fungus  or 
polypus  of  the  maxilhiry  sinus.  It  is  right,  however,  never  to  depend  en- 
tirely on  external  diagnostic  signs  in  diseases  of  the  antrum;  but  always, 
before  proceeding  to  any  further  operation,  to  perforate,  or  attempt  to  per- 
forate, the  tumor,  so  as  to  ascertain  its  nature.  In  a  case  related  by  M. 
Gensoul,  the  incompressibility  of  the  tumor  led  him  to  suppose  it  to  be  bony, 
and  he  was  proceeding  to  the  excision  of  the  upper  maxillary  bone,  when,  on 
plunging  a  pair  of  scissors  into  the  swelling,  it  proved  to  be  a  collection  of 
mucus,  within  the  antrum.'* 

When,  in  consequence  of  obstruction  of  the  nasal  aperture  of  the  antrum, 
a  simple  accumulation  of  mucus  takes  place  within  the  cavity,  a  swelling  is 
apt  to  form  behind  the  ala  nasi  and  into  the  nostril,  on  puncturing  which 
within  the  nostril,  a  large  quantity  of  glairy  fluid  is  discharged.  If  the 
natural  aperture  is  now  restored,  well  and  good;  but  if  this  does  not  happen, 
the  aperture  which  has  been  made  with  the  lancet,  or  with  a  sharp  point  of 
pure  potash,  continues  patent,  and  the  discharge,  becoming  purulent,  may 
continue  for  years.  Not  being  entirely  evacuated,  however,  by  such  an  aper- 
ture, the  walls  of  the  antrum  may  become  thiuued  and  elevated  about  half  an 
inch  below  the  edge  of  the  orbit,  the  molares  and  dens  sapientise  get  loose, 
aud  pus  ooze  through  the  alveoli ;  the  roof  and  the  floor  of  the  cavity  may 
soften,  the  bones  become  bare  internally,  and  caries  ensue. 

For  an  example  of  apparently  simple  accumulation  of  mucus  within  the 
maxillary  sinus,  I  may  refer  to  a  case  which  occurred  to  M.  Dubois : — 

C'a.ie  77. — The  patient,  when  a  boy  of  7  years  of  age,  was  observed  to  have  a  hard 
round  tumor,  about  the  size  of  a  filbert,  near  the  root  of  the  nasal  process  of  the  left 


PRESSURE   ON  THE   ORBIT   FROM   THE   MAXILLARY   SINUS.        101 

upper  maxillary  bone.  It  gave  no  pain,  and  did  not  appear  to  be  increasing.  A  blow, 
however,  which  he  received  about  a  year  after  by  a  fall,  excited  this  tumor  to  grow, 
which  it  did  by  almost  insensible  degrees  till  he  was  15.  It  then  began  to  enlarge  more 
evidently  and  to  cause  slight  pain.  By  the  time  he  was  18,  it  was  so  considerable  in  size 
as  to  raise  the  floor  of  the  orbit,  so  that  the  eye  was  pressed  upwards,  and  appeared  less 
than  the  other,  on  account  of  the  limited  motion  of  the  lids.  The  palate  was  depressed, 
so  that  it  formed  a  swelling  of  about  the  size  of  an  egg  divided  longitudinally;  the  nos- 
tril was  almost  completely'  closed,  and  the  nose  was  twisted  to  the  right.  The  cheek  was 
prominent;  and  the  skin  below  the  lower  eyelid,  and  covering  the  upper  part  of  the 
tumor,  Avas  of  a  livid  color,  and  seemed  ready  to  give  way.  The  upper  lip  was  pushed 
upwards,  and  the  whole  length  of  the  gums  on  the  left  side  had  advanced  beyond  the  level 
of  those  on  the  right.     Breathing,  speech,  mastication,  and  sleep,  were  impeded. 

Sabatier,  Pelletan,  and  Boycr  being  called  into  consultation,  the  unanimous  opinion 
appears  to  have  been  that  this  was  a  case  of  fungus  of  the  maxillary  sinus,  requiring  an 
operation.  So  much  thinned  was  the  bone  behind  the  upper  lip,  that  Dubois  felt  there  a 
degree  of  fluctuation,  and  proceeded  to  open  the  sinus  at  that  place,  expecting  merely  to 
give  issue  to  a  small  quantity  of  ichorous  fluid,  and  then  to  encounter  the  fungous  tumor. 
The  opening,  however,  allowed  a  very  considerable  quantity  of  ropy  substance  to  escape, 
similar  to  what  is  found  in  ranula.  The  probe  being  passed  into  the  opening,  entered 
evidently  a  large  cavity,  quite  free  of  any  kind  of  fungous  or  polypous  growth.  It  is 
probable  that  the  opening  made  at  this  first  operation,  if  kept  from  closing,  would  have 
served  for  the  complete  cure  of  the  disease;  but  Dubois  appears  to  have  thought  differ- 
ently, and  proceeded,  five  days  afterwards,  to  extract  three  teeth,  and  to  remove  the  cor- 
responding portion  of  the  alveolar  process.  This  enabled  him,  on  placing  the  patient  in  a 
favorable  light,  to  see  the  whole  interior  of  the  dilated  sinus,  at  the  upper  part  of  which, 
and  near  to  the  edge  of  the  orbit,  he  discovered  a  canine  tooth,  which  he  extracted. 
After  this,  the  cavity  gradually  shrunk ;  the  tumor  of  the  cheek,  that  of  the  palate,  and 
the  displacement  of  the  nose,  continued  for  some  time ;  but  after  17  months  no  deformity 
existed.  '^ 

A  collection  of  pus  within  the  maxillary  sinus,  whether  produced  in  conse- 
quence of  primary  inflammation  of  its  lining  membrane,  or  of  inflammation 
excited  by  diseased  teeth,  which  is  more  generally  the  case,  is  not  unfre- 
quently  evacuated  in  part  through  the  opening  of  the  sinus  into  the  nostril  ; 
much  oftener,  however,  that  opening  appears  to  be  obstructed,  so  tliat  the 
pus  oozes  through  the  alveoli,  or  collects  and  distends  the  sinus,  producing 
a  series  of  symptoms  similar  to  those  which  occur  in  cases  of  simple  mucocele 
of  the  antrum. 

Case  78. — Some  years  ago,  I  had  under  my  care  a  gentleman,  in  whom  the  left  maxil- 
lary sinus  was  distended  to  such  a  degree  that  the  face  was  strikingly  deformed,  the 
bone  absorbed  at  the  most  prominent  part  of  the  cheek,  and  the  eye  partially  displaced. 
I  directed  the  second  molaris,  which  was  in  a  decayed  state,  to  be  removed  ;  and  through 
the  alveolus,  I  perforated  the  sinus  so  as  to  give  exit  to  a  considerable  quantity  of  puru- 
lent fluid.  I  then  pushed  up  a  lachrymal  style  into  the  opening,  removing  it  every  day 
and  injecting  the  sinus  with  tepid  water.  Under  this  treatment,  the  secretion  of  matter 
ceased,  and  the  sinus  shrunk  to  its  natural  size. 

In  neglected  cases  of  suppuration  within  the  maxillary  sinus,  various  parts 
of  its  walls  are  apt  to  be  absorbed,  in  consequence  of  the  pressure  of  the 
accumulated  pus,  or  rendered  carious  from  inflammation.  The  floor  of  the 
orbit  sometimes  suffers  these  changes.  The  matter,  issuing  from  the  sinus, 
infiltrates  behind  the  lower  eyelid,  which  swells  and  inflames,  sometimes  in 
the  neighborhood  of  the  lachrymal  sac,  and  at  length  there  is  formed  a  fistulous 
opening  through  the  eyelid,  by  which  matter  is  from  day  to  day  discharged. 
Perhaps  the  patient  is  brought  to  us  in  this  state,  when  on  passing  a  probe 
along  the  fistula,  we  readily  ascertain  that  it  enters  a  diseased  maxillary 
sinus. 

Case  79. — In  a  case  of  this  sort,  in  which  the  eye  was  already  lost  and  the  floor  of  the 
orbit  fistulous,  Bertrandi,  having  introduced  a  probe,  or  slender  perforator,  along  the 
fistula  into  the  maxillary  sinus,  directed  it  as  perpendicularly  as  he  could  against  the  in- 
ferior wall  of  that  cavity,  and  while  with  two  fingers  of  his  left  hand  he  pressed  against 
the  roof  of  the  mouth,  he  pushed  the  instrument  through  the  alveolar  process  from  above, 


102       PRESSURE   ON   THE   ORBIT   FROM   THE  MAXILLARY   SINUS. 

between  the  last  two  molares.     After  this  opef ation,  the  pus  ceased  to  flow  by  the  fistula 
of  the  orbit,  and  the  patient  recovered." 

The  mode  of  operating  followed  in  this  case  may  be  adopted  when  the 
jaws,  as  is  sometimes  the  case,  cannot  be  suflSciently  separated  to  permit  a 
similar  openina;  into  the  sinus  to  be  made  from  below.  Wherever  the  open- 
ing is  made,  whether  at  the  fossa  canina,  or  through  one  of  the  alveoli,  it 
ought  to  be  kept  patent,  either  by  a  dossil  of  lint,  a  lachrymal  style,  or  a 
silver  canula,  which  is  to  be  withdrawn  daily,  and  the  sinus  injected  either 
with  water  or  a  weak  solution  of  nitrate  of  silver.  The  patient  may  also  use 
a  gargle  frequently,  and  press  it  up  into  the  antrum. 

Cases  of  suppurating  maxillary  sinus  have  sometimes  been  successfully 
treated  by  the  introduction  of  a  seton  through  the  dilated  cavity,  although 
this  is  not  a  practice  to  be  much  recommended.  The  seton  is  passed  either 
through  openings  in  the  bone  already  formed  in  the  course  of  the  disease,*^ 
or  by  new  perforations.  Weinhold  penetrates  from  the  outside  of  the  cheek 
into  the  diseased  antrum,  and  brings  out  the  perforating  instrument  on  the 
palate  ;'^  Hedenus  separates  the  cheek  from  its  connection  with  the  superior 
maxillary  bone,  and  then  pushes  a  strong  needle,  armed  with  woollen  threads, 
through  the  diseased  cavity.'" 

In  some  instances,  where  the  cavity  was  much  dilated,  a  cure  has  been 
effected  by  practising  an  extensive  opening  into  the  side  of  the  antrum  above 
the  alveoli  f^  and  in  others,  only  after  considerable  exfoliations  of  its  walls.*' 

2.  Poll/pus  or  fungus  of  the  maxillary  sinus. — It  may  not  be  possible  to 
recognize  this  very  serious  disease  in  its  incipient  stage ;  but  as  it  advances, 
it  always  affects  the  neighboring  parts  in  such  a  way  as  to  render  evident  the 
nature  of  the  case,  and  vindicate  the  employment  of  an  effective  surgical 
treatment.  The  dilated  sinus  is  changed  in  form  ;  the  teeth  belonging  to 
the  affected  bone  become  loose,  or  fall  out  spontaneously ;  the  alveolar  pro- 
cess becomes  spongy,  and  from  its  cavities  there  sprout  out  fungous  granu- 
lations ;  there  is  frequent  bleeding  from  the  corresponding  nostril ;  respiration 
through  that  nostril  becomes  impeded  ;  and  on  inspection,  a  polypous  mass 
is  found  stretching  into  it  from  the  antrum ;  often  the  same  growth  raises  and 
destroys  the  skin  in  the  situation  of  the  lachrymal  sac  ;  sometimes  it  extends 
across  the  nostrils,  producing  by  its  pressure  the  absorption  of  the  septum 
narium,  and  projects  at  the  inner  angle  of  the  opposite  eye  also  ;  the  cheek 
is  greatly  dilated  and  deformed,  and  at  length  the  prominent  point  of  the 
bony  shell  gives  way ;  the  floor  of  the  orbit  is  destroyed,  and  the  eyeball  is 
pushed  upwards  and  forwards  from  its  place ;  the  palate  is  softened  and  de- 
pressed; if  nothing  is  done  to  remove  the  polypus,  frequent  hemorrhages 
weaken  the  system,  hectic  fever  comes  on,  and  death  closes  the  scene. 

The  order  in  which  the  symptoms  occur  varies  in  different  cases.  Some- 
times a  violent  feeling  of  toothache  is  the  first  symptom  ;  sometimes  a  swel- 
ling in  the  seat  of  the  lachrymal  sac  ;  sometimes  a  bleeding  from  the  nose. 
Frequently,  the  patient  has  been  conscious  of  a  stuffing  of  the  corresponding 
nostril  for  years.  Then,  there  follows  violent  itching  of  the  lower  eyelid 
near  the  margin  of  the  orbit ;  to  which  are  added  fulness  and  hardness  there, 
protrusion  of  the  eyeball,  oedema  of  the  conjunctiva,  and  the  appearance  of 
a  polypus  in  the  nostril.  Attempts  are  made,  perhaps,  to  tie,  or  to  twist  off 
the  polypus ;  and  it  is  then  discovered  to  sprout  from  the  interior  of  the 
antrum.  The  patient  may  present  himself  with  a  fungous  growth  in  the  seat 
of  the  lachrymal  sac,  the  nostril  being  filled  with  the  polypous  growth  from 
the  antrum,  but  the  antrum  itself  not  dilated.  I  have  known  such  a  case 
taken  for  an  exostosis  of  the  ethmoid  bone,  and  operated  on  as  such.  For 
years,  the  patient  has  sometimes  noticed  that  one  side  of  his  face  felt  dif- 
ferently from  the  other,  especially  in  shaving. 


PRESSURE  ON  THE   ORBIT  FROM   THE   MAXILLARY   SINUS.        103 

In  general,  no  exciting  causes  can  be  fixed  on  by  the  patient.  In  one 
case,  a  blow  on  the  face  with  a  rope  seven  years  before,  was  mentioned  as 
likely  to  have  been  the  cause. 

It  scarcely  admits  of  doubt  that  there  are  essential  differences  in  the  nature 
of  the  polypous  or  fungous  growths,  which  are  met  with  in  the  upper  maxilla 
or  within  the  antrum.  The  success  which  has  attended  the  treatment  in  some 
cases,  in  which  the  tumor  has  been  slowly  destroyed,  and  the  fatal  result  in 
other  cases  where  extirpation  of  the  tumor,  or  even  excision  of  the  upper 
maxillary  bone,  has  been  accomplished,  would  lead  us  to  this  conclusion. 
There  is  reason  to  believe  that  the  most  frequent,  as  well  as  the  most  dan- 
gerous diseases  of  the  antrum,  partake  of  the  nature  of  encephaloid  cancer 
or  fungus  haematodes,  which  in  some  cases  seems  to  be  formed  entirely  within 
the  cavity,  proceeding  from  the  mucous  membrane,  and  in  its  progress  de- 
stroying the  bones  ;  while,  in  other  cases,  the  bones  appear  to  be  first 
affected,  so  that  the  disease  is  a  malignant  growth  developed  within  the  sub- 
stance of  the  bone,  and,  in  fact,  osteo-sarcoma.  I  have  also  known  the  dis- 
ease to  be  developed  at  the  same  time  within  the  antrum,  and  in  the  perios- 
teum at  the  lower  edge  of  the  orbit. 

The  bones  which  are  implicated  vary  also  in  different  cases ;  for  sometimes 
the  disease  is  confined  to  the  upper  maxillary  bone,  while  in  others  the  sphe- 
noid gives  rise  to  the  tumor,  which  pushes  itself  forwards  into  the  antrum 
and  the  orbit. 

That  the  direction  of  the  pressure  of  a  fungus  within  the  antrum,  is  differ- 
ent in  different  cases,  is  a  fact  of  which  I  am  convinced  from  cases  which 
have  come  within  my  own  observation.  In  some,  chiefly  children  or  adoles- 
cents, the  principal  protrusion  is  forwards  and  outwards,  so  that  the  floor  of 
the  orbit  is  less  disturbed  ;  in  others,  the  pressure  is  chiefly  inwards,  so  that 
the  tumor  speedily  makes  its  appearance  in  the  nostril,  destroys  the  septum 
narium,  and  rises  into  view  at  the  inner  canthus  of  each  eye,  covered  only 
by  the  integuments;  while  in  a  third  set,  and  these  chiefly  old  people,  the 
fungus  makes  little  or  no  pressure  outwards,  but  proceeds  inwards  and  up- 
wards, causing  absorption  of  the  floor  of  the  orbit,  destroying  the  soft  parts 
within  that  cavity  by  exciting  inflammation  and  suppuration,  and  lastly 
affecting  the  orbitary  plate  of  the  frontal  bone. 

Treatment. — Though  polypus  of  the  antrum  shows  itself  in  the  nose  and 
in  the  orbit,  it  is  not  to  be  attacked  in  either  of  these  directions.  It  is 
through  the  facial  wall  of  the  cavity  that  the  tumor  is  to  be  reached.  This 
is  illustrated  by  the  following  case,  which  also  serves  to  show  the  effects  of 
the  disease  on  the  orbit : — 

Case  80. — James  Macculloch,  aged  53,  •who  became  a  patient  under  my  care,  at  the 
Glasgow  Eye  Infirmary,  in  February,  1828,  stated  that  he  had  been  sensible  of  a  stuffing 
of  the  right  nostril  for  some  years  ;  that  six  months  before  his  admission  he  had  been 
attacked  with  supra-orbital  pain,  darting  towards  the  right  side  of  his  head ;  and  in  a 
ehort  time  after  this,  with  pain  in  the  region  of  the  right  maxillary  sinus,  stretching 
towards  the  floor  of  the  orbit,  and  increased  when  he  opened  his  mouth.  This  was  soon 
followed  by  stillicidium  lachrymarum  ;  a  soft  elastic  swelling,  in  the  situation  of  the  right 
lachrymal  sac;  and  protrusion  of  the  eyeball  forwards,  outwards,  and  upwards,  from  the 
orbit.  He  complained  of  a  want  of  the  sense  of  taste  in  the  right  side  of  his  mouth.  He 
slept  little  on  account  of  the  pain  above  the  eye.  On  examining  the  palate,  it  was  found 
to  be  yielding  and  elastic  under  the  right  maxillary  sinus.  For  several  weeks,  the  vision 
had  been  double,  in  consequence  of  the  displacement  of  the  right  eye.  The  conjunctiva 
was  inflamed,  the  eyelids  adhered  in  the  morning,  and  in  consequence  of  the  exposed 
state  of  the  protruded  eye,  a  small  ulcer  existed  at  the  lower  edge  of  the  cornea.  The 
right  nosti'il  was  found  to  be  filled  by  a  polypous  excrescence,  of  a  white  color  and  me- 
dullary texture,  which  bled  profusely  on  being  touched. 

After  clearing  away  this  substance  with  the  polypus-forceps,  a  carious  opening,  sufficient 
to  admit  the  end  of  the  little  finger,  was  found  to  exist  between  the  nostril  and  the  maxil- 
lary sinus.     With  the  finger  introduced  through  this  opening,  it  was  ascertained  that  the 


104       PRESSURE   ON  THE   ORBIT  FROM  THE   MAXILLARY   SINUS, 

sinus  was  completely  filled  with  the  same  kind  of  polypous  excrescence  which  had  occu- 
pied the  nostril.  The  clearing  of  the  nostril  was  performed  on  the  19th  ;  and  it  is  re- 
markable, that  this  had  so  much  relieved  the  pressure  on  the  orbit,  that  five  days  after, 
when  I  proceeded  to  open  the  maxillary  sinus,  the  ulcer  of  the  cornea  was  already  cica- 
trized, evidently  in  consequence  of  the  eyeball  having  retreated  somewhat  into  the  orbit, 
so  as  to  allow  it  to  be  better  defended  by  the  lids. 

On  the  24th,  I  made  an  incision,  oblique  in  its  direction,  from  above  downwards,  and 
from  without  inwards,  through  the  cheek,  down  to  the  bone,  with  the  intention  of  open- 
ing the  sinus  and  removing  its  contents.  I  found,  however,  that  the  polypus  had  already 
produced  absorption  of  the  outer  wall  of  the  sinus,  to  the  extent  of  half  an  inch  in 
diameter.  Through  this  opening  the  polypus  was  broken  down  and  extracted.  It  re- 
sembled brain  in  color  and  consistence.  The  bony  parietes  of  the  sinus  were  felt  through- 
out to  be  diseased  ;  its  nasal  side  much  disorganized;  the  os  unguis  gone;  the  orbital 
side,  and  indeed  the  whole  interior  of  the  sinus,  denuded  of  its  lining  membrane.  A 
long  dossil  of  lint  was  introduced  into  the  sinus.  In  a  few  days,  a  profuse  secretion  of 
white  fetid  matter  flowed  from  the  whole  of  the  internal  surface  of  the  sinus,  on  remov- 
ing the  dossil  of  lint. 

By  the  4th  March,  the  nose  and  lachrymal  region  were  much  more  natural  in  their 
appearance,  and  the  eye  more  in  its  place.  A  solution  of  chloride  of  lime  (^i-  to  Ibij.  of 
water)  was  daily  injected  into  the  sinus,  with  the  view  of  correcting  the  fetor  of  the  dis- 
charge. The  long  dossil  of  the  lint  was  carefully  introduced,  so  as  to  fill  the  cavity  com- 
pletely. By  the  9tli,  all  pain  had  ceased,  the  eye  was  still  more  in  its  place,  the  vision 
improved,  and  the  shape  of  the  face  much  more  natural.  The  discharge  had  lost  its 
fetor,  and  was  less  in  quantity.  By  the  18th,  the  double  vision  was  gone.  By  the  27th 
April,  there  was  very  little  discharge,  and  the  vision  was  much  improved.  On  the  5th 
August,  the  report  runs  thus :  General  health  and  local  symptoms  go  on  improving. — 
On  pressing  the  site  of  the  lachrymal  sac,  thick  white  matter  issues  from  the  lower  punc- 
tum,  but  is  diminishing  under  the  use  of  an  injection  of  the  nitras  argenti  solution. 
Antrum  seems  contracting,  and  discharges  very  little.  Water  injected  by  the  opening, 
flows  out  by  the  nostril. 

On  the  whole,  this  case  proved  much  more  satisfactory  than,  from  the  very  disorganized 
state  of  the  sinus,  I  had  expected.  Vision  and  life  were  saved  bj'  the  operation.  More 
than  six  years  after,  the  patient  was  in  good  health,  the  wound  much  contracted,  the 
sinus  still  kept  open  with  a  bent  wooden  style,  and  no  appearance  of  any  reproduction  of 
the  polypus.  In  April,  1835,  however,  MaccuUoch  presented  himself  at  the  Eye  In- 
firmary, with  similar  symptoms  on  the  left  side,  as  had  formerly  attended  the  commence- 
ment of  the  disease  of  the  right  antrum.  He  was  ordered  to  be  received  as  an  in-patient, 
but  appears  to  have  declined  admission. 

In  the  case  which  I  have  just  now  related,  the  bleeding  was  easily  re- 
strained ;  but  in  other  instances  profuse  hemorrhage  has  followed  the  cutting 
or  tearing  away  of  the  tumor,  so  as  to  demand  the  application  of  the  actual 
cautery.  This  means  had  also  been  employed  for  destroying  the  remains  of 
the  fungus,  when  it  could  not  be  completely  extirpated. 

The  sinus  might  have  been  cleared,  in  Maccullocb's  case,  without  making 
any  incision  through  the  integuments,  namely,  by  detaching  the  cheek  from 
the  upper  maxillary  bone ;  but  in  this  way  the  discharge  would  of  course 
have  flowed  into  the  mouth,  which  would  have  been  very  disagreeable  to  the 
patient,  and  he  would  have  been  exposed  to  foreign  substances  entering  the 
sinus.  When  we  are  anxious  about  the  personal  appearance  of  the  patient, 
we  will  perhaps  prefer  this  mode  of  operating  ;  but  when  that  is  less  our 
object  than  a  ready  and  effectual  method  of  getting  rid  of  the  disease,  the  in- 
cision through  the  cheek  will  be  adopted. 

The  method  of  operating  followed  by  Desault,  in  fungus  of  the  maxillary 
sinus,  consisted,  not  merely  in  opening  that  cavity,  after  detaching  the  cheek 
from  the  bone,  but  in  removing  with  the  gouge  and  mallet,  a  considerable 
portion  of  the  alveolar  process.**  I  should  regard  this  as  in  general  unne- 
cessary, and  to  be  had  recourse  to  only  when  this  portion  of  the  wall  of  the 
antrum  is  unsound,  or  gives  origin  to  the  morbid  growth.  Through  the 
mouth,  it  may  be  somewhat  difficult  sufficiently  to  lay  open  the  sinus ;  but 
by  cutting  through  the  cheek,  the  bone  may  be  so  completely  exposed,  and 
an  opening  made  of  such  a  size  into  the  sinus,  as  shall  readily  permit  the 


PRESSURE   ON   THE   ORBIT   FROM   THE   MAXILLARY   SINUS.        105 

diseased  mass  to  be  removed.  Since  I  first  published  these  remarks  in  1830, 
a  still  more  formidable  operation  has  been  frequently  performed  for  the  cure 
of  fungus  of  the  maxillary  sinus,  as  well  as  for  other  diseases  of  the  upper 
maxilla,  namely,  total  excision  of  the  upper  maxillary  bone.  An  operation 
of  such  severity  should  be  had  recourse  to,  only  where  there  is  reason  to 
conclude,  first,  that  the  disease  is  so  confined  to  the  maxillary  and  neighbor- 
ing bones,  that  it  can  be  completely  removed  ;  and,  secondly,  that  it  cannot 
be  destroyed  by  any  other  method.  A  fungus  completely  confined  within 
the  antrum  may  always,  I  apprehend,  be  extirpated,  without  sacrificing  more 
than  a  portion  of  its  parietes ;  it  is  not  probable  that  a  malignant  tumor, 
originating  within  the  antrum,  but  which  has  already  thrown  its  ramifications 
into  the  nostril  and  the  orbit,  could  be  removed,  even  by  the  sacrifice  of 
several  of  the  other  bones  of  the  face  besides  the  upper  maxillary.  Still 
more  hopeless  are  fungous  tumors  originating  in  the  ethmoid  or  sphenoid.^ 

The  following  case  is  worthy  of  consideration,  not  less  on  account  of  the 
great  degree  of  disorganization  produced  by  the  disease,  than  for  the  sim- 
plicity of  the  method  of  cure  : — 

Case  81. — A  man,  aged  36,  applied  to  Dr.  Eble,  on  account  of  an  ulcerated  state  of  the 
left  cheek,  with  protrusion  and  amaurosis  of  tlie  eye  of  that  side.  The  cheek  was  not 
merely  inflamed,  painful,  and  partly  ulcerated ;  but  the  subjacent  bone  was  exposed, 
softened,  and  perforated  in  five  different  points.  The  probe,  introduced  through  these 
openings,  was  met  by  an  elastic  fleshy  substance,  which  completely  filled  the  antrum,  and 
by  pushing  up  the  roof  of  this  cavity  had  driven  the  eyeball  forwards  and  outwards.  The 
floor  of  the  antrum  Avas  yet  entire ;  but  the  alveolar  process  at  one  place,  where  formerly 
there  had  been  a  carious  tooth,  gave  issue  to  a  considerable  quantity  of  fetid  ichor.  The 
eye  was  so  much  protruded,  that  it  could  not  be  covered  by  the  lids ;  the  amaurosis  so  far 
advanced  that  the  patient  could  at  a  footstep's  distance  perceive  very  large  objects  but 
obscurely;  the  motions  of  the  eye  extremely  difficult;  severe  nocturnal  pain  in  the  bottom 
of  the  orbit  prevented  sleep.  The  patient  had  always  been  healthy,  except  that  for  the 
last  two  years  he  had  suffered  from  severe  toothache,  for  which  he  had  had  three  carious 
teeth  extracted  ;  and  from  ulcers  of  the  gums.  He  had,  moreover,  experienced  an  in- 
creasing weakness  of  sight.  At  this  period,  the  surgeons  who  attended  him  opened  twice 
a  swelling  over  the  second  and  third  molare.s,  and  at  each  time  a  quantity  of  yellowish 
and  slightly  fetid  pus  was  evacuated. 

To  limit  the  spread  of  the  ulcerative  inflammation  of  the  cheek,  Dr.  Eble  ordered  leeches 
to  the  sound  parts,  and  the  diseased  parts  to  be  bathed  with  a  lukewarm  lotion,  and 
carefully  cleaned.  The  swelling  and  pains  diminished,  and  the  ulcerated  places  became 
cleaner.  The  matter  not  escaping  easily  from  the  antrum  in  consequence  of  the  smallness 
of  the  openings,  he  dilated  these  with  sponge-tent,  and  then  endeavored  to  destroy  the 
polypous  mass,  by  means  of  nitrate  of  silver,  which  he  applied  daily  through  one  or  other 
opening,  for  the  space  of  10  minutes.  In  four  weeks,  there  was  a  free  space  of  4  lines 
betwixt  the  edges  of  the  openings  and  the  polypus,  so  that  he  could  now  inject  into  the 
interval,  twice  daily,  a  saturated  solution  of  nitrate  of  silver.  This  hastened  very  much 
the  destruction  of  the  polypus;  for  in  14  days  the  eyeball  was  perceptibly  retracted,  and 
its  motions  had  become  freer.  The  violent  pains  at  the  bottom  of  the  orbit  were  at  the 
same  time  mitigated ;  but  vision  was  not  improved,  although  the  pupil  was  not  so  much 
dilated.  In  the  8th  week  of  the  treatment.  Dr.  Eble  removed  with  the  scissors  the  portion 
of  bone  between  two  of  the  openings,  and  in  consequence  of  this  was  enabled  to  apply  the 
caustic  more  freely,  by  which  the  complete  destruction  of  the  polypus  was  effected  in  the 
12th  week.  It  now  appeared  that  the  osseous  walls  of  the  antrum  were  nowhere  carious, 
but  only  spongy,  and  that  the  floor  of  the  orbit  had  suffered  very  little.  As  the  polypus 
shrunk,  all  the  symptoms  of  amaurosis  were  removed,  and  the  eye  returned  into  its  natural 
situation;  a  good-conditioned  suppuration  took  place  in  the  whole  parts  affected;  the  ob- 
stinate growth  of  the  mucous  membrane  stopped,  and  the  spongy  bone  became  firmer  in 
its  texture ;  healthy  granvilations  sprung  from  all  the  openings  ;  and  these  gradually 
contracted  until  one  after  the  other  closed.  In  four  months,  the  patient  was  ijerfectly 
cured.  25 

A  remarkable  instance  of  successful  extirpation  of  a  maxillary  fungus 
occurred  in  the  practice  of  Dr.  Thomas  White  of  Manchester.  Indeed,  the 
bones  of  the  orbit  appear  to  have  suffered  more  in  this  case  than  in  any  other 
on  record. 


106       PRESSURE   ON   THE   ORBIT   FROM  THE   MAXILLARY   SINUS, 

Case  82. — The  patient  was  a  female.  In  two  years'  time,  the  tumor,  situated  betwixt 
tlie  left  zj'gomatic  process  and  the  nose,  put  on  a  frightful  appearance ;  having  grown  to 
such  a  bulk  that  it  pressed  the  nostrils  to  one  side,  so  as  to  stop  the  passage  of  air  through 
them,  and  thrust  the  eye  out  of  its  orbit,  so  that  it  lay  on  the  left  temple.  Though  thus 
distorted,  the  eye  still  performed  its  office.  The  swelling  occupied  the  greater  part  of 
the  left  side  of  the  face,  extending  from  the  lower  part  of  the  upper  jaw  to  the  top  of 
the  forehead,  and  from  the  farthest  part  of  the  left  temple  to  the  external  canthus  of  the 
eye.  Upon  handling  the  tumor.  Dr.  White  found  an  unusual  and  unequal  bony  hardness. 
It  was  of  a  dusky  livid  color,  with  varicose  veins  on  the  surface,  and  there  was  a  soft 
tubercle  projecting  near  the  nose,  where  nature  had  endeavored  in  vain  to  relieve  herself. 

Dr.  White  began  the  operation  with  a  semicircular  incision  below  the  dislocated  eye, 
in  order  to  preserve  that  organ  and  as  much  as  possible  of  the  orbicular  muscle ;  then 
carrying  the  incision  round  the  external  and  inferior  part  of  the  tumor,  he  ascended  to 
the  place  where  he  began,  taking  care  not  to  injure  the  left  wing  of  the  nose.  After 
taking  away  the  external  part  of  the  tumor  which  was  separated  in  the  middle  by  an  im- 
perfect suppuration,  there  appeared  a  large  quantity  of  a  matter  like  rotten  cheese,  in 
part  covered  by  a  bony  substance,  so  carious  as  to  be  easily  broken  through.  Abundance 
of  this  matter  was  scooped  away,  with  a  great  many  fragments  of  rotten  bones.  Upon 
cleansing  the  wound  with  a  sponge.  Dr.  White  found  the  left  bone  of  the  nose,  and  the 
zygomatic  process,  carious,  and  removed  them.  He  says  there  were  no  remains  of  the 
bones  composing  the  orbit.  The  optic  nerve  was  denuded  as  far  as  the  dura  mater ;  this 
membrane  and  the  pulsation  of  the  vessels  of  the  brain  were  apparent  to  the  eye  and 
touch.  The  superior  maxillary  bone,  in  the  sinus  of  which  the  disease  had  had  its  origin, 
was  surprisingly  distended,  and  in  some  places  carious.  The  alveolar  process  was  pro- 
bably in  this  state,  as  Dr.  White  mentions  that  he  removed  it.  He  then  applied  the 
actual  cautery  to  the  rest  of  the  bones,  taking  care  not  to  injure  the  eye  and  neighboring 
parts,  which  were  sound. 

The  patient  drew  her  breath  through  the  wound,  and  was  so  incommoded  by  the  fetid 
matter  flowing  into  her  throat,  that  she  was  obliged  for  several  weeks  to  lie  on  her  face, 
to  prevent  suffocation.  Notwithstanding  her  miserable  condition,  nature  at  length 
assisted,  laudable  pus  appeared,  sound  flesh  was  generated,  and  the  patient  recovered. 
The  eye  returned  to  its  place,  and  she  enjoyed  the  perfect  sight  of  it.  The  only  inconve- 
nience that  remained,  was  a  constant  discharge  of  mucus  from  the  inner  canthus  of  the 
eye.  26 

Mr.  Plowship  has  illustrated,  by  an  engraving,  the  great  extent  to  which 
the  bones,  forming  the  parietes  of  the  antrum  may  be  dilated  by  this  disease. 

Case  83. — The  patient,  whose  skull  he  has  represented,  a  woman  about  30  years  of  age, 
was  received  into  the  Westminster  Hospital,  with  an  extraordinary  swelling  upon  the  right 
side  of  the  face,  producing  great  distortion  of  countenance,  but  not  attended  with  any 
discoloration  of  the  skin.  The  basis  of  the  tumor  extended  upwards  to  the  eye,  which 
was  almost  closed,  and  reached  below  to  the  chin ;  the  adjacent  angle  of  the  mouth  being 
much  depressed,  and  thrown  out  of  its  line,  and  the  nose  pressed  aside  towards  the  left 
cheek.  In  the  most  prominent  part,  the  tumor  projected  about  four  inches  beyond  the 
general  line  of  the  bones  of  the  face.  On  the  inside  of  the  mouth,  the  tumor  was  very 
large,  having  extended  itself  across  the  palate,  nearly  to  the  opposite  teeth.  The  tumor 
was  confined  entirely  to  the  bones  about  the  upper  jaw ;  it  was  apparently  fleshy,  and 
where  it  extended  across  the  roof  of  the  mouth,  it  was  of  a  florid  red  color.  The  teeth 
of  the  upper  jaw,  thrown  out  of  their  natural  situation,  formed  an  angle  with  the  re- 
maining part  of  the  alveolar  circle.  All  those  teeth  involved  in  the  extent  of  the  tumor, 
were  thus  forced  into  the  middle  of  the  mouth,  greatly  impeding  deglutition. 

The  disease  was  of  five  years'  standing,  and  had  begun  with  a  small  soft  swelling  in 
the  right  nostril.  In  this  state,  it  had  produced  no  uneasiness.  On  the  presumption  of 
its  being  a  polypus,  the  tumor  had  been  partially  extracted  at  difl'erent  times.  These 
operations  seemed  only  to  accelerate  the  progress  of  the  disease,  aggravating  the  degree 
of  uneasiness  and  pain  the  patient  now  suffered,  and  hastening  the  increase  of  the  swell- 
ing. W' hen  the  complaint  had  become  more  completely  formed,  there  were  two  or  three 
teeth  which  from  their  horizontal  position  were  very  much  in  the  way,  and  troublesome 
from  their  being  loose.  Although  the  operation  of  removing  them  required  no  great  eff"ort, 
it  was  attended  with  such  a  hemorrhage  as  brought  the  patient  very  low,  before  it 
could  be  effectually  checked.  A  second  violent  bleeding  took  place  about  three  weeks 
afterwards,  from  a  spontaneous  breach  in  the  softer  part  of  the  tumor.  This  reduced 
her  so  much  that  she  languished  only  a  week  longer. 

On  dissecting  the  tumor,  it  proved  to  be  a  fleshy  mass,  or  excrescence,  not  contained 
merely  within  the  antrum,  but  surrounding  and  enclosing  all  the  bones  of  the  upper  jaw. 
These  bones  had,  from  pressure,  suffered  a  separation  at  their  respective  points  of  union, 


PRESSURE   ON   THE   ORBIT   FROM   THE   MAXILLARY   SINUS.       lOT 

with  such  a  degree  of  extension  and  attenuation  of  their  substance,  that  in  many  places 
they  were  reduced  to  the  thinness  of  paper.  The  os  malse  was  detached  from  the  rest 
of  the  bones,  and  (though  in  its  natural  state  a  very  solid  bone)  exhibited  a  cribriform 
appearance. 

The  origin  and  nature  of  the  disease  cannot  be  a  matter  of  any  doubt.  The  bones  had 
most  likely  remained  uninjured  till  the  soft  fungous  yascular  mass  from  within  the  cavity 
of  the  antrum  began  to  operate,  first  by  producing,  absorption  of  the  membrane  lining 
that  cavity,  and  then  by  the  pressure  of  its  peculiar  and  partially  organized  texture,  not 
exciting  regular  absorption  of  the  bone,  but  sufficiently  loosening  its  structure  to  admit 
of  considerable  distention.  In  the  progress  of  the  disease,  as  might  naturally  be  ex- 
pected, the  circulation  in  the  periosteum  made  some  effort  towards  repairing  the  mischief, 
by  the  secretion  of  new  bone,  as  happens  in  cases  of  necrosis,  although  this  effort, 
owing  to  the  almost  disorganized  condition  of  that  membrane,  had  proved  irregular  and 
abortive.^ 

The  following  case  illustrates  the  cure  by  excision  of  the  upper  maxillary 
bone : — 

Case  84. — Janet  Steel,  aged  42,  admitted  into  the  Eoyal  Infirmary  of  Edinburgh,  on 
the  20th  November,  1834,  stated  that,  about  ten  years  before,  she  had  received  a  kick  on 
the  face  from  a  cow,  which  was  followed  by  swelling  that  never  entirely  disappeared. 
In  the  beginning  of  1834,  she  began  to  suffer  pain  in  the  seat  of  enlargement,  and  at  the 
same  time  remarked  a  great  increase  in  the  rapidity  of  the  growth.  The  superior  molar 
and  bicuspid  teeth  of  the  affected  side,  soon  afterwards  loosened  and  came  away.  Within 
a  few  months  of  her  admission,  the  progress  of  the  disease  had  not  been  so  rapid,  but  it 
had  advanced  so  far  as  to  be  very  distressing,  and  threatened  to  prove  still  more  serious. 

The  cheek  was  considerably  distended  by  a  tumor  springing  from  the  superior  maxilla, 
which,  though  firm,  did  not  possess  the  hai-dness  of  bone.  When  the  finger  was  drawn 
across  the  lower  margin  of  the  orbit,  an  inequality  in  its  surface  was  detected,  and  the 
floor  of  the  cavity  could  be  felt  distinctly  elevated.  The  palate,  throughout  the  whole  of 
its  extent  on  the  left  side,  and  also  for  some  distance  beyond  the  mesial  plane,  was  greatly 
thickened,  and  extremely  irregular  on  its  surface,  which  exhibited  the  characters  of  a 
malignant  ulcer.  The  patient  in  all  other  respects  enjoyed  good  health,  and  it  was,  there- 
fore, thought  proper  to  attempt  eradication  of  her  formidable  and  extensive  disease,  which 
was  evidently  confined  to  the  superior  maxillary  bone. 

On  the  28th,  the  patient  being  seated  in  a  chair,  a  perpendicular  incision  was  made, 
by  Professor  Syme,  from  the  inner  angle  of  the  eye  down  through  the  lip,  and  another 
from  the  convexity  of  the  malar  bone  to  the  angle  of  the  mouth.  The  flap  thus  formed 
was  dissected  up,  and  the  integuments  on  each  side  turned  back  so  as  to  expose  the 
whole  surface  of  the  maxillary  bone.  One  blade  of  a  pair  of  cutting  pliers  was  then 
introduced  into  the  nostril,  and  the  other  into  the  orbit,  so  as  to  divide  the  ascending 
nasal  process.  A  notch  was  next  made  with  a  saw  in  the  malar  protuberance,  which 
then  readily  yielded  to  the  pliers.  After  this,  only  the  palate  and  septum  of  the  nose 
remained  to  be  divided,  which  was  done  by  first  circumscribing  the  morbid  surface  in  the 
roof  of  the  mouth  with  a  sharp-pointed  straight  bistoury,  and  then  cutting  through  the 
bone  with  the  pliers.  The  diseased  mass  was  now  easily  turned  out  to  the  side,  and  de- 
tached from  its  connections,  when  it  appeared  that  the  tumor  had  been  removed  quite 
entire.  It  was  of  moderately  firm  consistence,  and  of  a  yellowish  color,  springing  from 
tlie  maxillary  bone  and  filling  the  antrum.  By  its  pressure  it  had  caused  absorption,  as 
well  as  displacement,  of  the  floor  of  the  orbit. 

The  arteries  requiring  ligature  having  been  tied,  the  patient  was  conveyed  to  bed.  An 
hour  after  the  operation,  the  cut  edges  of  the  integuments  were  brought  into  accurate 
contact  by  the  interrupted  suture,  except  at  the  two  points  where  the  lip  was  divided, 
each  of  which  was  secured  by  the  twisted  suture,  a  sewing-needle  being  used  for  tte  pur- 
pose. Cloths  moistened  with  cold  water  were  diligently  applied.  The  wounds  healed  by 
the  first  intention,  and  the  patient  was  dismissed  on  the  20th  December,  with  wonderfully 
little  deformity. ^^ 

Fungus  of  the  maxillary  sinus  occasionally  proves  fatal,  not  so  much  by 
the  hemorrhage  which  attends  it,  or  the  hectic  fever  it  induces,  as  by  the 
pi-essure  it  causes  on  the  brain.  "  I  have  seen,"  says  Bertrandi,  "  a  polypous 
excrescence,  so  situated,  that,  inferiorly  it  destroyed  the  bones  of  the  palate  ; 
it  filled  the  mouth,  and  anteriorly  consumed  the  maxillary  bone  ;  superiorly, 
it  pushed  the  eye  almost  out  of  its  socket ;  at  length  it  destroyed  the  roof  of 
the  orbit,  pressed  upon  the  brain,  and  the  patient  died  apoplectic. "-^ 

Case  85. — .Janet  Anderson,  aged  44,  applied  at  the  Glasgow  Eye  Infirmary,  on  the  2-5th 
March,  1838.     She  stated  that  nine  weeks  before  that  date,  her  left  lower  eyelid  had 


108       PRESSURE   ON   THE   ORBIT   FROM  THE   MAXILLARY   SINUS, 

assumed  a  dark  red  color,  as  if  affected  with  ecchymosis  from  a  blow.  For  twelve  months 
she  had  beeu  much  troubled  with  pain  in  the  left  side  of  her  head,  attended  by  a  feeling 
of  pressure  and  stoppage  in  the  left  nostril,  which  was  deficient  in  moisture  and  sense  of 
smell.  She  complaiued  of  numbness  over  the  left  side  of  her  face,  and  the  hearing  of 
the  left  ear  was  impaired.  Both  left  eyelids,  as  well  as  the  conjunctiva,  were  cedematous 
at  her  admission ;  a  symptom  which  generally  attends  cases  of  pressure  on  the  orbit, 
from  whatever  quarter  or  cause  the  pressure  arises.  She  stated  that,  since  the  swelling 
of  the  eyelids  commenced,  her  head  had  been  relieved.  There  were  no  symptoms  of 
dacryocystitis.  The  vision  and  the  power  of  moving  the  eye  were  natural.  Tongue 
cleau.  Pulse  ninety-six.  She  was  ordered  to  be  bled  at  the  arm,  and  to  take  two  grains 
of  calomel  with  half  a  grain  of  opium  at  bedtime. 

Juue  13th,  Has  not  attended  since  25th  Mai'ch,  and  went  away  without  being  bled  or 
getting  the  pills.  Pain  gone.  Still  considerable  swelling  between  the  upper  eyelid  and 
eyebrow,  with  fluctuation  towards  the  inner  angle  of  the  eye.  Skin  of  a  d.ark  red  color. 
Conjunctiva  of  lower  eyelid  red  and  swollen.  The  eyeball  is  somewhat  displaced  towards 
tlie  side  of  the  orbit.  An  incision  being  made  through  the  upper  eyelid  into  the  swelling, 
some  matter  was  discharged,  and  a  considerable  cavity  was  felt  with  the  probe,  extend- 
ing to  the  periosteum  of  the  orbit.  A  poultice  was  applied,  and  two  aloes  and  blue  pills 
ordered  to  be  taken  at  bedtime. 

15th,  Complains  of  chilliness  about  6  o'clock  P.  M.,  followed  by  a  hot  fit.  A  grain  and 
a  half  of  sulphate  of  <iuina  were  ordered  thrice  a  day. 

18th,  Chilliness  and  feverishness  diminished.  The  dose  of  sulphate  of  quina  was 
increased  to  two  grains. 

24th,  Feverishness  gone.     Sulphi^te  of  quina  continued. 

28th,  A  swelling  projects  from  beneath  the  eyeball,  of  considerable  size,  and  possess- 
ing an  indistinct  fluctuation.  The  discharge  from  the  opening  above  the  eyeball  has 
become  very  trifling.  She  states  that  purulent  matter  is  frequently  discharged  through 
the  left  nostril. 

July  5tli,  Last  night  the  swelling  opened  spontaneously,  a  little  below  the  inner  can- 
thus,  and  discharged  a  considerable  quantity  of  thick  matter.  A  probe  introduced  by 
the  opening,  passes  through  the  lower  eyelid,  nearly  to  the  outer  canthus,  and  also  back 
into  the  orbit,  to  the  depth  of  about  an  inch. 

13th,  Fluctuation  being  felt  below  the  eyeball,  an  incision  was  made  with  a  lancet  to 
the  deptli  of  an  inch,  but  no  matter  flowed. 

23d,  She  was  ordered  to  omit  the  sulphate  of  quina,  and  to  take  two  grains  of  calomel 
with  half  a  grain  of  opium  thrice  a  day. 

Feeling  her  strength  declining,  she  left  the  Infirmary  on  the  29th ;  and  died  on  the 
morning  of  the  4th  August. 

The  eyeball  was  found  in  a  state  of  exophthalmos,  and  pressed  towards  the  temple ; 
the  conjunctiva,  in  a  thickened  and  fleshy  state.  The  whole  surface  of  tlie  left  hemi- 
sphere of  the  brain  was  covered  with  thick,  green,  and  very  fetid  pus.  At  the  forepart 
of  the  left  anterior  lobe  there  existed  a  very  considerable  depression  of  the  cerebral  sub- 
stance, to  the  extent  of  about  five-fourths  of  an  inch  in  diameter,  and  the  membranes 
covering  this  spot  were  much  discolored. 

On  raising  the  left  anterior  lobe  from  the  orbitary  process,  purulent  matter  was  seen 
to  issue  from  the  orbit,  through  an  ulcerated  spot  of  the  dura  mater,  towards  the  nasal 
edge  of  the  roof  of  the  orbit,  where  there  was  a  small  carious  perforation  of  the  bone. 
This  opening  corresponded  to  the  depression  on  the  surface  of  the  brain  already  men- 
tioned. It  seemed  probable,  that  the  matter,  issuing  from  tlie  orbit  into  the  cavity  of 
the  cranium,  had  caused  that  depression,  and  that  the  matter  had  been  confined  there  for 
a  time,  but,  increasing  in  quantity,  had  spread  itself  over  the  surface  of  the  brain,  as 
already  mentioned. 

The  orbit,  besides  containing  a  considerable  quantity  of  pus,  was  filled  behind  and  to 
the  nasal  side  of  the  eyeball,  with  a  tumor  of  a  whitish  yellow  color,  and  rather  more 
than  cheesy  consistence,  which,  along  with  the  collection  of  purulent  matter,  had  pressed 
the  eyeball  forwards  and  towards  the  temple.  The  muscles  were  displaced  in  the  same 
direction. 

The  lumor,  which  had  the  usual  appearance  of  antral  polypus,  filled  the  antrum  com- 
pletely, the  bony  partition  between  this  cavity  and  the  orbit  being  destroyed.  The 
posterior  part  of  the  nasal  wall  of  the  orbit,  and  the  greater  part  of  the  ethmoid  bone, 
were  reduced  to  carious  fragments,  mixed  with  thick  offensive  pus. 

This  case  was  considered  by  my  colleagues  and  myself  as  one  of  orbital  abscess ;  but 
the  dissection  proved  it  to  have  been  one  of  antral  polypus,  the  orbital  disease  being 
merely  secondary,  as  well  as  the  inflammation  of  the  brain,  of  which  the  patient  died. 
The  circumstances  which  led  us  to  regard  it  as  an  orbital  abscess,  were  the  appearances 
of  the  eyelids,  the  discharge  of  pus  when  they  were  punctured,  and  the  total  absence  of 
any  enlargement  of  the  cheek,  or  any  external  dilatation  of  the  antrum.     The  only  cir- 


PRESSURE   ON   THE   ORBIT   FROM   THE   MAXILLARY   SINUS.       10& 

cumstance  upon  which,  perhaps,  we  did  not  lay  sufficient  stress  in  forming  our  diagnosis 
was  the  state  of  the  nostril. 

Case  86. — In  1817,  I  had  an  opportunity  of  examining  a  skull  in  the  possession  of  Pro- 
fessor Prochaska,  which  had  suffered  an  extraordinary  change  in  structure  and  form, 
from  a  tumor  which,  in  all  probability,  originated  in  one  of  the  antra.  The  patient  was 
18  years  old  when  he  died.  During  his  apprenticeship  to  a  shoemaker,  he  had  been  ill- 
used  by  his  master,  knocked  down  by  blows  on  the  head,  and  kicked  by  him  while  on  the 
ground,  in  consequence  of  which  he  began  to  be  affected  with  weakness  of  sight  and  pro- 
minence of  the  eyes.  In  1786,  he  was  brought  to  Prochaska,  then  at  Prague.  Both 
eyes  were  amaurotic,  and  protruding  from  the  orbits,  the  bones  both  above  the  orbits 
and  at  the  sides  of  the  nose  tumefied,  and  respiration  through  the  nostrils  obstructed. 
He  continued  in  this  state  till  1791,  without  pain  and  almost  without  any  other  inconve- 
nience than  the  amaurosis.  Gradually,  however,  the  eyes  protruded  more  and  more  ; 
the  face  above  the  orbits,  at  the  root  of  the  nose  and  throughout  the  whole  ujiper  jaw, 
became  enlarged,  as  did  also  the  palate,  which  began  to  project  into  the  cavity  of  the 
mouth.  Ichorous  discharge  followed  from  the  nostrils,  with  frequent  and  profuse  bleed- 
ing. For  four  weeks  before  his  death,  he  was  confined  to  his  bed  from  weakness,  breath- 
ing not  at  all  through  the  nostrils,  and  with  difficulty  through  the  mouth;  his  mind, 
however,  not  affected.  On  the  morning  of  the  18th  September,  1791,  his  mother  found 
him  insensible;  and  in  the  evening  of  that  day,  respiration  through  the  mouth  and  nose 
being  completely  impeded,  he  died. 

The  head,  examined  externally,  presented  above  the  eyes  two  tumors  into  which  the 
supra-orbitary  arches  had  degenerated;  while  the  root  of  the  nose,  and  the  upper  jaw 
on  each  side,  were  so  much  swollen  that  no  part  of  the  nose  but  the  point  and  pinuaj  was 
visible. 

On  dissection,  the  right  nostril  at  its  anterior  part  was  found  greatly  dilated,  the  car- 
tilaginous septum  being  pushed  to  the  left  side;  posteriori 3%  the  osseous  septum  was 
destroyed,  and  both  nostrils  were  converted  into  one  ample  cavity,  filled  by  a  tumor 
remarkable  for  its  spongy  excrescences,  and  which  by  its  pressure  had  dilated  and  pushed 
down  the  palate.  On  opening  the  cranium,  the  anterior  and  middle  lobes  of  the  brain 
were  found  to  be  of  an  unnatural  ash  color,  and  that  portion  which  lies  upon  the  cribri- 
form plate  of  the  ethmoid  and  orbitary  processes  of  the  frontal  bone  dissolved,  along  with 
the  dura  mater,  into  a  pulp  of  the  same  color,  and  in  contiict  with  the  tumor  proceeding 
from  the  nostrils.  On  account  of  the  morbid  condition  of  the  brain,  none  of  the  nerves 
from  the  olfactory  to  the  auditory  could  be  distinguished.  The  internal  part  of  the  basis 
of  the  skull,  from  the  orbitary  processes  of  the  frontal  to  the  basilar  process  of  the  occi- 
pital bone,  was  tumefied  and  softened.  After  this  examination  was  made,  the  head  was 
submitted  to  maceration,  which,  being  finished,  there  fell  out  from  the  basis  of  the  cra- 
nium, and  from  the  nostras,  a  ponderous  mass,  partly  like  lard,  partly  cartilaginous,  but 
not  at  all  osseous,  which,  by  means  of  its  soft  processes,  had  penetrated  into  the  osseous 
swellings  nbove  the  orbits,  filliug  all  the  interstices  of  the  radiating  laminte  into  which 
these  swellings  had  degenerated,  and  emerging  at  these  places  under  the  common 
integuments. 

The  following  was  the  state  of  the  cranium  :  The   orbitary  processes  of  the  frontal 


Fig.  7. 


Fig.  8. 


bone,  the  ethmoid,  the  vomer,   the  turbinated  bones,  the  little  wings  of  the  sphenoid, 
and  its  middle  part  (except  the  anterior  clinoid  processes,  which  adhered  by  osseous 


110       PRESSURE   ON  THE   ORBIT   FROM   THE   MAXILLARY   SINUS. 

filaments  to  the  remaining  part  of  the  sella  Turcica),  the  anterior  part  of  the  basilar 
process  of  the  occipital  bone,  and  the  apices  of  the  petrous  portions  of  the  temporal 
bones,  as  far  as  the  carotid  canals,  were  so  completely  consumed,  that  the  -vast  cavity  of 
the  nostrils,  along  with  that  of  the  mouth,  opened  into  the  cavity  of  the  cranium.  Forth 
from  the  cranium  also,  as  well  into  the  compressed  and  deformed  orbits,  as  into  the 
supra-orbitary  swellings  already  described,  there  were  many  larger  and  smaller  openings. 
The  superior  maxillary  bones,  with  their  nasal  processes,  and  the  proper  bones  of  the 
nose,  were  much  expanded,  and  so  thinned  away,  that  they  presented  various  gaps, 
opening  into  the  cavity  of  the  nostrils.  The  palatine  processes  of  the  superior  maxillary 
bones  had  disappeared ;  the  pterygoid  process  of  the  sphenoid  bone,  on  the  right  side, 
had  so  receded  in  its  superior  part,  that  the  spheno -palatine  foramen  much  enlarged, 
opened  into  the  zygomatic  fossa.  The  left  antrum  Highmorianum  had  disappeared  from 
compression,  and  the  right  opened  backwards  by  a  large  hiatus.*' 

The  fatal  termination  of  fungus  of  the  antrum,  when  left  to  itself,  and 
the  favorable  result  of  extirpation  of  the  tumor,  or  of  excision  of  the  upper 
maxillary  bone,  in  many  cases  now  recorded,  should  lead  us  at  once  to  pro- 
pose an  operation,  and  not  for  a  single  day  to  leave  the  tumor  to  proceed  in 
its  slow  but  certain  work  of  destruction.  The  advocates  for  excision  of  the 
bone  speak  very  positively  regarding  the  fruitlessness  of  any  other  mode  of 
treatment.  "The  opening  of  the  cavity,  with  an  attempt  to  clear  it  of  the 
soft  pulpy  mass,"  says  Mr.  Liston,^*  "as  formerly  practised,  is  totally  inad- 
missible; it  is  a  piece  of  unmeaning  and  utterly  useless  cruelty.  If  anything 
is  to  be  done,  it  ought  to  be  undertaken  with  a  thorough  determination  to 
go  beyond  the  limits  of  the  morbid  growth,  to  remove  the  cavity  which  holds 
it,  and  thus  get  quit,  if  possible,  of  all  the  tissues  implicated,  or  which  may 
have  become  disposed  to  assume  a  similar  action."  These  opinions  of  Mr. 
Liston  must  appear  far  too  sweeping  and  dogmatical  to  any  one  who  atten- 
tively considers  the  cases  on  record,  in  which  the  plan  of  operating  which  he 
condemns,  appears  to  have  been  completely  successful. 

Mr.  Fattison''^  makes  mention  of  two  cases,  in  which  tying  the  common 
carotid  artery,  without  any  other  operation,  was  sufficient  to  cure  this  dis- 
ease.    In  the  hands  of  others,  this  measure  has  failed.-" 

3.  Aneurism  by  anastomosis  affecting  the  upper  maxillary  hone. — In  his 
Appendix  to  Burns  on  the  Surgical  Anatomy  of  the  Head  and  Xeck,  Mr. 
Tattison  has  given  some  particulars  of  a  case  which  he  considered  to  be  an 
aneurism  by  anastomosis  of  the  maxillary  sinus,  and  for  which  he  tied  the 
common  carotid  artery. 

Case  87. — The  disease  had  existed  for  many  years ;  and  under  tlie  notion  of  its  being 
a  polypus  either  of  the  nose  or  the  antrum,  attempts  had  been  uuide  to  extirpate  it. 
These  were  abandoned,  however,  on  account  of  the  hemorrhage  which  they  produced, 
and  the  patient  afterwaitls  continued  to  be  troubled  with  violent  bleedings  from  the  tumor 
on  the  least  exertion.  The  morbid  growth  had  expanded  the  antrum,  deformed  the  face, 
and  protruded  the  eye,  like  other  tumors  in  the  same  situation ;  but  on  pressing  the  dis- 
eased mass  between  two  fingers,  one  introduced  into  the  mouth  and  another  placed  ex- 
ternally, that  peculiar  pulsatoi-y  throbbing  which  characterizes  anastomosing  aneurism, 
was  at  once  detected. 

Immediately  after  tying  the  carotid  artery,  the  appearance  of  the  tumor,  as  it  presented 
itself  in  the  nostril,  became  remarkably  changed.  Just  before,  it  seemed  distended,  almost 
to  bursting  ;  but  as  soon  as  the  direct  circulation  into  it  was  removed,  its  distension  ceased, 
its  surface  became  shrivelled,  and  its  pulsatory  movement  could  no  longer  be  felt.  The 
appearance  of  the  countenance  daily  improved  ;  the  swelling  subsided  ;  the  malar  bone 
and  zygoma,  which  had  been  completely  buried  in  the  tumor,  as  it  was  absorbed,  again 
became  evident;  and  two  years  and  a  half  after  the  operation,  the  remaining  deformity 
was  so  trifling  as  to  be  hardly  perceptibly. 3* 

Case  88. — Mr.  Liston  had  occasion  to  remove  a  tumor  involving  the  left  upper  maxil- 
lary bone.  Upon  a  careful  examination,  it  was  found  to  be  composed  entirely  of  erectile 
tissue,  but  it  did  not  seem  to  have  had  its  origin  in  the  maxillary  sinus,  nor  in  the  mucous 
tissue.  It  had,  however,  compressed  and  displaced  the  bone,  and  nearly  caused  oblitera- 
tion of  the  antrum.  It  was  a  fortunate  occurrence,  Mr.  L.  remarks,  that  this  tumor  was 
cut  out  clean  along  with  the  bone,  from  which  it  was  inseparable.     Any  wound  of  the 


PRESSURE   ON  THE   ORBIT   FROM   THE   MAXILLARY   SINUS.       Ill 

tissue  would  have  caused  great  embarrassment,  in  all  probability,  from  hemorrhage,  and 
•would  have  rendered  the  operation  more  diflBcult  and  dangerous.* 

4.  Fibrous,  osteo-Jihrous ,  cartilaginous,  or  Jihro-cartilaginous  tumor  of  the 
upper  maxillary  bone. — Designated  by  these  appellations,  a  class  of  non- 
malignant  tumors  has  been  described  by  Lizars,  Gensoul,  Liston,  Solly,  and 
others,  as  affecting  the  upper  maxillary  bone.  They  are  said  to  be  very  firm, 
and  altogether  destitute  of  the  resiliency  presented  by  a  cyst,  and  sometimes 
even  by  a  fungus  within  the  antrum  ;  of  a  globular  or  botryoidal  form  ;  often 
homogeneous  in  structure,  but  sometimes  cartilaginous  externally,  with 
spicul^e  of  bone  internally,  or  containing  a  glairy  albuminous  substance. 
They  often  appear  to  originate  in  some  external  injury ;  commence  in  the 
osseous  structure  or  in  the  periosteum  ;  sometimes  reach  a  rery  large  size,  but 
are  extremely  slow  in  their  progress,  and  do  not  affect  the  constitution,  except 
by  the  pressure  they  exercise  on  the  surrounding  parts.  Tumors  of  a  malig- 
nant kind  are  generally  attended  with  headache,  stuflBng  of  the  nostril,  pro- 
trusion of  the  eye,  and  expansion  of  the  upper  part  of  the  face  ;  they  advance 
by  rapid  strides,  and  speedily  affect  the  general  health.  If  such  symptoms 
are  absent,  there  is  a  probability  that  the  case  is  one  of  the  present  class, 
and  therefore  more  likely,  if  it  does  not  yield  to  the  use  of  iodine,  to  be 
benefited  by  excision  of  the  affected  bone. 

Case  89. — For  the  purpose  of  ascertaining  the  nature  of  a  tumor  projecting  from  the 
front  of  the  upper  maxillary  bone,  Mr.  Stanley  pierced  it  with  a  grooved  needle,  from 
the  inside  of  the  mouth.  The  sensation  attendant  on  the  passage  of  the  instrument  through 
the  tumor  assured  him  that  it  was  composed  of  cartilage,  with  particles  of  bone  dispersed 
through  it.  An  ointment,  containing  first  iodide  of  potassium,  afterwards  iodine,  was 
kept  constantly  applied  to  the  cheek,  and  during  its  use  the  tumor  slowly  diminished. 
At  the  end  of  a  week,  about  two-thirds  of  its  bulk  had  disappeared. ^^ 

Case  90. — The  same  author  has  figured  the  face  of  a  boy,  14  years  of  age,  enlarged  and 
distorted  by  a  compound  growth,  which  originated  in  the  upper  maxilla,  filled  the  cavities 
of  the  nose  and  orbits,  and  extended  into  the  cavity  of  the  cranium.  The  growth  was 
composed  of  two  distinct  substances.  The  portion  of  it  which  filled  the  nostrils  consisted 
of  a  soft,  very  vascular  tissue;  whilst  the  portion  of  it  occupying  the  deeper  cavities  of 
the  nose  and  the  orbits,  and  extending  into  the  cavity  of  the  cranium,  consisted  of  carti- 
laginous substance  mixed  with  bone.  The  disease  had  been  of  very  slow  growth.  Both 
eyes  were  protruded  from  the  orbits.  In  one  orbit  the  optic  nerve  had  disappeared,  and 
in  the  other  the  nerve  was  considerably  elongated.  The  portion  of  the  tumor  which  pro- 
jected into  the  cavity  of  the  cranium  was  imbedded  in  the  anterior  lobes  of  the  cerebrum.^ 

The  mode  in  which  excision  of  the  upper  maxillary  bone  was  at  one  time 
generally  performed,  may  be  gathered  from  Case  84.  The  incisions  through 
the  cheek  have  since  been  simplified  by  Dieffenbach  and  O'Shaughnessy  ; 
and  the  bone  has  actually  been  excised  by  Horner  within  the  mouth,  and 
without  any  incision  through  the  cheek.  The  object  of  these  changes 
has  been  to  avoid  the  deforming  cicatrices  which  necessarily  ensue,  when 
incisions  of  the  soft  parts  are  carried  through  the  lip,  and  the  palsy  of 
the  muscles,  which  follows  division  of  the  branches  of  the  facial  nerve.  In 
some  cases,  the  alveolar  process  and  the  bony  palate  may  be  saved ;  in 
others,  these  parts  require  to  be  removed.  The  same  remark  applies  to  the 
floor  of  the  orbit.  The  separation  of  the  bony  attachments  is  accomplished 
chiefly  by  the  cutting  pliers.  [Although  this  is  not  the  place  to  consider 
the  minutise  of  the  operation  of  excision  of  the  superior  maxillary  or  the 
various  operative  procedures  proposed  for  the  removal  of  growths,  malignant 
or  otherwise,  of  the  antrum,  we  should  not  pass  over  the  subject  here  with- 
out some  allusion  to  the  important  modification  of  the  ordinary  operation 
of  Liston  proposed  by  Professor  Mussey,  of  Cincinnati,  with  a  view  to 
the  preservation  of  the  floor  of  the  orbit.  It  consists  in  separating  the 
maxilla  from  the  malar  "by  running  a  narrow  saw  downwards  and  outwards 
from  the  orbit,  through  the  latter  bone,  just  outside  of  the  malo-maxil- 


112       PRESSURE  ON  THE   ORBIT   FROM  THE   MAXILLARY   SINUS. 

lary  suture,  nearly  parallel  with  that  suture,  and  extending  the  cut  to  the 
spheno-raaxillary  fissure.  The  nasal  process  was  sawn  at  its  base,  downward 
and  inward  from  the  orbit  to  the  nostril,  to  disturb  as  little  as  possible  the 
lachrymal  canal."  The  value  of  such  a  modification,  when  practicable,  and 
it  can  be  only  otherwise  when  the  floor  itself  is  involved  in  the  disease,  must 
be  apparent  to  every  one  who  has  seen  the  evil  effects  to  the  eye  from  com- 
plete excision. — H.j 

For  a  history  of  the  operation,  and  minute  accounts  of  the  manner  of  per- 
forming it,  the  reader  may  consult  the  works  mentioned  in  the  note.^^  Of 
course,  uo  operation  of  the  kind  should  be  attempted  unless  there  is  good 
ground  to  believe  that  the  necessary  incisions  can  be  made  through  healthy 
parts,  beyond  the  limits  of  the  disease.  Although  certainly  one  of  the 
severest  operations  which  the  surgeou  is  called  upon  to  perform,  and  the 
painful iiess  of  which  it  appears  dangerous  to  attempt  to  deaden  by  the  use 
of  chloroform,  the  recovery  is  often  prompt  beyond  expectation.  The  super- 
vention of  erysipelas  is  the  thing  most  to  be  dreaded. 

5.  Exostosis  of  the  maxillary  sinus. — Osseous  tumors  springing  from  the 
walls  or  cavity  of  the  antrum,  have  not  unfrequently  been  known  to  disfigure, 
or  even  to  obliterate,  the  orbit.  To  distingnisU  such  cases  from  the  diseases 
of  the  antrum  already  considered,  will  require  very  great  attention.  A 
maxillary  exostosis  sometimes  reaches  a  great  size  ;  but  to  whatever  size  it 
may  grow,  its  most  prominent  point  never  softens,  which  constitutes  an  im- 
])ortant  diagnostic  mark,  by  which  it  may  be  distinguished  from  abscess,  and 
from  polypus.  The  following  cases  will  serve  to  show  that  the  nature  of  such 
growths  is  by  no  means  uniform.  They  are  apt  to  be  combined  with  hyper- 
ostosis of  the  other  bones  of  the  same,  or  even  of  the  opposite,  side  of  the 
face. 

Case  91 . — Maxillary  exostosis  cured  hy  mercury.  Boyer  relates  the  case  of  a  man,  who, 
for  more  than  10  years,  had  an  exostosis  of  the  left  maxillary  sinus.  The  eye  on  that 
side  was  affected  with  stillicidium  lachrymarum.  The  eyeball  was  pushed  forward,  the 
nose  twisted  to  the  right,  the  nostril  closed,  and  the  palate  somewhat  swollen.  The  tumor 
was  verj'  prominent  upwards  and  outwards,  and  the  skin  coverinp;  it  red  and  shining.  The 
visage  was  excessively  deformed.  The  exostosis  had  appeared  soon  after  a  venereal  in- 
fection, which  had  been  followed  by  secondary  symptoms.  It  had  increased  slowly;  but 
for  several  years  had  made  no  progress.  Painful  at  first,  it  had  ceased  to  be  so  when  it 
became  stationary.  The  patient,  of  his  own  record,  resolved  to  try  fully  the  effect  of  the 
liquor  of  Van  Swieten  ;  and  after  having  tnken,  without  any  medical  advice,  and  in  less 
tlian  three  months,  128  grains  of  corrosive  sublimate,  he  was  entirely  freed  of  the  exos- 
tosis. The  eye  returned  into  the  orbit,  the  stillicidium  ceased,  and  the  nostril  becjime 
free.  A  depression  on  the  cheek,  and  an  adhesion  of  the  skin,  marked  what  had  been 
the  situation  of  the  tumor. '^ 

Case  02.  —  Orbit  obliterated  by  a  maxillary  exostosis.  I  recollect  noticing  a  very  remark- 
able sktdl  in  the  museum  of  the  Ecole  de  Mededne  at  Paris,  to  which  collection  it  was 
presented  by  Pi'ofessor  Sue.  It  has  been  described^  as  an  example  of  osteo-sarcoma, 
but  I  think  there  can  be  scarcely  any  doubt  of  its  being  an  exostosis  of  the  walls  of  the 
maxillary  sinus.  The  osseous  tumor,  which  is  actually  not  much  less  than  an  ordinary 
cranium,  is  smooth  and  polished  externally,  very  thin  at  its  upper  part,  hard  and  covered 
with  bosses  posteriorly,  and  interiorly  filled  with  osseous  cysts.  It  springs  from  the  right 
maxillary  sinus  and  lower  part  of  the  frontal  bone,  and  extends  from  the  right  mastoid 
process  towards  the  left  maxillary  bone.  No  trace  is  to  be  seen  of  the  right  orbit;  the 
right  nostril  is  entirely  obliterated;  as  well  as  a  portion  of  the  left  orbit.  The  tumor 
proceeds  downwards  and  forwards  from  its  origin,  to  a  level  with  the  basis  of  the  lower 
jaw,  measuring,  from  the  mastoid  process,  12  inches  in  length,  and  in  circumference  16 
inches. 

Case  93. — Maxillary  exostosis  passing  through  the  orbit  into  the  cavity  of  the  cranium.  In 
the  collection  at  St.  Thomas's  Hospital,  London,  there  is  the  skull  of  a  fish-woman,  who 
had  long  been  remarkable,  even  at  Billingsgate,  for  her  hideous  appearance.  Two  large 
swellings  had  been  formed  under  the  orbits  in  the  forepart  of  the  cheeks,  between  which 
the  nose  appeared  wedged,  and  the  nostrils  were  closed.  Each  eye  projected  considerably 
from  its  socket.  This  person  was  seized  with  a  fit,  which  seemed  to  be  of  an  apoplectic 
nature,  and  in  that  state  was  brought  to  St.  Thomas's  Hospital,  where  she  died  almost 


PRESSURE  ON   THE   ORBIT  FROM  THE   MAXILLARY  SINUS.       113 

immediately.  Upon  examination  of  the  head,  an  exostosis  was  found  growing  from  each 
antrum,  and  forming  the  large  swellings  upon  the  cheeks.  The  exostosis  projected  also 
into  the  orbits,  so  as  to  occasion  the  protrusion  of  the  eyes.  On  the  left  side,  the  exos- 
tosis entered  the  cranium,  projecting  inwards  through  the  orbitary  process  of  the  os  frontis, 
and  occasioning  such  pressure  on  the  brain  as,  under  a  considerable  excitement  of  the 
vessels  of  that  organ,  produced  apoplexy,  which  proved  fatal.*' 

Case  94. — Maxillary  exostosis  removed  by  operation — Disease  returns.  An  Irish  laborer, 
aged  24,  admitted  into  Guy's  Hospital,  1st  August,  1835,  stated  that,  when  15  years  of 
age,  he  perceived  a  small  tumor  in  the  right  nostril,  which  had,  since  that  period, 
gradually  increased.  At  his  admission,  the  tumor  occupied  the  whole  right  side  of  the 
face.  The  right  nostril  was  enormously  expanded,  and  was  filled  up  by  the  growth,  which 
was  so  large  as  completely  to  conceal  the  eye  on  that  side.  The  tumor  extended  down- 
wards into  the  mouth,  being  there  connected  with  the  palatine  and  alveolar  processes  of 
the  right  supei'ior  maxillary  bone,  and  projected  forwards  so  as  to  press  the  lip  beyond 
the  teeth,  to  the  extent  of  two  inches. 

The  surface  of  the  tumor  was  irregular.  Its  most  prominent  parts  were  situated  under 
the  right  orbit  and  opposite  to  the  ala  nasi.  They  were  slightly  discolored  by  inflamma- 
tion ;  but  the  reddened  surface  of  those  projections  indicated  no  approach  whatever  to 
the  change  in  the  vascular  system,  which  evinces  the  existence  of  malignant  disease. 
The  patient  complained  of  no  pain ;  nor  had  he  suffered  much  during  the  course  of  the 
disease.  His  general  health  appeared  good  ;  but  he  was  greatly  emaciated,  more  from 
want  of  food  than  from  the  constitutional  effects  of  his  disorder. 

Mr.  Morgan  found  the  tumor  almost  uniformly  firm,  and  of  a  bony  hardness,  even  at  its 
most  prominent  point.  He  was  therefore  led  to  conclude  that  it  consisted  of  a  morbid 
deposit  of  bone.  He  knew  of  no  cases  of  malignant  disease  of  bones,  where  the  enlarge- 
ment had  proceeded  to  the  same  extent,  and  the  disease  existed  for  so  long  a  time,  the 
shell  of  the  excrescence  retaining  the  character  of  hone.  There  was  no  softening  of  the 
prominent  point  of  the  tumor  in  this  case ;  and  he  therefore  concluded  that  it  was  one  of 
common  exostosis. 

Desirous  of  being  certain  of  the  nature  of  the  disease,  he  made  a  crucial  incision 
between  the  most  prominent  points,  over  the  right  nostril,  and,  by  means  of  a  trephine, 
removed  a  portion  of  the  tumor,  which  proved  to  be  true  exostosis.  A  semilunar  in- 
cision was  then  made,  extending  over  the  nostril,  from  the  internal  angle  of  the  right 
eye  to  the  centre  of  the  upper  lip.  A  similar  incision  was  made  on  the  outer  side,  com- 
mencing at  the  external  angle  of  the  eye,  and  joining  the  former  at  the  lip.  The  integu- 
ments were  then  dissected  from  around  the  tumor,  and  with  a  metacarpal  saw  it  was 
removed.  As  it  was  of  a  spongy  texture,  it  offered  little  resistance  to  that  instrument. 
No  great  quantity  of  blood  was  lost  during  the  operation,  the  exostosis  not  being  very 
vascular.     The  integuments  were  brought  together  by  the  uninterrupted  suture. 

A  section  of  the  tumor  proved  that  it  was  composed  of  an  outer  hard,  thin  shell  of 
bone,  inclosing  a  mass  of  spongy  cancellated  structure,  devoid  of  all  appearance  of  car- 
cinomatous or  fungoid  disease. 

The  wound  suppurated.  The  tumor  in  the  mouth  gradually  decreased.  Hardly  any 
exfoliation  took  place.     The  patient's  general  health  was  speedily  restored.*^ 

The  disease  in  this  case  returned.  The  patient  died  at  Birmingham,  in  spring,  1842, 
nearly  seven  years  after  the  operation,  so  that  his  life  may  fairly  be  said  to  have  been 
prolonged  by  it  for  nearly  that  period.  A  figure  is  given  in  Guy's  Hospital  Reports,  Vol. 
vii.  p.  491,  London,  1842,  repi-esenting  a  cast  of  his  head,  taken  after  his  death,  and 
showing  a  tumor  of  enormous  size. 

Case  95. — Exostosis  of  the  maxillary  sinus  not  discovered  till  after  extirpation  of  the  pro- 
truded eyeball.  Mrs.  Craig,  aged  24,  was  admitted  into  the  Glasgow  Royal  Infirmary,  5th 
January,  1828;  at  which  time,  the  right  eyeball  was  so  much  protruded  as  to  be  almost 
out  of  the  orbit.  As  I  had  occasion  to  see  this  patient  before  she  went  to  the  Royal 
Infirmary,  I  may  mention  that  the  protrusion  was  directly  forwards,  so  that,  though  the 
idea  of  the  exophthalmos  probably  depending  on  exostosis  of  the  orbit,  naturally  occur- 
red to  my  mind,  I  could  not  have  been  led  to  assign  any  one  of  the  sides  of  that  cavity 
as  more  likely  than  another  to  be  the  seat  of  such  a  growth.  Ectropium  and  chemosis 
attended  the  proti'usion.  The  cornea  was  ulcerated  and  muddy,  the  pupil  dilated  and 
immovable,  and  vision  lost.  The  patient  had  constant  severe  pain  in  the  bones  of  the 
orbit  and  right  side  of  the  head,  rendered  more  acute  by  pressiire.  She  had  rheumatic 
pain  of  the  knees.  Her  health  was  greatly  impaired,  but  had  improved  since  she  gave 
birth  to  a  child,  8  weeks  before  her  admission.  The  vision  of  the  eye  had  been  dim  for 
18  months,  and  completely  lost  for  four.  The  pain  of  the  head  was  of  12  mouths'  standino- 
and  the  prominence  of  the  eye  of  8  weeks'.  She  had  had  some  discharge  of  yellow  fluid 
fi-om  the  right  ear,  about  the  time  when  the  sight  was  lost,  but  not  afterwards.  Her  mouth 
was  aflected  by  pills,  which  she  had  taken  for  five  or  six  weeks. 
8 


114       PRESSURE   ON   THE   ORBIT   FROM   THE   MAXILLARY   SINUS. 

Dr.  Anderson,  under  whose  care  she  came  on  her  admission  into  the  Infirmary,  sus- 
pected syphilis  ;  but  she  denied  it ;  and  as  the  mercury  seemed  to  have  had  little  other 
effect  than  that  of  increasing  debility,  he  suspended  its  use,  and  endeavored  to  procui-e 
relief  from  other  medicines  and  external  applications,  chiefly  opiates  and  narcotics.  These 
did  not  succeed.  He  then  evacuated  the  humors  of  the  eye,  but  this  also  was  ineifectual. 
He  next  extirpated  the  eye;  after  which,  a  tumor  about  the  size  of  a  hazel-nut  was  dis- 
covered on  the  floor  of  the  orbit,  solid,  nodulated,  and  bony.  The  pressure  of  this  exos- 
tosis had  been  the  cause  of  the  pain  and  protrusion  ;  but  as  it  was  firmly  fixed,  and  not 
likely  to  exert  any  injurious  pressure,  it  was  not  considered  prudent  to  attempt  its  re- 
moval. From  some  inflammation  and  fulness  in  the  right  nostril.  Dr.  Anderson  had  been 
led  to  suppose  it  likely  that  there  might  be  a  fungous  or  other  tumor  pushing  upwards 
from  the  antrum  to  the  orbit.  The  relief  from  pain  was  remarkable  after  the  extirpation 
of  the  eye.  Plummer's  pill  and  a  decoction  of  sarsaparilla,  were  now  used  for  several 
weeks,  during  which  time  the  patient  got  almost  quite  well :  but  whether  this  proceeded 
from  the  removal  of  the  eye,  the  dischai-ge  which  succeeded  it,  or  the  medicine.  Dr. 
Anderson  does  not  decide.  He  believes  that  all  of  these  were  useful.  It  was  his  inten- 
tion to  advise  the  insertion  of  a  pea  issue  in  the  neck,  and  a  continuance  of  the  medicine  ; 
but  the  patient  left  the  Infirmary  on  the  1st  of  March,  without  receiving  these  instruc- 
tions. At  that  time  her  health  was  good,  and  there  was  no  appearance  of  increased 
growth  in  the  orbit. ""^ 

Case  96. — Exostosis  of  each  upp&r  maxillary  bone.  A  stout  healthy-looking  man,  57  years 
of  age,  dated  the  origin  of  his  complaint  at  a  period  14  year^  before  Mr.  Kowship  saw 
him,  which  was  in  1811.  He  was  in  perfect  health;  and  on  a  windy  day  was  walking  up 
Hampstead  Hill,  when  he  was  suddenly  attacked  with  a  violent  itching  and  heat  in  both 
his  eyes,  which  induced  him  to  rub  them  vehemently.  Before  he  could  reach  home,  the 
irritation  had  increased  to  that  degree,  that  he  was  unable  to  open  his  eyes  in  the  light. 
Inflammation  supervened,  and  a  small  tumor  formed  just  below  the  inner  angle  of  each 
eye,  about  the  size  of  a  hazel-nut.  These  swellings  burst  inwardly,  discharging  after- 
wards fi-eely  between  the  eyelids.  The  inflammation,  treated  by  fomentations  with  poppy 
heads  and  other  occasional  remedies,  went  on  for  about  12  weeks.  It  had  then  so  far 
subsided,  that  he  could  open  his  eyes  and  bear  the  light  tolerably  well,  so  that  he  went  to 
work  again. 

About  a  fortnight  after  this,  having  been  exposed  all  night  to  cold  and  rain  in  the  winter 
season,  he  had  a  fresh  attack.  He  applied  to  Mr.  Ware,  who  ordered  a  warm  poultice 
over  each  eye,  as  the  swellings  were  again  returning  on  each  side  of  the  upper  part  of  the 
nose.  This  treatment  was  coutinudl  for  about  six  weeks,  when  the  abscess  at  the  angle 
of  tlie  right  eye  burst,  evacuating  its  contents  upon  the  cheek.  Two  weeks  afterwards, 
that  upon  the  left  side  broke  and  a  copious  discharge  followed.  The  formation  of  these 
abscesses,  particularly  that  upon  the  left  side,  was  attended  with  pains  in  the  head,  the 
severity  of  which  he  could  compare  to  nothing  but  the  sensation  of  his  head  splitting 
asunder.  These  pains  spread  also  through  the  bones  of  his  face.  During  this  attack,  he 
could  get  no  rest  day  or  night  for  the  space  of  three  months.  A  considerable  degree  of 
projection  or  tumor,  apparently  osseous,  was  now  observable  below  the  inferior  margin  of 
each  orbit,  and  the  eyes  had  become  much  more  prominent  than  natural.  He  was  at  this 
time  a  patient  in  St.  Bartholomew's  Hospital,  where  his  case  excited  much  attention. 

One  day  one  of  the  pupils  observing  the  right  eye  to  be  protruded  from  the  orbit,  pro- 
ceeded to  examine  it  rather  hastily,  when,  as  he  pressed  the  tumor  and  pushed  back  at 
the  same  time  the  eyelid,  the  globe  of  the  eye  suddenly  sprung  out  beyond  the  palpebrae. 
With  some  difiiculty  it  was  reduced  again.  At  this  time  he  had  some  power  of  perceiv- 
ing light  with  the  right,  but  more  with  the  left  eye.  The  pains  in  his  head  and  face  con- 
tinued so  severe,  that  he  was  frequently  almost  distracted.  The  inflammation  of  the  eyes 
was  still  violent,  particularly  that  of  the  left.  He  was  often  delirious,  and  it  was  some- 
times with  difiiculty  he  was  prevented  from  tearing  his  eyes  out,  in  the  rage  of  pain  and 
delirium.  At  length  the  right  eye  burst,  from  the  intensity  of  the  inflammation.  The 
contents  of  the  eyeball  having  escaped,  the  excessive  inflammation  declined,  and  the 
patient  became  somewhat  better.  The  osseous  tumors,  however,  still  continued  to  grow, 
although  their  increase  was  very  slow.  Although  nothing  seemed  either  to  have  arrested 
their  progress,  or  much  relieved  his  complaint,  he  now  found  his  general  health  much 
improved. 

Some  time  after  this,  he  was  putting  down  a  turn-up  bed;  and  not  being  able  to  see 
what  he  was  about,  the  bedstead  slipped  from  his  hand  and  fell,  one  of  the  feet  striking 
him  with  great  force  immediately  upon  the  ball  of  the  eye  that  was  protruded  and  lying 
upon  the  hard  tumor  in  the  cheek.  By  this  accident  the  globe  of  the  left  eye  was  burst ; 
but  he  suffered  no  particular  pain  at  the  moment,  beyond  the  mere  confusion  arising  from 
so  severe  a  blow  upon  the  face.  A  good  deal  of  inflammation,  however,  soon  came  on, 
but  subsided  again  spontaneously. 


PRESSURE   ON   THE   ORBIT   FROM   THE    SPHENOID    SINUS.  115 

Subsequently  to  tliis  period  he  usucally  eujoyed  very  good  health,  and  in  1815  remained 
well.  He  merely  observed  that  whenever  he  took  cold,  it  was  particularly  apt  to  affect 
his  head  with  a  transient  return  of  his  old  inflammatory  pains.  On  separating  the  pal- 
pebrie,  the  conjunctivae  still  retained  strong  marks  of  the  severe  inflammation  they  had 
long  suffered.  The  tumors  of  the  maxillary  bones,  feeling  as  hard  as  ivory,  and  not  in 
the  least  painful  when  pressed,  appeared  to  occupy  very  nearly  the  whole  space  of  each 
orbit,  as  well  as  the  cavities  of  the  nostrils,  which  were  almost,  if  not  entirely,  obliterated. 
In  the  integuments  covering  the  tumors,  were  several  enlarged  and  varicose  veins.  From 
the  slow  and  uniform  growth  of  the  swellings,  and  from  the  great  pain  that  attended  their 
production,  as  well  as  from  other  circumstances  connected  with  the  history,  Mr.  How- 
ship  considers  that  there  is  every  reason  to  believe  that  the  original  afl'ection  was  the 
means  of  exciting  a  copious  secretion  of  osseous  matter,  of  a  more  dense  texture  than  is 
natural  to  the  parts ;  a  change,  he  observes,  which  genei'ally  results  from  healthy  ossiiic 
inflammation.''-' 

I  understand,  that  part  of  the  skull  of  this  patient  is  preserved  in  tlie  j\Iuseum  of  the 
Royal  College  of  Surgeons  of  England ;  and  from  the  recollection  I  have  of  the  prepara- 
tion, it  is  it,  I  think,  which  is  represented  by  Mr.  Haynes  Walton,  at  page  347,  of  his 
Operative  Ophthalmic  Surgery.  He  describes  the  osseous  tumors  as  completely  filling 
both  orbits,  the  cavities  of  the  nose,  and  probably  the  antra ;  extending  as  far  back  as  the 
pterygoid  plates  of  the  sphenoid  bone,  and  projecting  more  than  three  inches  in  front  of 
the  face. 

Exostosis  of  the  maxillary  siiins  is  plainly  one  of  the  cases  in  which  extir- 
pation of  the  upper  maxillary  bone  might  be  required. 

§  5.  Pressure  on  the  Orhit  from  the  Sphenoid  Sinus. 

The  sphenoid  sinuses  are  each,  when  fully  developed,  of  size  sufficient  to 
admit  the  end  of  the  little  finger.  They  are  very  variable,  however,  in  size  ; 
and  are  large  or  small,  according  as  the  other  nasal  sinuses  are  more  or  less 
expanded.  They  lie  before  and  beneath  the  sella  Turcica,  below  and  to  the 
inner  side  of  the  foramen  opticum,  and  to  the  iuner  side  of  the  spheno-orbital 
fissure.  The  partition  which  separates  the  one  sinus  from  the  other,  rarely 
runs  in  the  middle  plane  of  the  body.  They  communicate  with  the  upper 
meatus  of  each  nostril ;  and,  like  the  other  sinuses  of  the  face,  are  lined  by  a 
continuation  of  the  Schneiderian  membrane.  From  analogy,  then,  we  may 
infer  that  they  are  subject  to  the  same  diseases  as  the  frontal  and  maxillary 
sinuses. 

I  know  of  no  instance  on  record  in  which  the  sphenoid  sinuses  were  dilated 
by  suppuration.  In  a  case  recorded  by  Dr.  Bright,  in  which  a  fungous 
growth  is  mentioned  as  having  occupied  this  situation,  the  appearances  are 
but  loosely  described.  The  chief  symptom  during  life  was  tic  douloureux  in 
the  corresponding  side  of  the  face.**  Sir  Robert  Carswell  has  figured  a 
medullary  tumor  projecting  into  the  cavity  of  the  cranium  from  the  cells  of 
the  sphenoid  bone.*"^ 

The  consequences  of  dilatation  of  the  sphenoid  sinuses  on  the  orbit,  and  on 
the  vessels  and  nerves  entering  that  cavity,  must  be  a  matter  of  conjecture. 
Expansion  of  the  sinuses  could  not  take  place  easily,  either  downwards  or 
backwards ;  and  were  their  walls  to  be  pressed  either  upwards  or  outwards, 
we  should  presume  that  they  would  deform  the  posterior  part  of  the  orbit, 
impede  the  circulation  of  blood  to  and  from  the  eye,  and  destroy  its  sensitive 
power  and  motion. 

In  a  case  in  which  I  was  consulted,  of  severe  neuralgia  of  the  face,  which 
resisted  all  remedies,  and  was  attended  with  palsy  of  the  muscles  of  the  eye, 
ulcer  of  the  cornea,  and  amaurosis,  the  uvula  was  dragged  completely  to  one 
side  of  the  fauces,  while  on  the  opposite  side,  and  behind  the  velum,  there 
was  a  firm  tumor,  which  I  conjectured  might  arise  from  a  dilatation  of  one  of 
the  sphenoid  sinuses.  It  also  occurred  to  me  that,  were  this  conjecture  just, 
the  cavity  of  the  distended  sinus  might,  in  such  a  case,  be  artificially  opened, 
and  its  contents  evacuated,  through  the  mouth. 


116      PRESSURE   ON   ORBIT   FROM   THE   CAVITY  OF   THE  CRANIUM. 

Mr.  Hewitt  has  recorded*''  a  case,  in  which  he  extirpated  the  upper  max- 
illary bone  on  account  of  a  fibrous  tumor,  which,  after  the  bone  was  removed, 
was  found  really  to  lie  behind  it.  The  tumor  occupied  various  regions  of  the 
side  of  the  face,  adhered  to  the  pterygoid  processes,  had  insinuated  itself  under 
the  temporal  muscle,  and  into  the  orbit  by  the  spheno-maxillary  fissure,  had 
nearly  obliterated  the  antrum,  the  posterior  wall  of  this  sinus  having  been 
forced  by  it  against  the  anterior  one,  while  the  origin  of  the  disease  was  in 
the  sphenoid  sinus,  and  roof  of  the  nostril.  The  patient  died  from  the  intru- 
sion of  blood  into  the  bronchia,  while  under  the  influence  of  chloroform  during 
the  operation. 

§  6.   Pressure  on  the  Orbit  from  the  Cavity  of  the  Cranium. 

Although  congenital  malformations  do  not  exactly  fall  within  the  scope  of 
the  present  work,  I  may  just  mention  that  the  bones  of  the  orbit  are,  in  some 
rare  instances,  defective  from  birth,  so  as  to  permit  an  encephalocele,  or  pro- 
trusion of  the  brain,  to  exist  through  them.  In  a  case  related  by  Mr.  Lyon,*^ 
an  encephalocele  was  situated  at  each  inner  canthus,  and  looked  somewhat 
like  a  greatly  dilated  lachrymal  sac  on  each  side  of  the  nose.  Such  cases  are 
not  to  be  meddled  with  ;  they  may  of  themselves  subside,  shrink,  and  disap- 
pear ;  punctured,  they  will  prove  fatal. 

In  some  diseased  states  of  the  encephalon,  the  orbits  are  pressed  forward ; 
their  roof  becomes  nearly  vertical,  forming  a  posterior  wall  to  the  cavity  ;  and 
their  apex  approaching  their  base,  they  become  much  shallower  than  natural, 
and  the  eyeballs  protuberant.  This  takes  place  in  chronic  hydrocephalus. 
It  is  remarkably  the  case  in  the  hydrocephalic  skull,  figured  by  Dr.  Baillie,*^ 
and  which  is  preserved  in  the  Hunterian  Museum  at  Glasgow.  I  have  now 
before  me  the  skull  of  an  adult,  so  much  dilated  by  a  diseased  state  of  the 
brain,  that  the  distance  from  the  external  meatus  auditorius  to  the  crown  of 
the  head,  which  commonly  measures  G  inches,  amounts  to  7^  inches  ;  while 
almost  every  part  of  its  parietes  is  so  much  thinned  in  consequence  of  pres- 
sure, as  to  be  diaphanous.  The  ordinary  depth  of  the  orbit  is  ly^  inches  ; 
whereas  in  this  skull  it  strikes  one  at  the  first  glance  as  unnaturally  shallow, 
and  on  measurement  is  found  only  1  jV  inches  in  depth. 

In  another  set  of  cases,  one  or  other  orbit,  rarely  both  at  once,  although 
often  the  one  and  then  the  other,  are  not  merely  deformed  by  the  pressure 
arising  from  disease  within  the  cranium  ;  but  some  part  of  their  walls,  and 
especially  their  roof,  becomes  involved  by  the  disease  of  the  brain  or  of  its 
membranes,  is  partially  absorbed,  inflamed,  and  is  destroyed  by  caries  or 
necrosis.  IJnder  such  circumstances,  death  is  generally  preceded  by  amaurosis 
and  exophthalmos. 

Many  cases  might  be  quoted  of  diseased  dura  mater  producing  the  de- 
struction of  the  orbit  by  pressure  and  absorption.  Most  of  the  cases  of  this 
kind  on  record  appear  to  have  succeeded  injuries  of  the  head,  by  blows  or 
falls.  In  some  of  them  the  dura  mater  was  diseased,  without  any  remarkable 
morbid  change  of  the  brain  ;  in  others,  the  brain  was  likewise  affected.  In 
some,  the  disease  of  the  dura  mater  was  fungous ;  in  others,  hydatiginous  or 
encysted. 

Mr.  Hawkins  cautions  us  against  mistaking  fungus  haematodes  in  the  diploe 
of  the  skull  for  fungous  tumor  of  the  dura  mater.  He  says  the  disease  of  the 
bone  spreads  to  the  tables,  and  hence  to  the  periosteum  and  dura  mater,  adhering 
to  the  sound  dura  mater,  and  looking  as  if  it  arose  from  it.  A  similar  view 
was  entertained  on  the  subject  by  the  Wenzels.  The  disease,  whatever  be  its 
origin,  sometimes  attacks  several  parts  of  the  cranium  at  once,  and  is  attended, 
I  believe,  with  a  pulsatory  feeling  in  the  tumor,  synchronous  with  the  move- 
ments of  the  brain.     The  cases  related  by  Louis  sufficiently  show  the  danger 


PRESSURE   ON  ORBIT  FROM  THE  CAVITY  OF  THE  CRANIUM.      lit 

of  meddling  with  such  tumors,  death  occurring  in  a  few  days,  or  even  a  few 
hours,  after  an  injudicious  puncture,  or  other  operation/" 

Disease  originating  in  the  pia  mater  or  in  the  brain,  and  destroying  the 
orbit,  must  necessarily  be  rare  ;  but  the  case  already  quoted  (page  93)  from 
Mr.  Hunter,  shows  the  possibility  of  such  an  event. 

The  following  cases  illustrate  the  efiFects  which  the  orbit  and  its  contents 
may  suffer  from  diseases  originating  within  the  cranium : — 

Case  97. — A  man,  51  years  of  age,  fell  from  his  horse  and  received  a  severe  contusion 
on  the  head.  Four  years  afterwards,  his  memory  began  to  fail ;  from  day  to  day  this 
defect  increased,  till  he  could  no  longer  recollect  what  he  had  uttered  a  moment  before. 
Frequent  and  violent  epileptic  fits  succeeded,  but  appeared  to  yield  to  different  remedies, 
employed  during  six  months.  Severe  and  uninterrupted  headache  next  supervened.  No 
remedy  was  found  to  calm  this  symptom ;  and  after  six  months,  the  patient  died.  For 
six  weeks  before  his  death,  the  left  eye  had  been  turned  from  its  natural  position  in  the 
orbit.     On  that  side  of  the  head,  the  pain  had  been  comparatively  slight. 

On  dissection,  a  considerable  portion  of  the  two  tables  of  the  middle  anterior  part  of  the 
right  parietal  bone  was  found  carious  ;  while  various  other  places  to  a  smaller  extent  were 
similarly  affected.  A  fungous  tumor  adherent  to  the  dura  mater,  had  produced  the  ab- 
sorption of  the  roof  of  the  left  orbit,  and  thus  made  its  way  into  that  cavity.  The  same 
tumor  had  destroyed  the  cribriform  plate  of  the  ethmoid  bone ;  and  the  corresponding 
portion  of  brain  was  also  diseased.*' 

Had  the  patient  survived  for  any  considerable  time  longer,  there  can  be  no 
doubt  that  the  existence  of  this  fungous  tumor  pressing  through  the  orbit, 
would  have  been  manifested  still  more  distinctly,  by  external  changes. 

Case  98. — Marechal  had  under  his  care  a  young  man,  20  years  of  age,  whose  left  eye 
•was  prominent  and  turned  outwards,  in  consequence,  apparently,  of  a  tumor  at  the  inner 
angle  of  the  eye,  attended  by  headache,  giddiness,  watering  of  the  eye,  and  dryness  of 
the  nostril.  Marechal  attacked  the  tumor  with  caustic,  and  then  punctured  the  eschar, 
when  thei-e  flowed  out  two  or  three  tablespoonfuls  of  lymph,  a  little  reddish  in  color ; 
after  which  the  eye  was  restored  almost  to  its  natural  place. 

On  being  appointed  surgeon  to  Louis  XIV.,  Marechal  handed  the  patient  over  to  Petit. 
When  the  eschar  separated,  something  like  a  vesicle  presented  itself  in  the  middle  of  the 
opening.  On  puncturing  this  vesicle  with  the  lancet,  a  fluid  escaped,  similar  to  what 
had  previously  been  discharged,  only  less  in  quantity.  Two  days  after,  a  third  was 
opened  in  the  same  way,  but  discharged  very  little.  The  eye  again  became  displaced 
outwards  and  forwards,  as  it  had  been  at  the  first ;  the  head  became  heavy,  fever  super- 
vened, and  in  a  short  time  the  patient  died  lethargic. 

On  opening  the  head  nothing  remarkable  was  found  in  the  brain  ;  the  dura  mater 
investing  the  lower  part  of  the  middle  lobe  of  the  cerebrum  appeared  considerably 
elevated ;  and  on  endeavoring  to  detach  it  from  the  squamous  portion  of  the  temporal, 
it  was  found  united  to  the  bone,  and  the  bone  changed  into  a  cartilaginous  or  fleshy  sub- 
stance. The  roof  of  the  orbit  was  changed  in  like  manner ;  while  three  hydatids  or 
vesicles,  full  of  reddish  fluid,  and  each  about  the  size  of  a  walnut,  were  found,  one  in  the 
orbit ;  a  second,  half  in  the  orbit,  half  in  the  cranium  ;  and  the  third,  in  the  hollow 
formed,  by  the  union  of  the  sphenoid  with  the  petrous  and  squamous  portions  of  the 
temporal  bone.  That  hollow,  as  well  as  the  sphenoid  bone,  where  it  forms  the  optic 
foramen,  was  also  softened.  In  fact  this  altered  state  of  bone  extended  from  the  petrous 
portion  of  the  temporal  to  the  inner  angle  of  the  eye ;  the  os  planum  and  the  os  unguis 
being  likewise  affected. ^2 

Case  99. — A  lighterman,  stout  and  healthy,  aged  29,  after  frequent  bleedings  from  the 
right  nostril,  and  an  obstructed  and  snufiling  respiration,  was  attacked  with  severe  pain 
over  the  whole  front  of  the  head,  accompanied  by  a  sense  of  weight  in  that  part,  and 
extreme  lethargy.  Although  naturally  of  an  active  cheerful  disposition,  he  became 
morose,  indolent,  and  fond  of  solitude ;  at  intervals  he  was  attacked  with  tremors,  cold 
perspirations,  and  syncope.  These  symptoms  had  become  established,  when  the  right 
eye  began  to  protrude  from  its  socket ;  his  pain  was  at  this  time  more  severe,  and  a 
copious  glairy  discharge  was  set  up  from  the  nostril.  As  the  disease  advanced,  his  man- 
ner to  his  relations  became  strange,  his  intellect  confused,  and  gait  unsteady.  The  pro- 
trusion increased  for  several  weeks.  The  pain  did  not  abate,  except  for  a  few  hours 
after  occasional  blood-letting.  Convulsions  at  length  ensued,  and  terminated  his  exist- 
ence, about  three  months  after  the  commencement  of  the  exophthalmos. 

It  is  remarkable  that  he  retained  the  vision  of  the  affected  eye  up  to  the  period  of  its 
protrusion ;  and  before  that  symptom  became  obvious,  he  described  the  sensation  of 


118      PRESSURE   ON   ORBIT  FROM   THE   CAVITY   OF   THE   CRANIUM. 

something  pushing  the  eye  out  of  its  socket.  During  the  whole  period  of  his  disease, 
although  his  bowels  were  extremely  torpid,  he  had  a  good  appetite,  and  little,  if  any, 
febrile  irritation.  These  particulars  Mr.  Travers  learned  from  the  surgeon  and  relatives 
of  the  patient,  having  himself  seen  him  only  a  few  days  before  his  death. 

On  dissection,  the  following  appearances  were  observed  :  Behind  the  right  orbit  lay  a 
tumor,  which  had  the  appearance  of  an  oblong  polypous  cyst ;  and  anterior  to  this,  and 
distinct  from  it,  was  a  blood-colored  fungus,  filling  the  orbit,  and  extruding  the  eyeball. 
The  cyst  lay  anterior  to  the  dura  mater,  adhering  to  its  surface,  and  so  situated  as  to 
make  the  right  hemisphere  of  the  cerebrum  appear  as  if  deprived  of  its  anterior  lobe. 
The  ethmoid  bone,  frontal  sinus,  and  orbitary  plate  of  the  os  frontis,  on  the  same  side, 
were  in  a  state  of  caries,  so  that  the  finger  passed  readily  from  the  orbit  into  the  cavity 
of  the  cranium  and  posterior  nares.  A  large  quantity  of  yellow  viscid  matter  occupied 
the  frontal  sinus,  such  as  had  been  discharged  during  life  by  the  nostril.  The  os  frontis 
in  front  of  the  sinus,  and  above  the  orbit,  was  denuded,  and  presented  numerous  small 
ulcerations.  The  anterior  lobe  of  the  brain  was  discolored  and  softened ;  there  was  a 
quantity  of  water  in  the  left  ventricle,  and  some  fluid  blood  in  the  right.  On  making  a 
transverse  section  of  the  riglit  hemisphere  of  the  brain,  it  was  found  broken  down  in  its 
texture,  and  the  dura  mater  partially  absorbed  at  its  basis,  the  tumor  having  opened 
into  the  ventricle.  The  right  thalamus  was  much  diminished  in  bulk,  thougli  entire. 
The  htematoid  fungus  in  the  orbit  was  mingled  with  spicuke  of  bone.  The  dura  mater, 
to  which  the  cyst  adhered,  was  continuous  behind  the  cyst,  except  at  the  lower  part 
where  it  was  destroyed.  The  disease  appeared,  therefore,  to  be  connected  with  the 
external  surface  of  the  dura  mater,  and  by  its  increase,  to  have  occasioned  absorption  of 
the  bones,  and  displacement  of  the  eye,  and  ultimately  to  have  ulcerated  tlirough  the 
dura  mater  and  anterior  cerebral  lobe,  and  discharged  itself  into  the  right  ventricle. 
The  eye  and  its  muscles  were  sound  ;  as  were  also  the  optic  and  other  nerves  of  the  orbit. 
The  olfactory  nerve  had  disappeared,  along  with  the  ethmoid  bone,  on  the  right  side.^^ 

Case  100. — A  robust  man,  aged  48  years,  whose  employment  led  him  to  the  frequent 
lifting  of  heavy  loads,  was  in  the  act  of  lowering  from  his  cart  a  package  of  above  500  lbs. 
weight,  when  his  foot  slipping,  he  was  struck  by  the  package  on  the  head.  No  bad 
effects  appeared  immediately  to  result,  so  that  he  not  only  carried  the  load  away  to  its 
destination,  after  placing  it  on  his  head,  but  continued  for  five  weeks  to  pursue  his  ordi- 
nary occupation.  After  that  period  he  began  to  complain  of  feelings  of  internal,  obtuse, 
pressing  pain  in  that  part  of  the  head  wliero  tiie  right  parietal  bone,  along  with  the 
frontal,  forms  the  coronal  suture  ;  and  the  pulse  became  quick,  full,  and  hard.  To  these 
symptoms  there  followed  epileptic  fits,  which  were  renewed  several  times  in  the  course 
of  the  day.  The  fever  and  pain  of  the  head  became  mitigated,  digestion  and  nutrition 
were  unimpeded,  but  the  patient  continued  for  more  than  a  year  totally  unfit  for  any 
employment,  on  account  of  the  fre(|uency  of  tlie  epileptic  attacks. 

About  15  months  after  the  accident,  the  pain  of  the  head  again  increased  to  such  a 
degree,  as  to  deprive  him  of  rest  both  night  and  day,  and  to  cause  such  suffering  that  he 
could  not  help  crying  out.  Violent  fever  ami  delirium  accompanieil  the  pain.  These 
symptoms  continued  for  several  weeks,  but  the  epilepsy  ceased.  The  pain  gradually 
descended  to  the  right  ear  and  eye  ;  and  in  proportion  as  it  became  more  severe  in  the 
orbit,  it  subsided  in  the  upper  part  of  the  head.  The  eyeball  became  inflamed  and 
swollen,  and  was  protruded  from  the  orbit.  On  raising  the  upper  eyelid,  the  cornea  was 
seen  to  be  turbid,  the  pupil  expanded  and  immovable,  the  iris  green,  and  vision  very  im- 
perfect. Onyx  followed,  commencing  at  the  lower  edge  of  the  cornea,  and  advancing  till 
the  whole  cornea  was  affected.  Violent  pain  continued,  proceeding  from  the  bottom  of 
the  orbit  towards  the  external  parts  of  the  eye,  and  attended  at  length  by  a  discharge  of 
blood  from  the  inner  canthus  and  right  nostril.  After  this,  the  pain  ceased,  and  the 
patient  had  only  two  fits  of  epilepsy.  The  left  eye,  with  the  exception  of  a  little  redness 
at  the  inner  canthus,  was  healthy.  Memory  fulled,  and  the  vital  functions  became 
enfeebled. 

About  18  months  after  the  accident,  the  epileptic  fits  returned,  they  were  more  fre- 
quent and  more  violent  than  before,  and  some  few  short  lucid  intervals  excepted,  they 
were  attended  with  constant  stupor  and  absence  of  mind.  Respiration  became  impeded, 
and  the  patient  died  in  violent  convulsions. 

On  sawing  through  the  cranium,  the  bones  of  the  right  side  were  seen  to  be  bent  out- 
wards, they  were  harder  than  those  of  the  left,  their  two  tables  thicker,  and  their  diploe 
wanting.  The  vessels  of  the  dura  mater  were  dilated,  and  filled  with  blood.  The  mem- 
brane firmly  adhered  at  every  point  to  the  inner  surface  of  the  skull,  except  over  the  roof 
of  the  orbit,  where  a  considerable  portion  of  it  was  separated  from  the  bone,  thickened, 
and  in  a  state  of  suppuration.  The  dura  mater,  tunica  arachnoidea,  andpia  mater,  were 
at  that  spot  united  together  and  firmly  adherent  to  the  brain.  The  corresponding  part 
of  the  roof  of  the  orbit  was  rough.     The  substance  of  the  i-ight  hemisphere  of  the  brain 


PRESSURE   ON   ORBIT   FROM   THE   CAVITY   OF   THE   CRANIUM,        119 

was  softer  than  that  of  the  left,  and  of  a  dirty  brownish-white  color;  the  right  lateral 
ventricle  was  enlarged  and  filled  with  thin  fluid  ;  the  lower  surface  of  the  right  anterior 
and  middle  lobes  was  occupied  by  a  number  of  steatomata,  from  the  size  of  a  pea  to  that 
of  a  filbert,  and  corresponding  to  the  destroyed  portion  of  the  dura  mater,  and  the  rough 
part  of  the  roof  of  the  orbit.  The  Gasserian  ganglion,  and  its  three  branches,  were  sur- 
rounded by  a  firm  cartilaginous  mass ;  the  motor  oculi  was  compressed  and  changed  in 
color.  Within  the  cranium,  the  abducens  was  contracted  to  the  size  of  a  small  thread  ; 
but  both  it  and  the  motor  oculi  were  of  their  ordinary  thickness,  within  the  orbit.  The 
internal  surface  of  the  right  side  of  the  cranium  upwards  to  the  middle  of  the  frontal 
bone,  and  backwards  over  the  middle  and  great  wings  of  the  sphenoid  to  the  sella  Tur- 
cica, was  rough.  The  cartilaginous  mass  surrounding  the  Gasserian  ganglion  was  found 
to  proceed  through  the  sphcno-orbital  fissure  into  the  orbit,  surrounding  the  optic  nerve 
and  so  filling  up  the  space  between  the  superior,  external,  and  inferior  straight  muscles, 
as  to  envelope  their  origin  and  vessels,  the  posterior  part  of  the  naso-ciliary  nerve,  the 
inferior  branch  of  the  motor  oculi,  the  abducens  nerve,  and  the  ophthalmic  ganglion. 
The  same  cartilaginous  substance  was  traced  tlrrough  the  spheno-maxillary  fissure,  into 
the  zygomatic  fossa. ^^ 

Case  101. — In  June,  1838,  I  lost  a  patient,  in  my  private  practice,  from  fungus  of  the 
dura  mater.     His  age,  when  he  died,  was  69. 

He  first  consulted  me  about  ten  years  before  his  death,  on  account  of  stuffing  in  the 
nostrils,  loss  of  sense  of  smell,  deafness,  and  gradually  increasing  amaurosis.  These 
symptoms  occurred  in  the  order  in  which  I  have  mentioned  them,  the  amaurotic  affec- 
tion ended  in  total  blindness  in  1830 ;  and  about  a  year  after  that,  his  eyes  were  observed 
to  protrude  considerably  from  their  sockets.  This  symptom  went  on  increasing,  and  the 
right  temple  became  dilated  and  elevated,  by  some  cause  residing  within  the  orbit.  The 
swelling  in  the  temple  was  very  painful  to  the  touch,  or  when  he  had  the  part  shaved. 
For  a  long  time,  he  suffered  severely  from  headache,  the  pain  commencing  after  the  loss 
of  sight,  and  about  the  time  when  the  exophthalmos  was  first  observed.  About  18  months 
before  death,  the  right  eyeball  was  so  much  protruded  that  it  burst,  and  was  destroyed. 
About  three  years  before  death,  he  was  attacked  frequently,  during  six  or  eight  months, 
■with  profuse  epistaxis.     At  last,  he  died  dropsical. 

At  one  period  of  his  life,  this  patient  snuffed  a  great  deal ;  but  he  dropped  that,  and 
had  recourse  to  smoking  and  chewing.  He  knew  no  cause  of  his  disease ;  he  could  trace 
it  to  no  fall  or  blow  on  the  head.  Indeed,  previously  to  the  stuffing  of  his  nostrils,  which 
was  the  first  symptom,  he  had  always  been  healthy,  except  that  he  was  occasionally 
troubled  with  tremors,  or  rigors,  for  a  few  days  at  a  time.  He  was  not  liable  to  head- 
ache before  his  sense  of  smell  began  to  fail.  He  never  had  any  fits,  faintings,  or  para- 
lytic symptoms. 

The  pain  of  his  head  was  greatly  relieved  by  the  internal  use  of  laudanum.  From  the 
state  of  complete  deafness  and  blindness  in  which  he  was  for  some  years  before  his  death, 
it  was  difficult  to  know  how  far  his  memory  or  judgment  was  affected. 

On  inspection,  the  brain  was  found  to  be  in  no  respect  materially  diseased.  The  pitui- 
tary gland  was  sound,  and  the  cerebral  surface  of  the  dura  mater  was  entire.  Under  the 
dura  mater,  between  it  and  the  basis  of  the  skull,  and  especially  behind  the  sella  Turcica, 
there  was  an  extensive  fungous  tumor,  of  a  dark-red  color,  soft  and  brainy  in  consistence. 
This  tumor  originated,  or  seemed  to  originate,  from  the  cranial  surface  of  the  dura  mater. 
It  spread  across  to  each  temporal  bone,  which  was  in  a  state  of  caries.  It  dipped  into  the 
nostrils  and  filled  both  orbits,  their  roof  and  posterior  parts  being  removed  by  absorption, 
as  was  also  the  cribriform  plate  of  the  ethmoid  bone,  and  the  outer  wall  of  the  right  orbit. 
The  tumor,  where  it  filled  the  right  orbit  and  protruded  into  the  temple,  was  unlike  the 
rest,  being  firm  and  whitish,  like  cartilage.  This  portion  could  not  be  distinctly  sepa- 
rated from  the  rest  of  the  diseased  mass;  but,  it  seemed  probable  that  this  portion  was 
the  lachrymal  gland,  enlarged  and  changed  in  structure.  The  optic  nerves,  between 
their  chiasma  and  the  orbits,  were  pale  and  flat  like  ribbons.  ^^ 


'  Medical   Transactions ;    Vol.   ii.   p.    353 ;  '  See  a  case  by  Vater,  Philosophical  Trans- 

LondoD,  1772.  actions  ;  Vol.  xxxiii.  p.  147  ;  London,  1726. 

=  Hunter  on  the  Blood,  Inflammation,  and  '  Runge  de  Morbis  Siiiiuim  Os.«is  Frontis  at 

Gunshot  Wounds;    Vol.  ii.   p.  307;    London,  Maxilla  Superioris ;  in  Ilaller's  Disputationes 

J812.  Chirurgieae  ;  Tom.  i.  p.  212;  Lausannaj,  1755. 

3  Ibid.  p.  287.  °  Novi  Coinmenfarii  Societatis  Regire  Gottin- 

*  Stanley  on  Diseases  of  the  Bones,  p.  150;  gensis;  Tom.  iii.  p.  85  ;  Gottiugaj,  1737. 

London   1849.  °  See  a  case  by  Tott,  Giafe  und  WaUher's 

'  Guy's  Hospital  Reports ;  Vol.  i.  p.  493 ;  Journal  der  Chirurgie  und  Augenheilkunde  ; 

London,  1SS6.                                 .  Vol.  xi.  p.  G62 ;  Berlin,  1828. 


120      PRESSURE   ON  ORBIT  FROM  THE   CAVITY   OF   THE   CRANIUM. 


'°  Lehro  von  den  Augenkrankheiten ;  Vol. 
ii.  p.  570;  Wien,  1817. 

"  Neue  Bibliothek  fiir  die  Cliirurgie  nnd 
Ophthalmologic ;  Vol.  ii.  p.  365;  Hannover, 
1820. 

'^  Ibid.  p.  245.  For  a  case  of  hydrops  cys- 
ticus  of  frontal  sinus,  which  occurred  in  the 
practice  of  Professor  Jager,  see  Brunn,  de  Hy- 
drope  Cystico  Sinuum  Frontalium ;  Berolini, 
1829  :  and  Ammon's  Klinische  Darstellungen, 
Vol.  ii.  p.  26;  Berlin,  1838. 

'^  Beitrage  zur  Medizin,  Chirurgie  und  Oph- 
thalmologie,  von  C.  C.  Wuth,  p.  116  ;  Berlin, 
1844.  For  a  case  of  polypus  in  the  nose,  throat, 
maxillary,  and  frontal  sinuses,  see  Levret,  Ob- 
servations sur  le  Cure  de  plusieurs  Polypes,  p. 
235  ;  Paris,  1749.  For  a  case  of  huge  deform- 
ing polypus  of  right  frontal  sinus,  see  Auvert, 
Selecta  Praxis  Medico-chirurgica ;  Fasciculus 
I.  tab.  v. 

'*  On  the  diseases  of  the  maxillary  sinus, 
consult  Bordenave,  in  the  Memoires  do  I'Aca- 
demie  Royale  de  Chirurgie ;  Vols.  xii.  and  xiii. 
12mo ;  Paris,  1774. 

''  Lettre  Chirurgicale  sur  quelques  Maladies 
Graves  du  Sinus  Maxillaire  et  de  I'Os  Maxil- 
laire  Inferieur;  p.  50;  Paris.  1833. 

"  Beyer,  Traite  des  Maladies  Chirurgicales; 
Tome  vi.  p.  140  ;  Paris,  1818. 
'^  Ibid.     Tome  vi.  p.  153. 
"  See  a  case  treated  by  Ruffell,  Memoires  de 
I'Academie  Royale  de  Chirurgie ;  Vol.  xii.  p. 
68  ;  12mo  ;  Paris,  1784. 

'"  Grafe  und  Walther's  Journal  der  Chirurgie 
nnd  Augenheilkunde  ;  Vol.  iii.  p.  62;  Berlin, 
1822 

*°  Ibid.  Vol.  ii.  p.  397  ;  Berlin,  1821. 
"'  Chirurgie    Clinique    de    Montpellier,    par 
Delpech  ;  Vol.  ii.  pp.  125,  130  ;  Paris,  1828. 

*^  See  a  case  by  Krimer,  Grafe  und  Walther's 
Journal  der  Chirurgie  und  Augenheilkunde; 
Vol.  X.  p.  606;  Berlin,  1S27. 

*^  (Euvres  Chirurgicales;  Tome  ii.  p.  165; 
Paris,  1813. 

'■'  On  excision  of  the  upper  maxillary  bone, 
consult  Gensoul's  work  already  referred  to : 
Syme,  Edinburgh  Medical  and  Surgical  Jour- 
nal; Vol.  xliv.  p.  1  :  Guthrie,  London  Medical 
Gazette ;  Vol.  xvii.  pp.  315.  618  :  Institutes  of 
Surgery,  by  Sir  Charles  Bell ;  Vol.  i.  p.  233 ; 
Edinburgh,  1838. 

^'  Ammon's  Zeitschrift  fiir  die  Ophthalmo- 
logie  :  Vol.  i.  p.  307  ;  Dresden,  1831. 

**  White's  Cases  in  Surgery,  p.  135 ;  London, 
1770. 

'^  Howship's  Practical  Observations  in  Sur- 
gery and  Morbid  Anatomy,  p.  22 ;  London, 
1816. 

*'  Edinburgh  Medical  and  Surgical  Journal ; 
Vol.  xliv.  p.  2 ;  Edinburgh,  1835. 

^'  Traite  des  Operations  de  Chirurgie,  traduit 
par  SoUier,  p.  303  ;  Paris,  1794. 

'°  Prochaska  has  given  two  engravings  ex- 
hibiting a  front  and  a  side  view  of  this  skull, 
in  his  Disquisitio  Anatomico-Physiologica  Or- 
ganism! Corporis  Humani,  p.  172 ;  Viennae, 
1812.  A  reduced  copy  of  these  engravings,  I 
have  introduced  into  the  text.  "The  case  of 
Louis  Niacre,  related  by  Alibert  (Nosologie 
Naturelle;  Tome  i.  p.  529;  Paris,  1817),  and 
that  of  a  boy  who  died  in  St.  Bartholomew's 
Hospital,  referred  to  by  Cooper  (Dictionary  of 


Practical  Surgery,  article  Polypus),  appear  to 
have  been  examples  of  antral,  not  nasal,  po- 
lypus. 

"'  Practical  Surgery,  p.  307;  London,  1846. 

"*  Burns  on  the  Surgical  Anatomy  of  the 
Head  and  Neck,  p.  484;  Glasgow,  1824. 

'^  Magendie,  Journal  de  Physiologie ;  Tome 
vii.  p.  180 ;  Paris,  1827. 

"  Op.  cit.  p.  464. 

''  Op.  cit.  p.  307. 

"  Op.  cit.  p.  147. 

"  Ibid.  p.  148:  and  Illustrations,  PI.  13,  fig. 
4,  and  PI.  17,  fig.  3.  In  pi.  16,  fig.  8.  Mr. 
Stanley  has  represented  a  fibrous  tumor  origi- 
nating within  the  antrum,  which,  with  part  of 
the  jaw,  was  removed  by  Mr.  Luke. 

'*  Lizars'  Practical  Surgery  ;  Part  ii.  p.  99  ; 
Edinburgh,  1839 ;  Gensoul,  Op.  cit. :  Listen, 
Medico-chirurgical  Transactions  ;  Vol.  xx.  p. 
195;  London,  1837;  Solly,  Medical  Gazette; 
Vol.  xxxvii.  p.  89;  London,  1846;  Review  of 
Dieffenbach's  Operative  Chirurgie.  Medico- 
chirurgical  Review  for  October,  1850,  p.  287  ; 
Review  of  O'Shaughnessy  on  Diseases  of  the 
Jaws  :  British  and  Foreign  Medical  Review 
for  July,  1845,  p.  195  ;  Horner,  Dublin  Medical 
Press;  Vol.  xxiii.  p.  345;  Dublin,  1850  :  Iley- 
felder.  Medical  Times  and  Gazette,  July  10, 
1853,  p.  119. 

^'  Boyer,  Traits  des  Maladies  Chirurgicales ; 
Tome  vi.  p.  168;  Paris,  1818. 

*°  Dictionnaire  des  Sciences  Medieales ;  Tome 
XXXV.  p.  25;  Paris,  1819.  See  description  and 
figures  of  another  skull,  affected  with  exostosis 
of  the  mnxillary  sinus,  by  Bordenave,  Memoires 
de  I'Acadiraie  Royale  de  Chirurgie;  Tome  xiii, 
p.  412;  12mo;  Paris,  1774. 

"  Surgical  Essays,  by  Cooper  and  Travers ; 
Vol.  i.  p.  169  ;  London.  1818. 

*^  Guy's  Hospital  Reports;  Vol.  i.  p.  403; 
London,  1836. 

*'  Glasgow  Medical  Journnl;  Vol.  i.  p.  319  ; 
Glasgow,  1828.  After  Mrs.  Craig's  return  home 
to  Paisley,  Dr.  Anderson  was  informed  that  she 
died  from  •  the  exostosis  affecting  the  brain, 
probably  by  pressure. 

"  Ilowship,  Op.  cit.  p.  26  ;  London,  1816. 

*'  Bright's  Report  of  Medical  Cases;  VoL  ii. 
p.  506;  London,  1831. 

"  Illustrations  for  the  Elementary  Forms  of 
Disease;  Carcinoma,  PI.  ii.  Fig.  7;  London, 
1838. 

'"  Medico-Chirurgical  Transactions;  Vol. 
xxxiv.  p.  43  ;  London,  1851. 

*■*  Edinburgh  Monthly  Journal  of  Medical 
Sciences  for  May,  1842,  p.  406. 

■"  Series  of  Engravings  Illustrative  of  Morbid 
Anatomy :  Fasciculus  X.  Plate  iii.  Fig.  1 ; 
London, 1799. 

'°  See  Lawrence,  Medical  Times  and  Gazette, 
August  6,  1853.  p.  129. 

"  Quoted  from  Jauchius,  by  Louis,  in  his 
paper  on  Fungous  Tumors  of  the  Dura  Mater ; 
Memoires  de  I'Academie  Royale  de  Chirurgie  ; 
Tome  xiii.  p.  62  ;  12rao  ;  Paris,  1774. 

'^  Petit,  Traite  des  Maladies  des  Os;  Tome 
ii.  p.  325;  Paris,  1759. 

'^  Travers'  Synopsis  of  the  Diseases  of  the 
Eye,  p.  411;  London,  1820. 

'*  Landmann,  Commentatio  Pathologico- 
Anatomica  exhibens  Morbum  Cerebri  Oculique 
singularem ;  Lipsiae,  1820. 


LACHRYMAL  XEROMA  OR  XEROPHTHALMIA.                       121 

"  On  fungus  of  the  pericranium,  skull,  and  Diagnosi ;  Vratislavire,  1S25:  Blasius  de  Fungi 

dura  mater,  consult  I.  und  C.  AVenzel  iiber  die  Durse   Matris    accuratiori    Distinctione  ;   Kalis 

schwammigen  Auswuchse  auf  der  aussern  Him-  Saxonutn,  1829:  Walshe   on   Cancer,  p.    504; 

hant;  Mainz,  1811:  Tilanus  de  Funguso  Durje  London,  1846. 

Meningis   excrescento  ;    Trajecti   ad   Rhenuui,  -■■   Mussey's  Report  on  Surgery  in  Trans,  of 

1818  :  Seerig  de  Fungi  Durje  Matris  Origins  et'  the  American  Med.  Assoc,  p.  364;  Phila.,  1850 . 


CHAPTER    II. 
DISEASES  OF  THE  SECRETING  LACHRYMAL  ORGANS. 


SECTION  I. — INJURIES  OF  THE  LACHRYMAL  GLAND  AND  DUCTS. 

It  must  be  diflficult  to  wound  the  superior  portion  of  the  lachrymal  gland, 
or  glandula  innominata,  with  any  ordinary  instrument,  penetrating  into  the 
cavity  of  the  orbit ;  still,  it  might  be  possible  to  reach  it,  for  instance,  with 
a  penknife,  driven  upwards,  backwards,  and  outwards,  into  the  fossa  lachry- 
malis ;  and  we  can  easily  enough  suppose  the  inferior  portion,  or  glandulge 
congregatse,  and  the  excretory  ducts  of  the  gland,  to  be  divided,  in  such  a 
penetrating  wound.  The  effects  of  such  an  injury  will  be  apt  to  resemble 
those  of  a  wounded  parotid  gland  or  duct ;  that  is  to  say,  the  frequent  dis- 
tilling of  tears  like  that  of  saliva,  will  be  likely  to  prevent  the  healing  of  the 
wound,  and  produce  what  is  termed  o,  fistula  lachrymalis  vera.  I  know  of  no 
such  case  on  record ;  but  the  thing  seems  possiV^le.  A  penetrating  wound, 
then,  which  we  suspect  may  have  implicated  the  lachrymal  gland  or  divided 
some  of  its  ducts,  we  should  endeavor  to  unite  with  more  than  common  care ; 
employing  for  that  purpose  sutures,  strips  of  adhesive  plaster  over  the  wound, 
and  a  compress  and  roller  over  the  eyelids,  and  enjoining  the  patient  to  keep 
the  eye  as  much  as  possible  at  rest,  till  the  cure  be  completed. 

Lacerated  wounds,  going  on  to  suppuration  and  involving  the  lachrymal 
ducts,  may  end  in  the  destruction  or  obliteration  of  these  canals,  and  give 
rise  to  incurable  lachrymal  xeroma. 

Case  102. — Larrey  relates'  that  a  soldier  received  a  musket-shot  towards  the  superior 
external  angle  of  the  left  orbit.  Half  of  the  ball  took  the  direction  of  the  temple,  and 
passed  under  the  temporal  aponeurosis,  whence  it  was  easily  extracted ;  the  other  half 
penetrated  into  the  orbit,  and  lodged  in  the  lachrymal  gland.  The  wound  of  the  eyelids 
being  enlarged,  the  remaining  half  of  the  ball  was  removed,  along  with  the  lacerated 
gland.  The  wounds  healed  readily,  and  the  eye  was  not  only  saved,  but  continued  to  be 
sufficiently  moistened  to  permit  its  ordinary  motions  to  be  performed. 


Clinique  Chirurgicale  ;  Tome  i,  p.  396 ;  Paris,  1829. 


SECTION  n. — LACHRYMAL  XEROMA  OR  XEROPHTHALlVnA. 

From  ^Dpof  dry  and  J^^ua  or  J<f>9aX^of  eye.     The  ancient  xerophthalmia,  or  dry  lippitudo, 
was  what  is  now  called  ophthalmia  tarsi. 

There  are  two  kinds  of  xeroma,  or  dryness  of  the  eye,  the  one  lachrymal 
and  the  other  conjunctival ;  the  former,  depending  on  a  suppressed  or  im- 
perfect secretion  of  tears  ;  the  latter,  on  a  deficiency  of  the  mucous  secretion, 
which,  in  the  natural  state,  lubricate  the  surface  of  the  eye.^ 

Lachrymal  xeroma  may  be  owing  to  a  diseased  condition  of  the  substance 
of  the  gland,  to  a  want  of  the  proper  nervous  energy  upon  which  its  secre- 


122  LACPIRYMAL  XEROMA   OR  XEROPHTHALMIA. 

tive  power  depends,  or  to  an  injured  state  of  its  ducts,  such  as  may  arise 
from  an  abscess  behind  the  upper  eyelid. 

I  am  not  certain  that  xeroraa  is  a  common,  though  it  maybe  an  occasional 
symptom,  in  inflammation  of  the  gland.  The  assertion  that  it  accompanies 
scirrhus  or  enlargement  of  that  body,  is  contradicted  by  the  cases  related  by 
Mr.  Todd  and  Dr.  O'Beirne.^  Yet  we  can  scarcely  suppose  that  the  function 
of  the  lachrymal  gland  will  go  on  without  impediment,  when  its  substance  is 
either  much  inflamed,  or  greatly  indurated. 

We  are  not  surprised  to  meet  with  xeroma  in  old  people,  either  by  itself, 
or  attendant  on  amaurosis  ;  for  in  them  the  gland  is  shrunk,  and  the  nervous 
energy  of  the  fifth,  like  that  of  all  the  nerves,  diminished.  We  meet,  how- 
ever, with  this  symptom  as  a  frequent  attendant  on  the  incipient  stage  of 
amaurosis,  even  in  those  not  far  advanced  in  life  :  and  we  hail,  as  a  favorable 
omen  in  such  cases,  the  return  of  the  lachrymal  secretion  ;  for,  we  almost 
invariably  find  that,  after  this  change,  vision  begins  to  improve. 

Chronic  pains  of  the  head  are  sometimes  greatly  relieved  by  a  renewed 
activity  of  the  lachrymal  gland. ^ 

We  may  regard  the  xeroma  which  occasionally  attends  deep  grief,  as  a 
purely  nervous  or  sympathetic  phenomenon. 

In  all  those  cases,  when  we  look  at  the  eye,  no  appearance  of  dryness  is  to 
be  observed ;  for  the  mucous  secretion  of  the  conjunctiva  is  not  aficcted. 
The  eye  looks  as  moist  and  slippery  as  ever,  but  the  patient  complains  that 
it  is  never  wet ;  or,  if  it  be  at  times  bedewed  with  tears,  great  relief  is  ex- 
perienced, evidently  showing  that  the  dryness  depends  on  want  of  the  lachry- 
mal, not  of  the  conjunctival,  secretion. 

If  xeroraa  seems  to  depend  on  inflammation  of  the  lachrymal  gland,  or  if 
we  suspect  any  incipient  affection  likely  to  lead  to  enlargement  or  change  of 
structure  of  that  body,  local  bleeding,  and  other  antiphlogistic  remedies,  will 
be  proper.  Sternutatories  are  found  useful,  when  want  of  nervous  energy 
seems  to  be  the  cause.  If  the  affection  appears  to  be  sympathetic,  purga- 
tives, tonics,  and  antispasmodics  may  be  had  recourse  to.  The  influence  of 
music  has  sometimes  been  very  remarkable  in  removing  the  xeroma  attendant 
on  grief.* 

As  a  substitute  for  the  tears  in  xeroma,  Wathen  recommends^  the  use  of  a 
saponaceous  lotion.  Three  or  four  drops  of  a({ua  potasses  are  to  be  added  to 
two  ounces  of  tepid  water,  filling  about  two-thirds  of  an  eye-cup.  This  is  to 
be  applied  to  the  open  eye,  for  a  minute  or  more.  It  gives  little  or  no  pain, 
brings  away  all  the  morbid  excretions  from  off  the  eye  and  its  lids,  and  as 
instantly  removes  what  the  patient  calls  the  cloud  from  his  sight.  But  as  this 
will  quickly  return,  its  frequent  application  will  be  requisite.  In  order  to 
excite,  if  possible,  the  natural  secretion  of  tears,  it  ought  to  be  made  fresh 
every  time  it  is  used,  and  its  strength  gradually  increased,  till  it  becomes,  not 
only  a  wash,  but  a  stimulus. 

Keeping  the  eye  at  intervals  in  tepid  water  alone,  for  some  minutes  at  a 
time,  the  same  author  remarks,  is  not  only  a  substitute  for  the  tears,  but  along 
with  the  means  already  mentioned,  serves  also  to  relax  the  parts,  and  dispose 
them  to  resume  their  natural  functions. 


'  Mr.  Wardrop  has  recorded  (Lancet,  29  Nov.  ■*  Dictionnaire  des  Sciences  Medicales  ,•  Tome 

1834,  p.  3i4)  a  coiigeiiital  case  of  lachrymal  and  xxxv.  p.  71  ;  Paris,  1819. 

conjunctival  xeinina.  '  Method  of  eurin<i;  the  Fistula  Lachrymalis, 

*  See  Section  V.  of  this  Chapter.  to  which  is  added  a  Dissertation  on  Epiphora, 

'  Collections  from  the  unpublished  Medical  &c.,  p.  71;  London,  1792. 

Writings  of  the  late  C.  H.  Parry,  M.  D. ;  Vol. 

i,  p.  263  ;  London,  182o. 


EPIPHORA.  123 

SECTION  ni. — EPIPHORA. 
From  ETTi  upon  and  '^ifta  I  carry. 

This  is  the  reverse  of  the  last  disease  ;  for  the  tears  are  secreted  and  dis- ' 
charged  too  abundantly,  and  too  frequently.  Like  xeroma,  however,  epiphora 
may  be  regarded  rather  as  a  symptom  than  as  a  disease  in  itself. 

Diagnosis. — Epiphora,  or  excessive  lachrymation,  must  not  be  confounded 
with  stillicidium  lachrymarum.  The  difference  is,  that  the  latter  arises  merely 
from  some  incapability  in  the  excreting  parts  of  the  lachrymal  organs  to 
remove  the  tears  and  the  mucus  of  the  conjunctiva,  after  they  had  done  their 
duty ;  while  epiphora  is  a  disease  of  the  secreting  lachrymal  organs,  or  an 
over-discharge  of  tears. 

Causes. — Any  mechanical  or  chemical  irritation,  applied  to  the  conjunctiva, 
a  particle  of  dust,  for  example,  on  the  inside  of  the  upper  eyelid,  or  a  grain 
of  salt  intruding  into  the  eye,  instantly  produces  a  discharge  of  tears,  or 
epiphora.  This  is  the  natural  means  employed  to  wash  away  the  foreign 
body,  or  to  dilute  the  chemical  substance. 

Inflammation  of  the  eye,  or  eyelids,  and  especially  phlyctenular  inflamma- 
tion of  the  conjunctiva  (the  disease  commonly  known  by  the  name  oi  scrofu- 
lous opJithalmia),  is  an  extremely  frequent  cause  of  epiphora.  We  observe 
that  the  subjects  of  the  last  mentioned  disease,  if  they  attempt  to  open  the 
eye,  are  affected  with  instant  epiphora  and  spasm  of  the  orbicularis  palpe- 
brarum. We  can  be  at  no  loss  to  explain  the  connection  between  the  eyelids, 
conjunctiva,  and  lachrymal  gland,  when  we  recall  to  mind  that  the  lachrymal 
nerve,  a  branch  of  the  first  division  of  the  fifth  nerve,  having  passed  through 
the  lachrymal  gland,  spends  its  ultimate  branches  in  the  conjunctiva,  orbicularis 
palpebrai'um,  and  skin  of  the  upper  eyelid.^  In  many  cases  of  scrofulous 
conjunctivitis,  the  redness  is  slight,  perhaps  scarcely  an  enlarged  vessel  is  to 
be  seen  on  the  surface  of  the  eyeball,  and  as  yet  no  phlyctenuloe  have  made 
their  appearance ;  but  the  epiphora,  and  intolerance  of  light,  are  acute. 

Epiphora  is  occasionally  a  symptom  of  disordered  digestion,  especially  in 
children,  and  of  worms  in  the  intestines.  Indeed,  even  when  connected  with 
scrofulous  ophthalmia,  we  may  regard  both  the  ophthalmia  and  the  epiphora 
as  originating,  in  many  cases  at  least,  in  improper  food,  and  in  disorder  of 
the  digestive  organs.  It  may  also  be  made  a  question,  whether  phlyctenular 
ophthalmia  is  not  sometimes  the  consequence  of  lachrymation  in  children; 
the  inordinate  flow  of  tears  being  excited  by  the  pain  which  accompanies 
teething,  and  by  other  causes.  Profuse  attacks  of  epiphora  often  attend 
hysteria  and  hypochondriasis,  and  are  associated  in  such  cases  with  exagge- 
rated feelings  of  affliction  and  mental  depression.  In  such  cases,  all  the 
symptoms  are  confirmed  and  aggravated,  if  recourse  is  had  to  dram-drinking. 

Treatment. — Before  prescribing  any  remedy,  general  or  local,  for  epiphora, 
let  us  assure  ourselves  that  it  depends  on  no  mere  mechanical  irritation  of  the 
eye,  such  as  that  of  an  inverted  eyelash,  a  particle  of  dust  imbedded  in  any 
part  of  the  conjunctiva,  or  minute  growth  on  the  internal  surface  of  either 
eyelid. 

We  seldom  require  to  prescribe  for  epiphora  alone.  I  have  known  it  com- 
pletely and  permanently  removed  by  an  emetic.  A  regulated  diet,  purgatives 
followed  by  tonics,  and  occasionally  antacids,  will  be  found  highly  useful,  in 
removing  some  of  the  more  common  causes  of  the  disease.  A  mixture  of 
rhubarb  and  supercarbonate  of  soda  repeated  every  day,  or  every  second 
day,  and  followed  up  by  a  coui'se  of  the  sulphate  of  quina,  is  a  plan  of  treat- 
ment which  I  have  often  found  effectual. 

Of  local  remedies,  the  most  useful  are  the  vapor  of  laudanum,  and  the 


124   INFLAMMATION  AND   SUPPURATION  OF  THE  LACHRYMAL  GLAND. 

lunar  caustic  solution.  Into  a  cup  of  boiling  water,  a  teaspoonful  of  lauda- 
num is  mixed,  the  cup  held  under  the  eye,  the  eyelids  opened,  and  the  vapor 
allowed  to  come  into  contact  with  the  conjunctiva.  The  eye  is  then  bathed 
with  the  mixture  by  means  of  a  bit  of  old  linen.  This  may  be  done  twice  or 
thrice  a  day.  A  tincture  of  belladonna,  used  in  the  same  way  as  the  lauda- 
num, is  also  serviceable.  In  some  cases,  nothing  relieves  more  the  irritability 
of  the  conjunctiva,  on  which  epiphora  so  much  depends,  than  a  solution  of 
from  two  to  four  grains  of  lunar  caustic  in  an  ounce  of  distilled  water, 
dropped  on  the  eyeball  with  a  camel-hair  pencil,  once  or  twice  a  day. 

Blisters  are  useful  in  epiphora.  They  are  perhaps  more  likely  to  be  so, 
when  applied  before  the  ear,  or  on  the  temple,  as  they  will  then  act  more 
directly  on  the  branches  of  the  temporal  nerves,  which  anastomose  with  the 
lachrymal  nerve. 


'  Soemnierring,  Abbildungen  des  menschli-     ternarum    Oculi   Humani   Descriptio;    §  162; 
chen  Auges.  p.  44  ;  Tab.  iii.  Fig.  5 ;  Frankfurt     Lipsice,  1810. 
am  Main,  1801.     Roseniniiller,  Paitium    Ex- 


SECTION  IV. — INFLAMMATION  AND  SUPPURATION  OF  THE  LACHRYMAL  GLAND. 

§  1.  Inflammation  and  Suppuration  of  the  Glandulce  Congregatce. 

This  is  by  no  means  an  uncommon  affection ;  and  having  somewhat  the 
appearance  of  a  hordeolum  or  stye,  it  often  passes  as  such.  The  external 
angle  of  the  eyelids  is  swollen,  red,  and  painful ;  and  if  the  upper  lid  is 
raised,  several  of  the  acini  of  the  glandulse  congregatae  are  seen  to  be  en- 
larged. In  the  course  of  a  few  days,  one  or  more  of  them  point  and  dis- 
charge pus,  on  the  inside  of  the  upper  or  lower  lid,  close  to  the  commissure. 
Sometimes,  on  pressure,  a  long  thread  of  matter  may  be  seen  oozing  from 
one  of  the  lachrymal  ducts.  Considerable  pain  attends  the  suppuration  of 
the  glanduliB  congregatoe,  and  not  unfrequently  there  is  chemosis  of  the  con- 
junctiva of  a  whitish  color,  with  puriform  secretion  from  the  membrane. 

The  causes  are  similar  to  those  of  hordeolum.  In  one  case,  I  found  that  a 
hog's  bristle,  lodged  in  the  upper  sinus  of  the  conjunctiva,  had  brought  on 
this  affection.  I  admitted  a  boy  as  a  patient  at  the  Glasgow  Eye  Infirmary, 
who,  in  consequence  of  a  blow  with  a  stone,  was  affected  with  swelling  and 
redness  of  the  upper  eyelid  towards  its  outer  extremity ;  the  eyebrow  was 
elevated,  and  the  eyelid  depressed  ;  and  on  raising  the  eyelid,  a  considerable 
fleshy  projection  was  seen  between  the  inside  of  the  eyelid  and  the  eyeball, 
which  I  considered  to  be  the  inferior  portion  of  the  lachrymal  gland  in  a 
state  of  inflammation. 

Warm  fomentations,  and  a  small  poultice  of  bread  and  warm  water,  con- 
tained in  an  oiled  bag,  generally  form  the  treatment.  Leeches  are  seldom 
demanded  ;  the  disease  is  generally  too  far  advanced  before  we  see  it,  to 
admit  of  resolution  by  cold  applications  ;  and  the  lancet  is  rarely  required  to 
evacuate  the  matter. 

§  2.  InflammatioJi  and  Suppuration  of  the  proper  Lachrymal  Gland. 

The  glaudula  innominata,  or  superior  portion  of  the  lachrymal  gland,  is 
liable  to  become  inflamed,  constituting,  from  the  size  of  the  part  affected  and 
the  deepness  of  its  seat,  a  much  more  serious  disease  than  the  one  now 
described.  Children  of  a  scrofulous  constitution  are  the  general  subjects  of 
this  affection,  which  is  by  no  means  a  common  one. 

Symjnoms. — Pain  in  the  seat  of  the  gland,  and  increasing  fulness  above 


INFLAMMATION  AND   SUPPURATION  OF  THE   LACHRYMAL  GLAND.    125 

the  external  angle  of  the  eyelids,  are  the  first  symptoms  which  are  remarked. 
By  and  by,  a  red  and  tense  swelling  rises  at  the  upper  outer  angle  of  the 
orbit ;  the  upper  lid  can  be  raised  with  difficulty,  if  at  all ;  the  conjunctiva 
is  inflamed,  and  the  eyeball  is  pushed  forwards  from  the  orbit.  When  the 
inflamed  gland  is  enlarged  to  the  utmost,  the  sympathetic  swelling  of  the 
neighboring  cellular  substance  and  the  chemosed  conjunctiva  advance  so 
much  in  front  of  the  globe  of  the  eye,  as  completely  to  conceal  it.  The  pain 
in  the  orbit  and  head  becomes  more  and  more  severe.  Unless  the  progress 
of  the  inflammation  is  arrested,  fever,  restlessness  and  delirium,  usher  in  the 
local  symptoms  of  suppuration  ;  fluctuation  becomes  more  and  more  distinct ; 
and  at  last  the  matter  points  and  bursts,  by  one  or  more  openings  through 
the  upper  eyelid.  The  skin  of  the  upper  lid  may  slough  to  a  considerable 
extent  before  this  happens.  From  the  matting  together  of  the  parts,  the 
eyeball  is  apt  to  be  left  in  a  distorted  state,  being  turned  towards  the  temple. 
Sometimes  before  exit  is  afforded  to  the  matter  by  the  spontaneous  bursting 
of  the  abscess,  the  periosteum  of  the  fossa  lachrymalis  takes  on  inflammation, 
and  the  bone  becomes  affected.  The  case  then  turns  out  a  very  tedious  one, 
ectropium  of  the  upper  eyelid  follows  (Fig.  3,  page  76),  and  the  fistula,  as 
has  already  been  explained,  does  not  heal  till  the  bone  becomes  healthy,  or 
till  the  diseased  portion  of  it  is  discharged,  which  may  not  be  accomplished 
for  years. 

Causes. — Blows  on  the  external  angular  process  of  the  frontal  bone,  even 
slight  lacerated  wounds  of  the  upper  eyelid,  and  exposure  to  cold,  are,  I 
believe,  the  common  causes  of  inflammation  of  the  lachrymal  gland.  I  have 
known  the  glandula  innominata  to  suppurate  and  burst,  in  little  more  than 
eight  days  after  an  injury  of  the  upper  lid.  Mr.  Todd  states,  that  the  greater 
number  of  cases  which  had  fallen  under  his  observation,  were  not  idiopathic, 
but  succeeded  to  inflammation  of  the  conjunctiva,  or  some  other  form  of 
ophthalmia.  He  had  known  inflammation  of  the  lachrymal  gland  to  accom- 
pany what  he  terms  the  psorophthalmia  of  children,  when  that  disease  was 
severe,  or  aggravated  by  neglect,  exposure  to  cold,  or  by  the  incautious  use 
of  stimulating  or  astringent  applications.  He  is  also  of  opinion  that,  in  some 
cases,  inflammation  of  the  gland  ushers  in  the  ordinary  forms  of  ophthalmia, 
and  gives  rise  to  symptoms  generally  attributed  to  inflammation  of  the  eye 
alone.* 

Besides  the  acute  form,  there  is  a  chronic  inflammation  of  the  lachrymal 
gland,  almost  entirely  confined  to  the  early  periods  of  life,  and,  in  all  proba- 
bility, depending  on  a  scrofulous  predisposition.  In  this  aflTection,  there  is 
obvious  enlargement  of  the  gland,  with  occasional  oedematous  tumefaction  of 
the  upper  eyelid ;  the  patient  seldom  complains  of  much  pain,  but  generally 
of  a  sensation  of  fulness  above  the  globe,  and  an  inability  to  move  the  eye 
of  that  side  as  freely  as  the  other.  On  making  pressure  between  the  globe 
of  the  eye  and  the  temporal  extremity  of  the  upper  edge  of  the  orbit,  an  im- 
mediate and  copious  discharge  of  tears  is  produced.  Mr.  Todd  inclines  to 
attribute  scrofulous  ophthalmia  to  the  morbid  secretion  of  the  lachrymal 
gland,  during  the  course  of  chronic  inflammation ;  and  mentions  the  case  of 
a  young  lady,  who,  on  one  side  had  chronic  inflammation  of  the  gland,  with 
frequent  attacks  of  pustular  conjunctivitis,  while  on  the  other  side,  the  gland 
was  healthy,  and  no  ophthalmia  ever  occurred. 

Besides  chronic  inflammation,  Mr.  Todd  represents  the  lachrymal  gland  as 
subject  to  an  affection  still  more  decidedly  scrofulous,  characterized  by  the 
age  and  constitution  of  the  patient ;  by  slowness  of  progress,  although  the 
gland  in  this  disease  sometimes  acquires  considerable  magnitude ;  absence  of 
pain  ;  and  the  tumor  presenting  a  surface  more  or  less  lobulated.  He  states 
that  in  some  instances  this  affection,  after  a  certain  period,  will  continue 


126         ENLARGEMENTS  OF  THE  LACHRYMAL  GLAND. 

stationary  for  many  months,  or  even  for  years,  wliile  in  others  it  will  undergo 
that  form  of  suppurative  inflammation  peculiar  to  scrofulous  glands,  and  will 
thus  prove  a  tedious  and  troublesome  disease.  It  is  probable  that  this 
scrofulous  enlargement  of  the  lachrymal  gland,  especially  when  the  affection 
has  existed  on  each  side,  has  sometimes  been  confounded  with  the  diseases  to 
be  described  in  the  next  Section.^ 

Treatment. — In  acute  inflammation  of  the  lachrymal  gland,  leeches  are  to 
be  applied  liberally  to  the  upper  eyelid,  forehead,  and  temple  ;  blood  may 
also  be  taken  from  the  temple  by  cupping ;  purgatives,  rest,  cooling  lotions, 
and  the  whole  antiphlogistic  plan  of  treatment  are  to  be  adopted ;  venesec- 
tion is  to  be  employed,  if  the  fever  runs  high.  Calomel,  with  opium,  is  to  be 
given,  in  frequent  small  doses. 

In  cases  of  chronic  inflammation  of  the  lachrymal  gland,  or  of  slow  scrofu- 
lous enlargement,  the  anti-scrofulous  regimen  is  to  be  prescribed  ;  nourishing 
food,  sea-air,  tonics,  &c.  The  constant  application  of  cold  cloths;  a  few 
leeches  to  the  neighborhood  of  the  gland ;  a  succession  of  small  blisters  to 
the  forehead,  temple,  and  back  of  the  ear ;  small  doses  of  calomel,  or  blue 
pill,  at  night,  with  a  saline,  or  other  laxative,  next  morning,  will  also  prove 
beneficial.  Iodide  of  potassium,  I  have  found  a  slow,  but  effectual,  remedy. 
If  scrofulous  inflammation  of  the  gland  ends  in  suppuration,  we  must  not 
allow  the  skin  to  become  extensively  diseased,  but  employ  the  lancet  as  soon 
as  fluctuation  is  distinct.  If  protrusion  and  disorganization  of  the  eye  be 
threatened,  the  gland  ought  to  be  extirpated. 


'  Dulilin  Hospital  Keports;   Vol.  iii.  p.  408  ;     tion  of  the   Lachrymal   Gland,  in  the  Medical 
Dublin,  1S22.  Gazette;  Vol.  iii.  pp.  523,  52i ;   London,  1829. 

'  See  Daviel's  2d  and  3d   Cases  of  Extirpa- 


SECTION  V. — CHRONIC  AND  SPECIFIC  ENLARGEMENTS  OF  THE  LACHRYMAL  GLAND. 

Chronic  enlargement,  as  well  as  inflammation,  affects  either  the  glandular 
congregatie,  or  the  glandula  innominata  separately  ;  but  it  is  rarely  the  case 
that  both  portions  of  the  secreting  lachrymal  apparatus  are  involved  in  dis- 
ease at  the  same  time. 

§  1.   Hypertrophy  of  the  Glandulce  CongregatcB. 

I  have  seen  the  glandule  congregatai  on  both  sides  aff'ected  with  chronic 
enlargement.  The  upper  eyelids  drooped  at  the  temporal  extremity,  while 
the  glands  presented  granulated  tumors,  of  the  size  and  nearly  of  the  shape 
of  an  orange  seed.  Similar  cases  are  noticed  by  MM.  Laugier  and  Riche- 
lot,  by  whom  they  were  treated  antiphlogistically  at  first,  and  afterwards  by 
the  exhibition  of  sulphate  of  quina.^  Dr.  A.  Anderson  reports  a  case  in 
which,  in  addition  to  repeated  leeching,  the  inunction  of  mercurial  ointment 
was  useful.'^ 

§  2.   Hypertrophy,  Cliloroma,  Scirrhus,  and  Medullary  Fungus  of  the  Lach- 
rymal Gland. 

The  lachrymal,  like  other  glands  of  similar  structure,  suffers  several  kinds 
of  slow  enlargement,  one  of  which  has  generally  been  regarded  as  scirrhous. 
Besides  scirrhus,  however,  cases  on  record  show  the  gland  to  be  subject  to 
simple  hypertrophy,  to  medullary  fungus,  and  to  a  peculiar  affection  different 
from  all  of  these. 

Symjjtoms. — Whatever  be  the  nature  of  the  chronic  enlargement  of  the 


ENLARGEMENTS  OF  THE  LACHRYMAL  GLAND.         12T 

lachrymal  gland,  the  progress  of  the  disease  may  be  divided  into  four  stages. 
In  the^rs^,  the  eyeball  is  protruded  directly  forwards,  and  cannot  be  turned 
readily  towards  the  temple  ;  the  patient  complains  of  epiphora,  with  burning 
heat  and  lancinating  pain  in  the  upper  and  external  part  of  the  orbit ;  but 
presents  no  perceptible  swelling  in  that  region.  In  this  stage,  which  may 
last  for  years,  it  may  be  difficult  to  diagnosticate  an  afTectiou  of  the  lachry- 
mal gland.  In  the  second  stage,  there  is  more  protrusion  of  the  eyeball  from 
the  orbit,  bleedings  sometimes  occur  from  the  nostril,  the  upper  lid  is  ex- 
panded and  puffy,  and  the  gland  is  so- much  enlarged  as  to  form  a  projecting 
tumor,  which  through  the  skin  of  the  upper  lid,  or  by  the  finger  carried  into 
the  upper  sinus  of  the  conjunctiva,  can  be  felt  to  be  hard  and  lobulated.  In 
the  tldrd  stage,  the  gland  increases  so  much,  that  it  pushes  the  eyeball 
downwards,  inwards,  and  forwards,  but  chiefly  forwards,  till  it  seems  actually 
to  hang  upon  the  cheek.  If  the  disease  be  neglected,  or  the  patient  refuses 
to  submit  to  treatment,  the  fourth  stage  ensues,  in  the  course  of  which  the 
temporal  side  of  the  orbit  in  some  cases  begins  to  be  dilated,  the  eyeball 
actually  resisting  the  pressure  better  than  the  bones  ;  but  more  commonly 
the  protruded  eye  inflames,  swells,  suppurates,  and  bursts  ;  its  contents  are 
partly  evacuated,  partly  absorbed  ;  the  gland  goes  on  to  enlarge  till  it  com- 
pletely fills  and  dilates  the  orbit,  the  bones  of  which  are  sometimes  partially 
removed  by  progressive  absoi-ption,  or  destroyed  by  ulcerative  inflammation; 
the  lids  are  greatly  expanded,  and  the  lower  one  everted;  the  remains  of  the 
eyeball  are  seen  lying  on  the  front  of  the  tumor,  which  being  covered  by  the 
distended  and  inflamed  conjunctiva,  is  apt  to  be  taken  for  fungus  hasmatodes, 
or  some  other  enlargement  of  the  eye  itself;  still  continuing  to  grow,  the 
gland  presses  itself  downwards  through  the  spheno-raaxillary  fissure,  oblite- 
rates the  corresponding  nostril,  and  even  deforms  the  brain  ;  the  patient  is 
at  length  seized  with  apoplectic  symptoms,  or  dies  worn  out  by  pain  and 
fever. 

The  course  of  the  symptoms  varies  in  different  cases.  In  some  the  eyeball 
is  slowly  pressed  aside,  and  the  orl)it  dilated,  without  much  inflammatory 
action.  In  other  cases,  violent  exophthalmia  occurs  early,  with  inflammation 
of  the  whole  contents  of  the  orbit.  Double  vision  is  experienced  sometimes 
in  the  second  stage ;  in  other  cases,  not  till  the  third.  Dimness  of  sight, 
and  at  length  blindness  occur,  more  or  less  early  ;  but  it  is  surprising  to 
what  extent  sight  is  sometimes  retained  with  a  great  degree  of  protrusion  of 
the  eyeball  and  stretching  of  the  optic  nerve.  Although  it  is  generally  the 
case  that  the  eyeball  is  pushed  from  the  orbit  by  the  tumor,  it  sometimes 
happens  that  the  tumor  advances  in  front  of  the  eyeball,  and  covers  it  com- 
pletely. Thus,  in  a  case  operated  on  by  Sir  P.  Crampton,  on  removing  the 
tumor,  which  was  at  first  supposed  to  be  an  ocular  fungus,  the  collapsed 
eyel)all  was  found  ))eueath  and  behind  it.^ 

As  the  enlarged  gland  lies  between  the  orbit  and  the  levator  palpebrte 
superioris,  the  latter  is  pressed  upon,  and  loses  its  power  of  contraction; 
the  upper  eyelid  hangs,  therefore,  almost  motionless,  over  the  protruded  eye- 
ball, and  is  flaccid,  swollen,  and  strewed  with  varicose  vessels.  The  lower 
eyelid  is  always  more  or  less  everted. 

Diagnosis. — As  several  other  kinds  of  tumor  within  the  orbit,  cause  pro- 
trusion and  disorganization  of  the  eyeball,  we  must  carefully  examine  whether 
the  gland  is  actually  felt  hard,  lobulated,  and  enlarged.  Cases  occur  in 
which  the  lachrymal  gland  and  the  eyeball  arc  pushed  forward  together,  l)y 
a  tumor  deep  in  the  orbit,  and  we  may  fall  into  the  error  of  supposing  the 
lachrymal  gland  to  be  the  cause  of  the  exophthalmos,  while  the  gland  is  really 
not  enlarged,  but  merely  displaced.  In  such  cases  the  gland,  thouffh  it  feels 
lobulated,  is   soft,  not  hard  and  resisting.     After  the"^  eyeball  bursts,  the 


128         ENLARGEMENTS  OF  THE  LACHRYMAL  GLAND. 

appearances  in  cases  of  chronic  enlargement  of  the  lachrymal  gland  might 
easily  impose  on  a  careless  observer  for  those  of  fungus  hsematodes  of  the 
eye,  as  may  readily  be  concluded  from  examining  the  two  figures  in  Mr. 
Travers's  5th  plate ;  figure  1,  representing  fungus  hcematodes  of  the  eye,  and 
figure  2,  an  enlargement  of  the  lachrymal  gland.* 

Considerable  difficulty  is  likely  to  occur,  in  forming  a  diagnosis  between 
enlarged  lachrymal  gland  and  the  disease  described  by  Schmidt  under  the 
name  of  hydatid,  but  which,  I  am  convinced,  is  nothing  more  than  an  en- 
cysted tumor  closely  connected  with  the  gland.  An  exploratory  puncture 
would  decide  the  question. 

Diversities. — It  is  extremely  probable,  that  different  kinds  of  chronic 
enlargement  of  the  lachrymal  gland  have  been  confounded  with  each  other. 
That  the  enlargements  which  produce  the  symptoms  now  described,  are  in  all 
or  many  cases  malignant,  may  fairly  be  doubted  on  the  following  grounds : 
1st.  Their  occurring  in  children  as  well  as  adults;  2d.  The  extreme  slowness 
with  which  their  course  generally  proceeds  ;  3d.  Their  seldom,  if  ever,  affect- 
ing the  lymphatic  system  ;  4th.  Their  seldom,  if  ever,  undergoing  anything 
like  cancerous  ulceration  ;  and  5th.  The  extreme  rarity  with  which  anything 
like  malignant  disease  has  been  known  to  return  in  the  neighboring  parts, 
after  extirpation  of  the  gland. 

Independently  of  scrofulous  affections,  such  as  have  been  referred  to  in 
last  section,  there  seem  sufficient  grounds  to  admit  the  following  kinds  of 
chronic  enlargement  of  the  lachrymal  gland :  1.  Simple  hypertrophy ;  2. 
Chloroma,  or  fibro-plastic  tumor;  3.  Scirrhus;  4.  Medullary  fungus.  Of 
some  recorded  cases,  the  nature  is  doubtful. 

1.  Simple  hypertrophy. — The  following  congenital  case  of  this  sort  is 
recorded  by  Gluge  : — 

Case  103. — A  tumor  had  been  observed  from  birth  in  the  region  of  the  left  lachrymal 
gland.  It  slowly  extended  itself,  pushing  the  eyeball  downwards  and  inwards.  Dr. 
Cunier  extirpated  it,  when  the  patient  was  5^  years  old.  The  operation  was  tedious  and 
difiBcult.  The  extirpated  mass,  handed  to  l)r.  Gluge  in  morsels,  was  at  least  equal  in 
size  to  a  hen's  egg.  It  consisted  of  the  glandular  substance  and  of  the  ducts,  both  in  a 
hypertrophied  condition.  The  internal  surface  of  the  glandular  vesicles  was  lined  by 
epithelial  cells ;  and  the  whole  structure  normal,  only  increased  in  volume.* 

2.  Chloroma,  or  Jibro-plastic  tumor. — The  greater  number  of  cases  of  en- 
larged lachrymal  gland  come  under  this  head,  the  term  Jibro-plastic  tumor 
being  nearly  synonymous  with  the  simple  sarcoma  of  former  surgical  authors.^ 

Case  104. — I  have  now  before  me  two  greatly  enlarged  lachrymal  glands,  which  proved 
the  cause  of  death  in  a  girl  of  eight  years  of  age,  who,  from  a  distance,  was  brought  for 
advice  to  the  Glasgow  Eye  Infirmary,  on  the  17th  of  December,  1830. 

It  was  stated  by  the  parents  of  the  child,  that  for  about  five  weeks  they  had  observed 
the  left  e^'C  protruding  from  its  socket,  and  for  four  weeks  the  right  eye  also.  The  dis- 
ease on  both  sides  had  rapidly  increased.  The  cornea  of  the  left  eye  had  already 
sloughed.  The  right  eye  was  cedematous,  but  its  power  of  vision  was  still  considerable. 
The  child  complained  of  sudden  attacks  of  pain  in  the  ej-es,  but  nowhere  else.  Some  dis- 
charge of  blood  had  taken  place  from  the  right  nostril,  the  day  before  she  was  brought 
to  the  Infirmary.  The  patient's  appetite  was  impaired,  her  bowels  costive,  her  urine 
scanty,  and  she  slept  little.  From  the  Journals  of  the  Infirmary  it  appears  that  iodine, 
an  opiate,  laxatives,  and  blisters  behind  the  ears,  were  ordered. 

On  the  24th,  the  report  states  the  pain  to  be  on  the  whole  diminished.  The  protrusion 
of  the  left  eye,  however,  was  increasing.  The  right  cornea  was  partly  ulcerated,  the 
iris  inflamed,  and  the  humors  muddy.  The  bowels  were  more  regular,  and  the  urine 
natural  in  quantity. 

On  the  22d  of  January,  1831,  the  swelling  of  the  left  eye  is  said  to  have  increased; 
the  disease  of  the  right  to  be  stationary,  the  patient  still  discerning  light  and  shadow 
with  it,  the  pain  gone,  no  discharge  from  the  nostril,  the  appetite  good,  and  the  sleep 
natural.  On  the  31st,  both  eyes,  it  is  stated,  protruded  enormously,  the  posterior  por- 
tion of  the  globe  projecting  between  the  lids,  and  covered  by  the  palpebral  conjunctiva 
in  a  state  of  eversion.     For  two  days,  the  patient  had  had  more  pain  in  the  right  eye. 


ENLARGEMENTS  OP  THE  LACHRYMAL  GLAND.         129 

After  this  date,  the  child  was  not  again  brought  to  the  Infirmary.  We  afterwards 
learned,  however,  that  she  had  continued  to  experience  relief  from  the  opiate  at  night, 
so  that,  although  often  restless  and  lying  mostly  on  her  face,  she  never  complained  of 
pain.  For  some  weeks  before  death  she  was  deaf.  About  48  hours  before  that  event, 
which  happened  on  the  9th  of  March,  there  was  a  good  deal  of  hemorrhage  from  the 
right  nostril.  She  was  convulsed  about  an  hour  before  she  expired.  She  was  never 
comatose  nor  delirious. 

To  Mr.  John  Watt,  then  practising  as  a  surgeon  in  Glasgow,  I  am  indebted  for  the 
following  account  of  the  appearances  on  dissection  : — 

On  withdrawing  the  integuments  in  the  usual  way,  the  bones  of  the  cranium  were 
observed  to  be  here  and  there  of  a  light  green  color.  During  the  process  of  sawing  the 
cranium,  there  tlowed  from  the  vein  which  communicates  between  the  integuments  and 
the  longitudinal  sinus,  through  the  right  parietal  bone,  about  four  ounces  of  bloody 
serum.  A  number  of  small  tumors  were  found  growing  from  the  dura  mater,  corre- 
sponding to  the  spots  of  bone  which  showed  the  green  appearance  above  mentioned. 

Four  small  tumors,  also  growing  from  the  dura  mater,  each  about  the  size  of  a  shilling, 
were  observed,  one  over  the  cribriform  plate  and  crista  galli  of  the  ethmoid,  one  on  the 
petrous  portion  of  each  temporal  bone,  and  one  at  the  junction  of  the  lambdoid  with  the 
sagittal  suture.  In  all  these  places,  the  bones  were  carious,  and  the  tumors  dipped  into 
the  carious  spots. 

A  large  quantity  of  serous  fluid  was  effused  under  the  tunica  arachnoidea,  particularly 
towards  the  occiput.  The  brain  was  otherwise  healthy.  There  was  no  appearance  of 
disease  about  the  optic  nerves. 

On  reflecting  the  integuments  over  the  face,  each  orbit  was  found  to  be  occupied  by  an 
oval  lobulated  tumor,  nearly  '2i  inches  in  length,  and  If  inch  in  thickness.  These 
tumors,  which  were  regarded  as  the  lachrymal  glands  greatly  enlarged,  adhered  firmly  to 
the  periosteum,  where  it  is  reflected  from  the  os  frontis  to  give  support  to  the  upper  eye- 
lids and  contents  of  the  orbits.  This  membrane  being  cut  through,  the  enlarged  glands 
were  easily  turned  out  with  the  fingers,  and  dissected  from  the  conjunctiva  and  integu- 
ments. 

The  tumors,  externally  smooth,  but  lobulated,  exactly  resembled  each  other  in  size, 
texture,  and  every  other  particular.  They  were  of  a  light  greenish  or  whey  color,  the 
exact  color  of  the  tumors  of  the  dura  mater  already  mentioned.  They  also  resembled 
those  tumors  in  consistence,  being  of  a  firm  uniform  texture,  perfectly  homogeneous  in 
their  interior,  and  without  the  least  appearance  of  the  whitish  bands,  seen  in  scirrhus. 
They  not  merely  completely  filled  the  orbits,  but  projected  about  three-quarters  of  an 
inch  beyond  the  os  frontis,  pressing  forwards  the  eyeballs,  the  humors  of  which  had 
either  been  absorbed,  or  evacuated,  while  tlieir  coats  were  shrivelled,  dry,  and  pressed 
down  upon  the  cheeks.  A  small  tumor  of  the  same  greenish  color,  and  firm  texture,  was 
found  on  the  pars  plana  of  the  ethmoid,  in  the  right  orbit,  which  was  also  carious,  with 
the  tumor  dipping  into  the  nose.  The  hemorrhage  might  have  been  from  this,  or  from 
the  tumor  on  the  cribriform  plate. 

This  case  bears  considerable  resemblance  to  one  related  by  Mr.  Allan 
Burns,  in  which  the  lachrymal  gland  on  each  side,  the  lining  membrane  of  the 
nasal  sinuses,  and  the  dura  mater,  were  all  affected  with  the  same  sort  of 
degeneration.  Mr.  Burns'  supposes  the  disease  to  have  been  of  a  specific 
nature,  and  one  sui  generis. 

The  fact  that  the  lachrymal  gland  is  occasionally  converted  into  a  morbid 
structure,  of  firm  consistence  and  greenish  color,  while,  at  the  same  time, 
the  dura  mater,  periosteum,  and  Schneiderian  membrane  give  origin  to 
tumors  of  a  similar  description,  is  particularly  worthy  of  attention.  Besides 
the  case  above  related,  and  Mr.  Burns's  case,  other  instances  of  this  disease 
are  recorded.  In  a  case  published  by  Dr.  J.  H.  Balfour,^  the  eyeballs  were 
protruded  and  destroyed,  and  numerous  green  tumors  of  the  same  sort  as 
those  into  which  the  lachrymal  glands  were  converted,  were  attached  both  to 
the  outside  and  inside  of  the  skull,  and  grew  from  both  surfaces  of  the  dura 
mater.  In  a  case  recorded  by  M.  Durand  Fardel,^  the  lachrymal  glands  were 
not  affected,  but  green  tumors  were  found  between  the  dura  mater  and  the 
arachnoid,  between  the  bone  forming  the  external  meatus  of  each  ear  and  its 
lining  membrane,  in  each  tympaniftn,  in  the  spleen,  and  in  the.,^ellular  mem- 
brane surrounding  the  rectum.^" 

Case  105. — A  case  of  chloroma  occurred  to  Dr.  King,  of  Glasgow,  in  July,  1849,  in  a 
9 


130         ENLARGEMENTS  OF  THE  LACHRYMAL  GLAND. 

girl,  aged  6  years  and  7  months.  The  tumors  occupied  both  temples,  the  roof  and  super- 
ciliary region  of  each  orbit,  the  upper  part  of  the  forehead,  and  the  vertex.  A  remark- 
able circumstance  about  the  tumors  was,  that  by  times  they  increased  and  again  subsided. 
Thus  the  one  occupying  the  roof  of  the  right  orbit  increased  to  such  a  degree  as  to 
prevent  the  eye  from  being  exposed,  and  again  decreased  so  as  to  allow  the  action  of  the 
lid.  A  tumor  formed  on  the  mastoid  process  of  the  temporal  bone,  fully  larger  than  a 
pigeon's  egg,  but  had  nearly  disappeared  before  death.  The  patient  gradually  sunk,  and 
died  on  the  5th  October. 

On  withdrawing  the  scalp,  the  crown  of  the  head  presented  an  extraordinary  appear- 
ance, being  nodulated  all  over  with  flattened  swellings  of  a  yellowish-green  color.  On 
dividing  the  temporal  aponeuroses,  the  situation  of  the  temporal  muscles  was  found  com- 
pletely occupied  by  the  peculiar  green  substance.  The  two  swellings  over  the  eyes  were 
growths  of  the  same  nature,  covering  the  superciliary  ridge  and  the  outer  portion  of  each 
orbital  plate  of  the  frontal  bone,  pressing  the  left  eyeball  downwards  and  outwards,  and 
the  right  more  directly  downwards.  The  Avhole  contents  of  the  orbits  were  converted 
into  the  same  green  substance,  with  the  exception  of  the  eye,  its  muscles,  and  the  optic 
nerve.  The  various  bones  entering  into  the  composition  of  the  orbits  were  partially  dis- 
eased, spiculoe  of  bone  projecting  from  them  into  the  tumors.  No  trace  of  orbicularis 
palpebrarum  on  either  side  could  be  detected. 

A  tumor  occupied  the  external  surface  of  the  inferior  maxillary  bone.  The  inside  of 
the  dura  mater  presented  two  flattened  masses,  one  on  each  side  of  the  falx,  pressing  into 
the  substance  of  the  brain. 

In  all  these  situations,  the  diseased  masses  presented  exactly  the  same  character,  except 
in  so  far  as  it  varied  from  being  intermixed  with  the  surrounding  fibrous,  osseous,  or  mus- 
cular tissue.  The  fibrous  tissue  appeared  the  matrix  from  which  the  morbid  formation 
arose.  The  masses  were  perfectly  homogeneous,  without  trace  of  bloodvessels.  Both 
alcohol  and  water  speedily  diminished  the  intensity  of  the  green  color.  No  bile  could  be 
detected  in  the  alcohol  in  which  the  tumors  were  preserved.  The  substance  of  the  tumors 
contained  no  appreciable  sulphur,  leading  to  the  supposition  that  it  was  neither  albu- 
minous nor  fibrinous. 

Some  parts  of  the  external  table  of  the  skull  and  its  periosteum  were  perfectly  natural; 
but,  in  all  the  places  occupied  by  the  tumors,  the  periosteum  was  either  closely  adherent 
to  the  diseased  structure,  or  apparently  lost  by  being  converted  into  its  substance.  la 
all  these  places,  the  surface  of  the  skull  was  covered  by  a  layer  of  additional  or  new  bone, 
presenting  a  honeycomb  structure,  or  consisting  of  irregular  spicukie  and  thin  plates  of 
bone,  growing  from  the  outer  table  of  the  skull,  and  leaving  irregular  depressions  between 
them,  which  seemed  to  reach  to  the  surface  of  the  natural  bone.  Into  these  depressions 
the  substance  of  the  tumor,  or  the  periosteum  altered  in  the  manner  before  mentioned, 
extended  by  a  corresponding  set  of  irregular  processes,  Tiie  same  arrangement,  though 
to  a  less  extent,  existed  in  some  limited  portions  of  the  internal  table,  corresponding  with 
the  diseased  external  table. 

On  examining  the  preparations,  illustrative  of  this  case,  preserved  in  the  Anatomical 
Museum  of  Glasgow  College,  the  periosteum  of  the  lachrymal  fossae  appears  to  be  the 
origin  of  the  tumors  which  projected  from  the  orbits,  while  the  lachrymal  glands  seemed 
transformed  into  the  same  substance  as  the  tumors.  The  fibro-plastic  matter  has  infil- 
trated and  changed,  rather  than  displaced,  all  the  parts  with  which  it  had  come  into 
contact,  except  the  nerves,  the  muscles  in  the  orbits,  and  the  eyeballs." 

Chloroma,  or  green  tumor,  unless  it  belongs  to  the  class  of  amorphous 
jihrous  tumors  of  Vogel,  or  fibro-plastic  tumors  of  Lebcrt,"'  is  probably  dif- 
ferent from  any  of  the  morbid  formations  generally  recognized  by  patholo- 
gists. The  green  color  has  attracted  the  notice  both  of  Vogel  and  Lebert ; 
and,  as  it  does  not  depend  on  bile,  they  attribute  it  to  a  peculiar  proximate 
principle. 

The  following  case  I  regard  as  one  of  the  fibro-plastic  description : — 
Case  106. — Some  years  ago,  I  inspected  the  body  of  Mrs.  F.,  aged  60  years,  a  patient 
of  the  late  Dr.  G.  C.  Monteath.  She  had  long  been  afi"ected  with  protrusion  of  the  right 
eye  downwards,  inwards,  and  forwards;  and,  some  years  before  her  death,  the  eye  had 
burst.  We  found  the  empty  sclerotica  lying  on  the  front  of  a  tumor,  which  was  white 
and  granular,  the  grains  being  evidently  the  enlarged  acini  of  the  lachrymal  gland.  It 
was  as  large  as  a  man's  fist,  occupying  a  much-expanded  orbit,  and  pressing  itself  down 
into  the  spheno-maxillary  fissure.  It  had  been  the  means  of  destroying,  by  absorption, 
the  roof  of  the  orbit,  which  was  still  covered  by  dura  mater,  except  in  some  few  points, 
where  the  tumor  and  the  brain  were  in  contact.  It  had  deformed  the  brain  in  a  remark- 
able degree,  having  pressed  the  lower  surface  of  the  anterior  lobe  of  the  right  hemisphere 


ENLARGEMENTS  OF  THE  LACHRYMAL  GLAND.        131 

upwards,  and  the  anterior  surface  of  the  middle  lobe  backwards.  The  right  motor  oculi 
nerve  was  absorbed.  Within  the  cranium,  the  right  optic  nerve  was  smaller  than  the 
left;  within  the  orbit,  merely  its  neurilemma  remained.  The  right  nostril  was  obliterated 
by  the  presence  of  the  tumor.  The  frontal  and  maxillary  sinuses  on  the  right  side  were 
full  of  puriform  mucus.     This  patient  had  all  along  refused  to  submit  to  any  operation. 

The  case  of  Andrew  Smith,  related  by  Dr.  Halphin  ;"  that  of  Mary  Gib- 
bons, by  Mr.  Pemberton  ;"  and  that  of  David  Gibson,  by  Dr.  A.  Anderson  ;'5 
coincide  in  many  particulars  with  M.  Lebert's  description  of  fibro-plastic 
tumor. 

3.  Scirrhus. — The  evidence  that  the  lachrymal  gland  is  subject  to  scirrhus, 
is  by  no  means  ample. 

Himly  extirpated  the  gland,  for  what  he  believed  to  be  scirrhus.  He  seems 
to  have  been  so  disappointed  by  the  result  that  he  never  again  had  recourse 
to  the  operation.  The  eyeball  did  not  retreat  into  the  orbit,  vision  was  not 
improved,  and  the  patient  returned  with  the  eyeball  affected,  he  says,  with  the 
disease.  The  proof,  however,  that  the  eyeball  was  affected  with  scirrhus,  is 
quite  unsatisfactory.  The  patient  was  a  young  woman,  evidently  suffering 
from  scrofula,  and  the  disease  of  the  eyeball  appears  to  have  been  rather  a 
staphylomatous  degeneration  of  the  choroid  and  sclerotica,  than  anything 
malignant.'^ 

Mr.  Travers  tells  us  that  he  "removed  the  lachrymal  gland  greatly  enlarged, 
and  in  a  state  of  true  scirrhus,  from  the  orbit  of  a  middle-aged  man  ;"'^  but 
Mr.  Lawrence  hints  that  the  circumstance  of  a  lachrymal  gland  being  greatly 
enlarged  rather  militates  against  the  opinion  that  in  that  state  it  is  afflicted 
with  scirrhus.  "The  female  breast,"  says  he,  "when  affected  with  scirrhus, 
is  not  usually  augmented  in  bulk ;  sometimes,  on  the  contrary,  it  is  dimi- 
nished."*^ 

In  Mr.  Lawrence's  case  of  John  Clifton,  the  extirpated  gland  was  of 
"  the  size  of  a  large  walnut,  and  of  compact  homogeneous  texture.  It  had  a 
light  yellow  texture,  with  an  appearance  of  radiated  fibres  at  one  point ;  it 
approached  in  firmness  to  cartilage,  and  altogether  bore  a  near  resemblance 
to  the  firmest  part  of  a  scirrhous  mammary  gland."  The  operation  was 
performed  in  1826.  The  wound  healed  completely  by  adhesion,  and  the 
globe  of  the  eye,  which  had  been  protruded,  regained  its  natural  position. 
In  1839,  however,  when  Mr.  L.  saw  the  patient  again,  a  hard  swelling  had 
formed  about  the  middle  of  the  cicatrice,  under  the  superciliary  ridge,  a 
circumstance  which  is  certainly  suspicious.'^ 

Gluge  mentions  the  case  of  a  man,  40  years  old,  in  whom  hypertrophy  of 
the  lachrymal  gland  passed  into  a  state  of  cancer.  The  tumor  arose  without 
any  known  cause,  and  being  partially  extirpated,  it  speedily  grew  again. ^^ 

4.  Medullary  fungus. — The  only  case  I  have  found  recorded  of  medullary 
fungus  of  the  lachrymal  gland,  is  one  in  which  the  gland,  along  with  the  eye- 
ball, was  extirpated  by  Dr.  Tourtual,  jun.  The  eyeball  was  pushed  nearly 
an  inch  beyond  the  margin  of  the  orbit,  the  cornea  became  opaque,  the  tem- 
poral side  of  the  orbit  protruded,  and  the  patient  suffered  from  hectic  fever. 
The  tumor  was  covered  with  a  brownish  envelope,  being  within  of  brain-like 
appearance.  Three  years  after  the  operation,  a  soft,  painful  swelling  rose 
in  the  temporal  fossa,  the  hectic  fever  returned,  and  in  half  a  year  the  patient 
died.'^* 

DouUful. — Three  cases  by  Daviel,'^*  one  by  Todd,-^'  one  by  O'Beirne,^ 
Lawrence's  second  case,^^  one  by  Schott,-"  and  Bridget  Judge's  case  by  Roe,*' 
must  be  placed  under  this  head,  their  nature  not  being  sufficiently  evident. 

Causes. — In  a  majority  of  the  cases  on  record,  chronic  enlargement  of  the 
lachrymal  gland  is  ascribed  to  blows  and  other  injuries,  as  exciting  causes. 

Treatment. — In  the  early  stage  of  enlargement  of  the  lachrymal  gland, 


132        ENLARGEMENTS  OF  THE  LACHRYMAL  GLAND. 

leeching  and  cupping  may  be  tried,  on  the  same  principle  which  is  followed 
when  we  endeavor  to  reduce  a  suspected  scirrhus  of  the  mamma.  A  succes- 
sion of  blisters  may  be  applied  to  the  forehead  and  temple.  Iodine,  and 
other  solvents  and  sorbefacients  ought  to  be  used. . 

If  such  means  are  ineffectual  in  reducing  the  swelling,  extirpation  of  the 
gland  is  the  only  other  resource,  and  ought  to  be  employed,  especially  if  we 
have  reason  to  regard  the  case  as  one  of  simple  enlargement,  or  of  chloroma. 
In  cases  of  scirrhus  or  medullary  fungus,  the  operation  can  be  regarded  only 
as  a  palliative.  Chloroma  or  fibro-plastic  tumor  is  a  non-malignant  disease  ; 
the  circumstance,  however,  of  its  so  frequently  implicating  other  organs  along 
with  the  lachrymal  gland,  and  especially  the  dura  mater,  materially  affects 
the  prognosis. 

The  mode  of  operating  is  to  cut  down  directly  over  the  tumor,  through 
the  integuments  and  fibrous  layer  of  the  upper  eyelid,  parallel  to  the  edge  of 
the  orbit.  As  the  gland  lies  over  the  levator  palpebrse,  this  muscle  is 
avoided  in  this  method  of  operating,  which  it  could  scarcely  be  were  the 
operation  attempted  through  the  conjunctiva.  The  gland  being  exposed, 
projecting  from  the  lachrymal  fossa,  it  is  to  be  insulated  as  much  as  possible 
with  the  scalpel.  If  it  is  considerably  enlarged,  this  is  not  accomplished 
without  some  difficulty,  owing  to  the  impacted  state  of  the  gland  between 
the  bone  above  and  the  eyeball  beneath.  Sometimes  a  blunt-pointed  instru- 
ment is  useful  in  tearing  through  the  cellular  tissue ;  or  we  feel  all  around 
the  gland  with  the  finger,  and  cautiously  cut  through  the  connections. 
When  it  is  pretty  well  insulated,  we  seize  it  with  the  double  volsella,  and 
drawing  it  out  of  its  place  as  much  as  possible,  divide  its  remaining  adhe- 
sions. This  is  accomplished  with  more  or  less  difficulty,  according  to  the 
degree  of  matting  together  of  the  parts,  produced  by  previous  inflammation. 
The  eyeball  is  to  be  removed,  if  already  destroyed.  If  entire,  it  is  to  be 
left  untouched,  whether  vision  be  preserved  or  not.  The  bleeding  in  general 
is  inconsiderable.  After  it  has  ceased,  the  edges  of  the  wound  are  to  be 
brought  together  with  stitches  and  stripes  of  adhesive  plaster. 

The  eyeball  in  some  degree  goes  back  immediately  into  the  orbit,  and  the 
patient  opens  and  shuts  the  eye,  if  the  levator  be  safe.  The  parts  swell  a 
good  deal,  so  that  in  a  few  days  the  eye  is  again  pushed  out,  and  a  consider- 
able quantity  of  pus  may  escape  from  the  wound.  Gradually  the  swollen 
state  of  the  lids  subsides.  Neither  is  vision  nor  the  position  of  the  eye 
restored  immediately.  Weeks,  or  even  months,  may  be  requisite  before  these 
objects  are  accomplished ;  and  although  the  malposition  of  the  eye  is  always 
lessened  in  time,  if  not  entirely  removed,  vision  may  never  return.  The 
moisture  and  lubricity  of  the  conjunctiva  remaining  unaffected  after  extirpa- 
tion of  the  lachrymal  gland,  has  partly  given  rise  to  the  statement,  that  the 
patient  continues  capable  of  weeping.  Tears  are  undoubtedly  discharged, 
however,  from  an  eye  from  which  the  glandula  innominata  has  been  removed, 
owing,  no  doubt,  to  the  glanduloe  congregatas  being  left  untouched. 

Cases  of  extirpation. — The  details  which  had  previously  been  given  on  the 
subject  having  been  but  comparatively  few,**  a  great  degree  of  interest  has 
attached  itself  to  the  two  following  cases  by  Mr.  Todd  and  Dr.  O'Beirne, 
to  which  I  have  already  referred : — 

Case  107. — Mr.  Todd's  patient  was  a  woman  of  70  years  of  age.  The  lachrymal  gland 
formed  a  large  irregular  tumor,  occupying  the  upper  part  of  the  orbit,  projecting  more 
than  half  an  inch  beyond  the  superciliary  ridge,,  and  covered  by  the  upper  eyelid,  which 
was  so  stretched  upon  it  as  to  render  the  knotty  eminences  on  its  surface  very  conspicu- 
ous. The  tumor  was  extremely  hard.  It  was  movable  to  a  slight  extent,  in  a  transverse 
direction  only.  The  globe  of  the  eye  was  not  enlarged  ;  but  it  had  been  protruded  by 
the  tumor,  and  was  so  low  upon  the  cheek  that  the  cornea  was  nearly  on  a  line  with  the 
edge  of  the  ala  nasi.     The  lower  eyelid  was  everted,  and  appeared  dragged  down  with 


ENLARGEMENTS  OP  THE  LACHRYMAL  GLAND.         133 

the  globe;  the  conjunctiva  much  thickened,  and  chemosed;  the  transparency  of  the 
cornea  slightly  obscured.  There  was  no  apparent  disease  of  the  interior  of  the  eye. 
Vision  was  destroyed  by  the  pressure  of  the  tumor.  The  pains  were  severe  and  lanci- 
nating, extending  from  the  tumor  to  the  globe  of  the  eye,  and  were  accompanied  with  a 
sensation  of  heat  and  a  frequent  discharge  of  scalding  tears.  The  sufferings  of  the 
pntieut  were  most  severe  at  night,  and  she  was  almost  entirely  deprived  of  sleep  ;  not- 
withstanding which,  her  general  health  was  not  much  impaired,  and  her  appetite  was 
good.  She  attributed  the  disease  to  a  blow  received  on  the  eye  about  seven  years  before, 
from  which  peinod  she  had  been  subject  to  frequent  discharges  of  tears  from  that  eye, 
but  had  suffered  no  other  inconvenience  until  a  year  before  coming  under  Mr.  Todd's 
care,  when  the  tumor  began  to  project  under  the  temporal  extremity  of  the  ej'ebrow.  At 
first,  she  had  no  pain  or  headache ;  but  as  the  tumor  increased,  these  symptoms  set  in, 
and  ultimately  became  so  severe  that  she  was  anxious  to  undergo  any  operation  which 
held  out  a  prospect  of  relief. 

In  consultation  with  Mr.  Carmichael,  Mr.  Todd  determined  that  an  attempt  should  be 
made  to  extirpate  the  diseased  gland  alone,  and  in  the  event  of  that  being  found  im- 
practicable, either  from  extent  of  attachments  or  deep-seated  disease,  the  expediency  of 
removing  all  the  contents  of  the  orbit  was  fully  acceded  to;  the  intense  sufferings  of  the 
patient,  the  probable  nature  of  the  disease,  and  the  useless  state  of  the  eye,  appearing 
to  render  this  an  indispensable  alternative. 

The  patient  having  been  placed  on  her  back  on  a  table,  with  her  head  a  little  elevated 
and  secured  by  the  assistants,  a  transverse  incision  was  made  through  the  integuments, 
nearly  parallel  to  the  superior  margin  of  the  orbit,  from  one  extremity  of  the  tumor  to 
the  other.  Having  cut  through  the  orbicularis  palpebrarum  and  the  ligamentum  tarsi, 
Mr.  Todd  exposed,  by  a  careful  dissection,  the  entire  anterior  surface  of  the  gland. 
Being  firmly  wedged  into  the  orbit,  it  was  not  without  difficulty  that  the  handle  of  the 
scalpel  was  introduced  between  the  gland  and  the  superciliary  ridge,  in  order  to  detach 
it  from  the  orbitary  process  of  the  frontal  bone.  The  surface  of  the  gland  next  the  eye 
was  irregularly  lobulated,  and  the  lobes  had  insinuated  themselves  among  the  muscles 
and  other  contents  of  the  orbit,  so  as  to  render  their  disentanglement  extremely  difficult 
and  hazardous.  By  cautiously  tearing  their  cellular  attachments  with  the  end  of  the 
finger,  the  handle  of  the  knife,  and  the  blunt  extremity  of  a  director,  and  by  cutting  on 
the  finger  with  a  probe-pointed  bistoury  some  firm  membranous  bands,  which  could  not 
be  easily  broken,  Mr.  Todd  succeeded  in  extracting  the  entire  tumor.  On  a  careful  ex- 
amination, no  farther  disease  could  be  detected  in  the  orbit,  and  as  no  bleeding  occurred, 
the  globe  of  the  eye  was  gently  pressed  towards  its  natural  situation,  the  wound  dressed, 
the  parts  supported  with  a  compress  and  bandage,  and  the  patient  laid  in  bed,  with  strong 
injunctions  to  observe  the  strictest  quiet. 

The  extirpated  gland  was  much  larger  than  a  walnut.  On  the  surface  which  had  been 
towards  the  eye,  it  presented  three  considerable  eminences  or  lobes,  with  deep  fissures 
between  them.  It  was  almost  as  firm  as  cartilage,  and  more  elastic.  A  section  exposed 
several  small  cartilaginous  cysts,  which  contained  a  glairy  fluid,  the  interspaces  consist- 
ing of  a  firm  fatty  substance,  traversed  by  a  few  membranous  bands. 

Two  hours  after  the  operation,  an  alarming  hemorrhage  took  place,  which,  from  the 
great  depth  at  which  the  wounded  vessel  was  situated,  and  the  extensive  extravasation 
of  blood  into  the  loose  cellular  tissue  of  the  orbit,  was  with  difficulty  suppressed  by  pres- 
sure with  the  finger.  Dossils  of  lint  were  then  introduced  into  the  wound,  and  the  bleed- 
ing did  not  recur.  The  patient  passed  a  tranquil  night,  and  for  the  first  time  during 
many  weeks  enjoyed  refreshing  sleep.  On  the  following  day,  the  appearance  of  the  eye 
and  suiTounding  parts  was  by  no  means  encouraging.  The  globe  was  protruded  from 
the  orbit  as  much  as  before  the  opei\ation,  by  large  coagula,  which  occupied  the  situation 
of  the  tumor ;  the  lids  were  affected  with  extensive  ecchymosis ;  they  were  livid  and  cold, 
as  if  in  the  state  of  gangrene ;  and  the  cellular  tissue  of  the  conjunctiva  was  distended 
with  effused  blood.  Notwithstanding  these  unfavorable  appearances,  the  patient  had  ex- 
perienced much  relief  from  the  operation ;  she  was  free  from  acute  pain,  and  the  consti- 
tutional excitement  was  inconsiderable.  In  the  course  of  a  few  days,  the  coagulated 
blood  contained  in  the  orbit  began  to  dissolve,  and  suppuration  was  soon  established. 
The  globe  of  the  eye  began  slowly  to  return  into  its  natural  situation,  and  the  conjunctiva 
and  skin  of  the  eyelids  to  assume  their  healthy  appearance.  On  the  1 2th  day  after  the 
operation,  the  improvement  in  the  position  of  the  eye  was  quite  evident ;  but  it  was 
found  impossible  to  prevent  the  eversion  of  the  lower  eyelid,  in  consequence  of  a  thickened 
fold  of  the  conjunctiva,  which  extended  between  it  and  the  globe.  To  this  fold,  the 
nitrate  of  silver  had  been  frequently  applied  without  any  benefit;  Mr.  Todd  therefore 
removed  it  by  excision,  and  was  immediately  enabled  to  replace  the  lid,  which  showed  no 
farther  tendency  to  become  everted.     From  this  period,  the  patient's  recovery  was  un- 


134        ENLARGEMENTS  OF  THE  LACHRYMAL  GLAND. 

interrupted,  and  she  was  discharged  without  any  return  of  disease.  Vision  remained 
totally  lost,  the  pupil  greatly  contracted,  the  position  of  the  eyeball  almost  natural. 

Case  108. — A  man,  aged  22  years,  strong  and  athletic,  came  under  the  care  of  Dr. 
O'Beirne,  with  considerable  deformity  and  imperfect  vision  of  the  right  eye.  The  globe 
proiected  more  by  its  semidiameter  than  the  sound  eye,  yet  it  was  covered  almost  entirely 
by  the  upper  eyelid,  which  hung  loosely  over  it,  as  if  palsied ;  the  pupil  was  dilated  and 
insensible  to  light,  the  cornea  was  turned  towards  the  nose,  and  the  puncta  lachrymalia 
were  patulous.  The  upper  and  outer  part  of  the  orbit  was  occupied  by  a  tumor,  the 
outline  of  which  could  not  be  distinctly  traced,  but  to  its  growth  were  attributed  the 
protrusion  of  the  eye  and  impaired  vision.  The  patient  suffered  considerable  pain  of  the 
right  side  of  the  head  and  face,  and  much  irritation  and  watering  of  the  eye  were  pro- 
duced by  cold  air,  or  particles  of  dust.  All  objects  appeared  to  him  double ;  and  in 
endeavoring  to  reach  any  object,  his  hand  or  foot  generally  fell  short  of  it,  so  much  so  as 
to  prevent  him  from  working  even  as  a  laborer.  Aliout  two  years  before  coming  under 
Dr.  O'Beirne's  care,  he  perceived  first  of  .all  sparks,  and  occasionally  mists,  before  his 
eyes,  with  sharp  intermitting  pains  in  the  right  side  of  his  head  and  face ;  in  about  a 
year,  a  slight  prominence  and  inversion  of  the  globe  were  observed  ;  and  from  that  period, 
the  symptoms  gradually  proceeded  to  the  state  already  described. 

It  was  decided  in  consultation,  that  the  tumor  should  be  removed,  but  it  was  not  even 
suspected  that  the  lachrymal  gland  was  the  part  affected. 

The  operation  was  begun  by  an  incision  through  the  integuments  of  the  upper  eyelid, 
extending  from  the  inner  to  the  outer  angle.  The  orbicularis  palpebrarum  being  next 
divided,  some  portions  of  adipose  substance  which  presented  were  removed.  Dr.  O'Beirne 
then  introduced  his  finger,  and  at  once  discovered  that  the  disease  was  an  enlarged  and 
indurated  lachrymal  gland.  The  anterior  surface  of  the  tumor  was  exposed  by  dissection, 
and  it  was  finally  removed  by  cautiously  working  with  the  nail  of  the  little  finger,  for  it 
was  not  considered  safe  to  introduce  a  knife  into  the  back  of  the  orbit. 

The  surface  of  the  extirpated  gland  was  granular,  and  of  a  pink  color.  It  was  en- 
larged to  at  least  six  times  its  natural  size.  When  cut  into,  it  presented  a  hard,  mem- 
branous, or  rather  cartilaginous  centre,  from  which  septa  passed  to  the  circumference. 
No  sanies  could  be  perceived.  On  the  tumor  being  removed,  the  pupil  instantly  recovered 
its  contractile  power,  and  the  globe  retired  nearly  to  its  natural  situation.  Vision,  too, 
was  improved,  but  not  perfectly  restored.  Scarcely  any  hemorrhage  ensued,  and  the 
wound  was  dressed  simplj'.  With  the  exception  of  a  slight  erj-sipelas  of  the  scalp,  which 
yielded  to  the  usual  remedies,  the  patient's  recovery  was  uninterrupted,  and  the  wound 
was  completely  healed  on  the  14th  day  after  the  operation.  At  that  time,  vision  was 
perfect,  all  uneasiness  had  subsided,  and  the  eye  occupied  its  proper  place.  The  upper 
eyelid,  however,  having  continued  so  much  relaxed  as  to  obscure  a  great  part  of  the 
cornea,  a  camel's  hair  pencil,  dipped  in  sulphuric  acid  diluted  with  three  parts  of  water, 
was  applied  in  the  line  of  the  cicatrice.  In  a  few  days  a  slough  separated,  and  the  sub- 
sequent cicatrization  contracted  the  lid  to  its  natural  state.  The  patient  continued  per- 
fectly well,  and  suffered  no  inconvenience  from  the  loss  of  the  gland. 


'  Translation  of  this  work  into   French,  p.  "  Monthly  Journal  of  Medical  Science  for 

vi. ;  Paris,  1814.  August,  185.3,  p.  98. 

*  Monthly  .Journal  of  Metlical  Science,  Vol.  '^Vogel,  AnatoraiePatbologiquo  Generals,  p. 
viii.  p.  4fi5,:  E.linlnirgh,  1S48.  199  ;  Paris,  1847  :  Lebert,  Physiologie  Patholo- 

'  Dublin     Quarterly     .Journal     of     Medical  gique,  Tome  ii.  p.  120  ;  Paris,  1845  ;  lb.  Lancet, 

Science,  Vol.  i.  p.  80  :  Dublin,  1846.  Fehruary  26,  1853  :  p.  203. 

*  Travers'  Synopsis  of  the  Diseases  of  the  '^  Dublin    Quarterly    Journal    of    Medical 
Eye;  London,  1820.  Science ;  Vol.  i.  p.  88 ;  Dublin,  1846. 

'  Annales  d'Oculistique  ;  Tomo  xxiii.  p.  145;  '"  Ibid.     Vol.  iv.  p.  246;  Dublin,  1847. 

Bruxelles,  1850.  "  Monthly  Journal  of  Medical  Science  ;  Vol. 

^  See  Paget's  Lectures  on  Tumors;  Lect.  Y.  viii.  p.  464  ;  Edinburgh,  1848. 

Part  ii. ;  Medical  Gazette;  Vol.  xlviii.  p.  177;  "^  Ophthalmologische  Bibliothek,  von  Himly 

London,  1851.  und  Schmidt;  Vol.  iii.  Stuck  iii.  p.  159;  Jena, 

^  Surgical  anatomy  of  the  Head  and  Neck,  1807  :  Himly,  Krankheiten  und  Missbiidungen 

p.  385  ;  Glasgow,  1824.  des  menschlichen  Auges;  Vol.  i.  p.  291;  Berlin, 

'  Edinburgh  Medical  and  Surgical  Journal;  1843. 

Vol.  xliii.  p.  319  ;  Edinburgh,  1835.  "  Op.  cit.  p.  228. 

Journal    Hebdomadaire    des    Progr^s   des  "  Treatise  on  the  Diseases  of  the  Eye,  p. 

Sciences  Medicales;  Tome  iii.  p.  207;  Paris,  798;  London,  184J. 

1836.             _  _  '»  Ibid.  p.  802. 

'°  In  addition  to  the  cases  mentioned  in  the  *°  Atlas  der  pathologischen  Anatomic,  Zwei- 

text,  see  one  by  Williams,  in  which  the  peri-  ter  Theil.  17«e  Lieferung.  ;  Tab.  3  ;  Jena,  1850. 

cranium,  dura  mater,  and  various  other  organs  ^'  Himly,  Op.  cit:  Vol.  i.  p.  292  :  Amraon, 

were  affected;  Medical  Gazette;  Vol.  xliv.  p.  Klinische  Darstellungen ;  Vol.  ii.  p.  27  ;  Berlin, 

854;  London,  1849.  1838. 


ENCYSTED  TUMOR  IN  THE  LACHRYMAL  GLAND.  135 

^^  Quoted  in  Medical    Gazette ;   Vol.  iii.  p.  strangs ;  advertisement  at  the  end :  Frankfurt 

523;  London,    1829;  from    a    medical  journal  am  Main,  1836. 

published  at  Bordeaux  in  1829.  *^  Dublin  Quarterly  Journal  of  Medical  Sci- 

"  Dublin  Hospital  Reports  ;  Vol.  iii.  p.  419  ;  enee  ;  Vol.  i.  p.  92  ;  Dublin,  1816. 

Dublin,  1822.  °'  Richerand,    Nosographie      Chirurgieale  ; 

"  Ibid.  p.  426.  Tome  ii.  p.  31 ;  Paris,  1808  :  Warner's  Cases  of 

"^  Op.  cit.  p.  802.  Surgery,  p,  108;  London,  1784  :  Travers,  Op. 

'^^  Controverse  iiber  die  Nerren  des  Nabel-  cit. 


SECTION  VI. ENCYSTED  TUMOR  IN  THE  LACHRYMAL  GLAND. 

This  disease  appears  to  have  been  for  the  first  time  accurately  described 
by  Schmidt,  under  the  appellation  o{  glandula  lachrymalis  hydatoidea} 

It  certainly  consists  of  a  collection  of  thin  fluid  in  the  situation  of  the  supe- 
rior portion  of  the  lachrymal  gland.  This  fluid  Schmidt  supposed  to  be  tears; 
and  the  cysts  in  which  it  collects,  to  be  originally  nothing  more  than  one  of 
the  cells  of  the  cellular  membrane,  serving  to  hold  together  the  acini  or  grains 
of  which  the  gland  is  composed.  Whether  this  is  really  a  lachrymal  tumor, 
or  merely  a  cyst  situated  in  the  lachrymal  gland,  or  at  least  closely  connected 
with  it,  is,  in  a  practical  point  of  view,  a  matter,  perhaps,  of  little  conse- 
quence. Schmidt's  hypothesis  of  the  origin  of  the  cyst  is  quite  inconsistent 
with  the  assumption,  that  this  disease  is  at  all  analogous  to  the  entozoa, 
known  under  the  name  of  hydatids. 

That  it  is  a  rare  disease  may  be  concluded  from  the  fact,  that  Schmidt 
relates  only  two  cases  of  it ;  and  that  even  Beer's  vast  experience  had  brought 
only  three  under  his  observation.^  In  one  of  Beer's  cases,  the  diagnosis 
became  completely  evident  only  after  death.  In  the  tumor,  he  found  a  small 
quantity  of  fluid,  which  he  does  not  hesitate  to  call  tears  ;  and  which  was 
thin,  clear,  and  sharp  and  saltish  to  the  taste.  In  his  second  case,  he  0]iened 
the  tumor  during  life  ;  the  fluid  discharged  was  yellowish  like  serum,  but  so 
acrid,  that  it  immediately  caused  a  small  blister  when  applied  to  the  tongue. 
In  Beer's  third  case,  he  was  merely  consulted  in  the  commencement  of  the 
disease. 

Symptoms. — The  development  of  an  encysted  tumor  in  the  lachrymal  gland 
is,  in  some  cases  at  least,  very  rapid ;  and  its  consequences  not  merely  dis- 
tressing, but  dangerous.  One  of  the  most  striking  symptoms  attending  this 
tumor,  is  protrusion  of  the  eye.  It  is  pushed  forward  from  the  orbit,  and 
inward,  towards  the  nose;  and  ultimately  may  become  disorganized  by  inflam- 
mation. 

When  the  disease  produces  exophthalmos  merely,  the  patient,  perhaps  per- 
fectly well  in  every  other  respect,  complains  of  obtuse  deep-seated  pain  in 
the  orbit.  The  pain  is  as  if  something  behind  the  eyeball  were  pushing 
it  out  of  its  socket.  It  is  felt  most  when  the  patient  moves  his  eye  in 
different  directions,  and  especially  when  he  turns  it  towards  the  temple.  It 
daily  increases.  Nothing  unnatural  in  the  form  or  in  the  texture  of  the  eye 
or  eyelids  is  as  yet  discernible.  By  and  by,  there  is  added  to  the  pain  behind 
the  eye,  a  feeling  of  tension  in  the  orbit  and  over  the  side  of  the  head  ;  and 
the  eyeball  is  now  observed  to  be  somewhat  protruded  from  the  orbit  and 
towards  the  nose.  Some  few  individual  bloodvessels  excepted,  it  is  not  red. 
The  patient  h^  a  feeling  of  dryness  in  the  eye.  He  cannot  move  it  without 
great  aggravation  of  the  pain,  and  a  sensation  of  sudden  flashes  of  light.  At 
last,  he  is  totally  deprived  of  the  power  of  moving  it.  When  he  regards 
objects  with  the  protruded  eye,  he  sees  them  disfigured.  If  he  looks  with 
both  eyes,  he  sees  objects  double,  as  the  protruded  eye  stands  no  longer  in 
the  natural  axis  of  vision.     The  more  that  the  tumor  pushes  the  eyeball  out 


136  ENCYSTED   TUMOR  IN  THE  LACHRYMAL  GLAND. 

of  the  orbit,  vision  becomes  the  weaker  and  the  more  disturbed.  In  propor- 
tion as  the  disease  advances,  the  patient  loses  his  appetite,  and  is  deprived  of 
sleep.  The  hemicrania  becomes  uninterrupted,  by  day  and  night.  Vision 
is  entirely  lost.  The  eye  is  so  much  protruded,  that  it  rests  in  some  measure 
upon  the  cheek.  The  eyelids  lose  all  power  of  motion,  the  upper  one  being 
firmly  extended  over  the  protruded  eye.  The  patient  betrays  a  constant 
inclination  to  cover  the  eye  with  the  eyelids,  and  at  every  attempt  to  do  so 
the  eyeball  is  rolled  towards  the  nose.  A  resisting  hardness  is  felt  with  the 
finger  at  the  temporal  angle  of  the  eye,  between  the  protruded  eyeball  and 
the  external  edge  of  the  orbit.  The  eye  becomes  sullied  and  dusky.  If  nothing 
is  done  to  relieve  the  symptoms,  coma  and  death  are  the  consequences. 

Should  the  disease  produce  exophthabnia,  besides  obtuse,  deep-seated,  and 
constantly  increasing  pain  in  the  orbit,  there  is  pain  in  the  eyeball  itself; 
and  whereas,  in  the  former  case,  the  eye,  though  protruded  by  the  growing 
tumor,  preserves  its  ordinary  appearance,  in  the  present  case  it  is  rapidly 
destroyed  by  inflammation.  It  suppurates ;  and  unless  opened  by  the  knife, 
bursts,  discharging  blood  and  ichorous  matter.  The  membranes  do  not  col- 
lapse after  this  evacuation,  but  the  eyeball,  as  a  fleshy  shapeless  mass,  con- 
tinues to  protrude  from  the  orbit,  proving  how  much  its  organization  had 
suffered.  Tlie  pain  in  the  burst  eye,  and  in  one  side  of  the  head,  continues, 
the  patient  is  deprived  of  sleep  and  appetite,  and  the  lymphatic  glands  about 
the  face  become  enlarged.  Should  a  patient  present  himself  with  such  symp- 
toms, we  shall  naturally  be  led  to  suspect  the  existence  either  of  this  disease, 
or  of  some  other  affection  of  the  lachrymal  gland  ;  and  our  suspicions  will  be 
confirmed  if  we  find  a  resisting  hardness  between  the  destroyed  eyeball  and 
the  temporal  edge  of  the  orbit.  It  is  likely,  however,  that  this  may  be  detected 
at  a  much  earlier  period  of  the  disease. 

Could  we  dare  to  draw  conclusions  from  the  few  cases  of  this  disease  on 
record,  we  should  say  that  it  is  more  apt  to  terminate  fatally  when  attended 
by  exophthalmos,  than  when  accompanied  by  exophthalmia.  In  neglected 
cases,  however,  of  encysted  tumor  in  the  lachrymal  gland,  attended  by  exoph- 
thalmia, the  disorganization  is  apt  to  spread  to  the  bones  of  the  orbit,  and 
at  last  the  brain  itself  becomes  fatally  affected.  This  was  the  termination  of 
one  of  the  three  cases  observed  by  Beer. 

Treatment. — The  radical  cure  of  encysted  tumor  in  the  lachrymal  gland, 
would  consist,  no  doubt,  in  extirpating  the  tumor,  before  the  eye  became 
protruded,  at  least  to  any  considerable  extent ;  but  at  this  period,  we  cannot 
distinguish  the  disease  with  sufficient  certainty.  Even  had  we  the  means  of 
determining  that  the  commencing  exophthalmos  arose  from  the  cause  in 
question,  it  might  be  difficult  to  extirpate  this  vesicular  swelling  without  re- 
moving also  the  gland  in  which  it  is  situated,  or  with  which  it  is  intimately 
connected. 

A  palliative  treatment,  it  is  probable,  will  generally  be  adopted,  by  the 
employment  of  which  we  may  save  both  the  life,  and  the  eye  of  the  patient. 
It  may  even  happen  that  by  the  early  employment  of  this  palliative  cure,  we 
may  be  fortunate  enough  to  cure  the  disease  completely. 

The  palliative  cure  consists  in  puncturing  the  tumor.  This  should  be 
done,  if  possible,  from  under  the  upper  eyelid,  with  a  lancet  or  small  con- 
cealed bistoury,  directed  towards  the  seat  of  the  lachrymal  gland.  Should 
the  tumor  return  after  the  healing  of  the  wound,  the  operati(fn  must  be  re- 
peated. I  should  think  any  attempt  to  keep  the  wound  open,  and  the  tumor 
constantly  empty,  by  the  introduction  of  a  bougie  or  other  foreign  body,  out 
of  the  question,  if  the  incision  were  made  from  under  the  upper  eyelid.  But 
if  the  protrusion  of  the  eye  were  such  that  the  upper  eyelid  was  firmly 
stretched  over  the  eyeball,  and  that  no  instrument  could  be  passed  between 


L 


ENCYSTED   TUMOR   IN   THE   LACHRYMAL   GLAND.  131 

them,  the  tumor  would  require  to  be  opened  through  the  upper  eyelid,  and 
the  wound  might  be  afterwards  kept  open  by  a  bit  of  catgut,  so  as  to  give 
exit  to  any  reaccumulated  fluid,  and  perhaps  lead  to  a  radical  cure. 

That  through  the  opening,  wherever  it  be  made,  the  cyst  of  the  tumor 
shall  be  extracted,  cannot  be  regarded  as  very  likely  ;  although  this  took 
place  in  one  of  Schmidt's  cases. 

As  the  present  is  a  rare  disease,  I  am  induced  to  lay  before  the  reader  the 
particulars  of  the  following  cases  : — 

Case  109. — A  private  soldier,  aged  2()  years,  of  a  firm  and  corpulent  make,  became  ill 
with  fever,  from  fatigue  and  exposure  to  cold,  in  the  end  of  No. ember,  1800.  According 
to  the  history  of  the  case,  he  had  a  sliglit  typhus,  which  yielded  to  the  use  of  the  proper 
means,  so  that  he  left  the  hospital  in  the  beginning  of  January,  1801,  and  set  oil'  for  his 
regiment.  Some  days  before  he  left  the  hospital,  he  had  an  obtuse  deep-seated  feeling 
of  pressure  in  his  eye  ;  but  he  set  himself  out  against  it,  and  said  nothing  of  it  to  his 
medical  attendant.  He  was  about  eight  days  with  his  regiment,  when  he  observed  that 
this  obtuse  deep-seated  pain  grew  more  constant  and  more  troublesome.  But  as  he  could 
discover  nothing  wrong  about  his  eye  and  saw  perfectly  well,  he  let  matters  rest  as  they 
■were.  In  the  beginning  of  the  third  week,  the  feeling  of  pressure  became  violent,  he 
felt  pain  with  tension  in  the  eye  itself,  and  in  the  corresponding  half  of  the  head ;  the 
eye  became  red  and  dry,  and  began  to  project;  he  frequently  had  the  sensation  of  fiery 
spectra,  and  at  times  his  sight  failed  him.  About  this  time,  his  sleep  became  interrupted. 
AVith  these  s^'uiptoms,  he  was  unable  to  perform  his  duty  as  a  soldier.  His  medical  officer 
ordered  the  application  of  a  warm  poultice.  The  case  grew  worse  from  day  to  dny.  With 
the  beginning  of  the  fourth  week,  the  hemicrania  and  pain  in  the  eye  became  furious, 
day  and  night,  so  that  he  could  not  get  a  moment's  sleep:  the  eye  protruded  completely 
from  its  socket,  so  that  it  was  seen  from  the  other  side  over  the  root  of  the  nose;  it  was 
slightly  red,  but  not  swollen,  moist  and  slippery,  but  deprived  of  sight.  The  appetite 
for  food,  which  had  continued  till  now,  was  lost.  The  patient's  restlessness  rose  to  the 
extreme. 

In  this  state  he  was  brought  to  the  Military  Hospital  of  Vienna,  on  the  4th  February. 
Early  on  the  5th,  Schmidt  saw  him  for  the  first  time.  Besides  the  above-mentioned 
symptoms,  he  found  the  patient  aifected  with  spasm  of  the  superior  oblique  muscle, 
whereby  the  eye  was  every  instant  drawn  more  out  of  the  orbit,  and  towards  the  nose. 
The  eyelids  were  not  in  the  least  swollen,  but  quite  pushed  aside  from  the  eye.  Schmidt 
felt  distinctly  a  resisting  hardness  in  the  temporal  angle  of  the  orbit.  He  declared  before 
those  who  attended  the  visit,  that  the  disease  was  seated  in  the  orbit,  and  that  it  was 
probably  a  steatomatous  tumor.  Opium  intei-nally  and  externally,  warm  poultices  over 
the  eye  and  head,  nothing  checked  the  fury  of  the  pain.  Early  on  the  6th,  Schmidt 
found  the  patient  in  the  same  state,  only  that  the  eye  was  no  longer  lively,  but  dusky  and 
somewhat  like  the  eye  of  a  dying  person,  while  the  appearance  of  the  sound  eye  was  still 
very  lively.  The  pulse,  the  respiration,  and  all  the  other  functions,  were  not  in  the  least 
altered.  Schmidt  determined  to  evacuate  the  eye,  next  day,  by  an  incision.  Towards 
evening,  the  patient  fell  into  a  state  of  sopor,  became  insensible,  discharged  his  urine  and 
feces  involuntarily,  and  died  toward  midnight. 

On  dissection,  the  veins  and  sinuses  of  the  brain  were  found  distended  with  blood. 
There  was  no  accumulation  of  fluid  in  the  ventricles.  On  removing  the  orbitary  process 
of  the  frontal  bone  without  injuring  the  periosteum,  a  fluctuating  tumor  pressed  itself 
upwards  from  the  temporal  angle  of  the  orbit.  On  continuing  the  dissection,  the  muscles 
of  the  eye,  the  optic  nerve,  and  the  other  nerves  of  the  orbit,  were  observed  to  be  stretched 
and  elongated,  and  the  ophthalmic  vein  appeared  varicose.  The  lachrymal  gland  was 
smaller  than  usual,  and  in  connection  with  it  lay  the  fluctuating  tumor.  The  individual 
acini  which  were  more  remote  from  the  tumor,  and  were  directed  towards  the  upper  eye- 
lid, were  larger  and  more  coherent;  whilst  those  acini,  which  lay  upon  the  tumor,  were 
small,  and  both  appeared  and  felt  more  loosely  scattered  than  natural.  The  tumor  was 
in  diameter,  from  behind  forwards,  the  length  of  an  inch  ;  in  transverse  and  perpendicular 
diameters  somewhat  less  than  an  inch.  It  pressed  itself  close  upon  tbe  external  segment 
of  the  eyeball,  and  even  after  death,  held  the  eyeball  out  of  the  orbit  and  towards  the 
nose.  It  had  an  •external  and  an  internal  covering.  The  external  consisted  of  thick, 
cellular  membrane.  Between  this  and  the  internal  covering  was  a  quantity  of  interstitial 
fluid.  The  internal  covering  was  very  fine,  semitranspnrent,  and  contained  a  limpid  fluid. 
The  external  membrane  could  not  be  easily  separated  from  the  scattered  acini  of  the 
lachrymal  gland.     The  internal,  could  be  freely  extracted  from  the  external,  covering.* 

CtfsellO. — A  young  country-woman  came  to  Vienna  in  Maj',  1802,  and  sought  Schmidt's 
assistance.     She  had  weaned  her  child  two  months  before  ;  and  immediately  after  thai, 


138  ENCYSTED   TUMOR  IN   THE   LACHRYMAL   GLAND. 

upon  being  exposed  to  cold,  felt  violent  hemicrania  and  pain  in  the  eye.  After  some 
days,  the  eyeball  inflamed  severely,  became  swollen,  and  pressed  itself  forwards  from 
the  orbit.  When  the  woman  came  to  Schmidt,  the  inflamed  eye  had  the  size  of  a  man's 
fist,  the  cornea  was  completely  destroyed  from  suppuration,  and  the  iris  was  covered  by 
a  new  and  wartlike  production,  so  that  it  was  with  difiiculty  that  an  eye  could  be  recog- 
nized in  this  shapeless  mass  of  flesh.  Together  with  a  constant  pressing  pain  in  the  orbit, 
and  continual  hemicrania,  Schmidt  found  all  the  symptoms  detailed  in  the  former  case, 
with  the  exception  of  the  spasmodic  motions  of  the  eyeball.  He  mentions  that  the  parotid 
gland  upon  the  same  side,  was  swollen  towards  the  branch  of  the  lower  jaw,  but  more 
probably  the  swelling  affected  one  of  the  lymphatic  glands  lying  over  the  parotid. 

The  patient  was  admitted  into  the  hospital,  under  the  care  of  Mr.  KuttorflFer,  who 
passed  a  small  flat  trocar  under  the  upper  eyelid,  directing  its  point  towards  the  fossa 
lachrynialis,  where  the  resistance  and  hardness  were  felt.  More  than  an  ounce  of  ex- 
tremely clear  fluid  was  immediatel}'  discharged  through  the  canula.  The  canula  was 
removed,  and  for  several  days  this  clear  fluid  issued  from  the  wound.  Some  hours  after 
the  operation,  the  hemicrania  suddenly  and  considerably  diminished,  and  from  day  to  day, 
the  exophthalmia  became  less. 

On  the  14th  day  after  the  operation,  a  whitish  streak  was  observed  in  the  wound,  re- 
sembling pus,  but  which  could  not  be  removed  with  a  little  lint.  Mr.  Iluttorff'er  laid  hold 
of  this  with  a  pair  of  forceps,  and  drew  forth  the  cj'st,  or,  as  Schmidt  chooses  to  call  it, 
the  hydatid,  which,  as  represented  in  his  work,  must  have  measured  more  than  an  inch  in 
diameter.  After  other  14  days,  the  woman  left  the  hospital,  the  eye  having  diminished 
to  a  small  stump.* 

From  the  state  to  which  the  eyeball  is  reduced  in  exophthalmia  proceeding 
from  this  disease,  it  is  not  unlikely  that  cases  of  this  sort  have  sometimes 
been  taken  for  cancerous  affections,  and  the  eyeball  extirpated  with  tlie  cyst. 
An  iiistance  of  this  kind  we  find  in  the  Philosophical  Transactions  for  IT 55, 
related  by  Mr.  Spry.^ 

Case  111. — A  mariner's  wife  complained  of  violent  pain  in  her  left  eye,  and  sometimes 
of  very  acute  pain  in  the  temple  of  the  same  side,  with  some  defect  in  her  sight.  She  also 
imagined  that  her  ej'e  was  bigger  than  ordinary ;  but,  upon  inspection,  it  appeared  no  bigger 
than  the  other.  The  cornea,  however,  became  less  transparent,  and  the  pupil  greatly  dilated. 
The  vessels  of  the  conjunctiva  and  sclerotica  were  no  way  enlarged.  Bleeding,  blistering, 
and  purging,  proved  of  no  efi"ect.  On  the  contrary,  the  cornea  became  more  opaque, 
great  inflammation  of  the  conjunctiva  and  sclerotica  ensued,  and  an  apparent  prominence 
of  the  whole  eye.  She  was  again  purged,  and  a  seton  put  in  the  neck;  but  the  symptoms 
increased.  She  became  still  more  miserable.  The  conjunctiva  became  greatly  inflamed, 
with  eversion  of  the  upper  lid,  attended  with  great  pain.  Mr.  Spry  often  scarified  the 
conjunctiva,  which  bled  plentifully,  and  gave  her  ease  for  a  day  or  two.  He  also  took 
blood  from  the  temporal  artery.  But  the  eye  being  greatly  enlarged,  and  of  so  terrible 
an  appearance,  after  all  his  endeavors  for  eight  or  ten  months,  he  judged  the  disease  to 
be  carcinoma,  and  therefore  proposed  cutting  out  the  eye  as  the  only  remedy.  The  ope- 
ration, however,  was  deferred,  till  at  length  the  eye  becoming  much  larger,  and  the  pain 
increasing,  extirpation  was  had  recourse  to,  lest  the  bones  of  the  orbit  might  become 
carious. 

Mr.  Spry  having  begun  his  incision  round  the  upper  part  of  the  tumor,  had  not  cut 
deep  when  a  great  quantity  of  fluid,  like  lymph,  poured  out  upon  him  with  great  force, 
like  a  fountain.  The  tumor  subsided  a  good  deal ;  but  pursuing  the  operation,  he  found 
a  large  cyst,  which  filled  the  whole  orbit  behind  the  eye.  A  part  of  this  cyst  was  left  to 
slough  off  with  the  dressings.  The  whole  eye  being  cut  out,  he  filled  the  wound  with  lint. 
The  cure  went  on  with  success,  and  was  complete  in  a  month. 

On  examining  the  tumor  which  had  been  removed,  the  eye  appeared  a  little  bigger  than 
natural,  the  aqueous  humor  not  so  clear  as  usual,  the  crystalline  less  solid  and  transpa- 
rent, the  vitreous  almost  reduced  to  a  liquid  state,  the  cyst  very  strong  and  elastic,  with 
a  cavity  suflBcient  to  contain  a  large  hen-egg. 

There  can  be  little  doubt  that  this  was  a  misunderstood  case  of  encysted 
tumor  in  the  lachrymal  gland,  or,  at  any  rate,  of  encysted  orbital  tumor,  and 
not  at  all  a  carcinoma. 


'  Ueber    dio    Krankheiten    des   ThrSuenor-  '  Op.  cit.  p.  90. 

gans,  p.  73  ;  Wien,  1803.  ■•  Ibid.  p.  94. 

**  Lehre  von  den  Augenkrankheiten ;  Vol.  11.  '  Philosophical  Transactions;  Vol.  xlix.  Part 

p.  597;  Wien,  1817.  i.  p.  IS;  London,  1756. 


ENCYSTED   TUMOR  NEAR  LACHRYMAL  DUCTS.  139 


SECTION  VII. — ENCYSTED   TUMOR  IN  THE  VICINITY  OF   THE  GLANDULiE  CONGRE- 
GATE AND  LACHRYMAL  DUCTS. 

The  subject  of  this  section  seems  similar  in  nature  to  the  disease  last  con- 
sidered. Its  seat  appears  the  principal  difference ;  for  the  tumor  described 
in  the  last  section  is  seated  in  the  substance  of  the  superior  portion  of  the 
lachrymal  gland,  and  is  supposed  to  derive  the  fluid  which  it  contains  from 
the  gland  immediately ;  while  the  present  disease  lies  almost  immediately 
behind  the  conjunctiva,  in  the  vicinity  of  the  glandulge  congregatas,  and 
derives  its  fluid  according  to  Schmidt,^  from  one  or  more  of  the  lachrymal 
ducts.  Benedict^  describes  it  as  a  mere  dilatation  of  one  of  these  ducts. 
Encysted  tumor  in  the  lachrymal  gland  produces  a  series  of  dangerous  symp- 
toms, long  before  it  comes  into  view  itself,  if  ever  it  comes  into  view  ;  whereas, 
a  similar  tumor  in  the  vicinity  of  the  glandulas  congregatee  and  lachrymal 
ducts,  from  its  superficial  situation,  is  neither  productive  of  so  destructive 
effects,  nor  can  it  remain  so  long  concealed. 

Symptoms. — As  soon  as  it  has  reached  any  considerable  extent,  the  pre- 
sent disease  manifests  itself  by  the  following  symptoms  :  A  circumscribed 
very  elastic  swelling,  void  of  pain,  is  felt  immediately  behind  the  upper  eye- 
lid, towards  the  temporal  side  of  the  orbit.  If  the  tumor  has  already  reached 
such  a  degree  as  to  present  through  the  eyelid  the  size  of  a  hazel-nut,  and  if 
we  press  upon  it  pretty  forcibly,  the  patient  feels  the  pressure  in  the  eyeball, 
and  observes  fiery  spectra  before  the  eye.  If,  at  the  same  time  that  we  press 
the  tumor  from  without,  we  raise  the  upper  eyelid,  and,  in  some  measure, 
evert  it,  we  see  the  conjunctiva  project  in  the  form  of  a  distended  sac,  in 
which  we  discover  fluctuation.  When  the  tumor  has  reached  the  size  of  a 
pigeon's  qq^,  the  motions  of  the  eyeball  upwards  and  outwards  are  impeded ; 
yet,  when  we  raise  the  upper  eyelid  in  the  manner  just  now  mentioned,  the 
patient  is  immediately  able  to  move  his  eye,  without  difficulty,  towards  the 
temple,  the  eyeball  retiring  behind  the  tumor.  From  extreme  distention,  the 
conjunctiva,  and  the  cyst  in  which  the  fluid  is  contained,  are  so  thin,  that  the 
pressure  we  employ  in  examining  the  disease,  seems  almost  sufficient  to  rup- 
ture the  tumor.  One  of  the  characteristic  marks  of  this  disease,  we  are  told, 
is  the  momentary  increase  of  the  tumor  when  the  patient  weeps. 

Causes. — It  is  supposed  that  the  proximate  cause  is  one  or  more  of  the 
excreting  ducts  of  the  lachrymal  gland  terminating  in  the  loose  cellular  sub- 
stance under  the  conjunctiva;  that  one  of  the  cells  is  gradually  distended  by 
the  accumulating  tears,  and  at  last  forms  the  thin  sac,  the  projection  of  which 
gives  rise  to  the  symptoms  described.  That  this  is  the  real  nature  of  the 
case,  is  concluded  from  the  alleged  fact,  that  if  the  tumor  be  opened  through 
the  eyelid,  a  considerable  quantity  of  pure  tears  flows  through  the  incision, 
every  time  the  patient  weeps.  I  must  confess  that  I  have  no  faith  in  this 
etiology. 

Beer^  met  with  this  disease  six  times,  in  individuals  who  were  between  four 
and  fourteen  years  of  age.  In  two  of  these  cases,  an  apparent  exciting  cause 
had  preceded  the  disease.  In  the  one,  the  cause  was  a  bruise  on  the  upper 
edge  of  the  orbit,  from  the  springing  of  a  billiard  ball.  In  the  other,  it  arose 
after  the  incomplete  extirpation  of  an  encysted  tumor,  which  had  its  seat  at 
the  same  place. 

Treatment. — Beer's  plan  of  radically  curing  this  disease,  by  passing  a  seton 
through  the  nostril,  is  not  to  be  recommended.  It  is  not  only  apt  to  fail,  but 
may  leave  a  troublesome  fistulous  opening  through  the  lid. 

Either  the  simple  palliative  cure  should  be  had  recourse  to,  of  puncturing 
the  tumor  through  the  conjunctiva,  or  the  cyst  should  be  extirpated.     If  the 


140  TRUE  LACHRYMAL   FISTULA. — MORBID   TEARS. 

eyelid  cannot  be  sufficiently  everted,  to  allow  the  cyst  to  be  exposed  and  insu- 
lated through  an  incision  of  the  conjunctiva,  the  extirpation  should  be  per- 
formed through  an  incision  of  the  skin,  parallel  to  the  fibres  of  the  orbicularis 
palpebrarum. 

It  is  remarkable,  that  the  two  diseases  described  in  this  and  the  preceding 
section,  have  not  been  met  with,  as  far  as  I  know,  by  any  practitioner  in  this 
country. 


'  Ueber   die    Krankheiten    des    Thranenor-        '  Lehre  von  den  Augenkrankheiten  ;  Vol.  ii. 
gans,  p.  63;  Wien,  1803.  p.  51)3  j  Wien,  1817. 

*  Handbuch     der     praktischen    Aiigenheil- 
kunde;  Vol.  iii.  p.  163;  Leipzig,  1824. 


SECTION  VIII. — TRUE  LACHRYMAL  FISTULA. 

A  callous  opening,  so  small  as  almost  to  elude  the  naked  eye,  situated  in 
the  upper  eyelid,  towards  its  temporal  extremity,  and  from  which  there 
trickles  from  time  to  time  a  quantity  of  tears,  is  styled  a  true  lachrymal  jis- 
tida.  If  we  pass  an  Anel's  probe  into  the  orifice,  we  find  that  it  is  led  di- 
rectly towards  the  lachrymal  gland ;  but  we  neither  perceive  any  hardness  of 
the  gland,  feel  any  portion  of  bone  bare,  nor  give  the  patient  pain. 

True  lachrymal  fistula  may  arise  from  a  wound  of  the  lachrymal  gland,  the 
glanduUe  congregatie,  or  the  lachrymal  ducts.  More  frequently  it  is  the 
eflTect  of  abscess  of  tlie  upper  eyelid,  or  of  suppuration  of  the  lachrymal 
gland.  It  may  also  be  the  result  of  attempts  to  extirpate  an  encysted  tumor 
in  the  vicinity  of  the  lachrymal  ducts,  or  to  cure  that  disease  by  means  of  a 
seton. 

This  almost  capillary  fistula  will  require  the  Anelian  syringe,  armed  with 
its  finest  point,  to  inject  any  fluid  into  it.  Having  widened  the  fistula,  by 
repeated  introductions  of  the  Anelian  probe,  or  the  use  of  a  piece  of  fine 
catgut,  by  passing  the  Anelian  probe,  coated  with  nitrate  of  silver,  several 
times  with  a  rotatory  motion,  through  the  fistula,  we  may  expect  to  excite 
such  a  degree  of  inflammation  as  shall  end  in  its  closure.' 

A  stout  country  lad  had  a  fistula  of  this  kind,  3|  lines  deep,  and  com- 
pletely callous.  Beer  passed  quickly  into  the  opening,  and  to  the  bottom  of 
the  fistula,  a  red  hot  knitting-needle,  turning  it  round  several  times  upon  its 
axis.     Five  days  afterwards,  the  fistula  was  completely  closed.'' 


'  To  coat  a  probe  with  lunar  caustic,  place  a    flame  of  a   candle,  and  roll  the  probe  in  the 
bit  on  a  piece  of  silver  money,  such  as  a  six-     melted  salt,  till  it  is  sufficiently  covered, 
pence  ;  hold  this  with  a  pair  of  pliers  over  the         '  Lehre  von  den  Augenkrankheiten ;  Vol.  ii. 

p.  186;  Wien,  1817. 


SECTION  IX. — MORBID  TEARS. 


The  tears  are  at  all  times  an  irritating  secretion.  The  conjunctiva  is  in- 
stantly reddened  when  they  flow ;  and  although  we  were  to  grant  that  this 
was  consentaneous  with  determination  of  blood  to  the  lachrymal  gland,  pre- 
ceding the  discharge,  yet  we  observe  that  if  the  tears  are  so  profuse  as  to  run 
over  on  the  cheek,  the  skin  with  which  they  come  into  frequent  contact  be- 
comes inflamed  and  excoriated.  In  some  cases,  the  extraordinary  degree  of 
inflammation  which  the  tears  have  excited,  has  led  to  the  supposition,  that 


SANGUINEOUS   LACHRYM ATION. — DACRYOLITHS.  141 

their  chemical  properties  were  changed  by  disease,  so  that  they  had  acquired 
au  unusual  degree  of  acridness.  In  a  supposed  case  of  this  kind,  which  some 
years  ago  attracted  a  considerable  share  of  attention  in  Glasgow,  it  was  dis- 
covered, that  the  deep  lines  of  excoriation  which  ran  down  the  cheeks  of  the 
patient,  who  was  a  child,  were  not  the  work  of  the  tears,  but  the  effects  of  a 
deliberate  application  of  sulphuric  acid.  The  woman  who  kept  the  child, 
tempted  by  some  sinister  motive,  was  the  author  of  this  extraordinary  piece 
of  cruelty. 


SECTION  X. — SANGUINEOUS  LACHRYMATION.       H^MGRRHAGY  FROM  THE  LACH- 
RYMAL GLAND. 

Forestus,*  Havers, '^  and  others  have  recorded  cases  in  which  blood  flowed 
from  the  eyes  like  tears,  or  was  discharged  from  the  lachrymal  gland,  even  in 
such  quantity  as  proved  dangerous  to  life. 

Professor  Rosas  witnessed  a  disease  of  this  sort  in  a  child  of  nine  years  of 
age,  of  scorbutic  diathesis,  and  in  whom  it  yielded  to  anti-scorbutic  treat- 
ment.^ 

In  all  these  cases,  however,  it  is  doubtful  how  far  the  discharge  of  blood 
was  really  from  the  lachrymal  gland,  and  not  from  the  conjunctiva. 


'-  Observationes   et  Curatiotie.s   Medicinales,     thorp's   Abrirlgment ;  Vol.   iii.  part  i.  p.  252; 
Lib.  xi.     Obs.  1.3  :  Francofurti,  16.34.  London,  1716. 

*  Philosophical  Transactions,  No.  208.  Low-         '  Handbucb  fler  Augenheilkunde  ;  Vol.  ii.  p. 

347;  Wien,  1830. 


SECTION  XI. — DACRYOLITHS"^  OR  LACHRYMAL  CALCULI  IN  THE  LACHRYMAL 

DUCTS. 

■*  From  ^axfu  tear,  \i8o;  stone. 

The  tears,  like  the  saliva  and  all  other  fluids  transmitted  along  mucous 
surfaces,  are  occasionally  the  source  of  calcai'eous  depositions.  In  all  such 
cases,  the  concretions  which  are  met  with,  consist  of  all  the  chemical  consti- 
tuents of  the  fluids  by  which  they  are  surrounded  ;  but  they  also  occasionally 
contain  principles  derived  from  the  mucous  membrane.  Their  forms  they 
borrow  from  the  cavity  in  which  they  are  contained,  or  from  the  surrounding- 
structures  with  which  they  are  brought  in  contact,  as  is  observed  in  the  gall- 
stones, urinary  calculi,  intestinal  calculi,  salivary  calculi,  &c. 

Case  112. — MM.  Laugier  and  Richelot  mention  that  an  old  soldier  awoke  with  the  sen- 
sation of  a  foreign  body  in  his  left  eye,  ■which  was  affected  with  pain,  redness,  and 
lachrymation.  On  reversing  the  upper  eyelid,  a  small  whitish  point,  like  chalk,  was 
observed  on  the  surface  of  the  conjunctiva,  about  three  lines  above  the  edge,  and  at  a 
little  distance  from  the  temporal  angle.  With  the  point  of  a  probe,  it  was  felt  immovable 
and  hard.  Some  attempts  were  made  to  disengage  it  from  the  opening  of  one  of  the 
lachrymal  ducts,  where  it  seemed  fixed,  but  in  vain.  The  irritation  was  speedily  subdued 
by  soothing  lotions.  Two  months  afterwards  the  patient  left  the  hospital,  with  the  cal- 
culus still  in  its  place,  without  any  change  in  its  bulk,  or  any  renewal  of  uneasiness  from 
its  presence.' 

Case  113. — Ann  Clarke,  aged  19,  had  been  in  a  bad  state  of  health  for  some  months, 
and  frequently  complained  of  a  severe  pain  in  the  head,  particularly  across  the  forehead, 
and  over  the  left  eye,  for  which  she  had  been  bled  in  the  arm  and  had  leeches  applied  to 
the  temples,  but  without  permanent  relief. 

On  the  2'Zd  December,  1834,  inflammation  came  on  suddenly  in  the  left  eye,  attended 
with  a  good  deal  of  pain ;  this  increased  on  the  following  day,  and  towards  the  afternoon 
Bhe  felt  a  severe  lancinating  pain  in  the  upper  and  outer  part  of  the  orbit,  accompanied 


k 


142  INJURIES   OF   THE   EYEBROW  AND   EYELIDS. 

with  a  sudden  and  profuse  discharge  of  tears ;  immediately  after  which  she  perceived 
something  in  her  eye,  which,  on  removing,  she  found  to  be  a  small  hard  body,  resembling 
a  fragment  of  mortar.  At  first  she  supposed  it  to  be  some  extraneous  substance  which 
had  accidentally  fallen  into  her  eye ;  but  in  the  course  of  an  hour,  the  pain,  which  had 
remitted  on  the  removal  of  this  mass,  returned,  and  another  exactly  similar  came  away. 
Duriuo-  the  three  or  four  following  days,  as  many  as  23  were  discharged  with  the  same 
symptoms;  after  which  the  pain  and  inflammation  gradually  abated.  During  the  time 
that  these  bodies  were  escaping,  there  was  no  bleeding  or  purulent  discharge.  On  the 
day  following  the  removal  of  the  last  of  them,  there  were  slight  appearances  of  conjunc- 
tival inflammation;  but  on  everting  the  upper  eyelid,  no  ulceration  or  other  lesion  of  the 
mucous  membrane  could  be  perceived  there,  or  on  the  other  parts  of  the  eye.  She  com- 
plained of  slight  tenderness  on  pressure  in  the  situation  of  the  lachrymal  gland. 

Some  of  the  calculi,  which  had  been  preserved,  were  small,  rough,  very  hard,  and  of  a 
dirty  white  color;  the  largest  about  a  line  in  diameter.  On  being  viewed  with  a  micro- 
scope, they  looked  like  rough  pieces  of  chalk,  with  small  portions  of  silex  imbedded  in 
them.  On  analysis,  they  were  found  to  consist  principally  of  phosphate  of  lime,  with  a 
small  quantity  of  carbonate  of  lime,  and  traces  of  animal  matter. 

The  narrator  of  the  case  thinks  it  probable  that  the  calculi  were  lodged,  in  the  first 
instance,  in  the  lachrymal  ducts,  and  that  producing  much  irritation  there,  they  were 
discharged  with  a  gush  of  tears.* 

Concretions,  deposited  from  tlie  tears,  occur  in  the  sinuses  of  the  conjunc- 
tiva, in  the  caruncula  lachrymalis,  and  in  the  excreting  lachrymal  passages, 
as  I  shall  explain  more  fully  in  Chapters  IV.,  Y.,  and  VI.  Similar  concre- 
tions are  also  met  with  in  the  Meibomian  follicles. 


'  Translation  of  this  work  into  French;  p.        "  Medical  Gazette,  Vol.  xv.  p.  62S;  London, 
i. :  Paris,  1844.  1835. 


CHAPTER    III. 

DISEASES  OF  THE  EYEBROW  AND  EYELIDS. 


SECTION  I. — INJURIES  OF  THE  EYEBROW  AND  EYELIDS. 

Contusions,  wounds,  and  burns  of  the  eyebrow  and  eyelids,  even  in  cases 
where  they  at  first  appear  trifling,  are  often  productive  of  serious  effects. 
Lagophthalmos  and  ectropium  are  apt  to  be  the  consequences  of  neglected 
burns  and  abscesses  of  the  eyelids ;  while  incised  and  lacerated  wounds  of 
the  eyebrow  and  of  the  neighboring  integuments,  even  of  small  extent,  are 
often  followed  by  asthenopia,  and  occasionally  by  complete,  and  too  often 
incurable,  amaurosis. 

§  1.    Contusion  and  Ecchymosis. 

Blows  or  falls  upon  the  edge  of  the  orbit,  even  when  slight,  are  apt  to  pro- 
duce extravasation  of  blood  into  the  loose  areolar  tissue  of  the  eyelids.  The 
extravasation  or  ecchymosis  seldom  makes  its  appearance  immediately  after 
the  blow.  Five  or  six  hours  sometimes  elapse  before  the  swollen  eyelid 
assumes  the  livid  color  denoting  the  rupture  of  bloodvessels  and  subcutaneous 
effusion  of  blood.  In  other  instances,  however,  the  ecchymosis  is  sudden  ; 
and  the  quantity  of  blood  being  considerable,  a  degree  of  fluctuation  is  felt  in 
the  swollen  lid.  In  pugilistic  contests,  the  eyes  are  completely  closed  from 
the  swollen  and  ecchymosed  state  of  the  lids ;  but  the  seconds  make  an  open- 
ing in  the  skin  with  a  lancet,  and  squeeze  out  the  blood,  so  as  to  enable  the 


CONTUSION  AND   ECCHYMOSIS   OF  THE  EYELIDS.  143 

combatant  to  see  his  way  a  little  longer.*  It  sometimes  happens,  that  also 
the  subconjunctival  areolar  tissue  is  ecchymosed,  and  occasionally  the  effused 
blood  stretches  back  into  the  orbit,  and  even  protrudes  the  eyeball.  It  very 
rarely  happens  that  the  blood  effused  into  the  eyelids,  operates  as  a  foreign 
substance,  or  excites  inflammation.  In  some  cases,  it  is  collected,  as  it  were, 
in  a  cyst,  and  imitates  the  form  and  feeling  of  a  tumor.  I  have  seen  such  a 
spurious  cyst  extirpated.  On  laying  it  open,  it  contained  nothing  but  water 
and  blood.  Had  it  been  left,  it  might  perhaps  have  degenerated  into  some 
sort  of  tumor. 

Ecchymosis  sometimes  presents  itself,  not  merely  immediately  around  the 
part  struck,  but  in  other  places  more  or  less  remote.  Thus,  Ammon''  relates 
a  case  of  contusion  with  a  foil  in  the  vicinity  of  the  right  caruncula  lachry- 
malis,  with  profuse  ecchymosis,  protrusion  of  the  eyeball,  and  concussion  of 
the  brain.  On  the  third  day  after  the  accident,  an  ecchymosis  appeared  on 
the  left  side,  in  the  very  situation,  and  to  the  same  extent,  as  that  on  the 
right.  He  calls  this  a  sympathetic  ecchymosis  ;  and  could  trace  no  communi- 
cation from  the  right  side  to  the  left,  over  the  nose  or  forehead.  Some 
months  after  the  injury,  the  right  eye  became  amaurotic. 

Ecchymosis  (as  mentioned  p.  52)  is  sometimes  symptomatic  of  counter- 
fracture  of  the  walls  of  the  orbit.  In  this  case,  the  ecchymosis  increases 
slowly  for  days,  and  is  not  attended  by  any  considerable  swelling.  Sympto- 
matic ecchymosis  gradually  reaches  the  eyelids,  which  become  more  and  more 
discolored  ;  ecchymosis'from  direct  injury  extends,  on  the  contrary,  from  the 
eyelids  to  the  neighboring  parts. 

Under  ordinary  circumstances,  the  blood  in  ecchymosis  of  the  eyelids  is 
absorbed  in  the  course  of  two  or  three  weeks,  the  swelling  subsiding,  and  the 
skin  gradually  losing  its  livid  color  as  the  absorption  goes  ou,  becoming  first 
brownish,  and  then  yellow. 

In  cases  of  bruise  and  ecchymosis  of  the  eyelids,  we  must  endeavor  to  pre- 
vent or  abate  inflammation,  and  promote  absorption  of  the  effused  blood. 

The  first  of  these  objects  is  to  be  obtained  by  the  application  of  leeches, 
followed  by  the  continual  use  of  evaporating  and  slightly  astringent  lotions. 
More  powerful  astringents,  and  gentle  pressure,  are  employed  to  accomplish 
the  second. 

To  remove  a  hlach  eye,  as  it  is  termed,  quickly,  is  the  great  desideratum 
with  the  patient,  who  often  visits  us  late  in  the  evening,  with  a  woful  dread 
of  what  his  appearance  must  be  next  morning,  unless  we  have  some  appli- 
cation which  can  prevent  or  remove  the  discoloration. 

If  the  blow  has  been  severe,  there  can  be  no  question  that  leeching  is  the 
proper  mode  of  treatment.  When  the  patient  is  a  scrofulous  child,  the  appli- 
cation of  leeches  is  called  for,  not  indeed  so  much  for  the  removal  of  the 
ecchymosis,  as  for  preventing  inflammation  of  the  periosteum  and  bones. 

If  the  blow  has  been  slight,  and  the  patient  is  a  robust  adult,  compresses 
wet  with  an  evaporating  lotion,  may  be  applied,  and  kept  in  close  contact 
with  the  skin,  by  means  of  a  roller  going  round  the  head.  Fomentations 
with  warm  water,  or  with  hot  spirits,  are  sometimes  used,  and  appear  to  do 
good.  A  popular  remedy  is  a  cataplasm  of  the  bruised  roots  of  the  con- 
vallaria  multiflora  or  Solomon's  seal.  The  roots  are  beat  into  a  pultaceous 
mass  in  a  mortar,  and  are  reapplied  every  half  hour  for  three  or  four  hours, 
or  longer  if  necessary.  They  cause  a  degree  of  redness  and  swelling,  and 
have  been  supposed  to  act  by  means  of  the  oedema  which  they  excite,  diluting 
the  effused  blood,  and  thus  promoting  its  absorption.  If  long  continued, 
they  produce  too  much  inflammation  ;  and  if  the  skin  be  abraded,  they  are 
too  irritating  to  be  applied  at  all. 

[A  popular  remedy  much  in  vogue  in  the  United  States,  and  one,  of  which 


144  POISONED   WOUNDS   OF   THE   EYELIDS. 

the  reminiscence  of  any  one's  school-boy  days  would  furnish  many  a  proof  of 
the  efficacy  in  the  prevention  of  the  "dreaded  black  eye,"  is  the  red  oil,  as  it 
is  commonly  called — which  always  in  former  times  held  its  position  in  the 
nursery  closet,  by  the  side  of  the  sulphur  and  molasses,  as  a  panacea.  It 
consists  of  the  flowers  of  the  Hypericum  perforatum  (St.  John's  wort), 
treated  with  sweet  oil.  It  does  undoubtedly  prevent  the  occurrence  of  ecchy- 
mosis  and  discoloration  of  the  skin,  when  applied  immediately  after  the  re- 
ceipt of  a  severe  bruise.  As  to  its  modus  operandi,  we  do  not  feel  ourselves 
qualified  to  pronounce  an  opinion.  Its  application  is  not  attended  with  the 
redness  and  swelling  consequent  on  the  use  of  the  cataplasm  of  Solomon's 
seal,  and  it,  therefore,  probably  does  not  act  in  the  same  manner. 

Its  use  is  not  followed  by  the  inflammatory  symptoms  which  ensue  after  the 
long-continued  use  of  the  latter  remedy.  It  is  simply  rubbed  over  the  part, 
and  one  or  two  applications  are  sufficient,  and  generally  even  one  is  all  that 
is  required  to  produce  the  desired  effect. — H.] 

Whatever  application  we  make  choice  of,  whether  a  solution  of  muriate  of 
ammonia,  a  spirituous  fomentation,  or  a  cataplasm  of  convallaria  roots,  the 
patient  ought  to  be  directed  to  keep  the  eyelids  at  rest,  and  to  maintain  a 
certain  degree  of  pressure  on  them  by  means  of  wet  folds  of  linen,  or  the 
cataplasm.  Motion  of  the  lids  appears  to  throw  the  effused  blood  more  into 
their  loose  cellular  substance,  while  rest,  and  gentle  pressure  tend  both  to 
prevent  this,  and  to  promote  absorption. 

By  lancing  an  ecchymosis,  more  harm  is  done  than  would  arise  from  allow- 
ing the  blood  to  remain. 

After  the  swelling  has  subsided,  those  who  are  ol)liged  to  appear  in  public, 
sometimes  contrive  to  paint  the  skin  from  day  to  day,  till  the  natural  color  is 
restored. 

§  2.   Poisoned  Wounds. 

The  eyelids  are  apt  to  suffer  from  the  stings  of  bees,  wasps,  gnats,  &c. 
From  the  poisonous  principle  infused  into  the  wound,  the  stings  of  those 
insects  sometimes  produce  severe  irritation  and  inflammation  ;  and  the  effects 
are  generally  aggravated  if  the  sting  is  left  in  the  wound.  If  we  allow  our- 
selves without  resistance  to  be  stung  by  a  wasp  or  a  bee,  the  insect  gradually 
disengages  the  sting,  without  breaking  it.  The  sting  is  flexible,  and  the 
wound  is  curved  or  in  a  zigzag  direction.  If  we  drive  the  insect  away,  the 
sting  is  caught  in  the  wound,  breaks  off,  and  is  left  behind.' 

The  result,  if  there  is  only  one  wound,  is  a  circumscribed  inflammatory,  or 
erysipelatous  swelling  of  the  eyelid  and  eyebrow,  sometimes  ending  in  a  small 
slough,  sometimes  in  a  consideral)le  abscess,  which  points  and  breaks  at  the 
place  of  the  sting.  If  there  are  many  punctures,  the  reaction  may  extend  be- 
yond the  seat  of  the  injury.  Rognetta  refers',  as  to  a  well-known  fact,  to 
the  case  of  an  unfortunate  postilion,  who  having  overturned  a  beehive  by  an 
accidental  stroke  of  his  whip,  was  so  stung  about  the  eyelids  and  rest  of  his 
face,  that  his  head  swelled  prodigiously,  fever  with  delirium  ensued,  and  he 
died  in  a  few  days. 

The  treatment  in  ordinary  cases  consists  in  extracting  the  sting,  and  ap- 
plying some  refrigerant  and  astringent  lotion,  as  vinegar  and  water,  or  a 
solution  of  muriate  of  ammonia. 

Gillraan  has  recorded'  a  case  of  bite  of  the  eyebrow  by  a  dog,  followed  by 
hydrophobia ;  and  Lecheverel,  one  of  bite  of  the  upper  eyelid,  near  the 
outer  canthus,  by  a  dog  not  mad,  which  also  produced  fatal  hydrophobia.^ 
A  case  of  this  sort  is  related  by  Mr.  Haynes  Walton",  who  does  not  hesitate 
to  recommend  the  wounded  part  to  be  excised  under  such  circumstances,  not 


I 


BURNS  AND   SCALDS   OF   THE   EYELIDS.  145 

conceiving  the  alleged  power  of  neutralizing  the  poison  by  escharotics  worthy 
of  confidence. 

Case  114. — The  whole  integuments  of  the  upper  eyelid  in  a  little  boy  who  was  brought 
to  me,  were  destroyed  by  inflammation  and  sloughing,  consequent  to  a  scratch  with  the 
claw  of  a  cat.  I  feared  lest  complete  ectropium  should  be  the  result;  but  the  wound 
healed  very  slowly,  and  the  margin  of  the  lid,  having  luckily  escaped,  seemed  to  prevent 
any  eversion. 

§  3.  Burns  and  Scalds. 

Burns  and  scalds  of  the  eyelids  present  many  shades  of  severity,  depending 
on  the  nature  of  the  medium  by  which  the  heat  is  applied,  the  length  of  time 
during  which  the  parts  are  exposed  to  its  influence,  and  the  extent  and  situa- 
tion of  the  surface  affected. 

For  example,  in  cases  of  exposure  to  common  flame,  the  eyelids  have  time 
forcibly  to  close,  so  that  only  a  very  small  portion  of  the  eyelashes  is  left 
unprotected.  Common  flame,  then,  singes  in  general  merely  the  ends  of  the 
eyelashes,  and  scarcely  ever  touches  the  eyeball. 

When  gunpowder  takes  fire,  and  burns  the  eyelids,  the  flame  being  so 
sudden  and  expansive,  the  lids  do  not  close  in  time,  and  the  eyelashes,  along 
with  the  eyebrows,  are  generally  completely  burnt  off,  and  often  the  con- 
junctiva, or  the  cornea,  is  also  injured.  When  unconfined  gunpowder  takes 
fire,  there  is  generally  no  propulsion  of  its  particles,  but  grain  after  grain 
ignites  and  is  consumed,  burning  of  course  the  lids  or  any  other  part  which 
is  exposed.  For  the  same  reason,  a  rocket  taking  fire  in  the  hand,  burns  the 
face  and  destroys  the  eyelashes  and  eyebrows,  but  leaves  no  grains  imbedded 
in  the  skin,  the  conjunctiva,  or  the  cornea ;  for  the  powder  is  previously 
ground  and  mixed  with  an  additional  quantity  of  charcoal.  When  confined, 
as  in  a  flask,  the  grains  of  gunpowder,  on  the  contrary,  are  driven  about 
unexploded,  and  fi.x  in  the  skin  of  the  lids,  in  the  conjunctiva,  or  in  the 
cornea.^ 

Case  115. — A  bit  of  a  lighted  cigar,  falling  on  the  inner  extremity  of  the  left  lower 
lid,  gave  rise  to  a  blister  and  ulcer,  with  much  thickening  of  the  lid  and  general  chemosis 
of  the  conjunctiva.  The  swelling  subsided  and  the  sore  healed  slowly,  under  the  appli- 
cation of  cold  water. 

A  person  falling  down  in  an  epileptic  fit,  perhaps  brings  the  eyelids  into 
merely  momentary  contact  with  the  ribs  of  the  grate  and  burns  them  super- 
ficially ;  or,  remaining  insensible  for  a  considerable  time,  and  lying  in  contact 
with  the  fire,  a  large  portion  of  the  integuments  of  the  face  is  disorganized, 
and  that  so  deeply,  that  on  the  eschar  separating,  the  bones  are  exposed. 

All  cases  of  burns  and  scalds  of  the  eyelids  should  be  treated  with  particu- 
lar care ;  for  there  is,  on  the  one  hand,  the  danger  of  anchyloblepharon,  or 
union  of  the  edges  of  the  lids,  and  on  the  other,  of  lagophthalmos  and 
ectropium. 

If  hot  water,  or  some  caustic  fluid,  is  the  offending  cause,  much  will 
depend  on  the  temperature  of  the  former,  and  on  the  degree  of  concentra- 
tion of  the  latter. 

It  is  chiefly  in  cases  of  scalds  from  boiling  water,  and  other  hot  or  caustic 
fluids,  as  sulphuric  acid,  in  which  the  cuticle  covering  the  edges  of  the  lids 
has  been  detached,  and  the  patient  afterwards  allowed,  from  carelessness,  to 
lie  for  a  length  of  time  with  the  lids  shut,  that  anchyloblepharon  follows. 
To  prevent  this,  if  possible,  the  patient  should  be  obliged  frequently  to  open 
his  eyes,  while  a  little  mild  salve,  melted  on  the  point  of  the  finger,  should 
be  introduced  along  their  edges.  Symblepharon,  or  union  of  the  lids  to  the 
eyeball,  is  sometimes  produced,  when  the  conjunctiva  has  been  injured  by  the 
burn  or  scald.     Its  prevention  should  be  attempted  in  a  similar  way. 

Burns  and  scalds  of  the  external  surface  of  the  lids,  which  have  not  been 
10 


146  BURNS  AND   SCALDS   OP  THE  EYELIDS. 

sufficiently  severe  to  produce  a  separation  of  the  cuticle,  much  less  to  destroy 
the  texture  of  the  cutis,  require  merely  to  be  kept  constantly  wet  with  water 
for  twenty-four  hours,  by  means  of  a  fold  of  linen.  The  same  application  is 
also,  I  conceive,  the  best  in  cases  in  which  the  skin  is  blistered  ;  only,  that 
as  soon  as  the  blister  has  fairly  formed,  it  ought  to  be  punctured  with  a  needle, 
to  let  its  contents  escape.  After  the  first  twenty-four  hours,  a  piece  of  soft 
linen,  spread  with  simple  cerate,  is  to  be  applied. 

Burns  so  severe  as  to  destroy  the  texture  of  the  cutis,  heal  only  by  a  slow 
process  of  granulation  and  cicatrization.  The  granulations,  upon  which  the 
new  skin  is  formed,  are  afterwards  absorbed,  so  that  a  great  degree  of  con- 
traction is  produced  ;*  and  if  the  eyelids  are  involved  in  the  cicatrice,  they 
are  liable  to  be  shortened  or  everted.  This  happens  more  frequently  to  the 
lower  than  to  the  upper  lid ;  while,  in  some  cases  of  destruction  of  the  skin 
stretching  from  the  outer  angle  of  the  eye  towards  the  temple,  we  find,  after 
the  burn  has  healed,  that  both  lids  are  dragged  outwards,  and  their  internal 
surface  exposed.  One  of  the  worst  cases  of  eversion  of  the  lids  from  a  burn, 
which  I  have  seen,  was  consequent  to  total  destruction  of  a  large  portion  of 
the  skin  of  the  face,  occasioned  by  a  child  falling  against  the  fire.  The  lobe 
of  the  ear  was  lost,  the  cicatrice  was  very  extensive,  and  both  lids  were  everted, 
and  dragged  towards  the  temple.  In  such  a  case,  it  is  impossible  to  prevent 
altogether  the  displacement  of  the  lids,  attendant  on  the  contraction  of  the 
cicatrice.  In  cases  of  burning  of  the  eyelids  from  the  individual  falling 
upon  the  fire,  where  the  destruction  of  parts  is  such  that  little  else  is  left 
than  cartilage  and  conjunctiva,  the  consequent  ectropium  is  necessarily  so 
great,  that  the  eye  inflames,  suppurates,  and  perishes,  from  exposure.  But, 
in  ordinary  and  less  severe  cases,  much  may  be  done  by  careful  dressing  and 
bandaging.  The  lids  must  be  kept,  as  much  as  possible,  on  the  stretch, 
during  the  progress  of  cicatrization ;  for  if  this  is  not  done,  little  or  no  new 
skin  will  be  formed,  but  the  ulcer  will  be  covered  at  the  expense  of  the  loose 
integuments  around,  in  the  same  way  as  an  ulcer  of  the  scrotum  will  some- 
times heal  up  without  almost  any  formation  of  new  skin.  The  patient,  then, 
in  whom  the  cicatrization  of  a  burn  in  the  neighborhood  of  the  eyelids  is 
going  on,  ought  not  to  be  allowed  to  use  his  eyes,  but  should  keep  the  lids, 
both  of  the  injured  and  of  the  sound  side,  constantly  shut,  except  when  the 
dressings  are  changed.  Let  pledgets,  spread  with  simple  cerate,  be  laid 
upon  the  parts,  and  round  the  head  a  roller  applied  so  as  to  press  gently  on 
the  lids,  and  keep  them  on  the  stretch.  This  will  appear  probably  a  very 
tedious  and  annoying  mode  of  treatment.  To  be  allowed  to  use  the  eyes, 
would  be  much  more  agreeable  to  the  patient,  till  he  found,  as  soon  as  the 
process  of  healing  was  finished,  that  he  could  only  incompletely  close  his 
lids,  or  that  a  portion  of  their  inner  surface  was  permanently  exposed  by 
eversion. 

Burns  by  gunpowder  are  to  be  treated  in  the  same  way  as  other  burns, 

*  [Such  a  doctrine  as  the  contraction  of  a  wound  healing  by  granulation  and  cicatriza- 
tion, being  produced  by  the  absorption  of  the  granulation,  is  not  tenable  at  the  present 
day,  when  we  have  the  microscopic  researches  of  Paget  and  others,  proving  most  con- 
clusively that  it  is  due  to  a  change  iu  the  form  of  the  lymph  corpuscles  or  nucleated  cells, 
composing  the  granulations.  These  cells  having  developed  themselves  from  a  round,  or 
oval  cell,  into  a  narrow  filament  of  cellular  or  fibro-cellular  tissue,  of  course  occupy  much 
less  space  than  when  they  composed  the  granulating  surface.  "The  whole  mass  of  the 
developing  cells  becomes  more  closely  packed,  and  the  tissue  that  they  form  becomes 
much  drier;  with  this,  also,  there  is  much  diminution  of  vascularity.  Thus,  there  re- 
sults a  considerable  decrease  of  bulk  in  the  new  tissue  as  it  develops  itself;  and  this 
decrease  beginning  with  the  development  of  the  granulation  cells,  continues  in  the  scar, 
and,  I  think,  suflaciently  accounts  for  the  contraction  of  both,  without  referring  to  any 
vital  power."  (Paget). — H.] 


WOUNDS  OF  THE  EYEBROW  AND  EYELIDS.  14T 

except  when  unexploded  grains  of  the  powder  have  been  forced  into  the 
skin  of  the  eyelids.  When  this  is  the  case,  the  particles  must  be  carefully- 
picked  out,  one  by  one,  with  a  cataract  needle  ;  an  operation  which  may  take 
hours  to  accomplish.  Under  such  circumstances,  we  should  not  trust  much 
to  the  application  of  a  poultice,  which  is  recommended  with  the  view  of  dis- 
solving and  bringing  away  the  grains  of  powder.  If  they  are  left  in  the 
skin,  indelible  spots  remain  as  if  the  person  were  tattooed. 

§  4.   Incised  and  Lacerated  Wounds. 

Punctured  wounds  of  the  eyebrow  and  eyelids  are,  in  general,  not  attended 
by  any  bad  consequences.  We  must  be  upon  our  guard,  of  course,  lest  a 
punctured  wound  of  the  upper  lid  has  gone  deeper  than  its  mere  external 
appearance  might  denote,  and  the  instrument  with  which  the  wound  was 
inflicted  penetrated  into  the  orbit,  or  through  the  orbitary  plate  of  the  frontal 
bone.  (See  page  54.)  We  must  also  examine  carefully  whether  any  portion 
of  the  instrument  (the  broken  end  of  a  stick,  for  example)  may  not  have 
separated  in  the  wound,  and  be  lodged  in  the  loose  areolar  tissue  around  the 
eyeball. 

The  edges  of  incised  wounds  of  the  eyebrow  are  to  be  brought  accurately 
together,  and  retained  by  the  interrupted  suture,  with  slips  of  court-plaster 
between  the  stitches.  Dieffenbach  used  the  twisted  suture  in  such  cases, 
inserting  fine  insect  pins,  and  twisting  a  thread  around  them.  The  same 
practice  is  to  be  followed  in  incised  wounds  of  the  eyelids.  Even  when  they 
are  parallel  to  the  fibres  of  the  orbicularis  palpebrarum,  and  implicate  only 
the  integuments,  we  shall  find  the  suture  the  best  means  of  maintaining  the 
edges  of  the  wound  in  exact  apposition,  and  thereby  preventing  any  un- 
sightly cicatrice.  Stitches  are  still  more  necessary  where  the  whole  thick- 
ness of  the  lid  has  been  divided,  either  transversely  or  vertically.  When  the 
wound  is  transverse,  we  may  content  ourselves  with  including  only  the  in- 
teguments in  the  suture  ;  but  in  vertical  wounds,  the  needle  ought  to  pass 
through  the  whole  thickness  of  the  divided  lid.  After  the  stitches  are  inserted 
and  the  slips  of  plaster  applied,  the  eyelids  are  to  be  closed,  and  covered 
with  a  pledget  spread  with  simple  cerate.  A  folded  piece  of  linen  is  to  be 
laid  over  the  sound  eye,  and  a  roller,  going  round  the  head,  is  to  press  gently 
upon  both  eyes,  so  as  at  once  to  keep  the  dressings  in  their  place,  and  to 
restrain  the  lids  from  moving.  Generally,  by  the  third  day,  union  is  effected, 
so  that  the  threads  may  be  cut  out,  or  the  pins  removed  ;  after  which,  the 
slips  of  plaster  are  to  be  replaced,  as  well  as  the  compresses  and  roller. 

If  the  edges  of  a  wound  of  the  lids  do  not  correspond,  they  must  be  made 
to  do  so  by  the  application  of  the  scissors.  If  a  large  piece  of  skin  be  lost, 
so  that  the  edges  of  a  transverse  wound  cannot  be  made  to  meet,  subsequent 
ectropium  may  sometimes  be  prevented,  by  making  an  incision  parallel  to 
the  wound,  and  about  a  quarter  of  an  inch  from  its  exterior  edge,  which  will 
allow  the  edges  of  the  wound  to  be  drawn  together.  A  vertical  wound  of 
either  eyelid,  passing  through  its  whole  thickness  so  as  to  divide  it  into  two 
flaps,  somewhat  like  the  two  portions  of  a  hare-lip,  has  received  the  name  of 
coloboma.  If  neglected,  the  edges  of  such  a  wound  are  apt  to  cicatrize  sepa- 
rately. A  similar  deformity  sometimes  occurs  congenitally.^  An  operation 
analogous  to  that  for  the  cure  of  hare-lip,  is  to  be  had  recourse  to  under  such 
circumstances.  The  edges  of  the  coloboma  are  to  be  pared,  and  then  accu- 
rately brought  into  contact,  and  kept  so  by  one  or  two  sutures  and  slips  of 
court-plaster,  till  reunion  is  completed. 

If  a  vertical  wound  of  either  eyelid  is  treated  merely  by  the  application  of 
plasters,  without  any  suture,  the  one  edge  of  the  wound  is  apt  to  slip  under 
the  other,  union  is  effected  in  this  position,  and  the  cilia  of  the  flap  which  is 


148  WOUNDS  OF  THE  EYEBROW  AND  EYELIDS. 

undermost,  are  turned  in  on  the  eye.  Should  this  have  happened,  the  two 
flaps  must  be  separated  with  the  knife,  and  their  edges  being  pared  with 
scissors,  must  be  brought  accurately  together  with  a  suture  or  two. 

Case  116. — A  little  boy  had  the  lower  eyelid  torn  through,  near  the  inner  can  thus,  by 
the  paw  of  a  dog.  He  was  carried  into  a  surgeon's  shop,  and  a  piece  of  adhesive  plaster 
put  over  the  wound.  Some  days  after,  being  called  to  see  him,  I  found  the  flap  rolled  in, 
so  that  the  cilia  were  out  of  sight.  The  adhesions  were  not  yet  so  strong,  but  I  could  tear 
them  asunder  with  a  probe ;  after  which  I  applied  stitches,  and  a  compress  and  roller. 

It  occasionally  happens  that,  through  a  wound  of  either  eyelid,  the  eyeball 
is  injured.  This  does  not  alter  the  mode  of  proceeding  with  regard  to  the 
lid.  So  instantaneous  is  the  instinctive  shutting  of  the  eye  when  approached 
by  any  foreign  body,  the  eyeball  rolling  upwards  and  the  lid  at  the  same 
moment  descending,  that  the  wound  of  the  lid  and  that  of  the  ball  will  pro- 
bably correspond,  when  the  eye  is  closed ;  and  the  eye  being  kept  in  that 
state  after  the  injury,  symblepharon  is  not  unlikely  to  take  place.  Mr.  Law- 
rence mentions  a  case  in  which  a  horizontal  wound  of  the  upper  lid  having 
been  neglected,  a  sort  of  button-hole  was  formed,  from  the  edges  not  having 
been  kept  in  apposition  ;  what  was  worse,  accretion  of  the  conjunctival  sur- 
face of  the  palpebra  to  the  globe  had  taken  place,  and  the  lid  hung  so  much 
over  the  globe  as  to  render  the  eye  almost  useless."  On  the  1st  May,  1836, 
I  saw  a  boy  at  the  Glasgow  Eye  Infirmary,  who  had  been  wounded  in  the 
upper  eyelid  six  weeks  before,  with  a  sharp  piece  of  stoneware.  The  lid  could 
not  be  raised  from  the  eyeball  so  as  to  bring  the  cornea  into  view.  There 
was  evidently  symblepliaron,  and  probably  the  eyeball  had  been  penetrated, 
at  the  time  of  the  wound,  as  well  as  the  eyelid. 

Lacerated  wounds  of  the  eyebrow  and  eyelids  do  not  so  readily  admit  of 
union  as  incised  wounds.  The  swelling,  inflammation,  and  suppuration  which 
ensue,  prevent  immediate  union.  Allowed  to  heal  without  particular  care, 
the  contraction  during  the  ])rogress  of  cicatrization  is  apt  to  produce  ectro- 
pium,  against  which  we  ought  to  guard  by  treating  lacerated  wounds  of  these 
parts  almost  exactly  as  we  would  do  incised  wounds.  Having  carefully 
cleaned  them,  and  removed  any  foreign  substances  which  may  have  been 
forced  into  the  cellular  membrane,  we  bring  the  edges  accurately  together. 
If  the  means  employed  to  produce  reunion,  do  not  succeed,  or  if  they  seem  to 
produce  additional  irritation,  they  must  be  removed,  and  the  cure  must  be 
eSected  by  the  second  intention.  When  the  contusion  and  laceration  attend- 
ing a  wounded  eyelid  are  very  great,  of  course  no  attempt  at  union  need  be 
made,  till,  by  leeching,  and  poulticing  with  bread  and  water,  the  irritation 
and  tumefaction  shall  have  subsided.  By  guarding  against  motion,  and  by 
the  careful  use  of  compresses  and  adhesive  plasters  after  the  parts  have 
become  quiet,  we  shall  often  be  able  to  accomplish  reunion  without  any  con- 
siderable deformity  or  displacement. 

[A  dressing  for  all  wounds  of  the  eyelids,  which,  whilst  it  would  keep  the 
lips  of  the  wound  in  close  apposition — paralyze  the  orbicularis  and  levator 
and  yet  be  devoid  of  the  weight  and  heat  of  the  compresses  and  bandages 
usually  employed  for  the  purpose — but  which  do  not'fulfil  all  that  they  are 
designed  to  accomplish — would  be  a  great  desideratum  to  the  ophthalmic 
surgeon.  We  believe  that  all  the  requirements  of  such  a  dressing  are  met 
in  the  dressing  which  we  are  now  in  the  habit  of  employing  in  wounds  of  the 
lids,  and  also  in  all  wounds  of  the  ball,  and  even  after  operations  for  cataract 
at  Wills's  Hospital.  It  consists  of  a  very  delicate  silk  tissue,  with  large 
meshes,  known  as  the  "Donna  Maria  gauze,"  which  we  secure  to  the  oppo- 
site sides  of  a  wound  by  means  of  the  collodion.  By  securing  one  end  first 
on  one  side  of  the  gaping  surface,  and  then,  after  the  collodion  has  become 
completely  firm,  drawing  on  the  other  end,  we  get  a  firm  purchase,  and  are 


WOUNDS  OP  THE  EYEBROW  AND  EYELIDS.  149 

enabled  to  approximate  the  lips  of  the  wound  with  a  much  greater  degree  of 
accuracy  than  by  the  use  of  either  the  ordinary  adhesive  plaster,  or  the  isin- 
glass cloth  applied  in  a  similar  manner.  Then  binding  the  free  end  down  on 
the  opposite  side,  we  have  the  wound  completely  closed;  and  yet  its  whole 
length  in  the  integument  is  exposed  through  the  delicate  meshes  of  the  tissue, 
and  we  can  make  such  topical  applications  as  we  may  desire  directly  to  it. 
-  The  introduction  of  this  mode  of  dressing  wounds  generally  is  due  to  the 
ingenuity  of  Dr.  Paul  B.  Goddard,  of  this  city,  who  has  employed  it  very  exten- 
sively in  all  his  surgical  dressings  ;  and  it  was  from  seeing  him  use  it  in  wounds 
of  the  face  that  its  general  and  peculiar  applicability  to  all  wounds  about  the 
eye  was  suggested  to  us.  We  now  employ  it  to  the  exclusion  of  all  other 
dressing  for  the  eye ;  and  it  is  also  employed  by  our  colleague,  Dr.  Harts- 
horne,  who  was  the  first  to  use  it  (at  our  suggestion)  in  the  hospital. 

In  a  simple  transverse  wound  of  the  upper  lid,  after  approximating  its  lips, 
and  securing  them  by  sutures,  if  necessary,  we  take  a  piece  of  the  gauze,  about 
one  inch  broad,  and  three  or  four  inches  long,  and  applying  one  end  to  the 
upper  lid  at  the  brow,  and  painting  it  over  with  the  collodion,  it  soon  becomes 
securely  bound  to  the  integuments.  We  paint  in  this  way  little  by  little, 
until  we  get  the  whole  of  it  covered  down  to  the  upper  lip  of  the  wound.  We 
then  allow  the  collodion  to  become  dry  and  firm.  Then  drawing  on  the  free 
end,  the  lips  of  the  wound  are  completely  approximated ;  and,  if  it  is  near  the 
brow,  we  secure  the  gauze  to  the  free  margin  of  the  lid,  and,  after  the  collo- 
dion has  become  dry,  then  we  securely  paralyze  the  muscles  of  the  lid  by 
fastening  what  remains  of  the  gauze  to  the  cheek,  having  previously  drawn 
the  upper  lid  down  to  the  lower,  and  pushed  up  the  integument  of  the  cheek, 
so  that  everything  may  be  tight  after  the  collodion  last  applied  has  evapo- 
rated. 

If  the  wound  is  near  the  ciliary  margin  of  the  lid,  we  do  not  bind  the  gauze 
in  a  second  place  to  the  lid,  but,  drawing  from  the  first  purchase,  we  close 
the  lids,  and  secure  the  dressing  to  the  cheek  as  above  described.  In  a  ver- 
tical wound,  after  having  closed  the  cut  by  a  piece  of  the  gauze  applied  hori- 
zontally, we  secure  the  quiet  of  the  lid  by  a  piece  applied  from  the  brow  and 
upper  lid  to  the  cheek,  covering  all  the  lid  with  the  collodion,  except  where 
the  wound  is,  which  we  leave  covered  by  the  gauze  only. — H.] 

Wounds  of  the  lids  from  explosions  often  present  a  frightful  appearance, 
and  are  apt  to  leave  the  parts  in  a  very  altered  condition. 

Case  117. — A  gunsmith,  employed  to  repair  a  musket,  which  he  was  told  was  not 
charged,  put  the  breech  of  it  in  the  fire,  and  looked  in  at  the  muzzle.  A  small  charge  of 
powder  which  was  in  it  exploded,  and  tore  his  right  upper  eyelid  through  at  its  inner 
extremity,  forming  a  deep  fissure  in  the  inner  canthus,  completely  charring  and  blacken- 
ing all  the  parts  with  powder,  and,  though  the  eyeball  was  left  entire,  burning  the  cornea 
and  rendering  it  opaque. 

Case  118. — Amraou"  gives  a  figure  of  a  boy,  who  was  wounded  by  a  musket-ball,  which 
passing  from  left  to  right,  struck  the  face  so  that  it  tore  away  the  left  lower  lid,  destroyed 
the  left  eyeball,  penetrated  the  arch  of  the  nose,  tore  away  the  right  lower  lid,  and  burst 
the  right  eyeball.  The  eyes  atrophied,  and  in  place  of  the  lower  lids  there  was  an  ex- 
posed red  mucous  surface ;  the  upper  lids,  being  no  longer  connected  at  their  extremities 
by  any  commissure,  were  slightly  everted,  and  had  lost  their  natural  motion. 

From  lacerated  wounds,  gangrene  and  sloughing  of  the  injured  part  may 
take  place,  and  one  or  other  lid  may  be  destroyed. 

Case  119. — A  man  calling  to  consult  me  regarding  an  afiFection  of  the  lungs,  T  noticed 
something  remarkable  about  one  of  his  eyes,  and  on  examination  found  the  lower  lid 
entirely  wanting.  The  skin  of  the  cheek  ended  abruptly  in  the  conjunctiva  oculi.  The 
upper  lid  was  elongated,  so  as  to  supply  the  deficiency.  On  inquiring  into  the  history  of 
the  case,  he  told  me  that,  several  years  before,  he  had  received  a  severe  injury  of  the  lid 
with  a  reaping-hook,  followed  by  such  a  degree  of  inflammatioD,  probably  gangrenous,  as 
destroyed  the  lid  entirely. 


150  WOUNDS   OF  THE  BRANCHES   OF   THE   FIFTH  NERVE. 

Ill  lacerated  wounds,  the  lids  may  be  so  much  injured,  that,  after  recovery, 
one  or  other  of  them,  or  both,  shall  be  found  adherent  to  the  eyeball,  and  the 
patient  scarcely  able  to  expose  any  part  of  the  eye.  If  the  smallest  chink, 
however,  continues  open,  the  eyeball  will  turn  towards  that  point,  and  vision 
be  thereby  accomplished ;  as  was  the  fact,  no  doubt,  in  the  case  related  by 
Smetius,*'^  in  which  the  lids  seemed  so  altered,  and  so  agglutinated  to  the 
eyeball,  that  when  the  patient  began  to  discern  objects,  it  was  absurdly  con- 
cluded that  he  saw,  not  from  between  the  lids,  but  down  the  nose,  which  had 
also  been  severely  injured,  and  remained  more  expanded  than  natural. 

Incised,  and,  still  more,  lacerated  wounds  of  the  lids  are  apt  to  bring  on 
erysipelas,  which,  by  passing  deep  into  the  orbit,  may  affect  the  brain  or  its 
membranes  and  cause  death,  as  I  shall  have  occasion  to  state  more  fully  in 
the  Third  Section  of  this  Chapter. 

Wounds  of  the  upper  eyelid  are  occasionally  followed  by  palsy,  in  conse- 
quence of  the  injury  done  to  the  levator  palpebraj  superioris,  or  to  the  branch 
with  which  it  is  supplied  by  the  third  nerve.  This  branch,  however,  cannot 
be  reached,  unless  the  wound  penetrates  pretty  deep  into  the  orbit,  and  tra- 
verses the  levator  muscle.  Pare  observes*'  that  the  patient,  when  he  wishes 
to  see,  is  obliged  to  raise  the  eyelid  with  his  finger.  He  attributes  this  con- 
sequence of  a  wound  of  the  upper  eyelid,  to  unskilfulness  or  inadvertence  on 
the  part  of  the  surgeon,  inasmuch  as  he  must  have  omitted  sewing  the  wound 
properly,  and  applying  the  necessary  compresses  and  bandage.  M.  Ribes 
mentions  the  case  of  a  soldier  who  had  received  a  cut  from  a  sabre  in  the 
upper  eyelid,  towards  the  superior  edge  of  the  tarsus.  The  wound  healed 
readily :  but  the  patient,  even  while  he  retained  the  faculty  of  vision,  saw 
none,  on  account  of  the  impossibility  of  raising  the  upper  eyelid,  which  con- 
tinued constantly  depressed."  Such  facts,  while  they  must  impress  us  with 
the  importance  of  leaving  nothing  undone  which  is  likely  to  procure  a  com- 
plete reunion  of  the  divided  parts,  may  serve  also  to  warn  us  against  pro- 
nouncing a  prognosis  too  decidedly  favorable,  in  those  cases  in  which  we 
have  reason  to  suspect  that  the  levator  of  the  upper  eyelid,  or  its  nerve,  may 
have  been  injured. 

Wounds  of  the  eyebrow  and  eyelids  are  sometimes  followed  by  effects  still 
more  serious.  I  have  already  (page  50)  quoted  a  case  from  Dease,  and  re- 
ferred to  another  by  Petit,  in  which  injuries  of  this  sort  were  followed  by 
inflammation  within  the  cranium,  and  death.  Weakness  of  sight,  or  even 
loss  of  vision,  is  another  consequence  apparently  arising  from  even  trifling 
injuries  of  the  eyebrows  and  eyelids,  which  has  attracted  much  attention. 
For  example,  Camerarius  relates  the  case  of  a  young  man  who  received  a 
slight  wound  at  the  inner  angle  of  the  left  eye  close  to  the  upper  eye- 
lid. The  wound,  though  small,  penetrated  to  the  bone,  and  the  patient 
immediately  felt  a  severe  pain,  which  was  attended  by  swelling  of  the  part, 
and  by  palsy  of  the  right  side  of  his  body.  The  vision  of  the  right  eye 
became  dim,  and  that  of  the  left  was  totally  lost,  although  nothing  appeared 
diseased  about  the  eye,  except  a  slight  dilatation  of  the  pupil.  The  left 
upper  eyelid  was  also  paralyzed.  The  use  of  hot  mineral  waters  seemed  to 
restore  the  motion  of  the  lid,  and  also  of  the  right  leg  and  arm.  The  sight 
of  the  right  eye  was  in  some  degree  recovered,  but  that  of  the  left  was  irre- 
mediably lost.  Morgagni  was  consulted  by  a  lady,  who  had  been  wounded 
close  to  the  left  eye,  in  two  places,  by  the  fragments  of  the  glass  of  a  carriage 
window.  She  had  seen  none  during  the  four  days  which  followed  the  acci- 
dent. One  of  the  wounds  was  near  the  outer  angle,  and  the  other,  which  was 
smaller,  was  under  the  commencement  of  the  eyebrow.  Sabatier  quotes^^ 
these  facts,  as  illustrative  of  the  effects  of  injuries  done  to  the  branches  of  the 
fifth  pair  of  nerves. 


AMAUROSIS  CONSEQUENT   TO  WOUNDS   OF  THE  EYELIDS.         151 

Petit  having  submitted  to  the  French  Academy  of  Surgery  the  case  of  an 
officer,  who  became  completely  amaurotic  in  consequence  of  a  sword-wound 
in  the  eyebrow ;  some  explained  the  fact  by  attributing  it  to  the  concussion 
of  the  brain,  produced  by  the  instrument  of  injury ;  others  thought  it  probable 
that  the  sword  had  penetrated  the  orbit,  and  touched  the  brain  ;  while  a  third 
party  denied  the  fact  altogether.  In  this  state  of  the  question,  Yicq  d'Azyr 
had  recourse  to  experiment.  He  laid  bare,  in  a  variety  of  animals,  the  frontal 
and  superciliary  branches  of  the  fifth  pair  ;  he  bruised  and  tore  the  exposed 
nerves  ;  and  convinced  himself  that  this  was  speedily  followed  by  blindness.^^ 

Sabatier,  Beer,  and  others  suppose,  that  the  injury  of  the  supra-orbitary 
nerve,  or  of  some  other  of  the  branches  of  the  fifth  pair,  operates  sympa- 
thetically on  the  eye,  through  the  medium  of  the  nasal  branch  of  that 
nerve,  which  assists  in  the  formation  of  the  lenticular  ganglion.  Admitting 
this  supposition  to  be  true,  the  question  naturally  arises,  how  an  injury  of 
the  fifth  pair,  operating  through  the  medium  of  the  lenticular  ganglion,  should 
produce  blindness.  This  point  has  been  taken  up  by  M.  Ribes,  who  con- 
tends that  the  ciliary  nerves  do  not  all  go  to  the  iris  ;  but  that  several  of 
them,  having  reached  the  anterior  part  of  the  eye,  penetrate  the  corpus  ciliare, 
and  send  filaments  back  towards  the  retina.*'  Even  such  a  connection,  were 
its  truth  established,  would  by  no  means  explain  how  the  irritation  arising 
from  an  injury  of  a  branch  of  the  fifth  nerve,  could  affect  the  retina,  unless 
through  the  medium  of  the  brain. 

Beer  has  discussed  the  subject  of  amaurosis  from  wounds  of  the  branches  of 
the  fifth  nerve,  at  great  length.'^  The  substance  of  his  observations  is,  that 
in  severe  cases  the  blindness  may  be  instantaneous ;  in  less  severe  cases,  slow, 
sometimes  not  till  after  the  process  of  cicatrization  has  begun,  or  is  com- 
pleted ;  that  it  may  be  a  consequence  of  tension  of  the  nerve,  or  pressure 
upon  it  produced  by  the  cicatrice ;  that  the  pupil  is  sometimes  expanded, 
sometimes  contracted,  in  such  cases ;  that  we  must  beware  of  confounding 
amaurosis  from  wounds  of  the  branches  of  the  fifth  pair,  with  amaurosis  from 
concussion  of  the  eyeball,  and  perhaps  laceration  of  the  retina,  and  bear  in 
mind  that,  along  with  a  wound  of  the  eyebrow  or  eyelids,  there  may  have  been 
a  severe  blow  on  the  eyeball ;  that  in  cases  in  which  the  amaurosis  is  really 
sympathetic,  vision  may  often  be  completely  restored  by  dividing  the  lacerated 
nerve. 

Chopart,'^  Boyer,*"  and  others  have  adopted  a  different  view  from  that  of 
Sabatier  and  Beer,  upon  the  subject  of  amaurosis  consequent  to  wounds  of 
the  eyebrow  and  eyelids.  They  have  observed  that  blindness  is  not  the  only 
attendant  on  such  injuries ;  but  that  convulsions,  palsies,  delirium,  coma,  and 
even  death,  have  not  unfrequently  been  known  to  result  apparently  from  such 
wounds,  but  in  fact  from  disease  of  the  brain,  either  concomitant  with,  or  pro- 
duced by,  the  external  injury.  They  have,  therefore,  concluded  that  we  ought 
not  to  account  the  amaurosis  a  mere  nervous  sympathetic  effect,  or  a  mere 
reaction  from  the  injured  nerve  of  the  face  upon  the  nerves  of  the  iris  or 
retina ;  but  that  the  irritation  arising  from  the  wound  is  propagated  to  the 
brain ;  that  the  nervous  symptoms  which  follow,  are  to  be  ascribed  to  disease 
arising  in  that  organ ;  and  that  the  affection  of  the  brain,  or  of  its  membranes, 
in  such  cases  generally  partakes  of  the  nature  of  inflammation,  followed  by 
effusion,  or  by  suppuration.  In  many  cases  of  this  sort,  the  result  has  been 
fatal,  and  dissection  has  demonstrated  the  truth  of  these  views ;  while  in  cases 
of  recovery,  we  should  be  led  to  suspect,  that  the  amaurosis,  and  other  nervous 
symptoms,  have  disappeared,  not  in  consequence  of  our  dividing  the  injured 
nerve,  but  from  the  diseased  state  of  the  brain  having  subsided. 

The  instances  on  record  which  show  that  very  serious  or  even  fatal  disease 
of  the  brain,  may  arise  in  connection  with  apparently  slight  wounds  of  the 


152  AMAUROSIS  CONSEQUENT   TO   WOUNDS   OF  THE   EYELIDS. 

eyebrow  or  eyelids  are  sufficiently  numerous.  Morgagni  lias  narrated**  several 
highly  interesting  cases  of  this  sort.  The  conclusion  to  be  drawn  from  such 
cases  is  evidently  this,  that  we  must  watch  the  effects  of  such  injuries,  keep 
the  patient  quiet  and  on  low  diet,  and  have  recourse  freely  to  the  use  of  blood- 
letting, if  there  appear  the  slightest  symptoms  of  any  affection  of  the  brain 
or  its  membranes.  Similar  practice  must  be  followed,  if  we  have  reason  to 
conclude  that  the  amaurosis  concomitant  with  a  wound  of  the  eyebrow  or 
eyelids  is  the  result,  not  of  the  injury  done  to  the  branches  of  the  fifth  nerve, 
but  of  concussion  of  the  eyeball.  I  have  seen  numerous  examples  of  a  blow 
on  the  eye  inducing  amaurosis,  without  in  the  least  affecting  the  vascularity, 
or  the  transparency,  of  its  different  textures  ;  and  I  can  easily  conceive  that, 
had  any  wound  of  the  integuments  in  the  neighborhood  of  the  eye  accompa- 
nied such  blows,  I  might  have  been  led  into  the  erroneous  supposition  that 
the  amaurosis  was  not  direct,  but  sympathetic. 

My  own  experience  leads  me  to  state,  that  a  very  considerable  proportion 
of  the  subjects  of  asthenopia  and  of  amaurosis  present  cicatrices  of  the  eye- 
brow or  its  neighborhood ;  and  a  suspicion  naturally  arises,  when  no  other 
more  likely  cause  is  detected,  that  these  affections  of  sight  have  originated 
in  injuries  of  the  branches  of  the  fifth  nerve.  In  some  cases  I  have  seen 
acute  inflammation  of  the  retina  and  iris  excited  by  snch  injuries  ;  much  more 
frequently  the  affection,  which  has  interfered  with  the  nutrition  of  the  eye 
and  the  soundness  of  the  retina,  has  either  been  slow  and  insidious  in  its  pro- 
gress, or  has  established  itself  soon  after  the  injury,  but  without  being  ob- 
served. In  all  such  cases  I  should  suspect  that  injury  of  the  branches  of  the 
fifth  nerve,  having  communicated  irritation  to  the  nervous  centres,  a  reflex 
disease,  probably  inflammatory,  was  propagated  from  them  to  the  optic  nerve, 
and  to  the  other  nerves  concerned  in  the  function  of  vision.  Such  consider- 
ations would  lead  us,  in  cases  of  suspected  injury  of  the  branches  of  the  fifth 
nerve,  not  only  to  enjoin  rest,  to  treat  the  patient  antiphlogistically,  but  to 
administer  calomel,  with  opium,  in  doses  sufficient  to  affect  the  system. 

It  is  proper  to  mention,  before  quitting  this  subject,  that  the  section  of  the 
injured  nerve,  proposed  by  Beer,  and  which  he  expressly  states  to  be  a  means 
which  had  never  failed  him,  has  been  repeated  in  several  instances  by  others, 
without  producing  any  effect  upon  the  amaurosis.  "I  have  met,"  says  Dr. 
Hennen,  "  with  one  or  two  cases  of  amaurosis  from  wounds  of  the  supra- 
orbitary  nerve  ;  the  perfect  division  of  the  nerve  produced  no  alleviation  of 
the  complaint,  but  after  some  time  the  eye  partially  recovered."*'^  "When 
the  defective  vision  follows  a  wound  in  the  forehead,"  says  Mr.  Guthrie, 
"  the  only  hope  of  relief  that  we  are  at  present  acquainted  Avith,  lies  in  a  free 
incision  made  down  to  the  bone,  in  the  direction  of  the  original  wound  ;  and 
even  of  the  efficacy  of  this  I  am  sorry  I  cannot  offer  testimony  from  my  own 
practice,  having  failed  in  every  case  in  which  I  tried  it."^ 

Many  other  remedies  deserve  a  trial,  in  cases  of  amaurosis  apparently 
arising  from  injuries  of  the  fifth  pair,  besides  the  operation  here  referred  to. 
In  a  case  recorded  by  Dr.  Lichtenstadt,  in  which  the  amaurosis  seems  to  have 
originated  in  a  wound  of  the  infra-orbitary  nerve,  made  in  opening  a  scrofu- 
lous abscess,  electricity  appeared  singularly  useful  in  restoring  vision.** 

It  is  well  known,  that  every  wound  of  the  branches  of  the  fifth  pair  does 
not  produce  amaurosis.  In  a  case  which  fell  under  my  observation,  mydriasis 
rather  than  amaurosis  was  the  effect  of  such  an  injury ;  for  while  with  the 
naked  eye  the  patient  could  not  tell  that  a  paper  held  before  him  was  printed, 
when  he  looked  through  a  pin-hole  in  a  card,  he  could  read  even  a  small  type. 
Magendie  has  even  endeavored  to  show  by  experiment  that  pricking  the 
branches  in  question,  especially  the  supra-orbitary,  infra-orbitary,  and  lachry- 
mal, has  no  bad  effect  on  vision.     He  has  been  led  to  propose  galvanizing 


PHLEGMON  OF  THE   EYELIDS. 


153 


the  eye,  by  touching  these  nerves  directly  with  the  wires  communicating  with 
the  opposite  poles  of  a  galvanic  trough.-'^  The  consideration  of  these  facts 
naturally  leads  us  to  regard  with  still  greater  doubt,  the  alleged  occurrence 
of  purely  sympathetic  amaurosis  from  slight  injuries  of  the  fifth  pair,  and  to 
suspect  that,  in  supposed  cases  of  this  soi't  there  has  been,  in  addition  to  the 
external  injury,  either  concussion  of  the  eyeball,  or  disease  excited  within  the 
cranium.^ 


•  '  Lawrence's  Treatise  on  the  Diseases  of  the 
Eye,  p.  126;  London,  1833. 

'  Zeitschrift  fiir  die  Ophthalmologie;  Vol.  i. 
125;  Dresden,  1830. 

'  Reaumur,  Histoire  des  Guepes;  Meinoires 
de  rAcademie  Royale  des  Sciences,  1719;  p. 
350;  Amsterdam,  1723. 

*  Cours  public  d'Ophthalmologie  ;  Lancette 
Franfaise,  7  Janvier,  1S37. 

'  Dissertation  on  the  Bite  of  a  Rabid  Animal, 
p.  170;  London,  1812. 

^  Quoted  from  Bulletin  des  Sciences  Medi- 
cales  ;  Tome  ii.;  Paris,  1808:  in  Langenbeck's 
Bibliothek;  Vol.  iii.  p.  666:  Gottingen,  1810. 

'  Operative  Ophthalmic  Surgery,  p.  93;  Lon- 
don, 1853. 

'  See  Lonsdale,  Medical  Gazette ;  Vol.  xi.  p. 
696;  London,  1833. 

°  Das  Auge,  vom  Professor  Beer,  p.  55  ; 
Wien,  1813  :  Heyfelder,  Amnion's  Zeitschrift 
fiir  die  Ophthalmologie;  Vol.  i.  p.  481;  Dres- 
den, 1831. 

'°  Op.  cit.  p.  127. 

"  Klinische  Darstellungen  der  Krankheiten 
des  Auges;  Zvfeiter  Theil;  Taf.  vi.  fig.  17; 
Berlin,  1838. 

'^  Trnka  de  Krzowitz,  Historia  Amauroseos, 
p.  16:  Vindobonae.  1781. 

"  (Euvres;  Li  v.  x.  Chap.  24. 

'*  Memoires  de  la  Societe  Medicale  d'Emu- 
lation;  Vol.  vii.  p.  92  ;  Paris,  1811. 


"  Traite  d'Anatomie;  Tome  iii.  p.  228; 
Paris,  1791. 

"^  Journal  Complementaire  des  Sciences 
Medicates;  Vol.  xliv.  p.  201.  Paris,  1832. 

'''  Memoires  de  la  Societe  Medicale  d'Emu- 
latinn;  Tome  vii.  p.  99;  Paris,  1811. 

'*  Lehre  von  den  Augenkrankheiten ;  Vol.  i, 
pp.  176,  185,  189;  Wien,  1813. 

'°  Treatise  on  Chirurgieal  Diseases,  trans- 
lated by  TurnbuU ;  Vol.  i.  p.  267 ;  London, 
1797. 

^°  Traite  des  Maladies  Chirurgicales;  Tome 
V.  pp.  245,  248;  Paris,  1816. 

^'  De  Sedibus  et  Causis  Morborum,  Lib.  iv. 
Epist.  51;  Tom.  iii.  p.  59;  Ebroduni,  1779, 
See  a  case  in  Bright's  Reports;  Vol.  ii.  Part 
i.  p.  143;  London,  1831. 

^'^  Observations  on  some  Important  Points  in 
Military  Surgerj-,  p.  366;  Edinburgh,  1818. 

^'  Lectures  on  the  Operative  Surgery  of  the 
Eye,  p.  102;  London,  1823. 

^'  Grafe  und  W^alther's  Journal  der  Chirurgio 
und  Augenheilkunde  ;  Vol.  vi.  p.  569  ;  Berlin, 
1824. 

^^  Journal  de  Physiologic;  Tome  vi.  p.  156  ; 
Paris.  1826. 

^*  On  amaurosis  from  wounds  of  the  eyebrow, 
consult  Walther,  Grafe  und  Walther's  Journal 
der  Chirurgie  und  Augenheilkunde;  Vol.  xxix. 
p.  505;  Berlin,  1840. 


SECTION  II. — PHLEGMONOUS  INFLAMMATION  OF  THE  EYELIDS. 
Syn. — Blepharitis  phlegmonosa. 

Phlegmonous  inflammation  of  the  eyelids  occurs  more  frequently  in  children 
than  in  adults,  and  oftener  in  the  upper  than  in  the  lower  lid. 

Symptoms. — The  affected  lid  is  of  a  deep  red  color,  hot,  swollen,  and  very 
painful  on  being  touched.  The  swelling  spreads  from  the  edge  of  the  lid, 
but  is  generally  limited  in  its  progress  by  the  margin  of  the  orbit.  It  is  soon 
so  considerable  as  to  prevent  the  eye  from  being  opened;  the  pain  is  much 
increased  by  the  least  attempt  to  move  the  eye.  If  the  inflammation  is 
unchecked,  the  pain  becomes  pulsative,  the  swelling  increases,  assumes  a 
livid  red  color,  and  begins  to  point,  generally  about  the  middle  of  the  lid. 
The  pain  is  now  attended  by  a  pricking  sensation.  The  hardness  of  the 
swelling  diminishes,  and  at  its  most  prominent  part  it  becomes  less  sensitive 
to  the  touch.  The  lid  has  suppurated,  the  fluctuation  of  the  matter  is  now 
distinct,  and  by  and  by  the  abscess  bursts  through  the  integuments.  In 
some  cases  the  abscess  gives  way  on  the  inside  of  the  lid. 

Causes. — Abrasion  and  other  injuries  of  the  skin  covering  the  eyelids, 
appear  to  bring  on  phlegmonous  inflammation  ;  but  not  unfrequently  the 
cause  is  obscure,  especially  when  children  are  the  subjects. 

Fropiosis. — This  disease  being  neglected  or  mistreated,  a  portion  of  the 


154  ERYSIPELAS  OF  THE  EYELIDS. 

integuments  of  the  eyelids  may  be  lost,  from  ulceration,  or  from  the  inflamma- 
tion going  on  to  gangrene ;  the  consequence  will  be  contraction  of  the  lid, 
and  perhaps  ectropium. 

Treatment. — Leeches  to  the  swollen  lid,  followed  by  the  constant  applica- 
tion of  an  evaporating  lotion,  constitute  the  local  treatment  during  the  first 
or  purely  inflammatory  stage.  The  patient  is  also  to  be  purged,  to  keep  at 
rest,  and  live  low.  If  these  means  are  found  insufficient  to  procure  the  reso- 
lution of  the  inflammation,  a  warm  bread  and  water  poultice  is  to  be  applied 
in  a  linen  bag,  and  as  soon  as  fluctuation  is  distinct,  the  abscess  is  to  be 
opened  with  the  lancet,  the  incision  being  made  transversely,  or  parallel  to 
the  natural  folds  of  the  skin  of  the  eyelids.  The  matter  is  generally  found 
immediately  under  the  skin.  The  poultice  is  to  be  continued  till  the  swelling 
subsides,  and  the  abscess  ceases  discharging. 


SECTION  ni. — ERYSIPELATOUS  INFLAMMATION  OF  THE  EYELIDS. 

S'jn. — Blepharitis  Erysipelatosa. — DiflFuse  cellular  inflammation  of  the  eyelids. 
Fig.  Dalryniple,  PI.  \ll.fig.  3. 

In  erysipelas  of  the  face,  vulgarly  styled  the  rose,  the  eyelids  are  much 
affected,  especially  the  upper.  Erysipelas  may  also  arise  in  the  eyelids,  and 
be  confined  to  one  or  other  of  them,  or  afi"ect  both.  In  general,  one  side  of 
the  face  only  is  alfected ;  but  sometimes  both  at  once,  or  first  the  one,  and 
then  the  other.  The  disease  is  very  variable  in  severity.  Affecting  the 
eyelids,  without  tumor  or  vesication,  and  assuming  a  chronic  course,  it  is 
styled  erythema. 

Local  Symptoms. — In  erysipelas,  the  lids  are  much  swollen,  so  that  the  eye 
is  shut  up.  The  swelling  is  of  a  pale  red  color,  but  sometimes  of  a  bright 
scarlet,  or  even  of  a  deep  and  livid  red.  The  redness  disappears  on  pressure, 
but  instantly  returns  when  the  pressure  is  removed.  The  pain  is  in  general 
not  considerable,  nor  pulsative.  The  swelling  feels  hot,  and  the  patient 
complains  of  a  stinging  and  burning  sensation  in  the  part.  A  serous  effusion 
frequently  takes  place  under  the  cuticle,  which  becomes  elevated  in  vesicles. 
These  bursting,  allow  the  fluid  they  contain  to  escape  and  form  crusts.  On 
these  falling  off,  the  skin  is  generally  left  in  a  sound  state ;  and  the  swelling 
subsiding,  the  eyelids  recover  their  power  of  motion. 

In  more  severe  cases,  the  inflammation  runs  on  into  suppuration  and 
sloughing  of  the  subcutaneous  cellular  membrane.  In  such  cases,  the  redness 
has  more  of  the  livid  hue,  the  swelling  is  more  considerable,  and  soon  becomes 
tense  and  firm,  the  sensation  of  heat  and  pain  is  much  aggravated,  and  is 
attended  by  throbbing.  At  first,  the  areolar  tissue  contains  a  whey-like 
serum.  Mr.  Lawrence  mentions  his  having  seen  this  effusion  into  the  eyelids, 
almost  of  milky  whiteness.  It  gradually  becomes  yellow  and  purulent,  and  is 
diffused  through  the  swollen  cellular  membrane,  which  becomes  so  disorgan- 
ized, that  it  comes  away,  after  the  abscess  bursts  or  is  opened,  in  shreds 
soaked  with  matter.  An  erysipelatous  abscess  differs  from  a  phlegmonous 
one  in  this  respect,  that  it  is  not  bounded  by  a  sphere  of  adhesive  inflamma- 
tion, but  extends  irregularly  in  different  directions,  producing  extensive 
sloughing  of  the  cellular  membrane.  An  abscess  of  this  sort  communicates  a 
peculiar  boggy  impression  to  the  finger.  If  neglected,  suppuration  may  take 
place  as  well  beneath  as  exterior  to  the  orbicularis  palpebrarum,  and  even 
destroy  the  ligamentous  layer  of  the  eyelids.  At  length,  the  integuments 
give  way  in  one  or  more  points,  a  small  quantity  of  matter  is  discharged,  and 
ghreds  of  disorganized  cellular  membrane  may  be  extracted.     Left,  in  this 


ERYSIPELAS   OF  THE  EYELIDS.  155 

way,  to  run  its  course,  severe  erysipelas  leaves  the  lids  so  altered,  and  their 
several  textures  so  agglutinated  from  the  loss  of  the  connecting  cellular  mem- 
brane, that  they  are  long  before  they  recover,  if  ever  they  recover,  their 
natural  pliancy  and  mobility. 

The  conjunctiva.  Meibomian  follicles,  and  excreting  lachrymal  organs, 
always  suffer  more  or  less  in  erysipelas  of  the  eyelids.  A  puro-mucous  secre- 
tion accumulates,  during  the  night,  along  the  edges  of  the  lids,  and  in  the 
nasal  angle  of  the  eye.  From  this  symptom,  the  inexperienced  practitioner, 
called  to  an  advanced  case  of  erysipelas  of  the  lids,  is  apt  to  suppose  that  it 
is  one  of  contagious  ophthalmia.  The  absorption  of  the  tears  is  impeded, 
and  there  is  a  slight  accumulation  of  mucus  in  the  lachrymal  sac.  In  some 
cases,  a  stillicidium  lachrymarum  remains  after  all  the  other  symptoms  have 
disappeared.  In  severe  cases,  ending  in  diffuse  suppuration,  the  matter 
occasionally  penetrates  into  contact  with  the  lachrymal  sac,  which  is  already 
distended  by  the  presence  of  an  inordinate  quantity  of  mucus.  After  the 
integuments  in  such  a  case  give  way,  a  superficial  observer  may  be  deceived 
by  the  appearance  of  the  parts.  He  probably  pronounces  the  case  to  be 
a  fistula  of  the  lachrymal  sac,  and  forthwith  opens  the  sac.  It  may  happen, 
however,  that  the  purulent  matter  of  an  erysipelatous  abscess  actually  makes 
its  way  into  the  lachrymal  sac,  which  thus  comes  to  be  filled  with  pus  received 
from  without,  in  the  production  of  which  its  lining  membrane  has  had  no  share. 
The  latter  case,  which,  for  the  sake  of  distinction,  may  be  called  spurious 
fistula  of  the  lachrymal  sac,  must  be  carefully  distinguished  both  from  the 
former,  in  which  the  sac  is  entire,  though  distended  with  mucus,  and  from 
those  diseases  hereafter  to  be  described,  in  which  the  purulent  matter  which 
fills  the  sac,  is  the  result  of  inflammation  of  the  lining  membrane  of  that 
cavity  itself.  The  sac,  and  the  lachrymal  canals,  may  suffer  so  much  by 
being  involved  in  the  erysipelatous  abscess,  as  to  be  rendered  ever  afterwards 
unfit  to  execute  their  functions. 

Erysipelatous  inflammation,  spreading  from  the  eyelids  to  the  cellular  mem- 
brane of  the  orbit,  sometimes  terminates  in  abscess  within  that  cavity,  or 
effusion  of  matter  within  the  orbital  capsule.  This  appears  to  be  one  of  the 
modes,  perhaps  the  most  frequent  but  least  suspected  mode,  in  which  erysip- 
elas of  the  face  or  scalp  proves  fatal.  The  fatal  result,  under  such  circum- 
stances, is  generally  ascribed  to  effusion  within  the  head,  but  may  happen 
without  any  inflammatory  affection  of  the  membranes  or  substance  of  the 
brain  being  detected  after  death.  In  such  cases  the  formation  of  matter 
within  the  orbit  sometimes  takes  place  suddenly,  at  other  times  slowly  and 
insidiously.  The  matter  is  often  found  deposited  in  small  quantities  in  dif- 
ferent parts  of  the  orbit. 

Numerous  cases  similar  to  the  following  one,  are  recorded  by  M. 
Piorry  : — 

C«sel20.  —  A  woman,  aged  60,  who  had  been  admitted  into  the  Salpetriere,  on  ac- 
count of  slight  bronchitis,  was  seized  with  erysipelas,  commencing  on  the  right  cheek, 
and  affecting  chiefly  the  region  of  the  lachrymal  sac.  The  redness  extended  to  the  eye- 
lids, which  became  so  much  swollen  as  to  close  the  eye.  The  disease  spread  to  the  other 
parts  of  the  face  and  to  the  opposite  eye.  The  part  first  affected  ceased  on  the  fourth 
day  to  be  elastic,  and  became  doughy.  The  general  health  was  not  at  first  affected  ;  but 
the  pulse  rose  as  the  disease  made  progress,  and  on  the  third  day,  stupor,  coma,  and 
delirium  were  added  to  the  other  symptoms.     The  hairy  scalp  was  scarcely  affected. 

The  disease  was  not  at  first  regarded  as  one  of  serious  import.  An  abstemious  diet, 
and  some  simple  lotion,  made  up  the  treatment.  When  the  symptoms  grew  more  se- 
vere, and  the  much  swollen  eyelids  became  covered  with  vesicles,  numerous  leeches  were 
employed,  and  derivatives  applied  to  the  lower  extremities.  These  means  proved  fruit- 
less, and  the  patient  died  on  the  fifth  day. 

On  inspection,  24  hours  after  death,  the  skin,  which  had  been  so  very  red  during  life, 
was  everywhere  of  the  same  color  as  that  of  the  other  parts  of  the  body.    It  was  scarcely  at 


156  ERYSIPELAS   OF  THE   EYELIDS. 

all  thickened.  Pus  was  found  in  two  small  abscesses,  about  the  size  of  a  pea,  in  the  eel-' 
lular  substance  of  the  right  cheek,  close  to  the  periosteum ;  and  another  small  abscess, 
not  communicating  with  the  former,  was  situated  over  the  nasal  duct.  The  eyelids  pre- 
sented pus  in  their  cellular  tissue.  On  removing  the  roof  of  the  right  orbit,  small  deposi- 
tions of  pus  were  found  in  the  fatty  cellular  membrane  around  the  optic  nerve,  and  in  that 
covering  the  floor  of  the  orbit,  chiefly  towards  its  inner  wall.  There  was  no  large  ab- 
scess, neither  did  the  small  depositions  of  pus  communicate  with  one  another.  With  the 
exception  of  the  cellular  tissue,  noue  of  the  parts  within  the  orbit  appeared  inflamed ; 
but  the  same  was  the  case  with  the  skin,  although  during  life  it  had  presented  a  crimson 
color.  The  left  orbit  contained  no  pus;  nor  was  there  any  abscess  in  or  under  the  scalp. 
The  brain  presented  no  inflammatory  nor  other  diseased  appearance.  The  lungs  had  suf- 
fered from  pneumonia.  The  stomach,  otherwise  healthy,  contained  a  quantity  of  green- 
ish and  apparently  bilious  fluid.     The  intestines  were  sound.' 

It  sometimes  happens  that  the  cellular  membrane  of  the  orbit,  although 
considerably  affected  by  inflammatory  oedema,  does  not  suppurate.  On  the 
subsiding  of  the  acute  symptoms,  the  eyeball  in  such  cases  may  be  found  de- 
prived of  its  power  of  motion,  protruded,  or  even  amaurotic  from  the  pres- 
sure it  has  undergone. 

Case  121. — In  a  case  which  came  under  my  notice,  and  which  had  been  attended  with 
suppuration  of  both  upper  and  lower  lids,  the  lids  having  been  long  kept  closed,  and  the 
conjunctiva  much  inflamed,  union  took  place  between  the  upper  lid  and  the  lower  edge  of 
the  cornea,  ulceration  of  the  latter  having  no  doubt  preceded  this  symblepharon.  The 
probe  was  readily  passed  around  the  point  of  union,  and  the  adhesion  was  divided  so  as 
to  restore  to  the  lid  its  natural  motion.  Tlie  centre  of  the  cornea  was  found  to  be  clear, 
the  pupil  natural  in  size,  but  motionless,  and  the  retina  insensible. 

Constitutional  Symptoms. — Erysipelas  of  the  eyelids  is  generally  preceded 
by  rigors,  and  attended  by  a  considerable  febrile  irritation.  The  tongue  is 
loaded,  and  the  digestive  organs  much  deranged.  In  fatal  cases,  death  is 
preceded  by  delirium,  subsultus  tendinum,  and  coma. 

Causes. — As  this  disease  frequently  arises  suddenly,  without  any  local 
injury,  it  probably  owes  its  origin  to  some  peculiar  state  of  the  atmosphere, 
or  to  contagion.  It  is  certainly  much  more  apt  to  attack  those  whose  sto- 
mach and  bowels  are  in  bad  order.  Local  causes,  as  slight  injuries,  stings 
from  wasps  and  other  insects,  leech-bites,  incised  or  lacerated  wounds  of  the 
eyelids,  cuts  and  other  injuries  of  the  scalp,  the  application  of  blisters  on  the 
head,  exposure  of  the  eyes  suddenly  to  cold  after  long-continued  weeping, 
and  the  like,  serve  to  produce  it. 

Treatment. — An  emeto-cathartic  is  the  best  of  all  general  remedies  to  begin 
with,  in  erysipelas ;  for  example,  one  or  two  grains  of  tartras  antimonii,  with 
an  ounce  or  two  of  sulphas  magnesise,  dissolved  in  two  pints  of  water,  and 
a  teacupful  given  every  two  hours.  In  robust  subjects,  blood-letting  may  be 
practised  with  good  effect;  but  in  aged  or  debilitated  patients,  this  remedy 
can  scarcely  be  ventured  on.  Leeches  may  be  applied  on  the  temple  or  be- 
hind the  ear.  After  the  stomach  and  bowels  have  been  freely  evacuated, 
gentle  diaphoretics  are  to  be  employed.  The  patient  must  be  put  on  low 
diet. 

A  prejudice  exists  among  the  vulgar,  against  every  sort  of  wet  application 
in  erysipelas ;  but  I  have  witnessed  much  advantage  from  the  use  of  evapo- 
rating lotions  in  this  complaint,  and  have  never  seen  them  do  harm.  The 
part  affected  may  be  sponged  with  spirits  of  wine,  or  kept  wet  with  vinegar 
and  water. 

A  solution  of  nitrate  of  silver,  in  the  proportions  of  4  grains  to  1  ounce 
of  distilled  water,  dropped  once  or  twice  a  day  upon  the  conjunctiva,  re- 
presses the  inordinate  secretion  of  mucus. 

We  seldoiii  require  to  touch  the  eyelids,  when  affected  with  erysipelas,  with 
the  lancet.  Cases,  however,  do  occur,  in  which  scarifications,  or  even  pretty 
deep  incisions,  ought  to  be  employed. 

Sir  Richard  Dobson's  mode  of  scarification  consists  in  making  fine  punc- 


PHLEBITIS   OF  THE  EYELIDS.  157 

tures,  with  the  point  of  a  lancet,  over  the  whole  inflamed  part,  in  number 
from  ten  to  fifty;  then  fomenting  with  warm  water  in  a  sponge,  to  encourage 
the  bleeding  and  serous  discharge  ;  and  repeating  this  operation  two  or  three 
times  in  twenty-four  hours,  if  the  parts  look  red  and  tense.  If  done  early, 
it  shortens  the  disease  ;  at  all  events,  it  relieves  the  vessels  in  a  very  remark- 
able degree,  thus  producing  local  benefit,  while  it  also  serves  to  check  the 
severity  of  the  cerebral  and  general  symptoms.  It  prevents  vesication,  and 
what  is  more  important,  diminishes  the  chance  of  suppuration.  Provided 
the  punctures  are  very  minute,  and  not  lengthened  into  small  incisions,  they 
never  leave  any  permanent  marks,  even  on  the  smooth  skin  of  the  forehead, 
much  less  on  the  eyelids.^  Dr.  Bright  relates^  ten  cases  of  erysipelas,  treated 
by  minute  punctures.  In  most  of  them  the  lids  were  affected,  and  the  prac- 
tice appears  to  have  been  highly  beneficial. 

In  severe  cases  threatening  to  go  into  suppuration,  the  treatment  by  inci- 
sions ought  to  be  adopted.  One  or  more  transverse  incisions  through  the 
skin  and  subcutaneous  substance  of  the  affected  lid,  if  employed  early,  may 
prevent  suppuration  and  sloughing  ;  if  later,  it  will  afford  the  readiest  outlet 
for  the  matter  and  disorganized  cellular  membrane.  The  incision  is  to  be 
made  cautiously,  through  the  tissues  of  the  lid,  layer  by  layer,  and  is  immedi- 
ately to  be  followed  by  the  application  of  a  warm  bread  and  water  poultice. 

The  reader  will  find  cases,  serving  to  illustrate  both  the  progress  of  the 
complaint,  and  the  mode  of  treatment  by  incisions,  related  by  Mr.  Lawrence, 
in  his  valuable  paper  on  the  nature  and  treatment  of  erysipelas,  in  the  14th 
volume  of  the  Medico-Chirurgical  Transactions. 

Should  the  symptoms  in  erysipelas  of  the  lids  lead  us  to  suspect  that  the 
disease  is  tending  inwards  to  the  orbital  cellular  membrane,  calomel,  with 
opium,  should  be  given,  and  blisters  applied  behind  the  ear,  and  to  the 
temples.  If  the  eyeball  has  become  very  prominent,  and  it  seem  probable 
that  this  is  owing  to  the  infiltration  of  pus  into  the  cellular  substance  of  the 
orbit,  or  a  collection  of  fluid  in  the  orbital  capsule,  the  lancet  should  be  em- 
ployed to  give  the  matter  exit.  The  situation  where  matter  is  most  frequently 
deposited,  is  between  the  eyeball  and  the  floor  of  the  orbit.  Should  no 
matter  flow  on  making  a  deep  incision,  still  the  discharge  of  blood  will  pro- 
bably prove  serviceable.  The  method  of  opening  the  orbital  capsule  is  to 
divide  the  conjunctiva  over  the  space  between  the  rectus  internus,  and  rectus 
inferior,  as  in  the  operation  for  strabismus,  and  then  direct  the  lancet  back- 
wards by  the  side  of  the  eyeball. 

If  a  spurious  fistula  of  the  lachrymal  sac  has  formed,  it  is  to  be  washed 
out  once  a  day  with  tepid  water,  mixed  with  a  little  of  the  vinous  tincture 
of  opium.  A  small  quantity  of  lint  dipped  in  the  same  tincture  is  then 
introduced  into  the  abscess,  but  not  pushed  so  deep  as  to  enter  the  sac. 
After  the  fistula  has  healed,  should  Uennorrhcea  of  the  sac  continue,  it  will 
require  to  be  treated  as  explained  in  the  Third  Section  of  Chapter  VI. 


'  Piorry,  Clinique  Medicale  de  rHojiital  de         *  Medico-Chirurgical  Transactions,  Vol.  xiv. 
la  Pitie  et  de  I'Hospice  de  la  Snlpelriere,  en     p.  20(i ;  London,  1828. 

1832,  p.  381  ;  Paris,  1833.  =  lleports   of  Modical  Cases;  Vol.  ii.  p.  98  j 

London,  1831. 


SECTION  IV. — PHLEBITIS  OF  THE  EYELIDS. 
Syn. — Blepharitis  pblebitica. 

Case  122. — A  man  of  78  years  of  age  was  admitted  into  the  Hotel-Dieu  at  Nantz,  with 
erysipelatous  swelling  of  the  face  and  eyelids.  He  had  a  quick  pulse,  pain  in  his  fore- 
head, and  great  thirst.     General  blood-letting,  an  abstemious  diet,  and  diluents  were 


158  CARBUNCLE   OF  THE  EYELIDS. 

employed.  The  cedematous  state  of  the  eyelids  increased,  and  spread  to  the  ocular  con- 
junctiva. A  considerable  cedematous  swelling  was  also  observed  in  the  right  parotid 
region.  The  tension  and  redness  abated  considerably,  but  the  pulse  continued  quick,  the 
patient  talked  much,  became  delirious,  and  was  aflFected  with  tremors  of  the  limbs.  He 
died  with  distinct  symptoms  of  an  affection  of  the  brain. 

On  dissection,  a  circumstance  attracted  notice,  which  had  not  been  observed  during 
life ;  the  veins  of  the  forehead  and  temples  felt  hard,  as  if  distended  by  an  artificial 
injection.  The  scalp  was  swollen,  especially  posteriorly;  and  presented,  towards  the 
crown  of  the  head,  and  on  the  left  side  of  the  sagittal  suture,  a  small  superficial  ulcer, 
which  the  patient  had  not  mentioned,  so  that,  although  probably  the  cause  of  all  the 
symptoms,  it  had  not  been  known  during  the  life  of  the  patient. 

The  two  frontal  veins,  and  their  ramifications,  extending  to  the  crown  of  the  head,  were 
full  of  pus,  either  concrete  or  sanious.  At  several  places  it  was  difficult  to  separate  the 
viscid  ropy  pus  from  the  lining  membrane  of  the  veins.  The  palpebral  branches,  which 
anastomose  with  those  two  trunks,  were  injected  with  purulent  matter  more  or  less  solid. 
This  state  was  more  remarkable  on  the  left  side.  The  infra-orbitary  branches  of  the 
anterior  frontal  vein  of  that  side  were  in  the  same  state,  and  an  incision  of  the  eyelid 
and  cheek  disclosed  a  multitude  of  veins,  superficial  or  deep-seated,  filled  with  purulent 
clots  or  with  a  reddish  sanies.  The  two  temporal  branches,  and  their  ramifications,  even  the 
most  deep-seated,  the  anterior  and  posterior  auriculars,  and  the  ramifications  by  which 
they  originate  in  the  cranium,  were  in  the  same  state  on  the  right  side  only.  An  incision 
of  the  subcutaneous  cellular  tissue  and  of  the  muscles  of  that  region  presented  the  same 
appearance  as  the  cheek,  only  still  more  distinctly.  A  track  of  greenish  viscid  pus 
marked  the  course  of  all  those  vessels,  the  coats  of  which  were  in  some  places  entire,  in 
others  destroyed.  The  venous  anastomoses,  external  to  the  parotid,  formed  a  network, 
which  might  be  compared  to  a  varicose  tumor,  in  a  state  of  suppuration.  The  external 
jugular  vein  contained  a  black  adherent  clot,  a  little  softened  in  its  centre.  Its  internal 
surface  was  of  a  deep  red,  and  evidently  injected.  It  was  not  permeable  to  the  blood, 
except  towards  its  lower  part.  The  internal  jugular  vein  was  healthy  and  empty.  The 
right  ophthalmic  vein  was  diseased,  and  a  venous  abscess  existed  at  the  very  point  where 
it  leaves  the  orbit  to  enter  the  cavernous  sinus.  The  disease  terminated  suddenly  at  this 
place,  being  bounded  towards  the  cranium  by  a  clot  shutting  up  the  vein.  The  sinuses 
of  the  brain  did  not  participate  in  the  disease.  The  arachnoid  was  somewhat  opaque, 
especially  on  the  left  side  and  at  the  anterior  part  of  tlie  brain.  There  was  considerable 
serous  infiltration  under  the  arachnoid  ;  with  a  little  water  in  the  ventricles.  In  none  of 
the  organs  of  the  body  was  pus  detected,  except  in  the  veins  already  mentioned.  The 
liver  was  not  examined.' 

This  case  demonstrates  the  necessity,  when  erysipelatous  swellinj^  attacks 
the  eyelids,  of  examining  the  scalp  and  of  attending  to  the  state  of  the  veins 
of  the  face.  It  also  shows  that  too  much  dependence  must  not  be  placed 
upon  an  apparent  diminution  of  the  external  symptoms ;  for  in  this  instance 
the  tension  and  redness  fell,  notwithstanding  the  impeded  and  disorganized 
state  of  a  considerable  portion  of  the  venous  system,  and  the  close  approach 
of  death.  These  cautions  are  confirmed  by  a  case  of  phlebitis  related  by 
Dr.  Silvester'^  in  which  the  disease  spread  from  the  upper  lip,  along  the  sides 
of  the  nose,  to  the  eyelids,  forehead,  and  vertex,  and  proved  fatal  two  months 
after  the  first  appearance  of  the  symptoms. 


'  Archives    Generales   de   M^decine;    Mai,         '   Medico-Chirurgical     Transactions;     Vol. 
1837;  p.  63.  xxiv.  p.  36  ;  London,  1841. 


SECTION  V. — CARBUNCLE  OF  THE  EYELIDS. 
Si/n. — Anthrax  Palpebrarum. 

^  This  circumscribed,  gangrenous  inflammation  of  the  areolar  tissue  is  occa- 
sionally met  with  in  the  eyelids.  The  swelling  is  of  a  dark  red  or  purple 
color,  extremely  hard,  and  attended  by  severe  burning  pain.  Yesicles  rise 
on  its  surface,  occasioning  intolerable  itching.  Ichorous  matter  is  discharged, 
and  the  affected  areolar  tissue  and  skin,  becoming  black  and  sloughy,  at 


MALIGNANT  PUSTULE   OF  THE  EYELIDS.  159 

length  fall  out.  The  cavity  left  by  the  separation  of  the  slough  granulates 
and  heals  up. 

Carbuncle  occurs  principally  in  old  persons,  whose  constitutions  have  suf- 
fered from  irregularities  in  diet. 

Opium  to  relieve  the  pain,  bark  and  wine  to  support  the  strength,  laxatives, 
and  gentle  diaphoretics,  make  up  the  general  treatment. 

An  early  and  free  incision  into  the  tumor  most  effectually  relieves  the 
pain,  allows  the  matter  to  escape,  and  promotes  the  separation  of  the  slough. 
An  emollient  poultice  is  to  be  applied  after  the  incision  has  been  made,  and 
continued  till  the  cavity  left  by  the  slough  has  filled  up  by  granulation.  The 
sore  is  then  to  be  dressed  with  simple  cerate. 


SECTION  VI. — MALIGNANT  PUSTULE  OF  THE  EYELIDS. 
St/n. — Die  schwarze  Pocke,  Ger. 

The  disease  long  known  in  France  by  the  name  o^ pustule  maligne,  is  a  gan- 
grenous inflammation  of  the  skin,  characterized  at  its  commencement  by  a 
vesicle  filled  with  bloody  serum,  under  which  there  forms  a  small  lenticular 
induration,  which,  in  its  turn,  soon  becomes  surrounded  by  an  erysipelato- 
phlegmonous  tumefaction,  of  a  deep  red  color  and  glistening  surface.  Gan- 
grene seizes  the  tumor,  and  extends  rapidly  from  its  centre  to  its  circum- 
ference. This  disease  would  appear  in  by  far  the  greater  number  of  cases  to 
be  produced  from  contact  with  one  or  other  of  the  lower  animals,  affected  in 
a  similar  way,  or  from  contact  with  their  carcasses.  It  is  sometimes  commu- 
nicated from  one  human  being  to  another.  It  occurs  chiefly  in  farriers,  shep- 
herds, butchers,  tanners,  and  others  occupied  much  with  the  lower  animals  or 
their  remains  ;  attacking  those  parts  of  the  body  which  are  habitually  exposed, 
as  the  face,  the  hands,  the  arms,  or  such  as  have  been  accidentally  exposed ; 
and  has  been  more  frequently  met  with  during  the  existence  of  epidemic  dis- 
eases of  the  carbunculous  description  among  cattle  than  at  other  times. 
The  bloody  serum  of  the  pustule  is  the  means  by  which  the  disease  is  pro- 
pagated. Its  progress  in  individual  cases  is  rapid,  and  the  result  often  fatal. 
Death  has  been  known  to  occur  in  24  hours  after  the  person  was  attacked. 

Malignant  pustule  is  said  to  be  rare  in  Paris  ;  but  common  in  Burgundy, 
Franche-Comte,  and  Lorraine.  I  am  not  acquainted  with  any  account  of  this 
disease  as  observed  in  Great  Britain.  It  cannot  be  denied  that  the  cases 
published*  under  the  name  of  glanders  in  the  human  subject,  bear,  in  some 
respects,  a  similarity  to  those  of  malignant  pustule ;  but,  in  glanders,  a  con- 
stitutional affection,  somewhat  like  rheumatism,  precedes  the  characteristic 
local  symptoms,  while  the  contrary  is  the  case  in  malignant  pustule.  The 
latter  disease  displays  itself  from  the  commencement,  by  gangrenous  inflam- 
mation at  the  point  inoculated  ;  but  the  former,  only  after  serious  derange- 
ment of  the  general  health,  exhibits  a  pustular  and  gangrenous  affection  of 
the  skin,  along  with  an  eruption  on  the  Schneiderian  membrane,  and  a  dis- 
charge of  purulent  matter  from  the  nostrils.  These  last  symptoms  do  not 
occur  in  malignant  pustule." 

When  malignant  pustule  attacks  the  face,  the  erysipelato-phlegmonous 
inflammation  spreads  to  the  neck,  and  even  to  the  chest.  When  the  eyelids 
are  the  seat  of  the  disease,  the  face  becomes  enormously  swollen  and  exces- 
sively pained.  The  patient  is  affected  with  deep-seated  headache,  attended 
by  delirium.  This  is  followed  by  stupor,  and  great  prostration  of  strength. 
If  he  survives  the  separation  of  the  portion  which  has  become  gangrenous, 
the  lids  are  left  in  such  a  state  of  disorganization,  that  they  consist  of  little 


160  SYPHILITIC  ULCERATION  OP  THE   EYELIDS. 

more  tlian  conjunctiva.  The  consequence  is,  that  as  the  process  of  recovery 
takes  place,  they  are  so  greatly  everted,  that  the  eye  is  lost  from  want  of  its 
natural  protection. 

The  local  treatment  most  recommended  is  a  crucial  incision  of  the  tumefied 
part,  immediately  followed  by  the  application  of  the  actual  or  potential 
cautery. 

Internally,  gentle  stimulants  and  tonics  appear  to  be  most  worthy  of  con- 
fidence.^ 

'  Brown,  Medical  Gazette  ;  Vol.  iv.  p.  1.34  ;  des  Sciences,  pour  1766  ;   Enaux  et  Chaussier, 

London,   1829  ;   Elliotson,   Medico-Chirurgical  Methode  de  traiter  les  Morsures  des  Animaux 

Transactions;  Vol.  .xvi.  p.  170;  London,  1830;  enrages,  suivie  d'un  Precis  sur  la  Pustule  Ma- 

and  Vol.   xviii.   p.   201;  London,   IS.'iS  ;    Wil-  ligne  ;  Dijon,  1785  ;  Davy  La  Chevrie,  Disser- 

liams'  Elements  of  Medicine  ;  Vol.  ii.  p.  381 ;  tation  sur  la  Pustule  Maligne  de  Bourgogne  ; 

London,  1841;    Dublin    Quarterly  Journal    of  Paris,    1S07;    Basedow,   Griife    und  Walther's 

Medical   Science;   Vol.  viii.   p.  442;    Dublin,  Journal  der  Chirurgie   und  Augenbeilkunde  ; 

1849.  Vol.  vii.  p.  184;  Berlin,  1825;  Rayer,  Traitg 

^  Rayer,   Meuioires    de   TAcademie    Royale  des  Maladies  de  la  Peau  ;  Vol.  ii.  p.  71  ;  Paris, 

de  Mcdecine  :  Tome  vi.  p.  733  ;  Paris,  1837.  1827.     At  p.  613  of  the  same  volume,  a  fatal 

'  Morand,  Memoires  de  I'Academie  Royale  case  is  detailed  at  great  length. 


SECTION  VII. — SYPHILITIC  ULCERATION  OF  THE  EYELIDS. 

Si/n. — Blepharitis  syphilitica, 
/'i'^.  Dairy mple.     VI.  WJiga.  Z,  4.     V].Yl.fg.5. 

That  the  eyelids  are  not  unfrequently  the  seat  of  syphilitic  inflammation, 
is  a  conclusion  to  which  I  have  arrived  from  witnessing  numerous  cases  of 
this  sort.  Some  of  them  were  suspected  to  be  primary ;  the  greater  number 
were  secondary. 

AVhen  we  see  an  adult  affected  with  an  ulcer  on  one  eyelid  only,  which  has 
continued  for  weeks,  or  it  may  be  months,  and  has  not  yielded  to  local  appli- 
cations, but  has  rather  grown  worse,  we  should  suspect  syphilis.  I  have 
more  than  once  seen  syphilitic  inflammation  of  the  edge  of  an  eyelid  mistaken 
for  simple  ophthalmia  tarsi ;  a  mistake  which  may  produce  disastrous  conse- 
quences. A  similar  caution  applies  to  inflammation  and  ulceration  near  the 
inner  canthus  ;  for  syphilitic  ulceration,  in  this  situation,  is  sometimes  taken 
for  dacryocystitis. 

It  is  sometimes  difficult  to  distinguish  at  first  sight,  a  syphilitic  from  a 
cancerous  ulcer  of  the  eyelid.  In  syi)hilis,  the  skin  is  more  swollen,  and  of  a 
darker  color  than  in  cancer.  In  cancer,  the  edges  of  the  ulcer  are  harder 
and  more  elevated  than  in  syphilis.  The  surrounding  integuments  are  more 
glued  down  to  the  subjacent  parts,  and  the  surface  of  the  sore  not  so  foul. 
The  sore  is  also  studded  with  roundish,  whitish  tubercles,  over  which  creep 
varicose  vessels,  appearances  which  are  not  present  in  syphilis. 

Case  123. — An  old  man,  a  patient  at  the  Glasgow  Eye  Infirmary,  acknowledged  having 
been  treated,  some  time  before,  for  a  primary  affection ;  else  I  should  have  probably 
experienced  some  difficulty  in  deciding  respecting  tlie  nature  of  the  case.  The  lid  was 
much  swollen  and  everted,  its  conjunctiva  greatly  inflamed,  and  on  the  external  sui'face 
of  the  lid  there  was  a  deep  ulcer,  painful,  and  spreading  towards  the  inner  canthus.  The 
skin  round  the  ulcer  was  of  a  dark  red  color.  [  ordered  him  two  grains  of  calomel  and 
one  of  opium,  night  and  morning.  He  returned  in  five  days,  with  another  smaller  ulcer 
near  the  punctum  lachrymale  of  the  same  lid.  The  conjunctiva,  covering  the  inner  edge 
of  the  cornea,  was  also  in  a  state  of  ulceration.  The  first  ulcer  of  the  lid  was  extending 
upwards  and  inwards,  but  at  other  parts  of  its  edge  appeared  inclined  to  cicatrize.  The 
ulcer  of  the  cornea  was  touched  with  the  lunar  caustic  solution,  and  a  cai'rot  poultice 
ordered  to  the  lid.  Nine  days  after  this,  the  eversion  and  thickening  of  the  lid  had 
become  considerably  less;  the  first  ulcer  had  coalesced  with  that  near  the  punctum,  but 
was  granulating  and  filling  up.     Soon  after  this  the  mouth  became  sore,  and  the  ulcer 

\ 


SYPHILITIC   ULCERATION   OP   THE   EYELIDS.  161 

contracted  and  healed.  The  mercury  was  stopped  and  resumed  according  to  the  state  of 
the  mouth,  and  a  decoction  of  elm  bark  was  given.  As  the  lid  continued  to  be  everted 
after  the  ulcer  had  cicatrized,  the  thickened  and  inflamed  conjunctiva  was  scarified,  and 
the  red  precipitate  salve  was  applied  every  evening ;  after  which  the  lid  completely 
resumed  its  place,  scarcely  any  deformity  being  caused  by  the  cicatrice,  and  no  opacity 
left  on  the  cornea. 

Casel24:. — A  boy,  of  7  years  of  age,  was  brought  to  me  with  a  foul  sore  occupying 
a  great  part  of  the  right  lower  lid.  Pie  had  been  under  the  care  of  a  practitioner,  who 
treated  the  case  as  one  of  fistula  of  the  lachrymal  sac,  and  thrust  a  probe  through  the 
ulcer  in  the  direction  of  the  nasal  duct.  This  made  the  ulcer  much  worse.  At  first  I 
adopted  the  idea  that  it  was  a  scrofulous  sore  ;  but  in  a  few  days,  finding  it  to  increase 
rather  than  contract  under  mild  dressings,  and  the  internal  use  of  sulphate  of  quina,  I 
began  to  suspect  a  syphilitic  taint ;  and  on  examining  the  throat,  a  foul  ulcer  was  dis- 
covered on  the  velum.  I  gave  the  patient  calomel  and  opium,  under  the  influence  of 
which  the  ulcer  speedily  contracted,  and  healed  with  considerable  eversion.  How  the 
child  had  become  affected  with  syphilis,  appeared  at  first  quite  inexplicable  ;  but  at  last 
it  came  out  that  he  had  been  sleeping  for  some  time  in  the  same  bed  with  a  person  labor- 
ing under  primary  symptoms  of  that  disease. 

Case  125. — J.  S.  aged  20  years,  was  admitted  under  my  care,  at  the  Glasgow  Eye 
Infirmary,  on  the  28th  September,  1838.  He  was  born  with  a  congenital  deficiency  of  the 
upper  part  of  the  prepuce,  while  the  opening  of  the  urethra  was  not  through  the  glans 
penis,  but  close  behind  it.  He  had  a  chancre  on  the  glans,  a  second  on  the  malformed 
prepuce,  two  syphilitic  sores  on  the  scrotum,  and  a  suspicious  looking  superficial  ulcer  on 
the  right  leg.  He  dated  these  sores  from  the  month  of  May.  Ten  weeks  before  his 
admission,  a  small  hard  swelling  formed  on  the  middle  of  the  right  upper  eyelid,  which  he 
supposed  to  be  a  stye.  When  he  applied  at  the  Infirmary,  the  whole  of  the  eyelid  was 
much  inflamed,  and  rather  of  a  livid  color.  It  felt  hard  and  tuberculated,  and  was  a  good 
deal  swollen.  Along  its  margin,  to  about  two-thirds  of  its  extent,  it  was  in  a  state  of 
ulceration,  and  presented  a  considerable  notch  jiist  about  the  middle.  The  internal  sur- 
face was  much  inflamed,  the  conjunctiva  being  thickened,  and  discharging  a  considerable 
quantity  of  puriform  mucus.  He  constantly  held  a  handkerchief  to  the  eye,  to  relieve 
the  burning  pain  of  the  ulcer.  His  right  cornea  was  nebulous,  which  he  attributed  partly 
to  ophthalmia  in  childhood.  Pulse  108,  small.  Occasional  rigors.  He  comi^lained  of 
weakness.     He  had  used  no  mercury. 

The  appearances  in  this  patient  were  very  characteristic.  The  general  swelling  of  the 
whole  eyelid,  the  hard  nodulated  surface  of  the  swelling,  the  livid  color,  the  spreading  of 
the  ulcer  along  the  edge,  which  at  one  point  it  had  notched  by  a  complete  loss  of  sub- 
stance, extending  even  to  the  cartilage,  and  the  severe  pain  felt  in  the  part,  were  all 
well  marked,  so  that,  before  asking  any  questions  about  the  patient's  previous  health,  the 
syphilitic  nature  of  the  case  was  forced  upon  my  consideration.  The  patient  gave  a  very 
confused  account  of  the  rise  and  progress  of  his  ailment ;  but  there  could  be  little  doubt 
of  the  secondary  nature  of  the  ulcer  of  the  eyelid.  All  the  sores  speedily  healed  under 
the  influence  of  calomel  and  opium. 

Syphilitic  ulceration  of  the  eyelids  generally  occurs  either  on  the  edge, 
going  on  to  destroy  at  once  the  skin,  cartilage,  and  conjunctiva ;  or  on  the 
integuments,  proceeding  rapidly  to  form  a  deep  and  foul  excavation. 

Case  126. — In  a  girl,  aged  11  years,  who  came  under  my  care  at  the  Glasgow  Eye 
Infirmary,  6th  September,  1850,  the  disease  had  gone  on  for  6  months,  and  been  treated 
as  scrofulous.  It  had  commenced  over  the  left  lachrymal  sac,  and  at  her  admission  pre- 
sented a  deep  foul  ulcer  in  the  line  of  junction  of  the  lower  lid  with  the  cheek,  while 
another  ulcer,  |  inch  long,  occupied  the  space  between  the  eyebrow  and  the  upper  lid. 
She  was  speedily  brought  under  mercury,  there  being  every  reason  to  think  that,  had 
this  not  been  done,  the  left  lids  would  have  been  completely  destroyed.  The  ulcer  soon 
improved  in  appearance,  and  ultimately  healed,  leaving  some  degree  of  lagophthalmos. 

If  near  the  inner  canthus,  the  ulcer  is  apt  to  penetrate  into  the  lachrymal 
sac.  It  would  appear  that  sometimes  the  ulcer  commences  on  the  inside  of 
the  lid,  spreading  over  a  considerable  extent  of  the  conjunctiva.  Mr.  Law- 
rence mentions  his  having  seen  instances,  in  which  foul  syphilitic  ulcers 
spread  over  the  whole  of  the  inner  surface  of  the  upper  lid,  without  appearing 
externally.  In  one  case,  the  sore,  he  believes,  would  not  have  been  dis- 
covered, if  he  had  not  been  directing  his  attention  some  time  before  to  the 
subject,  so  that  he  was  led  to  evert  the  eyelid,  when  he  discovered  a  syphilitic 
ulcer  as  large  as  a  sixpence.^ 
11 


162  SYPHILITIC   ULCERATION   OP   THE   EYELIDS. 

In  one  case  only,  have  I  seen  a  sypbilitie  ulcer  occupying  the  inner  surface 
of  the  eyelid.  On  placing  my  finger  on  the  upper  lid  externally,  I  felt  as  if 
a  hard  knot  was  situated  internally,  and  a  purulent  discharge  flowed  at  the 
same  time  from  the  upper  sinus  of  the  conjunctiva.  I  everted  the  lid  and 
found  a  foul  deep  ulcer  on  its  inner  surface.  I  touched  it  repeatedly  with 
lunar  caustic,  and  it  healed  under  mercury. 

I  remember  M.  Cullerier  mentioning  in  his  lectures  at  the  Hopital  des 
Vhieriens  that  chancres  of  the  eyelids  were  sometimes  brought  on  by  a  kiss 
from  an  infected  person,  and  in  other  cases,  by  the  virus  being  conveyed  on 
the  finger.  In  one  case  which  I  treated,  I  was  led  to  suspect  that  the  disease 
had  been  directly  conveyed  in  some  such  way  to  the  eye  ;  for,  besides  a  deep 
ulcerated  notch  in  the  edge  of  the  lower  eyelid,  there  was  a  chancre  on  the 
conjunctiva  oculi,  close  to  the  margin  of  the  cornea.  The  pupil  of  the 
.affected  eye  was  small,  and  somewhat  dragged  towards  the  ulcer,  but  there 
was  no  iritis.  The  case  did  well  under  the  use  of  mei'cury.  A  similar  ulcer, 
however,  of  the  conjunctiva  oculi,  only  smaller,  existed  in  the  old  man  whose 
case  I  have  related,  and  in  whom  the  affection  was  secondary. 

A  case  is  narrated  by  Ricord,'^  in  which  the  finger  of  the  patient  had  served 
to  convey  the  virus  from  another  person  to  his  own  eyelid,  and  in  whom  the 
pre-auricular  and  submaxillary  glands  seemed  to  have  become  infected. 

Even  when  secondary,  a  syphilitic  ulcer  on  the  eyelid  may  be  the  only 
symptom  of  syphilis  then  manifest ;  but,  in  general,  secondary  sores  on  the 
eyelids  are  attended  by  other  secondary  symptoms,  particularly  by  ulcera- 
tions of  the  throat,  and  eruptions  on  the  skin. 

In  one  case,  I  saw  a  syphilitic  ulcer  on  the  edge  of^  the  eyelid  become 
covered  with  an  elevated  conical  scab,  such  as  is  presented  in  rupia  promi- 
nens. 

Both  the  primary  and  the  secondary  cases  are  most  effectually  relieved  by 
the  use  of  mercury.  Either  to  mistake  the  nature  of  the  ulceration,  or  to  trifle 
with  it  in  the  non-mercurial  way,  would  be  to  expose  the  patient  to  the  loss 
of  the  affected  lid,  and  even  of  the  eye.  Once  healed,  the  ulcer  is  very  apt 
to  return,  if  the  mercurial  course  is  prematurely  abandoned.  In  the  case  of 
rupia,  the  internal  use  of  iodide  of  potassium  proved  of  great  service,  along 
with  mercurial  external  applications. 

The  following  case,  related  by  Sir  Charles  Bell,  is  interesting  on  several 
accounts  : — 

Case  127. — A  man  presented  himself  in  the  hospital,  with  a  squint,  the  left  eye  being 
distorted  from  the  object.  On  the  upper  lid  of  the  right  eye,  there  was  a  deep  venereal 
ulcer.  The  man  was  in  danger  of  losing  that  eye,  and  required  prompt  assistance  ;  but 
before  he  could  be  brought  under  the  influence  of  mercury,  the  sore  became  deeper,  and 
the  cornea  opaque.  The  superior  rectus  muscle  being  injured  by  the  increasing  depth  of 
the  sore,  the  pupil  became  permanently  depressed.  The  sight  of  the  right  eye  being 
now  lost,  the  left  eye  came  into  use;  it  was  directed  with  precision  to  objects,  he  had  no 
difficulty  in  using  it,  and  it  daily  became  stronger. 

After  a  few  weeks,  medicine  having  had  its  influence,  the  sore  on  the  right  upper  eyelid 
healed,  the  inflammation  of  the  eye  and  opacity  of  the  cornea  gradually  diminished,  and 
the  light  again  became  visible  to  this  eye,  first  yellow,  and  then  of  a  deep  purple.  The 
muscles  now  resumed  their  influence,  and  the  right  eye  was  restored  to  parallel  motion 
with  the  left,  so  as  considerably  to  embarrass  vision.  But  the  inflammation  of  the  upper 
eyelid  had  been  so  great  as  to  diminish  its  mobility;  and,  what  appeared  remarkable,  the 
lower  eyelid  assumed  the  office  of  the  upper,  being  depressed  when  the  patient  opened 
the  eye,  and  elevated  and  drawn  towards  the  nose  when  he  attempted  to  close  it.  The 
upper  eyelid  was  not  only  stifi",  but  diminished  in  breadth  ;  so  that,  notwithstanding  the 
remarkable  elevation  of  the  lower  lid,  their  margins  could  not  be  brought  together,  and 
the  motion  of  the  eyeball  could  be  seen.  On  the  patient's  attempting  to  close  the  eye, 
the  pupil  was  always  elevated,  and  the  white  of  the  eye  exposed." 

Dr.  Campbell  has  recorded  a  case,  in  which  the  upper  and  lower  eyelids 
of  the  right  side  were  wholly  destroyed  by  syphilitic  ulceration  : — 


SYPHILITIC   ULCERATION   OP   THE   EYELIDS.  163 

Case  128. — Henry  ]\Iuir,  aged  28,  was  admitted  into  the  Edinburgh  Royal  Infirmary, 
on  the  17th  December,  1831,  with  his  whole  forehead  covered  with  incrustations  and  cica- 
trices. Commencing  at  the  left  superciliary  notch,  and  extending  to  the  external  angle  of 
the  right  orbit,  there  was  a  lengthened  depression,  apparently  the  result  of  an  exfoliation 
of  the  right  superciliary  ridge,  and  neighboring  portions  of  the  os  frontis.  Both  eyelids  of 
the  right  side  were  completely  gone,  and  the  conjunctiva  was  found  to  be  tightly  stretched 
from  the  upper  margin  of  the  orbit,  with  which  it  was  firmly  connected,  to  the  lower, 
being  here  continuous  with  the  integuments  of  the  cheek,  as  it  was  above  with  those  of 
the  forehead.  The  whole  conjunctiva  was  thickened,  and  the  portion  to  the  inner  side  of 
the  cornea  was  partly  in  a  granulated  state.  The  cornea  was  opaque,  and  appeared  as  if 
a  thickened  and  somewhat  corrugated  membrane  extended  over  it.  Within  the  external 
angle  of  the  os  frontis,  there  was  a  small  patch  of  red  membrane,  with  some  ulcerated 
points,  through  which  a  limpid  fluid,  like  tears,  sometimes  copiously  exuded.  A  con- 
siderable part  of  the  conjunctiva  appeared  superficially  ulcerated.  No  trace  of  the  puncta 
lachrymalia  could  be  discovered.  With  this  eye  the  patient  was  sensible  only  of  very 
strong  light,  as  that  produced  by  placing  a  lighted  candle  close  to  the  eyeball.  The  eye 
moved  in  the  orbit  to  a  limited  extent,  its  motions  being  retarded  by  the  tense  state  of 
the  conjunctiva. 

The  prepuce  had  been  entirely  destroyed  by  ulceration,  leaving  the  glans  penis  un- 
covered. There  was  an  ulcer,  with  undefined  edges,  encircling  the  root  of  the  penis,  and 
another  on  the  lower  side  of  the  penis  near  the  glans,  where  a  small  opening  communi- 
cated with  the  urethra,  and  allowed  a  great  part  of  the  urine  to  escape.  An  ulcer  of  a 
similar  character  was  also  observed  on  the  nates. 

No  satisfactory  history  could  be  obtained  of  the  case.  The  ulcers  were  believed  to  be 
syphilitic,  and  the  patient  admitted  that  he  had  taken  mercury  to  a  considerable  extent. 

When  the  patient  was  admitted  into  the  hospital,  a  considerable  part  of  the  sclerotic 
conjunctiva  presented  a  raw  surface  ;  but  after  the  use  of  an  astringent  lotion,  it  came 
to  be  covered  with  a  thin  film  of  new  cuticle,  excepting  two  very  limited  portions  at  the 
inner  and  outer  angles  of  the  eye.  At  two  places,  a  little  distant  from  each  other,  near 
the  outer  angle  of  the  eye,  and  a  little  below  the  situation  of  the  lachrymal  gland,  the 
tears  were  seen  exuding  from  very  minute  and  nearly  invisible  orifices,  where  they  col- 
lected in  globules,  and  whence  they  trickled  down  the  cheek.  At  the  inner  canthus,  there 
was  sometimes  seen  resting  upon  the  surface,  a  little  clear  fluid,  which,  it  was  conjec- 
tured, might  come  from  the  lachrymal  sac,  if  this  cavity  was  not  oblitei-ated.  The  patient 
sufi^ered  neither  pain  nor  inconvenience  from  the  exposed  state  of  the  eye. 

The  ulcers  on  the  genitals,  being  in  a  chronic  and  indolent  state,  showed  little  disposi- 
tion to  take  on  a  healthy  action  ;  but  by  putting  the  patient  on  a  generous  diet,  and  ad- 
ministering nitric  acid  internally,  together  with  the  local  application  of  lunar  caustic, 
followed  by  solutions  of  sulphate  of  copper  and  sulphate  of  zinc  to  the  sores,  these  were 
brought  into  a  healing  state. "i 

la  his  remarks  on  the  case,  Dr.  Campbell  observes,  that  in  carcinomatous 
affections  of  the  eyelids,  requiring  their  removal,  surgeons  have  directed  the 
eyeball  to  be  extirpated  at  the  same  time,  in  order  to  save  the  patient  from 
the  extreme  degree  of  suffering  which  would  otherwise  arise  from  its  constant 
exposure  ;  but  that  the  case  shows  a  state  of  irritation  not  to  be  an  invariable 
result  of  such  exposure,  since  the  patient  experienced  neither  pain  nor 
uneasiness,  nor  was  likely  to  do  so,  the  parts  being  covered  and  protected  by 
the  formation  of  a  new  cuticle  over  the  surface  left  exposed  by  the  loss  of 
the  eyelids. 

This  view  of  the  matter  is  so  far  confirmed  by  the  case  of  a  pauper  patient 
in  this  town,  whom  I  had  an  opportunity  of  examining  on  the  13th  Septem- 
ber, 1838,  through  the  kindness  of  Dr.  Jackson,  under  whose  care  she  then 
was.  I  shall  here  embody  the  account,  published^  by  Dr.  Jackson,  of  this 
patient,  with  such  additional  notes  as  I  took  of  her  state.  It  must  not  be 
overlooked,  however,  that  in  cases  such  as  those  described  by  Dr.  Campbell 
and  Dr.  Jacksou,  the  eyeball  would  gradually  accommodate  itself  to  expos- 
ure, in  proportion  as  the  eyelids  became  destroyed.  The  irritation  would 
necessarily  be  much  greater,  if  these  parts  were  removed  at  once  by  a  surgi- 
cal operation. 

Case  129. — The  patient  is  a  widow  of  60  years  of  age.  The  entire  nose  and  nasal 
bones,  a  considerable  j^ortion  of  the  ethmoid  bone,  and  of  the  superior  maxillai-y  bones, 
the  inferior  turbinated  bones,  the  vomer,  and  the  whole  hard  and  soft  palate,  have  been 


164  SYPHILITIC   ULCERATION   OF  THE   EYELIDS. 

destroyed  by  ulceration  and  exfoliation,  so  that  the  nostrils  and  mouth  are  converted 
into  one  opening,  without  any  sort  of  division  even  in  front.  The  opening  is  bounded 
above  by  the  ethmoid  bone,  and  below  by  the  tongue ;  and  is  capable  of  admitting  the  5 
fingers.  The  alveolar  processes  of  the  upper  and  lower  jaws  have  been  completely 
removed.  Over  the  centre  of  the  frontal  bone  there  is  a  large  depression,  the  conse- 
quence of  repeated  exfoliation,  and  the  integuments  there  are  still  in  a  state  of  ulcera- 
tion, leaving  portions  of  dead  bone  exposed.  The  whole  of  the  upper  lip,  and  the  greater 
part  of  the  lower,  have  been  destroyed  by  ulceration ;  but  the  integuments  surrounding 
the  cavern  into  which  the  nostrils  and  mouth  are  now  converted,  though  puckered  and 
drawn  inwards,  are  perfectly  cicatrized.  Especially  on  the  left  side,  the  finger  is  easily 
passed  from  the  nostril  into  the  antrum  Highmorianum. 

The  eyelids  on  each  side,  as  well  as  the  eyebrows,  have  been  completely  removed  by 
ulceration,  and  the  skin  has  united  to  the  conjunctiva,  covering  the  sclerotica.  The 
integuments  proceed,  in  fact,  from  the  circumference  of  the  orbits  into  tlie  conjunctiva 
bulbi,  without  forming  any  fold.  The  conjunctiva  of  each  cornea  is  semi-opaque,  permit- 
ting the  dark  appearance  of  the  iris  to  be  seen,  but  not  the  pupil.  The  eyeballs  present 
their  usual  size,  form,  and  consistence ;  but  are  almost  destitute  of  motion.  When  the 
patient  makes  an  eifort  to  move  the  eyes,  a  slight  motion  of  the  skin  is  observed.  Her 
whole  power  of  vision  consists  in  a  perception  of  light  and  shade.  She  cannot  distinguish 
whether  one  or  two  fingers  be  held  before  her  eyes.  The  want  of  eyelids  does  not  cause 
her  much  uneasiness  when  the  eyes  are  shaded;  but  when  she  turns  up  her  face  towards 
the  window,  or  to  a  bright  light,  the  eyes  are  pained.  Touching  the  eyeballs  does  not 
seem  to  excite  any  pain ;  they  never  appear  red  or  inflamed.  She  does  not  seem  to  sleep 
much,  and  never  soundly.  When  she  goes  to  sleep,  she  covers  the  eyes  with  a  bit  of  cloth. 
"When  she  sits  up,  she  keeps  her  head  depressed  towards  her  breast,  so  as  to  avoid  the  light. 

On  each  side  there  is  a  small  fistulous  opening,  apparently  communicating  with  the 
lachrymal  gland,  from  Avhich  there  is  a  constant  exudation  of  limpid  fluid.  When  she 
weeps,  which  she  does  frequently,  there  is  a  copious  flow  of  tears  from  these  openings 
down  the  cheeks,  and  she  says  that  at  the  same  time  she  feels  a  burning  pain  in  the  eye- 
balls.    The  surface  of  the  eyeballs  is  always  dry.;  never  covered  with  mucosity. 

No  puncta  lachrymalia  can  be  discerned  on  either  side ;  but  below  the  inner  canthus 
on  the  right  side,  there  are  two  ulcerated  openings  which  appear  to  lead  into  the  lachry- 
mal passage.  From  the  feeling  of  elasticity  which  pressure  in  the  neighborhood  of  the 
inner  canthi,  particularly  on  the  right  side,  yields  to  the  finger,  it  is  probable  that  the 
ossa  unguis  are  gone,  though  in  consequence  of  the  firmness  of  the  cicatrice  there,  and 
the  pain  which  pressure  produces,  it  is  difficult  to  ascertain  this  point  with  anything  like 
certainty.     No  other  part  of  the  orbits,  however,  appears  to  be  destroyed. 

She  seems  to  enjoy  a  considerable  degree  of  smell.  She  can  detect  a  bad  smell ;  and 
relishes  the  odor  of  snufi". 

She  speaks  with  great  difficulty,  but  her  daughter  understands  what  she  says.  It  is 
almost  impossible  for  her  to  swallow  fluids.  When  she  swallows  spoon  meat,  she  lies  on 
her  back,  and  throwing  the  morsel  down,  she  gulps  it  with  difficulty,  and  an  expression 
of  pain.  The  tongue,  from  its  constant  exposure,  is  swollen  and  inflamed.  Her  hearing 
is  much  impaired. 

Over  the  right  scapula,  there  is  a  large  ulcer,  through  which  several  pieces  of  bone 
have  passed.  The  whole  body  is  much  emaciated.  The  arms  and  hands  are  particularly 
attenuated,  and  their  joints  very  flaccid. 

The  commencement  of  her  complaint  she  dates  14  years  back.  The  bones  of  the  head 
were  aifected,  before  any  disease  appeared  in  the  face.  The  ulceration,  after  having 
destroyed  the  lower  lip,  attacked  the  upper  eyelids,  then  the  lower  eyelids,  whence  it 
spread  downwards  and  removed  the  nose  and  upper  lip.  The  eyelids  of  both  sides  were 
removed  before  the  nose  was  involved.  She  blames  her  husband  for  improper  conduct 
towards  her.  She  never  had  any  eruption.  She  had  not  taken  mercury  antecedently  to 
the  disease  commencing  in  the  face.  After  that,  she  was  salivated  by  mercury,  and  took 
large  quantities  of  sarsaparilla,  without  the  progress  of  the  disease  being  checked.  Large 
portions  of  bone  came  away  at  various  intervals. 

Dr.  .Tackson,  in  bis  notice  of  the  case,  remarks,  that  it  shows  to  what  a  dreadful  extent 
secondary  syphilis  will  proceed,  in  spite  of  mercury,  sarsaparilla,  &c.,  in  a  patient  in 
whom  the  primary  symptoms  have  not  been  treated  with  mercui-y.  He  thinks  the  exten- 
sive exfoliation  of  bone  could  not,  in  this  instance,  be  attributed  to  mercury,  but  to  the 
influence  of  syphilis. 


'  Lectures  in  the  Lancet ;  Vol.  x.  p.  324  ;         "  Nervous  System  of  the  Human  Body :  Ap- 
London,  1826  :  Lancet  for  1830 ;  1831 ;  Vol.  i.     pendix,  p.  Ivi ;  London,  1830. 
p.  735.  '  Edinburgh  Medical  and  Surgical  Journal ; 

^  Lettres  sur  la  Syphilis ;  p.  47  ;  Paris,  1851.     Vol.  xxxvii.  p.  254 ;  Edinburgh,  1832. 

'  Lancet,  8th  September,  1838,  p.  839. 


SYPHILITIC   ERUPTIONS. — CANCER   OP   THE   EYELIDS.  165 

SECTION  Vm. — SYPHILITIC  ERUPTIONS  AFFECTING  THE  EYELIDS  OF  INFANTS. 
Fig.  Devergie,  Clinique  de  la  Maladie  Syphilitique,  PI.  37  ;  Paris,  1826. 

Infants  have  been  repeatedly  brought  to  me,  as  affected  with  sore  eyes, 
whom  I  have  found  to  be  laboring  under  the  effects  of  congenital  syphilis. 
This  disease  generally  appears  within  a  few  weeks  after  birth,  about  the  anus 
and  organs  of  generation,  and  upon  the  face  and  hands.  It  assumes  the 
form  of  pretty  broad  and  flat  pustules.  They  break,  scab,  spread,  and  run 
into  one  another,  leaving  the  skin  of  a  dark  red  color,  excoriated,  and 
chapped,  over  almost  the  whole  body,  and  with  a  peculiar  wrinkled  withered 
appearance,  especially  about  the  lips.  The  eyelids  of  such  children  inflame 
and  adhere  in  the  morning ;  the  conjunctiva,  without  being  swollen  or  much 
inflamed,  secretes  puriform  mucus ;  the  Meibomian  and  ciliary  glands  give 
out  matter  ;  the  cilia  and  the  hair  of  the  head  fall  out ;  the  nostrils  become 
stuffed,  so  as  to  prevent  the  child  from  sucking ;  the  mouth  aphthous ;  the 
voice  hoarse ;  there  is  much  restlessness,  itching,  and  fretfulness  ;  and  great 
emaciation  ensues.  The  capsule  of  the  lens  is  sometimes  to  be  observed 
quite  red,  the  pupil  becomes  contracted,  the  retina  is  probably  insensible, 
and  atrophy  of  the  eyeball  ensues.  Not  unfrequently  the  cornese  become 
infiltrated  with  pus,  and  give  way ;  an  event  indicative  of  excessive  debility, 
and  generally  a  precursor  of  death. 

Cases  of  this  kind  are  much  more  frequent  in  infants  than  syphilitic  iritis, 
uncombined  with  an  eruption.  They  may  readily  be  distinguished  from 
ophthalmia  neonatorum,  but  are  sometimes  confounded  with  ophthalmia 
tarsi.     I  have  known  cases  treated  as  itch. 

Case  130. — A  child,  5  months  old,  was  brought  to  me,  with  the  left  eye  atrophic  and 
the  right  cornea  burst,  the  mouth  presenting  the  chapped  withered  appearance,  so  cha- 
racteristic of  infantile  syphilis.  The  eruption  had  disappeared.  The  mother  was  not 
conscious  of  having  had  any  disease.  A  practitioner  to  whom  she  had  applied,  had  given 
her  cream  of  tartar  and  sulphur,  telling  her  that  by  her  taking  this  medicine,  her  child 
would  be  cured. 

From  half  a  grain  to  a  grain  of  calomel,  combined  with  from  a  twelfth  to 
a  sixth  of  a  grain  of  opium,  is  to  be  administered  thrice  a  day.  From  one 
to  two  grains  of  hydrargyrum  cum  creta,  twice  or  thrice  a  day,  answer  very 
well.  In  a  few  days,  evident  improvement  takes  place  ;  and  by  perseverance 
in  the  remedy,  a  complete  and  permanent  cure  is  effected. 

Tepid  ablution  of  the  lids,  and  mild  red  precipitate  salve  to  their  edges  on 
the  child's  going  to  sleep,  make  up  the  local  treatment. 

The  father  will  be  found  to  have  labored  under  evident  symptoms  of  syphilis, 
previously  to  the  conception  of  the  child.  The  mother  may,  or  may  not,  have 
been  affected  with  evident  symptoms ;  and  it  is  remarkable,  that  she  rarely 
if  ever,  becomes  infected  from  her  child;  but  if  any  other  woman  nurses  a 
child  diseased  in  the  manner  described,  she  is  almost  sure  to  take  syphilis, 
becoming  affected  with  first  ulcers  on  the  nipples,  followed  by  sore  throat, 
sores  on  the  genitals,  an  eruption  on  the  skin,  and  iritis.  Those  who  handle 
the  child,  also,  are  apt  to  become  infected. 


SECTION  IX. — CANCER  OF  THE  EYELIDS. 


Syn.  Cancroide  ;  Lebert.     Epithelial  cancer.     Epithelioma :  Hannover. 
Fig.  Ammon,  Zweiter  Theil,  Tab.  IIL  figs.  1,  2,  .3,  6,  7.     Dalrymple,  PI.  V.  fig.  6. 

All  parts  of  the  skin  are  not  equally  liable  to  be  affected  with  cancerous 
ulceration.     That  of  the  face,  and  particularly  that  of  the  eyelids,  is  the  most 


166  CANCER  OF  THE  EYELIDS, 

liable  ;  and  next,  that  of  the  lower  lip.  This  disease,  slowly  consuming  the 
skin  and  the  muscles,  destroys  not  merely  the  eyelids,  but  perhaps  a  great 
part  of  the  cheek,  entering  also  into  the  orbit,  attacking  the  eyeball,  and  at 
length  proving  fatal.  Dr.  Jacob,  in  some  excellent  observations^  on  the  dis- 
ease, points  out,  as  its  characteristic  features,  the  extraordinary  slowness  of 
its  progress,  the  peculiar  condition  of  the  edges  and  surface  of  the  ulcer,  the 
comparatively  inconsiderable  suffering  produced  by  it,  its  being  incurable 
unless  by  extirpation,  and  its  not  affecting  the  neighboring  lymphatic  glands. 
Although  not  exempt  from  scirrhus  and  other  malignant  diseases,  the  eye- 
brow, and  especially  the  eyelids,  are  particularly  apt  to  suffer  from  that  variety 
of  cancer,  which,  from  its  structure  being  composed  in  a  great  measure  of 
epidermic  scales,  is  known  by  the  appellation  epithelial.  This  appellation, 
bestowed  on  this  variety  of  cancer  from  the  microscopical  character  of  one  of 
its  elements,  must  not,  however,  deceive  us  into  any  less  suspicious  notion  of 
its  malignancy,  than  what  was  previously  entertained. 

Symptoms  and  progress. — This  a9"ectiou  of  the  eyelids  rarely  occurs  until 
after  middle  life.  It  presents  two  stages  ;  one  of  induration,  and  another  of 
ulceration.  At  some  particular  spot,  either  close  to  the  edge  of  one  or  other 
of  the  lids,  but  much  more  frequently  the  lower  than  the  upper,  at  their  tem- 
poral angle,  or  on  the  side  of  the  nose,  near  the  lachrymal  caruncle,  some 
degree  of  thickening  and  elevation  may  at  first  be  discovered,  indicating  the 
existence  of  a  peculiar  kind  of  growth,  but  which  the  patient  often  neglects 
as  a  wart  or  something  of  no  consequence.  The  indurated  spot  is  at  first 
uuinflamed  externally,  presenting  the  natural  color  of  the  skin,  with  the  excep- 
tion perhaps  of  some  varicose  vessels  ramifying  over  it,  and  it  is  not  particu- 
larly sensible.  It  may  remain  in  this  state  for  a  considerable  length  of  time, 
and  attract  almost  no  attention  till  it  begins  to  ulcerate. 

That  the  disease  sometimes  originates  in  a  mere  crust  or  wart,  which  being 
picked  off  with  the  finger  leaves  a  raw  surface,  exposed  to  the  irritation  of  the 
tears,  and  apt  to  spread  by  ulceration ;  or  in  some  common  sort  of  tumor, 
which,  allowed  to  burst  on  the  inside,  or,  it  may  be,  on  the  outside  of  the 
eyelid,  becomes  fretted,  and  is  thus  induced  to  assume  the  ulcerous  or  can- 
cerous action,  is  a  doctrine*  which  must  be  received  with  some  hesitation.  It 
has  been  asserted,  indeed,  that  a  mere  scratch  or  excoriation  of  the  edge  of 
the  eyelid,  or  the  irritation  of  an  old  cicatrice,  such  as  that  which  results  from 
smallpox,  may  give  rise  to  cancer  of  the  eyelids  ;  but  it  is  probable,  that  the 
ulcerative  stage  of  the  disease  is  always  preceded  by  a  deposition  or  hyper- 
trophy of  a  specific  kind. 

As  exciting  causes,  I  may  mention  a  blow  with  a  rod  of  iron  on  the  lower 
edge  of  the  orbit,  as  giving  origin  to  the  disease  in  a  man  whose  eyelids  and 
eyeball  I  removed.  In  an  old  gentleman  who  consulted  me,  the  irritation  of 
the  frame  of  his  spectacles  brought  it  on  at  the  temporal  angle  of  the  eye, 
with  eversion  of  the  upper  lid. 

A  doubtful  point  is,  whether  the  Meibomian  follicles  are  often,  or  ever, 
the  original  seat  of  this  disease ;  but  it  seems  generally  admitted,  that  the 
induration  may  commence  in  the  conjunctiva,  and  may  be  limited  to  it  for  a 
long  time ;  the  whole  structures  of  the  eyelid  becoming  at  length  thickened 
and  knobbed,  and  assuming  a  dark  red  color.  The  conjunctiva  may  then 
become  ulcerated,  and  the  ulceration  gradually  involve  the  other  textures. 

Scirrhus,  ending  in  carcinomatous  ulcer,  has  not  been  sufficiently  distin- 
guished from  epithelial  cancer.  I  was  disposed  to  consider  scirrhous  a  case 
which  came  under  my  observation,  in  which  the  first  symptoms  were  hardening 
of  the  lower  lid,  fixedness  as  if  it  had  been  glued  to  the  eyeball  so  that  it 
could  not  be  moved,  and  a  remarkable  degree  of  retraction,  as  if  the  disease, 
originating  in  the  cellular  membrane  of  the  orbit,  had  dragged  the  eyelid 


CANCER   OF   THE   EYELIDS. 


16Y 


inwards.  In  another  case,  whicli  I  saw  at  the  Glasgow  Eye  Infirmary,  19th 
May,  1842,  a  tumor  nearly  an  inch  long,  and  half  an  inch  broad,  rose  from 
the  lower  lid,  covered  at  its  middle  with  a  scab.  The  patient  was  a  woman 
of  78.  On  extirpation,  the  tumor  was  found  made  up  of  a  mixed  soft  and 
gristly  substance,  apparently  scirrhous. 

In  former  editions  of  this  work  I  spoke  of  a  variety  of  callosity  of  the  eye- 
lids, under  the  name  of  tylosis  scirrhoeides ,  which  I  am  now  disposed  to  con- 
Fig.  9. 


sider  of  the  nature  of  epithelial  cancer.  I  described  it  as  attacking  the  lower 
lid  more  frequently  than  the  upper ;  affecting  more  the  inner,  than  the  outer, 
surface  of  the  lid;  being  of  a  white,  or  slightly  yellow  color,  more  or  less 
tuberculated,  and  apt  to  end  in  ulceration.  From  its  appearance  (Fig.  9),  its 
occurring  generally  in  old  people,  its  intractable  nature,  and  its  ending  in 
ulceration.  I  said  it  was  liable  to  be  confounded  with  scirrhus,  with  which, 
however,  I  considered  it  by  no  means  identical. 

I  mentioned  that  I  had  watched  some  cases  of  this  kind  for  a  number  of 
years;  and  although  the  induration  and  swelling  did  not  subside,  yet,  by  care 
to  avoid  injuring  the  part,  using  the  red  precipitate  salve  to  the  edges  of  the 
lids,  and  applying  lunar  caustic  solution  to  the  ulcerated  points,  the  complaint 
had  been  kept  at  bay,  and  the  operation  of  removing  the  affected  part 
avoided. 

I  said  that,  although  sometimes  successful  in  warding  off  the  progress  of 
the  disease,  in  other  cases  it  had  caused  such  irritation  of  the  eye,  increased 
so  much  in  size,  and  produced  so  much  deformity,  as  to  warrant  extirpation. 
This  I  had  recourse  to  in  the  instance  figured  above.  In  none  of  the  cases 
in  which  I  operated  before  ulceration  took  place,  has  there  been  any  relapse. 

The  anatomical  structure  of  epithelioma,  as  the  disease  now  under  our 
consideration  has  been  termed,  is  different  from  that  of  any  other  variety  of 
cancer.  It  consists  not  so  much  in  the  substitution  of  a  new  tissue,  as  in  the 
alteration  of  a  normal  one;  it  is  a  hypertrophy  of  the  superficial  epidermic 
layer,  complicated  by  inflammation  and  ultimately  by  ulceration.  The  cir- 
cumstance, however,  of  a  tumor  consisting  chiefly  of  epithelic  corpuscles  is 
not  to  be  deemed  sufficient  evidence  of  its  being  an  epithelial  cancer.  I 
have  no  doubt  this  would  be  the  case  nearly  equally  with  the  elevated  edges 
of  Jacob's  "  ulcer  of  peculiar  character,"  and  of  Cock's  "peculiar  follicular 
disease,"-^  as  well  as  of  several  other  varieties  of  growth  and  ulcer  of  the  skin, 
in  malignancy  and  other  particulars  widely  different  from  each  other.  Some 
epithelial  growths  are  perfectly  innocent. 

The  progress  of  the  ulceration  is  generally  very  slow.  I  have  known  it  for 
years  confined  to  the  lower  eyelid,  without  making  almost  any  advance ;  nay, 
occasionally  contracting,  and  partially,  or  even  totally,  cicatrizing ;  again  to 


168  CANCER   OF   THE   EYELIDS. 

commence,  and  spread  for  a  certain  space,  and  again  to  beal.  It  has  been 
known  to  remain  for  ten,  nay,  for  twenty  years,  without  making  much  pro- 
gress. In  other  cases,  however,  we  see  the  eyelids  entirely  destroyed,  the 
eyeball  exposed,  so  as  to  become  inflamed  and  at  last  to  burst,  the  lachrymal 
passage  laid  open,  the  bones  of  the  orbit  deprived  of  their  periosteum  and 
rendered  carious,  while  the  ulcer,  spreading  down  the  face,  eats  away  the 
cheek,  lays  bare  the  teeth,  and  at  last  forms  a  hideous  opening  communicating 
with  the  mouth.  Yet,  even  after  it  has  produced  the  most  shocking  deformity, 
its  progress  is  sometimes  stayed  for  months  or  for  years,  so  that  the  indi- 
vidual lives  with  his  eyelids  entirely  gone,  the  eyeball  dissected  from  almost 
all  its  connections,  and  perhaps  half  of  the  face  destroyed. 

The  appearances  of  the  diseased  surface  are  different  at  different  times. 
Sometimes  it  presents  a  scab,  which,  on  being  removed,  is  succeeded  by  an- 
other; but  generally  the  sore  exposed  on  removing  these  successive  scabs,  is 
found  to  be  slowly  enlarging,  growing  deeper,  and  becoming  more  painful. 
When  the  sore  becomes  an  open  ulcer,  too  large,  irregular,  and  active  to  be 
covered  by  a  scab,  we  observe  that  it  eats  away  all  parts  indiscriminately 
which  may  be  in  the  direction  in  which  it  is  spreading.  In  one  of  the  cases 
which  have  fallen  under  my  care,  the  ulceration  of  the  skin  appeai'ed,  after  a 
time,  entirely  to  cease,  while  the  disease  proceeded  deep  into  the  orbit  by  the 
inner  side  of  the  eyeball.  Not  unfrequcntly,  we  find  that  the  progress  of  the 
ulceration  is  checked  at  one  part  of  the  circumference  of  the  sore,  while  it  is 
advancing  at  another;  or  that  the  whole  sore  assumes,  for  a  time,  a  healing 
action.  When  this  is  the  case,  the  pain  grows  less,  the  edges  become  smooth 
and  glossy,  and  even  the  part  within  the  edges  becomes  smooth,  or  is  gradually 
covered  with  florid  healthy-looking  granulations.  These  are  occasionally  firm 
in  texture,  and  remain  unchanged  in  size  and  form  for  a  length  of  time. 
Veins  of  consideral>le  size  are  seen  ramifying  over  the  surface  of  the  sore. 
If  it  heals  up,  it  does  so  in  patches,  which  are  hard  and  smooth,  and  marked 
with  the  same  venous  ramifications.  When  it  again  begins  to  ulcerate,  it 
loses  its  florid  hue  and  glistening  and  granulating  appearance.  There  is 
often  a  tendency  to  actual  reparation,  as  well  as  to  cicatrization ;  there  is  a 
deposition  of  new  material,  and  a  filling  up  in  certain  places,  which  gives 
an  uniformity  to  the  surface,  which  othervvi.se  would  be  very  irregular.  The 
healing  which  occurs  may  take  place  on  any  part  of  the  surface,  whatever 
be  the  original  structure.  In  a  case  which  Dr.  Jacob  had  under  his  care,  the 
eyeball  itself,  denuded  as  it  was  by  ulceration,  became  partially  cicatrized. 

The  skin  in  the  vicinity  of  the  sore  is  not,  in  general,  much  thickened  or 
discolored,  differing  in  these  respects  from  the  disease  called  lupus,  or  noli 
me  tangere,  in  which  a  diffused  swelling  and  a  deep  blush  surround  the  ulcer. 
In  cancer  of  the  eyelids,  the  edges  of  the  ulcer  are  occasionally  formed  into 
a  range  of  elevations  or  tubercles,  of  a  pale  red  color,  which,  if  removed  with 
the  knife,  are  speedily  reproduced.  But  there  is,  in  general,  little  or  no  fun- 
gous growth  in  this  disease,  or  indeed  any  elevation,  except  at  the  edges  of 
the  sore. 

The  veins  which  ramify  over  the  surface  of  the  sore  are  apt  to  give  way, 
and  considerable  bleeding  to  take  place.  From  the  surface  itself  of  the  ulcer, 
there  is  no  considerable  bleeding.  When  hemorrhage  does  occur,  it  arises 
from  the  superficial  veins  giving  way,  and  not  from  sloughing  or  ulceration 
opening  the  vessels.  Sometimes  the  surface  of  the  sore  assumes  a  dark  gan- 
grenous appearance,  arising  from  effusion  of  blood  beneath. 

The  discharge  from  the  surface  of  the  sore  is  not,  in  general,  of  the  de- 
scription called  unhealthy,  nor  sanious,  but  yellow,  and  of  proper  consistence ; 
neither  is  there  more  fetor  than  from  the  healthiest  sore,  if  the  parts  be  kept 
perfectly  clean,  and  dressed  frequently.     Mr.  Travers,  however,  whose  short 


CANCER   OF   THE   EYELIDS.  169 

notice*  of  this  disease  differs  in  several  particulars  from  the  more  elaborate 
description  of  Dr.  Jacob,  mentions  that  it  is  attended  by  an  unhealthy  dis- 
charge. 

Dr.  Jacob  has  represented  the  sufferings  of  persons  laboring  under  this 
disease  as  not  very  acute.  He  says  there  is  no  lancinating  pain,  and  that  the 
principal  distress  appears  to  arise  from  the  exposure,  by  ulceration,  of  nerves 
and  other  highly  sensible  parts.  In  the  cases  he  had  met  with,  the  disease, 
at  the  worst  period,  did  not  incapacitate  the  patients  from  following  their 
usual  occupations.  He  states  that  one  gentleman,  who  labored  under  this 
disease  for  nine  years,  and  who  died  from  a  different  cause,  was  cheerful,  and 
enjoyed  the  comforts  of  social  life  after  the  ulceration  had  made  the  most 
deplorable  ravages.  These  statements  of  Dr.  Jacob  may  be  received  with 
implicit  confidence.  Yet  it  must  be  noticed  that,  when  the  ulceration  affects 
the  infra-orbitary  and  supra-orbitary  nerves,  very  severe  suffering  is  experi- 
enced. I  have  also  witnessed  the  most  excruciating  pain  when  the  eyeball 
was  attacked.  It  ulcerates  and  bursts,  the  lens  and  vitreous  humor  are 
evacuated,  and  sometimes,  till  this  emptying  of  the  eye  is  effected,  the  pain 
is  agonizing.  I  have  known  the  lens  protrude  through  the  cornea  for  several 
days,  producing  great  irritation. 

When  the  disease  extends  to  the  periosteum,  the  bones  of  the  orbit  are 
laid  bare,  and  become  carious.  They  sometimes  exfoliate  in  small  scales,  but 
more  generally  they  are  destroyed,  as  the  soft  parts  are,  by  an  ulcerative  pro- 
cess. This  may  proceed  to  such  a  length  as  to  expose  the  nostril  or  the 
antrum,  through  the  destroyed  orbit,  or  even  to  lay  open  the  cavity  of  the 
cranium  through  the  orbitary  plate  of  the  frontal  ])one.  Inflammation  of 
the  dura  mater  and  of  the  brain  will,  in  this  case,  soon  put  an  end  to  the 
patient's  sufferings  ;  although  more  commonly  he  dies  worn  out  by  fever, 
and  sometimes  diarrhoea. 

Diagnosis. — The  researches  of  Burns,  Hey,  Abernethy,  Wardrop,  Breschet, 
Fawdington,  and  others,  into  the  nature  of  malignant  tumors  and  ulcers,  have 
established  at  least  this  fact,  that  there  are  essential  differences  between  a 
number  of  diseases  formerly  confounded  under  the  appellation  of  cancer. 
We  are  now  at  no  loss  in  distinguishing  scirrhus  from  spongoid  tumor,  and 
spongoid  tumor  from  melanosis  ;  but  with  regard  to  the  malignant  ulcerations 
which  attack  different  parts  of  the  skin,  and  especially  the  skin  of  the  face, 
there  existed,  till  very  lately,  a  considerable  degree  of  confusion.  To  the 
microscopical  examinations  of  malignant  growths,  we  owe  the  important 
establishment  of  epithelial  cancer  as  a  distinct  species  of  disease. 

Dr.  Bateman,  Mr.  S.  Cooper,  and  others,  seem  to  consider  the  disease  of 
the  eyelids  which  we  have  been  considering,  as  noli  me  tangere,  which,  accord- 
ing to  Sir  A.  Cooper,  is  an  ulceration  of  the  cutaneous  follicles.  Dr.  Jacob, 
however,  observes,  that  the  disease  commonly  called  cancer  of  the  eyelids,  is 
evidently  peculiar  in  its  nature,  and  is  to  be  confounded  neither  with  genuine 
carcinoma,  nor  with  the  disease  called  lupxis,  or  noli  me  tangere.  From  the 
former  he  thinks  it  may  be  distinguished  by  the  absence  of  lancinating  pain, 
fungous  growth,  fetor,  slough,  hemorrhage,  and  contamination  of  the  lym- 
phatics ;  from  the  latter,  by  the  absence  of  the  furfuraceous  scabs,  and  in- 
flamed margins,  as  well  as  by  the  general  appearance  of  the  ulcer,  its  history, 
and  progress.  Mr.  Lawrence  has  contrasted'  cancer  of  the  skin  with  lupus  ; 
the  latter  is  a  disease  which  also  sometimes  involves  the  eyelids  f  but  in  fact 
it  is  not  easy  to  describe  in  words  the  differences  between  such  diseases. 

From  syphilitic  chancre,  cancer  of  the  eyelids  may  generally  be  distin- 
guished by  its  slow  progress,  by  its  not  causing  so  much  swelling  of  the 
integuments  around  the  ulcer,  and  by  its  history. 

Occurring  in  the  skin  over  the  lachrymal  sac,  I  have  known  this  disease 


170  CANCER  OF  THE  EYELIDS. 

mistaken  for  dacryocystitis.  One  patient  called  on  me  expressly  to  have  a 
style  introduced.  Another  had  actually  worn  a  style,  which  he  fancied  had 
dropped  down  into  the  nasal  duct,  and  which  he  wished  extracted.  There 
was  no  style  ;  it  had  probably  dropped  out  by  the  opening  through  the  skin. 

Prognosis.  — Left  to  itself,  epithelial  cancer  of  the  eyelids  compromises 
the  life  of  the  patient.  While  other  varieties  of  cancer  are  of  constitutional 
origin,  and  involve  the  economy  generally,  this  seems  entirely  a  local  disease ; 
and  hence,  no  doubt,  the  slowness  of  its  progress.  The  fact  of  there  being 
in  epithelial  cancer  no  tendency  to  lymphatic  propagation,  so  that  the  gene- 
ral health  may  remain  long  intact,  renders  the  prognosis  somewhat  less  un- 
favorable, and  seems  to  afford  grounds  for  the  hope  that  extirpation  may 
prove  a  complete  cure.     The  disease,  however,  often  returns. 

Treatment. — 1.  Alterative  and  other  medicines. — It  is  a  question  of  great 
importance,  whether  this  disease  can  be  removed  by  any  other  means  than 
the  knife,  or  powerful  escharotics.  Dr.  Jacob's  opinion  is,  that  it  bids  defi- 
ance to  all  remedies  short  of  extirpation.  "  I  have  tried,"  says  he,  "inter- 
nally, alterative  mercurials,  antimony,  sarsaparilla,  acids,  cicuta,  arsenic, 
iron,  and  other  remedies  ;  and  locally,  simple  and  compound  poultices,  oint- 
ments, and  washes,  containing  mercury,  lead,  zinc,  copper,  arsenic,  sulphur, 
tar,  cicuta,  opium,  belladonna,  nitrate  of  silver,  and  acids,  without  arresting 
for  a  moment  the  progress  of  the  disease.  I  have  indeed  observed,"  adds  he, 
"that  one  of  those  cases  which  is  completely  neglected,  and  left  without  any 
other  dressing  than  a  piece  of  rag,  is  slower  in  its  progress  than  another 
which  has  had  all  the  resources  of  surgery  exhausted  upon  it." 

Although  these  remarks  of  Dr.  Jacob  are  perhaps  rather  too  sweeping,  yet 
it  cannot  be  denied,  that  both  internal  and  external  remedies  have  extremely 
little  control  over  this  disease,  and  that  though  it  may  for  a  time  seem  to  mend 
under  their  influence,  it  has  rarely,  if  ever,  been  known  to  be  thoroughly 
cured,  except  by  destroying  the  part  with  escharotics,  or  removing  it  by  the 
knife. 

The  precipitated  carbonate  of  iron  sprinkled  on  the  sore,  and  arsenic  in- 
ternally, are  the  means  which,  I  believe  do  most  good.  I  have  known  them 
to  operate  as  palliatives,  but  never  to  produce  a  radical  cure;  and  therefore  I 
should  never  trust  to  them.  Whatever  treatment  improves  the  general  health, 
has  a  favorable  influence  on  the  local  disease.  I  have  known  the  ulcer  from 
this  cause  improve  considerably  under  the  employment  of  two  grains  of  calo- 
mel, with  half  a  grain  of  opium,  continued  each  night  for  several  months. 

2.  Diet. — Mild  nutriment,  without  wine,  is  the  diet  which  should  be 
adopted. 

Case  131.— Dr.  Twitchell,  an  American  surgeon  of  note,  aged  68,  cured  himself  of  a 
cancer  of  the  eyelid,  by  abandoning  the  use  of  flesh,  and  living  entirely,  for  two  years, 
on  bread,  milk,  and  cream.  The  disease  had  been  slowly  increasing  for  about  ten  years, 
and  had  been  twice  ineflfectually  removed  by  the  knife.' 

3.  Caustics. — These  means  are  certainly  not  much  to  be  commended ;  being 
more  painful  and  not  so  sure  as  the  knife.  They  do  occasionally  succeed, 
when  the  disease  is  limited  to  the  outer  surface  of  the  eyelid,  or  to  the  skin 
of  the  nose  ;  never,  when  the  whole  thickness  of  the  eyelid  is  affected.  Often 
they  do  harm  instead  of  good.^  As  caustics  which  act  not  on  the  surface 
alone,  but  deeply,  if  allowed  to  remain  in  contact  with  the  diseased  part,  may 
be  mentioned,  hydrate  of  potassa  and  quicklime,  made  into  a  paste  with  a  few 
drops  of  alcohol,  and  chloride  of  zinc,  made  into  a  paste,  with  flour  or  cal- 
cined sulphate  of  lime.  The  danger  of  using  such  substances,  on  the  eyelids, 
arises  from  their  aptitude  to  spread  to  the  eyeball.  The  best,  perhaps,  and 
most  manageable,  is  the  pencil  of  potassa  fusa. 

The  great  advantage  derived  from  arsenical  applications  to  lupus,  has  led 


CANCER   OF   THE   EYELIDS,  Itl 

to  their  use  in  cancerous  ulcerations  of  the  face ;  but  in  these  cases  they  are 
neither  so  efficacious,  nor  so  safe  as  in  the  former.  Sometimes  the  irritation 
produced  by  them  occasions  the  sore  to  spread  more  rapidly  than  it  would 
otherwise  do. 

Dr.  Jacob  mentions,  that  a  woman  in  the  Incurable  Hospital  at  Dublin, 
had  had  a  burning  cancer  plaster  applied  several  times,  and  seventeen  years 
after,  the  arsenical  composition  called  Plunket's  powder,  without  any  good 
effect.  A  gentleman,  to  whose  case  he  repeatedly  refers,  had  the  sore  healed, 
when  it  was  very  small,  by  the  free  application  of  lunar  caustic,  under  the 
care  of  Mr.  Travers.  It  broke  out  again,  however,  and  spread,  without  in- 
terruption, until  it  destroyed  the  lids  and  globe  of  the  eye.  Under  these 
circumstances,  he,  in  despair,  submitted  himself  to  a  quack,  who,  bold  from 
ignorance,  gave  a  full  trial  to  escharotics.  He  repeatedly  applied  what  was 
understood  to  be  a  solution  of  muriate  of  mercury  in  strong  nitric  acid,  which, 
in  a  short  time,  produced  a  hideous  cavern,  extending  from  the  orbitary  plate 
of  the  frontal  bone  above  to  the  floor  of  the  maxillary  sinus  below,  and  from 
the  ear  on  the  outside,  to  the  septum  narium  within.  The  unfortunate  gen- 
tleman survived,  the  disease  continuing  to  preserve,  in  every  respect,  its 
original  character. 

Case  132. — Dufresne,  a  bleacher,  aged  30,  was  admitted  into  the  Hotel  Dieu  on  the  23d 
February,  1831,  having  been  affected  for  seven  or  eight  months  with  a  carcinomatous 
ulcer  at  the  inner  angle  of  the  right  eye.  The  ulcer  had  continued  to  extend  itself  from 
the  very  commencement. 

jNI.  Duijuytren,  having  satisfied  himself  of  the  cancerous  nature  of  the  disease,  endea- 
vored to  effect  its  destruction  by  cauterization  with  the  nitrate  of  mercury  dissolved  in 
niti'ic  acid,  a  remedy  he  had  found  to  succeed  in  similar  cases.  Three  or  four  cauteriza- 
tions were  practised  at  intervals  of  eight  or  ten  days  ;  the  fourth  induced  an  erysipelas  of 
the  face,  which  had  not  been  cured  when  M.  Breschet  took  charge  of  the  patient.  He 
deferred  attacking  the  cancer  again,  till  the  erysipelas  had  entirely  disappeared. 

On  the  10th  April,  the  ulcer  was  of  an  oblong  form,  occupying  the  inner  angle  of  the 
right  eye,  and  the  corresponding  ala  of  the  nose  ;  its  base  had  a  fungous  nipple-like  ap- 
pearance, of  a  livid  color,  and  it  discharged  a  trifling  quantity  of  fetid  sanies.  Its  edges 
were  unequal,  notched,  and  a  little  inverted. 

An  ointment,  composed  of  seven  parts  of  lard  and  one  of  iodide  of  mercury,  was  now 
applied  daily  ;  but,  after  three  weeks,  the  ulcer  was  scarcely  in  the  least  improved.  The 
application  was  therefore  changed  for  another,  composed  of  seven  parts  of  lard  and  one 
of  biniodide  of  mercury.  In  a  few  days,  the  appearance  of  the  sore  was  completely 
changed,  its  base  became  of  a  vermilion  tint,  the  nipple-like  excrescences  and  fetid  dis- 
charge disappeared,  and  the  swollen  edges  gradually  shrunk.  After  12  days'  employment 
of  the  ointment,  the  sore  was  treated  with  simple  dressing,  and  healed  rapidly.  On  the 
3d  May,  the  patient  was  dismissed  entirely  cured,  without  deformity,  the  scar  being  white, 
flexible,  and  free  from  pain  or  tumefaction.^ 

4.  Extirpation  hy  the  hiife. — When  the  disease  exists  in  a  situation  which 
admits  of  extirpation  by  the  knife,  the  sooner  it  is  done  the  better. 

The  effects  of  removing  one  or  both  lids,  have  already  been  explained.  The 
upper  lid  will,  much  more  than  we  could  expect,  supply  the  loss  of  the  lower 
lid;  and  the  lower  that  of  the  upper.  If,  however,  the  whole  of  the  upper 
lid,  or  of  both  lids  be  removed,  the  cornea  will  become  gradually  opaque  from 
exposure,  and  the  conjunctiva  cuticular  and  insensible. 

Even  when  the  disease  is  confined  to  the  movable  part  of  the  lids,  I  con- 
sider it  better  to  remove  it  by  a  semilunar  incision,  than  by  one  of  the  form 
of  the  letter  V,  and  to  allow  the  wound  to  heal  by  granulation,  than  by 
bringing  its  edges  together  with  stitches. 

A  hook  or  ligature  being  passed  under  the  parts  to  be  removed,  so  as  to 

enable  us  to  hold  them  and  elevate  them  from  the  subjacent  textures,  the 

^.    incisions  ought  to  be  made  into  the  sound  parts.     If  the  disease  adheres  to 

K     the  perichondrium,  the  whole  thickness  of  the  lid  must  be  sacrificed  ;  if  to 

B    the  periosteum,  it  must  carefully  be  removed.     If  the  disease  has  spread  in 

I 


112  CANCER   OF   THE   EYELIDS. 

any  considerable  degree  to  the  conjunctiva  of  the  eyeball,  the  eye  can  scarcely 
be  saved,  although  this  appears  to  have  been  effected  in  one  instance,  by 
Grafe. 

Case  133. — Daviel  was  called  to  an  Ursuline  nun  at  Bordeaux,  45  years  old,  on  account 
of  a  tumor  -which  she  had  for  20  years  upon  her  right  upper  eyelid.  It  began  by  a  small 
wen,  and  increased  by  degrees  so  as  very  much  to  incommode  the  patient. 

She  applied  to  a  surgeon,  who  began  with  some  drops  of  a  liquid  caustic,  which  enraged 
the  tumor  still  more ;  he  appeased  it  again  by  anodyne  medicines ;  and,  although  the 
patient  felt  a  continual  sharp  pain  in  the  part,  the  tumor  remained  a  long  time  without 
any  sensible  increase.  She  consulted  another  surgeon,  however,  who  cut  off  the  tumor. 
The  ulcer,  which  was  the  result  of  this  operation,  did  not  heal,  but,  on  the  contrary,  made 
great  progress,  and  became  callous.  The  surgeon  touched  it  with  lapis  infernalis,  and 
sometimes  with  a  liquid  caustic,  which  much  increased  the  evil. 

Daviel  was  of  opinion,  that  there  remained  no  other  method  of  treatment,  but  a  farther 
extirpation,  which  might  not  only  save  the  eye,  but  prevent  an  incurable  and  fatal  cancer. 
The  disease  had  already  made  great  progress  under  the  eyelid,  and  it  was  much  to  be 
feared  that  it  would  spread  into  the  eye,  and  over  the  face.  He  passed  a  crooked  needle, 
with  a  waxed  thread,  under  the  lid,  by  which  he  suspended  and  drew  up  the  lid  and  the 
tumor,  which  he  cut  off  with  a  pair  of  curved  scissors,  as  far  as  he  could  under  the  orbit. 
Slight  hemorrhage  ensued,  but  was  soon  stopped  with  dry  lint,  and  a  compress  and 
bandagCi 

In  14  days  she  was  perfectly  cured  ;  and  although  the  lid  was  cut  away  very  high,  the 
eye  remained  very  neat  and  well,  performing  its  several  functions  properly  when  Daviel 
left  Bordeaux.  Six  years  afterwards,  he  found  the  patient  extremely  well,  seeing  per- 
fectly with  the  eye.  What  he  considered  very  singular  was,  that  the  skin  of  the  lid 
descended  pretty  low  to  the  cornea,  which  it  almost  covered ;  so  that  the  whole  globe  was 
in  a  manner  hid.     The  descending  skin  looked  like  a  lid  without  eyelashes.'" 

Case  134. — A  woman,  60  years  old,  had  a  cancerous  tumor,  for  16  years,  in  the  inner 
angle  of  the  right  eye.  It  began  by  a  little  wart,  which  itched  violently,  and  made  her 
scratch  it  very  often,  which  so  irritated  the  tumor,  that  in  a  little  time  it  became  as  large 
as  a  dried  fig  flattened,  with  its  edges  turned  outward  and  callous.  It  reached  from  the 
commissure  of  the  lids  to  the  ala  nasi,  and  adhered  to  the  bone. 

Daviel  dissected  off  the  tumor  down  to  the  periosteum,  but  did  not  lay  the  bone  bare; 
for  he  thought  it  sufficient  for  a  complete  cure  to  take  away  all  the  callosities.  But  he 
was  mistaken ;  for  the  swelling  increased,  and  the  wound  seemed  larger  than  before.  He 
used,  in  vain,  all  the  remedies  commonly  thought  of  in  such  cases  ;  he  scarified  the  edges 
of  the  ulcer,  to  bring  it  to  suppuration ;  but  it  became  more  hard  and  callous  than  before 
the  operation,  and  much  more  painful.  He  now  resolved  to  cut  away  all  that  remained 
of  the  tumor,  with  the  periosteum,  which  appeared  very  much  swelled.  This  second 
operation  was  so  successful,  that  the  swelling,  and  every  other  bad  symptom,  disappeared 
almost  suddenly.  In  three  days  the  wound  looked  red  and  very  well,  without  any  pain, 
and  the  cicatrice  was  perfectly  formed  on  the  loth  day  from  the  operation,  without  any 
sensible  exfoliation  of  the  bone,  or  the  least  deformity  of  the  eye.  Five  years  after  Da- 
viel saw  the  patient  in  perfect  health,  and  the  cicatrice  of  the  part  verj-  even." 

Case  135. — A  country  woman,  42  j-ears  of  ago,  sought  assistance  on  account  of  a  can- 
cerous tumor,  which  occupied  the  inner  third  of  the  upper  and  under  eyelids,  the  carun- 
cula  lachrym.alis,  and  the  inner  commissure,  as  far  as  the  back  of  the  nose,  and  was 
connected  with  the  conjunctiva  of  the  eyeball.  Although,  under  these  circumstances, 
there  appeared  little  hope  of  saving  the  eyeball,  yet  this  was  attempted  by  the  extirpa- 
tion of  all  the  diseased  parts.  For  this  purpose  Grilfe  passed,  from  the  side  of  the  eye 
towards  the  nose,  a  bodkin-shaped  instrument  through  the  middle  of  the  basis  of  the 
swelling,  and  carefully  separated  the  diseased  part  of  the  conjunctiva  from  the  eyeball. 
Then  with  a  pair  of  blunt-pointed  scissors  he  divided  the  upper  eyelid  as  far  as  the  arch 
of  the  orbit,  in  such  a  way  that  the  whole  inner  third  of  the  eyelid  was  separated  from 
the  middle  third  ;  a  similar  incision  was  then  made  through  the  lower  eyelid,  and  the  two 
extremities  of  these  incisions  joined  by  another  in  a  curved  direction  over  the  back  of  the 
nose.  The  carcinomatous  tumor  was  then  separated  from  the  bones.  After  this,  in  con- 
sequence of  the  retraction  of  the  remaining  parts  of  the  eyelids,  nearly  the  whole  of  the 
inner  half  of  the  anterior  hemisphere  of  the  eye  was  exposed. 

The  wound  was  dressed  simply  with  warm  water,  and  the  same  dressing  continued 
daily.  To  the  joy  of  all  concerned,  the  eyelids  elongated,  whilst  the  granulations  ex- 
tended more  and  more  inwards,  and  within  three  weeks  Avere  united  in  such  a  way  by  a 
cicatrice,  that  not  the  slightest  deformity  or  exposure  of  the  eye  remained.  The  repro- 
duced commissure  was  found,  on  close  inspection,  to  want  the  puncta  lachrymalia,  the 
caruncula,  and  semilunar  fold.     The  loss  of  all  these  parts,  and  the  complete  removal  of 


OPHTHALMIA  TARSI.  ITS 

both  canaliculi  laclirymales,  produced  no  stillicidium  lachrymarum,  -which,  on  physiolo- 
gical grounds,  was  to  have  been  expected.  Kudolphi  was  requested  to  examine  the 
patient ;  but  he  was  as  unsuccessful  as  Grafe,  in  discovering  the  manner  in  which  the 
tears  were  removed  after  the  destruction  of  the  parts  above  mentioned.'^ 

In  several  cases,  I  have  removed  a  large  portion  of  both  lids,  along  with 
their  nasal  commissure,  and  have  been  surprised  at  the  rapidity  with  which 
the  wound  healed,  and  the  little  deformity  which  ensued.  In  one  instance, 
however,  the  cicatrice  drew  the  lids  so  much  towards  the  nose,  that  the 
patient  could  open  the  eye  but  very  incompletely.  In  the  case  already 
referred  to,  in  which  I  removed  both  lids,  along  with  the  eyeball,  the  skin 
contracted  in  the  course  of  healing  so  as  to  cover  the  whole  front  of  the  orbit, 
leaving  an  aperture  sufficient  only  to  allow  a  quill  to  enter. 

When  one  or  other  lid  has  been  removed  by  the  disease  or  by  the  knife,  it 
has  been  proposed  to  replace  it  by  a  new  lid  formed  out  of  the  neighboring 
integuments.*^  So  far  as  the  loss  of  the  lower  lid  is  concerned,  such  a  pro- 
cedure is  unnecessary.  The  deformity  and  inconvenience  arising  from  the 
want  of  the  lower  lid  is  trifling.  The  mere  contraction  of  the  cicatrice  suf- 
fices to  bring  up  the  cheek  to  the  level  of  the  lower  edge  of  the  orbit.  The 
skin  unites  to  the  conjunctiva,  and  at  first  sight,  it  is  not  observed  that  the 
eyelid  has  been  removed.  The  palpebral  opening  is  a  little  smaller  than 
natural,  both  from  above  downwards,  on  account  of  the  upper  lid  descending 
more  than  usual,  and  transversely,  from  the  external  angle  of  the  lids  having 
assumed  a  rounded  form.  Autoplasty,  under  such  circumstances,  would  do 
little  good. 

It  is  different  with  the  upper  eyelid.  As  its  loss  is  likely  to  lead  to  a  cal- 
lous state  of  the  investing  membrane  of  the  eyeball,  opacity  of  the  cornea, 
and  loss  of  vision,  the  proposal  of  forming  a  supplementary  upper  lid  has 
somethino;  to  be  said  in  its  favor. 


'  Dublin  Hospital  Reports ;  Vol.  iv.  p.  232 ;  '  This    case    is    minutely   recorded   in    the 

Dublin,  1827.  Charleston   Medical  Journal,   for  Nov.   1849; 

-  Daviel,   Philosophical    Transactions  ;    Vol.  and   quoted  in  the  American   Journal  of  the 

xlix.  Part  i.  p.  186;  London,  1756, •  Warren's  Medical  Sciences,  for  July,  1850,  p.  269. 

Surgical  Observations  on  Tumors,  p.  27  ;  Bos-  *  See  Daviel's  1st  and  10th  cases,  Op.  cit.  p. 

ton,  1837.  186. 

"Guy's    Hospital    Reports,    Second    Series;  '  Quoted  from  the  Lancette  Fran^ai.se,  in  the 

Vol.  viii.  pp.  168,  170.  Lancet,  for  1830,  1831 ;  Vol.  ii.  p.  607. 

'  Synopsis   of  the  Diseases  of  the   Eye;  p.  '°  Op.  cit.  p.  189. 

100;  London,  1820.  "  Ibid.  p.  191. 

'  Lectures  on  Surgery;  London  Medical  Ga-  '^  1822.     Jahres-Berieht  iiber  das  clinische 

zette  ;  A^'ol.  vi.  p.  194;   London,  1830.  chirurgiseh-augenarztliche    Institut   der    Uni- 

•^  Basedow,  Grafe  uud  Walther's  Journal  der  versitat  zu  Berlin,  p.  3  ;  Berlin,  1823. 

Chirurgie  und  Augenheilkunde;   Vol.    xv.    p.  ''Auvert,    Selecta   Praxis,    Fasciculus    II.: 

497 ;  Berlin,  1831 :  Dalrymple's  Pathology  of  Ammon's  Darstellungen,   Zweiter  Theil,  Tab. 

the  Human  Eye,  PI.  V.  fig.  5  ;  London,  1849.  vi.  figs.  3,  4. 


SECTION  X. — ^INFLAMMATION   OF   THE  EDGES   OF   THE   EYELIDS,  OR  OPHTHALMIA 

TARSI. 

Syn. — Blepharitis  scrofulosa. 
Fig.  Dalrymple,  PI.  L  figs.  3,  4.   PI.  II.  figs.  1,  2. 

The  edges  of  the  eyelids  are  subject  to  an  inflammation  of  a  very  tedious 
character.  It  is  this  disease  which,  closing  the  Meibomian  follicles,  and 
destroying  the  bulbs  of  the  eyelashes,  produces  the  state  termed  hlear  eyes. 
If  long  neglected,  it  becomes  obstinate,  and,  in  some  respects,  incurable. 

We  usually  term  this  disease  ophthalmia  tarsi;  but  it  has  received  various 
names,  and  different  views  have  been  entertained  of  its  nature.     Any  one 


174  OPHTHALMIA   TARSI. 

affected  with  this  complaint,  was  called  by  the  Romans  lippus.  Hence  lippi- 
tudo,  which  we  sometimes  use  to  signify  the  effects  of  this  disease.  Celsus's 
lippitudo  was  what  we  now  designate  by  the  name  of  catarrhal  or  purulent 
ophthalmia.  Ophthalmia  tarsi  he  describes  under  the  name  of  xeroplithalmia 
or  lippitudo  arida.  Comparing  ophthalmia  tarsi  to  eruptions  of  the  hairy 
scalp,  it  has  been  called  by  some,  tinea  palpebrarum ;  while  others  have 
regarded  it  as  herpetic  or  porriginous.  As  itchiness  is  one  of  the  symptoms 
of  the  disease,  it  has  been  called  scabies  jjalpebrarum,  and  2}SorophthaI>m'a; 
but  that  this  complaint  ever  partakes  of  the  nature  of  psora,  is  a  notion 
which,  in  this  country,  is  entirely  laid  aside. 

Ophthalmia  tarsi  affects  the  Meibomian  follicles,  their  apertures  running 
along  the  edge  of  the  lid  near  its  inner  margin,  the  neighboring  portion  of 
the  conjunctiva,  the  glands  at  the  roots  of  the  eyelashes,  and  the  surrounding 
skin.     Even  the  cartilage  is  sometimes  implicated. 

Local  symptoms. — One  of  the  most  striking  symptoms  of  the  disease  is 
the  adhesion  of  the  edges  of  the  eyelids  in  the  morning,  by  means  of  a  glu- 
tinous and  superabundant  seci'etion  from  the  conjunctiva,  Meibomian  follicles, 
and  ciliary  glands.  Incrusting,  during  sleep,  into  a  gummy  consistence,  this 
matter  binds  the  eyelashes  together,  so  that  the  patient  is  obliged  either  to 
soften  them  before  opening  his  eyes  in  the  morning,  or  to  use  considerable, 
and  even  painful,  effort  for  their  separation.  This  is  accomplished  not  with- 
out tearing  out  some  of  the  eyelashes,  which  no  doubt  aggravates  the  inflam- 
mation of  the  sebaceous  follicles  at  their  roots,  and  produces  a  succession  of 
little  abscesses  and  ulcers.  Frequently  torn  out  in  this  way,  and  their  bulbs 
injured  or  destroyed,  the  eyelashes  are  apt  to  become  feeble,  dwarfish,  and 
irregular,  or  their  reproduction  to  cease. 

The  Meibomian  secretion,  naturally  bland,  and  small  in  quantity,  serving 
merely  to  smear  the  edges  of  the  eyelids,  so  as  to  prevent  them  from  adhering, 
and  to  conduct  the  mucus  of  the  conjunctiva  and  the  tears  towards  the  puncta 
lachrymalia,  becomes,  in  this  disease,  augmented  in  quantity,  and  changed 
into  a  puriform  matter.  This  matter  of  itself,  as  well  as  the  inflammation 
in  which  it  originates,  causes  constant  irritation,  and  frequent  itchiness  of 
the  eye  and  eyelids,  and  adhering  to  the  eyelashes,  prevents  the  little  ulcers 
from  healing  which  arise  at  their  roots.  The  tears,  excited  by  the  irritation, 
are  discharged  more  frequently  than  natural,  and  being  no  longer  conducted 
along  the  edges  of  the  lids  towards  the  puncta  lachrymalia,  as  they  are  in 
health,  they  drop  over  upon  the  cheek,  chafing  and  excoriating  the  integu- 
ments. The  consequence  is,  that  we  frequently  find  this  disease  attended 
with  much  swelling  and  redness  of  the  eyelids,  and  the  skin  of  the  cheeks 
inflamed,  ulcerated,  or  covered  with  scabs.  Not  unfrequently,  the  conjunc- 
tiva, lining  the  lids,  is  considerably  inflamed,  and  gives  out  a  disordered 
secretion.  One  or  more  of  the  Meibomian  follices  are  often  greatly  distended 
with  purulent  matter,  which  oozes  out  from  their  apertures  on  pressure.  In 
other  cases,  the  edges  of  the  eyelids  are  occupied  by  a  thick  crust  of  matter, 
under  which  ulceration  is  proceeding  slowly  to  destroy  the  secretory  api)a- 
ratus  of  the  eyelashes.  Sometimes  the  whole  substance  of  the  eyelids,  near 
their  edges,  is  thickened,  indurated,  and  distorted ;  a  state  which  is  termed 
tylosis. 

The  local  symptoms  of  ophthalmia  tarsi  vary  considerably  in  severity,  in 
obstinacy,  in  the  appearances  of  the  matter  discharged,  and  even  in  the  seat 
of  the  principal  morbid  changes ;  for,  in  some,  the  Meibomian  follicles,  in 
others,  the  ciliary  glands,  or  bulbs  of  the  eyelashes,  are  the  parts  chiefly 
affected. 

The  inflamed  state  of  the  conjunctiva  in  this  disease,  as  well  as  that  of  the 
Meibomian  follicles  themselves,  produces  a  feeling  of  sand,  or  a  sensation  of 


OPHTHALMIA   TARSI.  115 

roughness  in  the  eyes,  which  causes  the  patient  to  open  the  lids  partially, 
and  frequently  to  keep  them  close  altogether.  He  complains  also  of  feelings 
of  stiffness,  dryness  alternating  with  agglutination,  heat,  soreness,  and  in- 
tolerance of  light,  increased  in  the  evenings,  or  when  he  exerts  his  eyes  on 
minute  objects. 

Two  events  are  apt  to  follow,  when  ophthalmia  tarsi  has  continued  long, 
and  been  neglected.  The  one  is  a  partial  or  total  obliteration  of  the  Mei- 
bomian apertures,  along  the  margin  of  one  or  both  eyelids.  These  orifices 
are  in  fact  skinned  over.  In  this  case,  which  may  be  regarded  as  incurable, 
the  inner  margin  of  the  affected  lid  becomes  rounded  off,  instead  of  being 
angular  ;  it  is  smooth,  red,  and  glistening ;  no  Meibomian  secretion  is  seen 
oozing  out  upon  pressure,  and,  generally,  the  eyelashes  are  in  a  great  measure 
wanting.  The  other  event  is  lagophthalmos  and  eversion  of  the  lower  lid, 
originating  in  the  contracted  state  of  the  skin,  consequent  to  the  healing  up 
of  the  excoriated  eyelid  and  cheek.  Not  unfrequently,  these  two  sequela?  go 
together. 

Trichiasis  or  inversion  of  the  eyelashes,  distichiasis  or  misplaced  eyelashes, 
and  even  inversion  of  the  lids,  must  also  be  enumerated  among  the  effects  of 
long-continued  ophthalmia  tarsi.  Those  in  whom  the  palpebral  conjunctiva 
is  much  affected,  or  suffers  from  repeated  ulcerations,  and  who  acquire  a 
habit  of  opening  their  eyes  very  partially,  are  most  subject  to  inversion. 

Constitutional  symptoms. — Inflammation  of  the  edges  of  the  eyelids  is 
much  more  frequent  in  children  than  in  adults.  In  almost  every  case,  the 
patient  presents  undoubted  marks  of  a  scrofulous  constitution  ;  the  functions 
of  the  skin,  and  of  the  digestive  organs,  are  disordered ;  and  the  general 
health  impaired.  Occasionally,  we  find  the  disease  associated  with  scrofulous 
conjunctivitis,  enlarged  lymphatic  glands,  swollen  upper-lip,  sore  ears,  scald 
head,  tumid  abdomen,  paleness  and  looseness  of  the  skin,  restlessness  during 
the  night,  and  morning  perspirations.  In  general,  however,  ophthalmia  tarsi 
does  not  affect  the  general  health  in  so  great  a  degree  as  the  disease  called, 
scrofulous  ophthalmia  or  phlyctenular  inflammation  of  the  conjunctiva. 

Causes. — Ophthalmia  tarsi  is  by  no  means  always  a  primary  disease  ;  but 
frequently  takes  its  origin  from  catarrhal  ophthalmia,  ophthalmia  neonatorum, 
or  scrofulous  conjunctivitis,  or  from  the  affections  of  the  eyes  attendant  on 
measles,  scarlatina,  or  smallpox.  In  all  these  diseases  there  is  more  or  less 
inflammation  of  the  Meibomian  follicles,  and  when  the  other  symptoms  sub- 
side or  totally  disappear,  the  ophthalmia  tarsi  is  apt  to  remain.  When  this 
disease  appears  to  be  primary,  cold,  impure  air,  smoke,  and  filthincss,  ope- 
rating directly  on  the  eyelids,  are  among  the  most  common  exciting  causes  ; 
while  the  scrofulous  constitution,  aggravated  by  indigestible  or  unwholesome 
food,  and  other  causes,  affords  its  aid  in  perpetuating  the  complaint,  or  at 
least  in  favoring  relapses.  In  adults,  we  often  find  the  habitual  use  of  wine 
and  spirits  keeping  up  this  affection  of  the  eyelids.  Linnteus'  tells  us  that 
the  Laplanders  are  generally  blear  eyed.  He  ascribes  this  to  their  exposure 
to  the  sharp  winds,  the  reflection  from  the  snow,  the  fogs,  the  smoke,  which 
escapes  only  by  a  hole  in  the  roof  of  their  huts,  and  the  severity  of  the  cold. 
The  Finlanders  are  afflicted  in  the  same  way,  and  many  of  them  thereby 
deprived  of  sight. 

Treatment. — The  treatment  of  this  disease  comprehends,  1st,  Remedies 
likely  to  abate  the  inflammation,  upon  which  the  whole  train  of  symptoms 
originally  depends,  to  soothe  the  pain  and  itching,  and  prevent  the  bad 
effects  of  gluing  together  of  the  lids  ;  2dly,  Such  applications,  whether 
astringent,  stimulant,  escharotic,  or  epulotic,  as  may  deaden  the  excoriated 
and  ulcerated  parts,  promote  their  healing,  or  strengthen  the  debilitated  eye- 
lids ;  and  3dly,  Constitutional  remedies. 


It6  OPHTHALMIA   TARSI. 

1.  The  first  direction  to  be  given  to  the  patient,  or  to  his  attendant,  is 
never  to  attempt  to  open  the  eyes  in  the  morning,  till  the  concreted  purulent 
matter  is  completely  softened,  so  that  the  eyelids  may  separate  without  pain, 
and  without  injuring  the  eyelashes.  For  this  purpose,  a  teaspoonful  of 
milk,  with  a  bit  of  fresh  butter  melted  in  it,  may  be  employed  for  smearing 
the  lids,  rubbing  it  with  the  finger  gently  along  the  agglutinated  eyelashes. 
A  piece  of  soft  sponge,  wrung  out  of  hot  water,  is  then  to  be  held  upon  the 
eyelids  for  some  minutes ;  after  which  the  patient  will  find  the  eyelids  yield, 
without  pain,  to  the  least  effort  he  makes  to  open  them.  With  the  finger 
nail,  the  whole  of  the  matter  is  immediately  to  be  removed ;  and  should  it 
happen,  that  during  the  day,  or  towards  evening,  there  is  any  reappearance 
of  it,  the  same  plan  must  again  be  adopted.  This  is  absolutely  necessary, 
because  so  long  as  the  matter  is  allowed  to  remain,  no  application  of  lotion 
or  salve  can  be  of  any  use,  as  it  never  gets  into  contact  with  the  seat  of  the 
disease. 

2.  Occasional  scarification  of  the  palpebral  conjunctiva,  and  the  applica- 
tion of  leeches  to  the  external  surface  of  the  lids,  and  to  the  neighboring 
skin,  are  to  be  employed  for  the  purpose  of  subduing  the  inflammation. 

3.  Advantage  is  derived  from  emollient,  refrigerant,  and  sometimes  astrin- 
gent applications,  in  the  form  of  fomentations,  cataplasms,  pledgets,  and 
collyria. 

For  example,  after  the  lids  have  been  completely  freed  from  their  morbid 
secretion  in  the  morning,  they  may  be  fomented  with  warm  water,  or  a  warm 
decoction  of  poppy  heads,  chamomile  flowers,  the  leaves  of  water  germander, 
or  the  like ;  and  this  may  be  repeated  once  or  twice  in  the  course  of  the  day, 
till  the  pain  and  principal  inflammatory  symptoms  subside. 

Cataplasms  of  bread  and  water,  with  a  little  fresh  butter  or  olive  oil, 
inclosed  in  a  small  linen  bag,  and  laid  over  the  eyelids  through  the  night, 
are  useful  in  aggravated  cases.  A  cataplasm,  made  of  crumb  of  bread  and 
weak  vinegar,  is  often  of  service.  A  piece  of  caddis,  spread  with  some  soft 
cerate,  and  kept  upon  the  eyes  during  the  night,  is  useful. 

When  the  disease  is  slight  or  incipient,  an  evaporating  lotion  proves 
grateful  to  the  patient,  and  promotes  a  cure.  One  or  two  drachms  of  the 
spirit  of  nitrous  ether,  with  as  much  vinegar,  in  8  ounces  of  water,  frequently 
applied  to  the  lids  by  means  of  a  bit  of  sponge,  will  answer  this  purpose. 

In  cases  of  longer  standing,  and  especially  after  the  inflammatory  symp- 
toms are  somewhat  subdued,  it  is  advantageous,  repeatedly  during  the  day, 
to  bathe  the  eyelids  carefully  with  a  solution  of  from  one  to  two  grains  of 
corrosive  sublimate  in  eight  ounces  of  water.  This  solution  may  be  used 
cold  or  tepid,  as  the  patient  inclines  ;  and  after  the  outside  and  edges  of  the 
lids  are  well  soaked  with  it,  it  may  be  allowed  to  run  in  upon  the  eye,  so  as 
to  come  into  contact  with  the  inner  surface  of  the  lids. 

Other  collyria  may  also  be  employed;  as  a  weak  solution  of  sulphate  of 
zinc,  or  a  mixture  of  brandy  and  water.  One  of  the  chief  uses  of  the  col- 
lyria is  to  keep  the  eyelids  perfectly  clean,  without  which  no  cure  can  be 
effected. 

4.  Counter-irritation,  by  means  of  blisters  behind  the  ears  or  to  the  nape 
of  the  neck,  a  warm  plaster  between  the  shoulders,  or  a  caustic  issue  in  the 
neck,  is  often  attended  with  benefit.  Indeed,  it  rarely  happens  that  much 
good  can  be  done  without  a  continued  discharge,  in  those  cases  in  which  the 
lids,  from  long  neglect,  have  become  greatly  thickened  and  callous. 

5.  The  application  of  a  salve  to  the  edges  of  the  eyelids  at  bedtime,  is  an 
essential  part  of  the  treatment.  The  salves  Avhich  have  been  found  most 
useful,  are  those  possessed  of  a  stimulating  or  slightly  escharotic  power,  such 
as  the  red  precipitate,  or  the  subnitrate  of  mercury  salve.     The  latter,  com- 


OPHTHALMIA   TARSI.  ITT 

monly  known  by  the  name  of  citrine  ointment,  is  prepared  according  to  the 
formula  in  the  Pharmacopoeia,  but  is  usually  much  reduced  in  strength, 
before  being  employed  as  an  eye-salve.  The  former  consists  of  from  12  to 
20  grains  of  red  precipitate,  carefully  levigated  into  an  impalpable  orange 
powder,  and  mixed  with  one  ounce  of  butter,  or  lard,  free  from  salt.  About 
the  bulk  of  a  split  pea  of  the  salve  selected,  is  to  be  melted  on  the  end  of  the 
finger,  and  rubbed  into  the  roots  of  the  eyelashes,  and  along  the  Meibomian 
apertures,  every  night,  or  every  second  night,  according  to  the  sevei'ity  of 
the  symptoms  and  the  effects  produced.  If  much  irritation  follows  the  ap- 
plication of  the  salve,  once  every  second  night  will  be  sufficiently  often,  a 
little  simple  cerate,  softened  by  an  addition  of  axunge,  being  used  on  the 
alternate  nights. 

Some  surgeons  trust  their  patients  with  a  very  weak  salve  only,  which  is 
to  be  applied  freely,  by  rubbing  it  along  the  edges  of  the  lids ;  while,  with  a 
camel-hair  pencil,  they  themselves  apply  occasionally  some  stronger  salve, 
such  as  one  composed  of  10  grains  of  nitras  argenti  to  the  ounce  of  soft 
cerate,  taking  care  to  confine  the  application  to  the  diseased  parts. 

Salves  are  often  employed  for  the  cure  of  ophthalmia  tarsi,  without  almost 
any  eff"ect,  from  these  two  necessary  particulars  not  being  known  or  not 
attended  to  ;  namely,  that  the  salve  is  not  to  be  smeared  over  the  purulent 
crust  formed  by  the  disease,  but  applied  only  after  the  lids  are  freed  from 
every  particle  of  the  morbid  secretion  ;  and  that  it  is  not  to  be  pencilled 
softly  on,  but  pressed,  by  repeated  friction,  into  the  diseased  roots  of  the 
eyelashes,  and  into  the  mouths  of  the  Meibomian  follicles.  Unless  it  smarts 
considerably,  it,  in  general,  does  little  good. 

Other  salves  besides  those  above  mentioned,  are  sometimes  employed  in 
this  disease;  especially  Janin's,  which  consists  of  2  drachms  of  prepared 
tutty,  the  same  quantity  of  Armenian  bole,  and  1  drachm  of  the  white  pre- 
cipitate of  mercury,  with  half  an  ounce  of  lard.  In  old  people,  and  in  those 
incurable  cases  in  which  the  Meibomian  apertures  are  obliterated,  this  salve 
answers  better,  perhaps,  than  any  other.  The  ointment  of  oxide  of  zinc,  one 
composed  of  2  drachms  of  burnt  alum  to  1  ounce  of  lard,  and  various  others, 
have  also  been  used.  In  cases  supposed  to  be  porriginous,  a  mixture  of 
precipitated  sulphur  with  diluted  subnitrate  of  mercury  ointment,  has  been 
found  very  eifectual. 

Not  uiifrequently  we  meet  with  slight,  but  very  irritable  cases  of  ophthal- 
mia tarsi,  in  which  not  even  the  mildest  salve  can  be  borne.  Fomentations, 
with  poppy  decoction,  or  simply  with  warm  water,  afford  most  relief  in  such 
cases. 

6.  If  small  ulcers  are  present  along  the  edges  of  the  lids,  they  are  to  be 
touched  with  the  lunar  caustic  solution,  or  with  the  solid  nitras  argenti.  It 
is  useful,  also,  to  touch  the  inflamed  conjunctiva,  from  time  to  time,  with  the 
same  solution. 

When  the  lids  arc  greatly  thickened  and  indurated,  their  edges  much  in- 
crusted,  and  the  roots  of  the  eyelashes  ulcerated,  it  has  been  recommended 
to  extract  all  the  eyelashes,  and  then  touch  the  whole  diseased  surface  lightly 
with  a  pencil  of  lunar  caustic.  This  has  a  great  effect  in  healing  the  ulcers 
and  diminishing  the  swelling.  In  a  few  days,  the  caustic  may  be  repeated. 
Three  or  four  repetitions  are  generally  sufficient.  This  is  the  practice  of 
Quadri  of  Naples,  who,  in  the  interval  between  one  application  of  caustic 
and  another,  bathes  the  parts  with  brandy.^  Mr.  Lawrence,  who  also  recom- 
mends the  practice,  states  as  an  additional  inducement  to  extract  the  cilia, 
that  those  which  fall  out  by  ulceration  are  never  replaced,  because  the  bulb 
which  secretes  the  hair  is  destroyed ;  but  when  they  are  plucked  out,  they 
are  afterwards  restored.  It  is  not,  however,  absolutely  necessary  to  extract 
12 


178  OPHTHALMIA  TARSI. 

the  cilia,  in  order  to  derive  advantage  from  the  application  of  the  lunar 
caustic.  I  have  frequently  employed  it,  after  having  merely  cleared  the  cilia 
of  the  morbid  crust  which  adheres  to  them,  and  found  the  practice  highly 
useful. 

t.  As  the  obstinacy  of  ophthalmia  tarsi  almost  invariably  depends  on  a 
faulty  constitution,  tonics  and  alteratives  are  always  necessary.  The  tonics 
chiefly  to  be  depended  on  are  the  sulphate  of  quinia,  and  other  preparations 
of  bark,  the  mineral  acids,  the  precipitated  carbonate  of  iron,  and  chalybeates 
in  general.  These  are  to  be  given  in  appropriate  doses,  and  continued  for  a 
length  of  time.  A  solution  of  15  grains  of  muriate  of  barytes  in  half  an 
ounce  of  diluted  tincture  of  bark,  of  which  from  8  to  20  drops  are  given 
thrice  a-day,  in  a  wineglass  of  water,  is  much  recommended  by  Dr.  Zimmer 
of  Prague,  and  I  have  witnessed  good  eflFects  from  it.* 

The  alteratives  chiefly  employed  in  the  cure  of  this  disease,  are  iodine  and 
mercury,  the  former  as  iodide  of  potassium,  the  latter  in  the  form  of  Plum- 
mer's  pill.  Purgatives  are  useful  from  the  first ;  and  whether  alteratives  or 
tonics  are  afterwards  employed,  a  dose  of  laxative  medicine,  as  sulphate  of 
magnesia,  infusion  of  senna,  or  powdered  rhubarb  and  jalap,  ought  to  be 
occasionally  interposed. 

8.  The  regulation  of  the  patient's  diet  is  essential  for  the  cure  of  this  dis- 
ease. Care  is  to  be  taken  that  the  stomach  be  not  overloaded  at  Ijcdtime, 
or  disturbed  by  indigestible  or  improper  food  during  the  day ;  for,  if  this  be 
permitted,  the  morbid  secretion  from  the  lids  becomes  more  copious,  and  a 
greater  degree  of  irritation  and  inflammation  is  induced. 

9.  The  warm  bath,  with  sea-water,  if  it  can  be  had,  is  an  excellent  remedy. 
The  vapor-bath  is  also  useful.  If  neither  of  them  can  be  procured,  let  the 
tepid  pediluvium  be  employed  every  night  at  bedtime. 

10.  Pure  air,  and  regular  exercise,  are  to  be  recommended.  Violent  ex- 
ercise is  to  be  avoided,  as  Horace  knew,  himself  afflicted  with  this  disease  : — 

Namque  pila  lippis  inimicum  et  ludere  crudis.^ 

11.  The  clothing  of  those  affected  with  ophthalmia  tarsi  ought  to  be  par- 
ticularly attended  to.  A  delicate  child  is  easily  chilled.  The  skin,  stomach, 
liver,  and  bowels  are  thereby  disordered ;  and  an  attack  of  this  disease,  or  of 
scrofulous  conjunctivitis,  is  a  frequent  concomitant.  The  difliculty  of  curing 
these  diseases  is  always  increased,  when  the  weather  is  damp  and  cold. 

12.  Sleep  at  early  hours  is  of  great  consequence.  Hardly  anything  tends 
more  to  confirm  this  affection  of  the  lids,  than  sitting  up  late  at  night,  espe- 
cially if  the  eyes  are  at  the  same  time  employed  on  minute  objects. 

Prognosis. — So  obstinate  is  ophthalmia  tarsi  in  many  instances,  that  we 
are  not  unfrequently  asked,  if  it  will  ever  be  cured.  The  answer  depends  on 
the  state  of  the  Meibomian  apertures,  and  on  the  perseverance  of  the  patient, 
or  his  friends,  in  the  means  of  cure.  If,  from  neglect,  the  mouths  of  the 
Meibomian  follicles,  in  number  about  30  on  the  edge  of  each  eyelid,  are  par- 
tially, or  totally  obliterated,  so  that  the  skin  covering  them  is  smooth  and 
shining,  and  nothing  can  be  pressed  out  of  them,  the  case  is  so  far  incurable; 
and  the  patient  must,  for  life,  pay  attention  that  the  lids  do  not  get  worse. 
He  must  use  Jauin's  or  some  other  salve,  every  night ;  and  follow  the  gene- 
ral directions  regarding  diet,  clothing,  and  exposure,  already  laid  down.  If, 
on  the  other  hand,  the  Meibomian  apertures  are  patent,  however  much 
inflamed  and  disfigured  the  eyelids  are  by  the  disease,  the  case  is  perfectly 
curable  by  perseverance ;  but  even  after  the  symptoms  appear  completely 
gone,  the  remedies  will  require  to  be  continued,  for  months  at  least.  The 
establishment  of  puberty  exercises  its  influence  over  this,  as  over  other  scro- 
fulous diseases. 


PORRIGO   LARVALIS   AFFECTING   THE   EYELIDS.  179 

Sequelcs. — As  important  consequences  of  ophthalmia  tarsi,  may  be  men- 
tioned, tylosis,  or  chronic  thickening  of  the  whole  substance  of  the  lid ;  lip- 
pitudo,  excoriation  of  the  edges  of  the  lids,  or  blear  eyes ;  obliteration  of  the 
Meibomian  follicles,  the  cause  of  incurable  lippitudo  ;  madarosis,  or  loss  of 
the  eyelashes ;  lagophthalmos  and  ectropium,  from  the  contracted  state  of 
the  skin,  consequent  to  the  healing  up  of  the  excoriated  lids  ;  trichiasis,  or 
inversion  of  the  eyelashes;  distichiasis,  or  misplaced  eyelashes;  entropium, 
from  repeated  ulcerations  of  the  edges  of  the  lids,  and  contraction  of  the  car- 
tilages.    Several  of  these  sequelae  I  shall  take  up  separately. 


'  Lachcsis  Lapponica,  by  Smith;  Vol.  ii.  pp.  ^  Griife  und  AValther's  Journal  der  Chirurgie 

5,  132  ;  Loudon,  1811.  und  Augenheilkunde  ;  Vol.  xxiv.  p.  156;  Ber- 

^  Treatise  on  the  Diseases  of  the  Eye,  p.  339;  lin,  1836. 

London,  1833.  '  Horatii  Sat.  i.  v.  49. 

^  Annotazioni  Pratiche  sullo  Malattie    degli 
Occhi;  Lib.  i.  p.  145  ;  Napoli,  1818. 


SECTION  XI. — HERPES  AFFECTING  THE  EYELIDS, 

There  is  scarcely  any  cutaneous  disease  which  may  not  be  seen  occasion- 
ally on  the  eyelids. 

Herpes  I  have  often  met  with,  both  in  children  and  adults.  It  runs  its 
usual  course  of  about  a  fortnight,  leaving  pits,  like  those  of  smallpox.  Not 
unfrequently  it  attacks  the  cornea,  a  vesicle  having  its  seat  there,  ending  in 
an  ulcer. 

Gentle  laxatives  and  diaphoretics,  a  light  diet,  and  fomenting  the  eyelids 
with  warm  water,  make  up  the  general  treatment.  Should  ulceration  take 
place  on  the  cornea,  it  ought  to  be  touched  with  lunar  caustic  solution,  and 
the  eyelids  painted  over  with  the  extract  of  belladonna. 


SECTION  XII. — PORRIGO  LARVALIS  AFFECTING  THE  EYELIDS. 

Porrigo  larvalis,  or  crusta  lactea,  not  unfrequently  spreads  to  the  skin  of 
the  eyelids.  Infants  are  almost  exclusively  the  subjects  of  this  disease.  It 
is  characterized  by  an  eruption  of  pustules,  followed  by  thin  yellowish  or 
greenish  scabs,  which  often  intrude  upon  the  edges  of  the  lids,  sealing  them 
up,  and  preventing  the  child  from  opening  its  eyes.  Falling  off,  these  scabs 
leave  the  cuticle  red  and  tender,  marked  with  deep  lines,  and  apt  repeatedly 
to  exfoliate.  The  conjunctiva  sometimes  takes  on  puro-mucous  inflammation 
during  an  attack  of  porrigo  larvalis,  and  occasionally  the  cornea  gives  way, 
and  the  eye  is  destroyed.^  The  lymphatic  glandular  system,  in  neglected 
cases,  becomes  affected,  both  externally,  as  under  the  jaw,  and  internally,  as 
in  the  mesentery ;  diarrhoea  and  hectic  fever  follow,  and  the  patient  perishes 
in  a  state  of  great  emaciation. '^ 

Careful  ablution  of  the  lids,  with  some  mild  and  tepid  fluid,  as  milk  and 
water;  the  solution  of  nitrate  of  silver  (4  grains  to  ^i  of  distilled  water) 
dropped  on  the  conjunctiva  once  a  day  ;  and  the  red  precipitate  salve  applied 
to  the  edges  of  the  lids  at  bedtime,  will  be  found  useful ;  with  alterative  doses 
of  mercurial  purgatives,  followed  by  a  course  of  sulphate  of  quinia. 


'  Stenheim,  Grafe  und  Walther's  Journal  der        °  Bateman's  Practical  Synopsis  of  Cutaneous 
Chirurgie  und  Augenheilkunde ;    Vol.  xiv.  p.     Diseases,  p.  162 ;  London,  1849. 
75;  Berlin,  1830. 


180  MEIBOMIAN   CALCULI. 


SECTION  XIII. — VITILIGO  AFFECTING  THE  EYELIDS. 
Fig.  Guy's  Hospital  Reports,  Second  Series  ;   Vol.  vii.  p.  274  ;  London,  1S50. 

This  disease,  when  it  affects  the  eyelids,  of  which  I  have  met  with  several 
instances,  presents  a  row  of  yellowish,  or  ochre-colored,  flat  patches,  of  irre- 
gnlar  shape,  slightly  elevated,  presenting  scarcely  any  induration,  and  gene- 
rally appearing  on  both  sides  of  the  face  symmetrically.  They  are  seated  in 
the  cutis,  and  the  cuticle  covering  them  seems  healthy.  They  avoid  the 
margins,  and  appear  chiefly  in  the  loose  skin  of  the  lids,  sometimes  spreading 
slowly  to  the  sides  of  the  nose  and  to  the  checks.  Other  parts  of  the  body, 
as  the  palms,  fingers,  elbows,  &c.,  are  sometimes  affected  in  a  similar  man- 
ner. The  disease  sometimes  accompanies  jaundice,  and  has  been  supposed 
to  depend  on  a  defective  action  of  the  liver.  This  should  be  corrected. 
The  eyelids  should  be  fomented  with  vinegar  and  warm  water.  Benefit  has 
l)een  derived  from  the  repeated  application  of  the  nitrate  of  silver. 


SECTION  XIV. — ABSCESS  OF  THE  MEIBOMIAN  GLANDS. 

I  have  already  (page  114)  mentioned  the  occasional  occurrence  of  abscess 
of  the  Meibomian  glands,  as  an  attendant  on  ophthalmia  tarsi.  Idiopathic 
cases  of  this  kind  are  also  met  with,  one  or  more  of  the  glands  being  turgid 
with  puriform  fluid,  perhaps  without  any  affection  of  the  edge  of  the  lid,  but 
sometimes  with  a  swelling  of  its  edge  resembling  a  hordeolum.  On  everting 
the  eyelid,  we  immediately  discover  the  nature  of  the  case,  and  the  difference 
between  it  and  common  hordeolum.  Tlie  pus  sometimes  oozes  out,  under 
pressure,  at  the  aperture  of  the  inflamed  gland;  in  other  cases,  the  abscess 
requires  to  be  opened  with  the  lancet,  on  the  edge  or  the  inside  of  the  lid. 
In  other  respects  the  treatment  for  ophthalmia  tarsi  is  to  be  followed. 


SECTION  XV. — OBSTRUCTION  OF  THE  MEIBOMIAN  APERTURES. 

Occasionally  the  external  orifice  of  one  or  more  of  the  Meibomian  ducts 
becomes  covered  by  a  thin  film,  apparently  of  epidermis.  This  prevents  the 
«.scape  of  the  secretion,  which,  accumulating,  raises  up  the  film  into  a  small 
elevation,  like  a  phlyctenula.  This  does  not  actually  cause  pain,  but  gives 
rise  to  slight  uneasiness  when  the  eyelids  are  moved.  The  film  is  easily 
broken,  and  the  accumulated  secretion  removed  on  the  point  of  a  pin. 


SECTION  XVI. — MEIBOMIAN  CALCULI. 

Two  sorts  of  concretions  are  met  with  in  the  Meibomian  glands.  They 
differ  in  appearance,  and  in  the  direction  by  which  they  seek  to  escape.  The 
one  is  semi-transparent,  like  a  particle  of  rice,  and  soft  in  consistence.  It 
projects  by  the  orifice  of  the  follicle  it  occupies,  and  on  pressure  starts  out. 
The  other  is  white,  opaque,  and  calcareous ;  it  does  not  project  on  the  edge, 
but  on  the  inner  surface  of  the  lid,  sometimes  penetrating  through  the  con- 
junctiva, and  causing  great  irritation  of  the  eye.  For  its  removal,  the  con- 
junctiva covering  the  calculus  requires  to  be  divided  with  a  lancet,  or  cata- 
ract needle,  and  the  concretion  lifted  out  with  the  pointed  end  of  a  probe, 
or  edge  of  a  small  spatula.  Numerous  concretions  of  this  sort  are  often  met 
with  in  the  same  eyelid. 


PHLYCTENULA   AND   MILIUM   OF   THE   EYELIDS.  181 


SECTION  XVn. — HORDEOLUM, 
Fig.  Dalrymple,  PI.  IV.  Fig.  1. 

A  hordeolum,  or  stye,  is  a  furunculus,  or  small  boil,  projecting  from  the 
edge  of  the  eyelid.  According  to  some,  it  implicates  merely  the  cellular 
tissue  ;  but  Zeis  suspects'  that  it  has  its  seat  in  the  capsule  and  glands  of  the 
roots  of  the  cilia.     Certainly  it  is  not  an  abscess  of  the  Meibomian  glands. 

Symptoms. — The  swelling  is  of  a  dark  red  color,  very  hard,  attended  at 
first  by  stiffness  and  itching,  and  afterwards  by  a  great  degree  of  pain  in 
proportion  to  its  size.  The  tension  and  exquisite  sensibility  of  the  skin 
which  covers  the  edge  of  the  eyelids,  serve  to  explain  the  vehemence  of  the 
pain.  The  inflammation  spreads,  in  some  degree,  to  the  conjunctiva,  and  the 
motions  of  the  lids  are  impeded.  In  delicate  irritable  subjects,  fever  and 
restlessness  are  excited.  The  swelling  suppurates  slowly,  and  at  last  points 
and  bursts.  After  discharging  a  small  quantity  of  thick  pus,  and  sometimes 
a  little  disorganized  cellular  membrane,  it  subsides  and  disappears.  If  Zeis 
be  correct,  the  disorganized  substance  which  is  discharged,  must  be  the  cap- 
sules of  the  cilia.  The  cilia  fall  out  from  the  part  affected,  to  be  generally, 
but  not  always,  reproduced. 

Causes. — Hordeolum  is  most  frequent  in  scrofulous  subjects.  It  frequently 
depends  on  late  hours,  the  use  of  spirituous  liquors,  or  on  disordered 
bowels.     Pickles  and  peppers  produce  it. 

Treatment. — In  the  incipient  stage,  cold  applications  are  to  be  used,  as 
water  acidulated  with  vinegar,  or  an  iced  poultice.  If  suppuration  appears 
to  be  advancing,  a  warm  bread  and  water  poultice,  inclosed  in  a  little  bag  of 
linen,  or  a  roasted  apple  poultice  is  to  be  applied.  If  slow  of  bursting,  the 
abscess  may  be  opened  with  the  point  of  a  lancet.  The  pus  and  destroyed 
areolar  tissue  are  to  be  pressed  out,  and  the  poultice  continued.  It  some- 
times happens,  that  the  sloughy  matter  is  slow  of  coming  away,  in  which 
case  the  cavity  may  be  touched  with  a  pointed  piece  of  lunar  caustic,  after 
which  it  soon  closes. 

In  the  commencement  of  hordeolum,  an  emetic,  followed  next  day  by  a 
purge,  will  be  found  useful. 


Ammon's  Zeitschrift  fiir  die  Ophthalmologie  ;  Vol.  v.  p.  220  ;  Heidelberg,  1836. 


SECTION  XVIII. — PHLYCTENULA  AND  MILIUM  OP  THE  EYELIDS. 

Fig.  Walton,  Figs.  88,  89. 

Semitransparent  vesicles,  or  phlyctenulae,  filled  with  watery  fluid,  fre- 
quently occur  on  the  edges  of  the  eyelids,  especially  at  the  inner  canthus, 
sometimes  single,  often  in  groups,  varying  in  size  from  that  of  a  mustard- 
seed  to  that  of  a  pea.  Having  been  punctured  with  the  lancet,  their  walls 
are  to  be  laid  hold  of  with  a  pair  of  toothed  forceps,  and  snipped  off  with 
the  scissors. 

Small  white  tumors,  like  millet  seeds,  containing  a  suet-like  substance,  are 
often  observed  on  the  edges  of  the  eyelids.  They  are  to  be  opened  with  the 
point  of  the  lancet,  and  their  contents  pressed  out. 


182  TUMORS  IN   THE   EYELIDS. 


SECTION  XIX. — WARTS  ON  THE  EYELIDS. 
Fig.  Dalrymple,  PI.  V.  Fig.  1. 

Warts  are  not  uncommon  on  the  external  surface  of  the  eyelids,  and  some- 
times grow  from  their  edges.  Keeping  the  excrescence  constantly  covered 
with  a  piece  of  lint,  saturated  with  a  decoction  of  tormentil  root,  or  a  solu- 
tion of  carbonate  of  soda,  will  sometimes  serve  for  its  removal.  [Even  cold 
water  continually  applied  will  serve  the  same  purpose. — H.]  But  if  this 
does  not  succeed,  the  wart  may  be  tied  with  a  waxed  silk  thread,  close  to  its 
root ;  or,  if  it  has  a  broad  attachment,  destroyed  by  the  application  of  lunar 
caustic.     The  shortest  way  is  to  snip  off  the  excrescence  with  scissors. 


SECTION  XX. — SYCOSIS  AFFECTING  THE  EDGE  OF  THE  EYELID. 
Fig.  Dalrymple,  PI.  IV.  Fig.  5. 

To  others  this  may  seem  a  very  trifling  disease ;  but  to  the  patient  ex- 
tremely desirous  to  get  quit  of  it,  and  to  the  surgeon  who  finds  it  exceedingly 
difficult  to  disperse  it,  its  apparent  insignificance  affords  little  consolation. 
Other  hard  tubercles  of  the  same  kind  are  generally  present  on  the  face  ;  but 
the  one  which  is  situated  on  the  edge  of  the  lid,  or  so  close  to  either  punctum 
as  almost  to  surround  it,  shows  a  still  greater  tendency  to  persist  than  any 
of  the  rest.  On  the  edge  of  the  lid,  the  tubercle  sometimes  shoots  out  with 
a  sharp  edge,  which  may  be  snipped  off  with  the  scissors.  A  regulated  diet, 
the  use  of  laxatives  and  antacids,  daily  touching  with  sulphate  of  copper, 
and  warm  fomentations,  make  up  the  treatment. 


SECTION  XXI. — HORNY  EXCRESCENCES  ON  THE  EYELIDS. 
Fig.  Dalrymple,  PI.  V.  Fig.  2. 

The  exudation  from  a  sebaceous  follicle  becoming  indurated,  and  gradually 
covered  by  layers  of  desquamating  epithelium,  has  sometimes  pushed  itself 
into  the  form  of  a  little  horn,  projecting  in  a  curved  form  from  the  skin  of 
the  eyelids.  Seized  with  the  fingers,  the  horn  is  to  be  drawn  forwards,  and 
snipped  out  by  the  root. 


SECTION  XXII. — TUMORS  IN  THE  EYEBROW  AND  EYELIDS. 

The  eyebrow  and  eyelids  are  the  occasional  seats  of  various  kinds  of 
tumors.  We  shall  turn  our  attention  first  to  those  which  are  common  in 
their  occurrence,  then  to  those  which  are  rare. 

§  1.   Chalazion,  or  Fibrinous  Tumor. 

From  x^aXal^a.  a  hailstone.    Syn. — Tarsal  Tumor. 
Fig.  Dalrymple,  PI.  TV.  Fig.  2.     Walton,  Figs.  90,  91. 

This  extremely  common  disease  bears  some  resemblance  to  a  hordeolum, 
but  it  is  not  situated  on  the  edge  of  the  lid,  nor  does  it  point  towards  the 
edge.  It  is  generally  placed  at  some  distance  from  it,  and  when  it  comes  to 
point,  it  does  so  generally  towards  the  internal,  rarely  towards  the  external, 


TUMORS  IN   THE   EYELIDS. 


183 


surface  of  the  eyelid.  It  is  situated  either  between  the  orbicularis  palpebra- 
rum and  the  tarsus,  or  in  the  substance  of  the  cartilage  itself.  The  tumor  is 
at  first  movable  ;  but,  as  it  enlarges,  it  becomes  fixed,  and  the  skin  covering 
it  grows  red.  By  everting  the  lid,  we  cause  the  tumor  to  project  on  its  inner 
surface,  which  appears  inflamed,  and  often  presents  a  depression  over  the 
centre  of  the  tumor.  Fig.  10  shows  the  external  appearance  of  the  lower  lid 
affected  with  chalazion  ;   and  Fig.  11  its  inner  surface.     After  the  disease 


Fio;.  10. 


Fig.  11. 


has  continued  for  a  considerable  time,  that  portion  of  the  cartilage  which  lies 
behind  the  chalazion  becomes  thinned  by  absorption,  and  we  find  a  small 
fungus-like  substance  projecting  through  the  cartilage  and  palpebral  con- 
junctiva. In  one  case,  I  found  the  fungous  growth  making  its  way  through 
the  upper  punctum.  A  chalazion  often  goes  on  to  suppurate,  or  rather  sup- 
puration takes  place  round  the  tumor,  and  at  length  the  tumor  is  destroyed 
l3y  this  process,  the  abscess  evacuating  itself,  in  some  cases  on  the  outside, 
and  in  others  on  the  inside  of  the  lid. 

Chalazion  is  met  with  more  frequently  in  the  upper  than  in  the  lower 
eyelid.  Sometimes  it  occurs  in  both  at  the  same  time.  In  some  cases,  there 
are  more  than  one  in  the  same  lid.     It  is  very  rarely  seen  in  children. 

The  digestive  organs  of  those  who  are  troubled  with  chalazia,  are  generally 
in  bad  order ;  the  stomach  acid  and  flatulent ;  the  bowels  slow,  and  the 
evacuations  morbid.  In  incipient  cases,  the  further  progress  of  the  tumor 
may  often  be  checked  by  alterative  doses  of  the  blue  pill,  and  by  the  use  of 
laxatives  and  tonics,  especially  bark  and  steel.  Under  this  treatment,  I  have 
seen  many  such  tumors  disperse  entirely.  A  vinegar  poultice,  in  a  small 
linen  bag,  continued  every  night,  sometimes  proves  useful ;  as  weU  as  friction 
over  the  tumor,  with  camphorated  mercurial  ointment,  for  ten  minutes  twice 
a-day. 

Small  hard  chalazia  should  not  be  touched,  especially  if  situated  at  the 
extremity  of  either  lid.  When  it  has  attained  a  certain  size  and  become 
somewhat  softened,  this  sort  of  tumor  requires  to  be  removed  by  operation. 
As  it  is  unencysted,  it  is  needless  to  think  of  a  regular  extirpation.  If  this 
be  attempted,  the  operator  is  very  likely  to  be  foiled,  as  the  tumor  eludes 
dissection ;  or  if  he  still  persists,  he  may  extirpate  perhaps  a  piece  of  the 
cartilage,  and  leave  the  lid  with  an  opening  through  it,  like  a  button-hole.  I 
have  seen  cases  in  which  the  structure  of  the  lid  was  materially  damaged  by 
attempted  extirpations  of  chalazia ;  a  portion  of  the  cartilage  having  been 


184  TUMORS  IN   THE   EYELIDS. 

removed,  leaving  the  lid  inverted,  or  bound  to  the  eyeball  by  frfena.  All 
that  is  necessary,  in  general,  is  to  evert  the  affected  lid,  divide  the  tumor 
through  its  whole  length  with  the  lancet  pushed  through  the  cartilage,  and 
then  press  out  the  gelatinous-like  contents.  Pretty  firm  pressure  is  necessary 
to  effect  this.  If  the  tumor,  fairly  divided,  does  not  start  out,  the  pointed 
end  of  a  probe  may  be  passed  through  the  incision,  the  structure  broken  up, 
and  then  pressure  applied.  The  cavity  where  the  chalazion  was  lodged, 
immediately  fills  with  blood,  keeping  up  an  appearance  as  if  the  tumor  was 
still  there,  although  lessened  in  size ;  but  gradually  the  swelling,  redness, 
and  other  signs  of  the  disease,  go  off  entirely.  In  some  few  cases,  it  may  be 
proper  to  perform  this  operation  through  the  integuments ;  but,  in  general, 
the  tumor  lies  nearer  the  inner  surface  of  the  lid.  If  the  chalazion  threatens 
to  burst  through  the  cartilage,  or  if  there  is  already  a  little  opening  with  a 
small  fungous  protrusion,  the  incision  ought  to  be  made  in  the  line  of  this 
protrusion,  and  not  to  one  side  of  it,  even  though  the  tumor  is  more  promi- 
nent where  the  cartilage  is  still  entire.  It  is  much  easier  to  press  out  the 
chalazion  through  the  thinned  part  of  the  tarsus,  than  elsewhere.  If  the 
fungus  which  protrudes  is  considerable,  it  is  to  be  snipped  off.  Sometimes 
two  chalazia,  sitting  close  together,  appear  as  one ;  but  require  two  separate 
incisions  for  their  removal. 

Attempts  to  destroy  chalazia  by  caustic  are  always  ineffectual,  and  often 
hurtful,  producing  induration  of  the  lid,  and  sometimes  trichiasis.  A  mere 
division  of  the  tumor  through  the  conjunctiva  and  tarsus,  is  also  insufficient, 
even  with  the  application  of  caustic  introduced  through  the  wound;  the 
tumor  must  be  evacuated  in  the  manner  described.  By  this  means,  the  cha- 
lazion, if  not  in  a  state  of  suppuration,  is  generally  removed  entire.  It  is  of 
a  light  reddish  color,  and  gelatinous  consistence,  with  spots  of  blood  through 
it.  Becoming  white  and  opaque  on  being  immersed  in  diluted  alcohol,  dis- 
solving with  great  ease  in  acetic  acid,  and  being  thrown  down  by  prussiate 
of  potash,  it  seems  to  consist  of  an  imperfect  fibrinous  matter. 

§  2.  Molluscum,  or  Albuminous  Tumor. 

Si/n. — Glandiform  tumor.     Tumeur  folliculeuse,  Fr. 

Fig.  Dalrymple,  PI.  IV.  Fig.  3.     Walton,  Fig.  87.     Willis,  PI.  63. 

Molluscum  or  albuminous  tumor  occurs  much  more  frequently  in  children 
than  in  adults.  It  is  seated  in  the  skin  ;  sometimes  close  to  the  edge  of  the 
eyelid,  but  generally  at  some  distance  from  it.  When  close  to  the  edge,  the 
eye  is  apt  to  be  irritated  and  inflamed  by  its  presence.  The  integuments 
covering  the  tumor  are  so  thinned  as  to  allow  its  white  color  to  shine  through. 
It  presents  a  granulated  appearance  even  before  extirpation  ;  and  on  being 
removed,  is  still  more  distinctly  seen  to  be  formed  of  numerous  grains,  the 
acini  of  hypertrophied  sebaceous  glands.  The  tumors  vary  in  size  from  that 
of  a  pin's  head  to  that  of  a  horse-bean,  or  even  larger,  are  firm,  free  from 
pain,  unencysted,  and  not  apt  to  go  into  suppuration.  They  are  sessile  on 
a  contracted  base,  but  not  pedunculated.  In  their  centre  they  present  a 
small  orifice,  whence  a  whitish  fluid  exudes.  After  a  time,  the  integuments 
become  ulcerated,  and  the  mass  is  discharged  entire,  or  in  portions.  The 
eyelids  often  present  numerous  albuminous  tumors,  and  sometimes  they  are 
scattered  over  the  other  parts  of  the  face. 

It  is  well  ascertained,  that  this  disease,  when  recent,  proves  contagious, 
the  whitish  fluid  which  exudes  by  the  orifice  of  the  tumor  being  the  apparent 
medium  by  which  the  disease  is  communicated.  In  one  case,  I  saw  the 
hands  of  a  gentleman  inoculated  from  the  face  of  his  child.     The  recent  dis- 


TUMORS   IN    THE   EYELIDS.  185 

ease  is  styled  molluscum  contagiosum  ;  the  chronic,  which  seems  to  have  lost 
the  contagious  property,  and  has  often  been  known  to  last  for  many  years,  is 
called  molluscum  pendulum,  from  the  elongation  which  its  attachment  to  the 
skin  gradually  acquires. 

Chemical  examination  of  the  tumor  shows  it  to  possess  the  characters  of 
coagulated  albumen. 

If  albuminous  tumor  be  dependent  on  any  constitutional  cause,  it  seems  of 
scrofulous  origin.  I  have  seen  a  crop  disappear  from  the  eyelids  of  a  scro- 
fulous child,  during  the  use  of  the  sulphate  of  quina. 

Albuminous  tumors  may  be  destroyed  by  being  touched  with  potassa  fusa, 
nitrate  of  silver,  or  sulphate  of  copper ;  but  the  readiest  way  of  extirpating 
them  is  by  a  transverse  incision  through  the  integuments,  and  through  the 
diseased  mass.  By  firm  pressure  with  the  thumb-nails,  placed  on  the  sound 
skin,  we  are  then  able  to  bring  away  the  tumor  entire,  without  any  farther 
dissection.  Sometimes,  on  making  pressure  after  dividing  the  tumor,  the 
central  parts  only  of  it  escape,  leaving  the  exterior  layer  adhering  to  the 
skin,  almost  like  a  cyst.  By  repeating  the  pressure,  this  portion  is  also 
brought  away.* 

In  chronic  cases,  affecting  the  upper  eyelid,  the  tumor  sometimes  attains 
an  enormous  size,  so  as  to  hang  down  and  completely  cover  the  opening  of 
the  lids.  In  cases  of  this  sort,  examples  of  which  are  related  and  figured  by 
Liston^  and  Craigie,^'  the  rest  of  the  body  is  generally  covered  with  mollus- 
cous tumors.  To  remove  the  deformity  of  the  eyelid  under  such  circum- 
stances, an  elliptical  portion  of  skin,  embracing  the  diseased  structure, 
requires  to  be  removed,  and  the  edges  brought  together  by  stitches. 

§  3.  Encysted  Tumor. 

Encysted  tumors,  filled  with  serous  fluid,  or  with  suety  or  still  more  solid 
substance,  rarely  occur  in  the  eyelids.  Congenital  tumors  of  this  kind,  how- 
ever, are  not  unfrequently  met  with,  close  to  their  outer  angle,  or  above  the 
eyebrow.  Their  pappy  contents  are  sometimes  mixed  with  short  hairs,  like 
cilia,  having  bulbs,  and  growing  from  the  inside  of  the  cyst.  They  often  lie 
under  the  orbicularis  palpebrarum,  and  adhere  to  the  bone,  so  that,  when  we 
proceed  to  their  extirpation,  it  is  necessary  to  make  a  larger  incision  than 
the  size  of  the  tumor  might  seem  to  require,  and  to  dissect  carefully  round 
and  under  the  cyst,  laying  back  the  orbicularis  palpebrarum  as  well  as  the 
integuments ;  for  unless  this  is  done,  the  extirpation  will  be  effected  with 
difficulty.  When  seated  in  the  eyelids,  the  cyst  is  often  very  delicate,  so 
that  it  is  difficult  to  remove  it  entire.  If  the  cyst  bursts,  we  may  introduce 
one  blade  of  the  hooked  forceps  within  it,  while  the  other  seizes  it  exter- 
nally, and  go  on  to  dissect  out  the  cyst.  In  some  instances,  I  have  found 
the  cyst  seated  between  the  conjunctiva  and  the  orbicularis  palpebrarum,  so 
as  to  be  beyond  the  tarsus  ;  and  in  this  case,  the  extirpation  is  best  accom- 
plished through  the  inner  surface  of  the  lid. 

Instead  of  attempting  a  regular  extirpation,  it  may  sometimes  be  advisable 
merely  to  lay  open  the  cyst  with  the  lancet,  and  then  squeeze  out  its  con- 
tents, along  with  the  cyst,  which  I  have  sometimes  accomplished.  If  the 
cyst  cannot  be  thus  brought  away,  we  may  introduce  into  its  cavity  for  a  few 
seconds  a  pencil  of  lunar  caustic,  or  pure  potash.  After  a  few  days,  the  cyst 
comes  away,  and  the  wound  heals  up.  Or  the  tumor  may  be  divided  at 
once  into  two  halves,  the  contents  removed,  and  the  cyst  allowed  to  collapse ; 
then,  with  a  pair  of  forceps,  the  one  half  of  the  cyst  is  to  be  laid  hold  of, 
drawn  out  through  the  wound,  and  snipped  off  with  scissors,  and  the  same 
with  the  other  half.     If  any  part  of  the  cyst  is  left,  the  wound  will  perhaps 


186  TUMORS  IN   THE  EYELIDS. 

not  close,  or  is  apt  to  open  again,  after  being  healed,  and  continne  for  a 
length  of  time  to  discharge  matter.  Should  this  take  place,  it  may  be  pro- 
per to  make  an  incision,  and  remove  the  bit  of  the  cyst  which  had  been  left 
at  the  former  operation. 

[Both  encysted  and  fibrous  tumors  differ  very  much  as  to  their  original  seat 
of  development  on  the  lids.  They  may  begin  on  either  side  of  the  cartilage, 
and  by  pressure  produce  absorption  and  perforation  of  the  part  of  that  struc- 
ture with  which  they  come  in  contact,  and  then  manifest  themselves  more  or 
less  equally  on  both  sides;  or  no  alteration  in  the  condition  of  the  cartilage 
may  ensue,  and  the  tumor  remain  entirely  isolated  on  the  one  side,  or  become 
adherent  to  the  cartilage. 

When  developed  external  to  the  cartilage,  they  may  be  either  simply  sub- 
cutaneous, or  lie  between  it  and  the  orbicularis. 

When  subcutaneous  only,  they  are  more  defined  in  their  form,  and  more 
movable  than  when  they  are  covered  by  the  muscle. 

The  tumors  developed  beneath  the  orbicularis,  if  movable  at  first,  very  soon 
lose  that  character,  and,  becoming  adherent  to  the  cartilage,  perforate  that 
tissue,  being  kept  in  close  contact  with  it  by  the  action  of  the  orbicularis  ;  and 
hence,  it  generally  follows  that  the  tumors  which  perforate  the  cartilage  have 
had  origin  beneath  the  muscle. 

The  tumors  which  originate  on  the  inner  side  of  the  lid  are  developed  in 
the  tissue  connecting  the  conjunctiva  with  the  cartilage,  and  are  at  first  quite 
movable.  When  small,  they  give  an  undefined  fulness  to  the  part  of  the  lid 
beneath  which  they  He ;  but  when,  however,  they  attain  a  large  size,  and  are 
firm,  they  present  very  much  the  same  appearance  as  those  beneath  the 
muscle ;  but  their  true  seat  will  be  readily  shown  on  simply  everting  the  lid. 

Now  a  careful  examination  of  the  original  seat  of  these  tumors  is  of  some 
moment  in  determining  on  which  side  of  the  lid  the  incision  is  to  be  made 
for  their  removal,  as  we  shall  see  presently. 

A  source  of  great  annoyance,  and  a  not  nnfrequent  cause  of  failure  in  the 
complete  extirpation  of  these  little  growths,  is  in  the  profuse  hemorrhage 
which  follows  the  slightest  incision  of  the  lids.  To  avoid  this,  M.  Desmarres 
designed  his  ring-forceps,  which  consist  of  a  pair  of  ordinary  dressing  forceps, 
with  their  ends  armed — the  one  with  an  oval  plate  about  one  inch  by  half  an 
inch,  and  the  other  with  a  ring  of  the  same  dimensions.  They  are  to  be 
applied — the  one  blade  on  either  surface  of  the  lid,  and  firmly  pressed 
together  by  means  of  a  screw  and  button ;  this  will  completely  interrupt  the 
circulation  in  the  part  embraced  by  the  ring  through  which  the  tumor  is  to 
be  removed,  the  plate  beneath  serving  as  a  firm  basis,  on  which  the  incisions 
are  to  be  made. 

The  accompanying  wood-cut  represents  the  instrument  as  modified  by  Mr. 
Wilde,  of  Dublin.     His  modifications  consist  in  diminishing  the  size  of  the 

Fig.  12. 


plate  and  ring,  which,  in  the  original  instrument,  are  unnecessarily  large ; 
and  in  placing  the  button  and  screw  on  the  opposite  side,  so  that  the  ring 
can  be  placed  over  the  tumor  on  the  conjunctival  surface,  and  the  two  blades 


TUMORS   IN   THE   EYELIDS.  187 

screwed  together,  which  could  not  be  done  so  readily  under  such  circum- 
stances in  the  original  instrument. 

Mr.  Kolbe,  an  ingenious  instrument  maker,  formerly  of  Mr.  Ltier's  establish- 
ment in  Paris,  but  now  resident  in  Philadelphia,  has  substituted  the  wedge- 
shaped  slide,  similar  to  that  on  the  dog-toothed  forceps,  for  the  screw  and 
button.  This  enables  the  instrument  to  be  applied  with  equal  facility  for 
the  removal  of  the  tumor  on  either  side. 

Mr.  Wilde,*  of  Dublin,  prefers  removing  tarsal  tumors  by  incision  through 
the  conjunctiva,  whereas  Mr.  Desmarres'  evidently  employs  the  external  in- 
cision, to  the  exclusion  of  any  other  for  the  purpose.  Neither,  however,  in 
our  opinion,  should  be  used  exclusively. 

In  cases  of  simple  subcutaneous  tumors,  it  would  be  entirely  unnecessary 
to  evert  the  lid,  make  an  incision  down  to  the  tumor,  and  remove  it  in  that 
way ;  the  division  of  the  integument  is  all  that  would  be  required  in  such 
cases.  But  the  simple  subcutaneous  tumor  is  the  rarest  form  of  tarsal  growths 
we  meet  with,  the  majority  of  cases  about  which  we  are  consulted  being 
either  of  the  subconjunctival  or  submuscular  form,  and  the  latter  where  the 
cartilage  has  been  perforated  and  the  tumor  is  pointing  at  the  conjunctival 
surface,  for  these  are  the  forms  of  tumor  which  give  rise  to  the  greatest  irri- 
tation and  annoyance,  compelling  the  patient  to  seek  for  relief  at  the  hands 
of  the  surgeon.  In  such  cases,  the  operation  is  more  readily  and  perfectly 
performed  by  the  incision  through  the  conjunctiva. — H.] 

Simple  puncturing  of  encysted  tumors  does  not  answer  well,  as  it  is  apt  to 
excite  inflammation  in  the  neighboring  cellular  membrane,  and  lead  to  fun- 
gous growths  from  the  cyst. 

§  4.  Fihro-plastic  or  Sarcomatous  Tumor. 

Case  136. — A  Moor,  24  years  of  age,  applied  at  the  French  Hospital  at  Algiers  on 
account  of  an  enormous  nodulated  tumor  in  the  right  upper  eyelid,  of  several  years' 
standing,  the  origin  of  which  he  attributed  to  a  blow  with  a  stick.  The  tumor  hung 
down  so  far,  that  the  cilia  were  nearly  on  a  level  with  the  chin ;  it  rose  in  relief  above 
the  prominence  of  the  nose,  and  measured  6  inches  in  its  vertical  diameter,  and  5  in  its 
transverse.  The  upper  part  of  the  tumor  passed  into  the  orbit,  and  adhered  to  the  globe 
of  the  eye,  which  was  partially  atrophied,  with  its  cornea  opaque.  When  the  tumor  was 
raised,  however,  the  patient  appeared  to  discern  the  light. 

The  patient  was  much  harassed  by  this  morbid  growth ;  it  deranged  his  whole  system, 
disturbed  his  nutrition,  and  had  reduced  him  to  a  state  of  great  emaciation.  M.  Baudens, 
the  surgeon  of  the  hospital,  explained  to  his  colleagues  how  he  should  dissect  out  the 
tumor  from  below  upwards,  leaving  a  sufficient  portion  of  integuments  to  supply  the  loss 
■which  the  conjunctiva  would  suffer,  and  avoiding  in  his  operation  the  orbicularis  palpe- 
brarum, the  levator  palpebrte  superioris,  and  the  cartilage  of  the  lid.  His  opinion  was 
adopted,  but  the  opei'ation  was  more  troublesome  than  he  had  calculated,  chiefly  from 
the  immanageableness  of  the  patient. 

The  nodules  of  the  tumor  were  interspersed  among  the  fibres  of  the  orbicularis  palpe- 
brarum; and  the  operator  felt  his  difficulties  augmented  when  he  came  to  separate  the 
diseased  structure  from  the  eyeball,  which  he  was  most  desirous  not  to  injure.  He  con- 
trived to  manage  it,  by  using  his  forefinger  as  a  guard  between  the  eye  and  the  tumor ; 
and  syncope  having  come  on,  he  availed  himself  of  the  moment  to  dissect  the  integument, 
which  he  wanted  for  the  new  eyelid.  To  this  he  attached  the  edge  of  the  old  eyelid,  by 
a  few  stitches,  thus  preserving  the  cilia.  Simple  dressings  were  then  applied.  In  twenty- 
four  hours,  the  sutures  were,  removed,  the  cicatrice  being  consolidated.  In  eight  days, 
the  patient  was  almost  quite  well.  In  the  course  of  two  months,  the  cornea  recovered  a 
great  part  of  its  transparency.  The  lid  could  be  raised  and  depi'essed,  and  its  dimensions 
nearly  corresponded  with  those  of  the  opposite  side. 

As  to  the  tumor,  it  was  found  strongly  imbedded  in  a  fibrous  envelop,  several  lines  in 
thickness.  It  weighed  fifteen  ounces,  and  resembled,  in  every  respect,  a  mass  of  pale 
fibrin,  such  as  is  obtained  from  abstracted  blood.  A  number  of  little  serous  cysts  were 
seated  in  its  centre.^ 

Other  tumors,  still,  might  be  described ;  for  example,  neuroma  or  painful 
subcutaneous  tubercle,  scirrhus,  fungus  hcematodes,  melanosis,^  &c.     But  I 


188  TYLOSIS. NiEVUS   MATERNUS   OP   THE   EYELIDS. 

think  it  unnecessary  to  enter  on  the  particular  consideration  of  these  diseases 
as  affecting  the  eyebrow  or  eyelids. 


'  On  Molluscuui,  consult  Peterson,  Edinburgh  mic    Surgery.     Dublin   Quarterly   Journal    of 

Medical  and  Surgical  Journal,  Vol.  Ivi.  p.  279  ;  Medicine  ;  vol.  v.  p.  475  ;  1848.] 

Turnbull,  ib.  p.  463  ;  Cotton,  ib.  Vol.  Ixix.  p.  '  [Traite  des  Maladies  des  Yeux,  par  L.  A. 

82  ;  Caillault,  Archives  Generales  de  Medecine,  Desmarres.     P.  144.     Paris,  1847.    H.] 

4«  Serie  ;  tome  xxvi.  pp.  46,  316.      Paris,  1851.  "  Baudens,    Clinique   des   Plaies    J'Arraes  a 

^  Lancet,  July  13,  1844,  p.  489.  Feu;  p.  168;  Paris,  1826. 

^Edinburgh  Medical  and  Surgical  Journal.  ''  Edinburgh  Medical  and  Surgical  Journal; 

Vol.    Ixxv.  p.  108;   Edinburgh,  1851.  Vol.  xxxviii.  p.  324 ;  Edinburgh,  1832. 

*  [Wilde's  Report  on  the  Progress  of  Ophthal- 


SECTION   XXIII. — TYLOSIS,  OR  CALLOSITY  OF  THE  EYELIDS. 

There  are  several  varieties  of  thickening  and  induration  of  the  eyelids, 
which  merit  attention.  What  I  said  in  former  editions  of  this  work,  of  the 
scirrhoid,  I  have  transferred  to  the  head  of  epithelial  cancer.  (See  p.  165.) 
There  remain  the  scrofulous,  and  the  arthritic  varieties. 

1.  The  former  arises,  as  has  been  already  (page  174)  explained,  from  ne- 
glected ophthalmia  tarsi.  Iodide  of  potassium  or  Plummer's  pill  failing  to 
remove  it,  a  caustic  issue  in  the  nape  of  the  neck  is  perhaps  the  best  remedy 
for  this,  the  scrofulous  tylosis,  added  to  the  ordinary  treatment  of  inflamma- 
tion of  the  edges  of  the  eyelids. 

2.  Tylosis  arthritica  rarely  occurs,  except  in  those  whose  digestive  organs 
are  deranged  by  the  habitual  use  of  ardent  spirits.  It  is  attended  with  red- 
ness, attacks  generally  the  upper  eyelid,  and  seems  to  have  its  chief  seat 
external  to  the  cartilage.  The  whole  length  of  the  eyelid  is  commonly 
affected;  but  in  some  cases  merely  a  part,  and  that  not  unfrequently  the  neigh- 
borhood of  the  papilla  lachrymalis.  Occasionally,  the  Meibomian  glands  are 
evidently  enlarged ;  and  sometimes  the  disease  is  combined  with  chalazion.  I 
have  never  seen  this  variety  of  callosity  end  in  suppuration  or  ulceration. 
It  slowly  increases,  and  then  becomes  stationary.  The  patient  generally 
complains  of  thirst,  acidity,  and  want  of  appetite.  The  application  of  leeches, 
friction  with  camphorated  mercurial  ointment,  the  use  of  laxatives,  and  the 
exhibition  of  alteratives  internally,  I  have  sometimes  found  successful,  but 
often  fruitless,  in  this  complaint. 


SECTION  XXIV. N^VUS   MATERNUS,  AND   ANEURISM  BY  ANASTOMOSIS,*  OF  THE 

EYEBROW  AND  EYELIDS. 

Syn. — Mother's  mai-k,  Vulg.  Loupe  variqueuse.  Petit.  Tumeur  erectile,  Fr.  Incorrectly 
called  by  some  French  authors,  Fongus  hematode.  Der  Blutschwamm,  Ger.  Telangi- 
ectasia, from  rlXof  end,  ayyiiov  vessel,  and  Exras-jj  extension. 

Fig.  Bell's  Principles   of  Surgery,  vol.  i.  p.  461 ;  vol.  iii.   Nos.  56,  57,  pp.  261,  222.     Burns' 
Surgical  Anatomy  of  the  Head  and  Neck,  PI.  VIII.  Fig.  1.     Walton,  Fig.  73. 

Although  it  strictly  comprehends  every  sort  of  congenital  mark,  such,  for 
example,  as  that  called  mole,  the  term  ncevus  viaterniis  is  generally  used  to 
signify  only  a  particular  kind  of  anastomotic  or  erectile  tumor. 

It  seems  to  be  the  common  opinion,  that  anastomotic  tumors,  whether  con- 
genital or  acquired,  consist,  in  a  great  measure,  of  dilated  bloodvessels ;  and 
that,  in  some  cases,  these  are  chiefly  venous,  and  in  others  chiefly  arterial. 
Tumors  of  the  latter  sort  are,  in  fact,  aneurisms  hy  anastomosis,  and  are  cha- 
racterized by  their  rapid  and  dangerous  course,  continual  and  distinct  pulsa- 


N^VUS   MATERNUS   OF   THE   EYELIDS.  189 

tion,  and  the  great  dilatation,  tortuosity,  and  throbbing  of  the  arteries  which 
supply  them ;  while  the  former,  usually  called  ncevi,  are  without  pulsation, 
and  are  generally  slow  in  their  progress.  Both  sorts  give  out  arterial  blood 
on  being  punctured.  If  they  are  situated  on  the  head,  both  sorts  become 
suddenly  tense,  as  if  ready  to  burst,  when  the  patient  stoops,  or  if  he  is  ex- 
posed to  much  heat,  indulges  in  violent  exercise,  or  is  under  the  influence  of 
mental  excitement.  If  the  patient  be  a  child,  a  nsevus  assumes  this  state  of 
distention  when  it  cries.  The  terms  venous  and  arterial,  applied  to  these  two 
varieties  of  tumor,  may  be  incorrect ;  for  we  are,  as  yet,  in  a  considerable 
measure,  ignorant  of  the  real  structure  of  anastomotic  growths,  and  cannot, 
therefore,  pretend  perfectly  to  explain  their  nature.  The  appellations  joasstwe 
and  active  seem  less  objectionable.  When  laid  hold  of,  the  passive  have  a  pecu- 
liar dough-like  feeling,  yielding  slowly  to  pressure,  till  they  seem  empty  and 
flaccid,  then  filling  up  almost  immediately  to  their  former  size;  the  active,  on 
being  touched,  give  the  impression  of  a  violent  pulsatory  movement,  and  can 
scarcely  be  emptied  by  the  fingers,  unless  the  large  vessels  whence  they  derive 
their  blood  be  at  the  same  time  firmly  compressed. 

On  dissection,  a  nsevus  is  found  to  consist  of  lobes,  and  these  internally  to 
be  formed  of  irregular  cells,  or  loculi,  communicating  together.  The  walls 
of  these  cavities,  as  well  as  the  exterior  covering  of  the  lobes,  are  fibrous. 
The  relation  of  these  cavities  to  the  arteries  has  not  been  satisfactorily  made 
out ;  but  with  the  veins,  the  reticular  texture  of  the  lobes  freely  communi- 
cates ;  and  a  general  resemblance  to  the  structure  of  erectile  tissue  is  mani- 
fest. If  the  resemblance  is  real,  the  naevus  must  be  destitute  of  capillaries, 
and  therefore  the  blood  must  pass  through  it  with  increased  rapidity."^ 

The  distinction  of  cutaneous,  subcutaneous,  and  mixed  luevi,  is  of  con- 
siderable importance.  In  the  first,  the  disease  appears  to  be  seated  entirely 
in  the  skin,  which  is  sometimes  of  a  scarlet  color  ;  in  the  second,  the  integu- 
ments covering  the  tumor  not  being  at  all  implicated  in  the  disease,  can  be 
pinched  up  from  off  the  diseased  mass,  and  the  nature  of  the  case  may  be 
obscure ;  in  the  third,  both  the  skin  and  the  subjacent  areolar  tissue  are  in- 
volved, and  the  surface  presents  a  purple  or  livid  color.  Owing  to  the  re- 
sisting texture  of  the  skin,  the  progress  of  the  cutaneous  is  slower  than  that 
of  the  other  varieties.  The  limits  of  the  subcutaneous  and  mixed  are  much 
less  defined  than  those  of  the  cutaneous. 

In  the  eyelids,  there  occur  both  venous  or  passive,  and  arterial  or  active 
nsevi,  both  cutaneous,  subcutaneous,  and  mixed.  In  one  case  which  I  saw, 
the  tumor  was  most  prominent  on  the  conjunctival  surface  of  the  lid  ;  and  it 
sometimes  happens  that  the  disease  does  not  affect  the  lids  or  brow  merely, 
but  stretches  deep  into  the  orbit.  Not  uncommonly,  we  meet  with  a  small 
nsevus  on  the  lids,  and  one  or  more  larger  ones,  on  the  scalp,  trunk,  or  ex- 
tremities. The  branches,  however,  of  the  external  and  internal  carotids,  are 
much  oftener  concerned  in  anastomotic  tumors  than  any  other  arteries. 

In  some  instances  in  which  the  disease  occurs  on  the  lids  or  their  neigh- 
borhood, the  place  affected  is  from  the  first  of  a  bright  scarlet  color,  and 
whether  flat  or  slightly  pi'ominent,  whether  smooth  like  a  cherry,  or  granu- 
lated like  a  raspberry,  is  probably  cutaneous  merely.  In  other  instances, 
the  integuments,  in  the  seat  of  the  disease,  appear  at  birth  merely  a  little 
puffy,  but,  after  a  time,  they  become  doughy,  livid,  and  swollen,  while  through 
them,  there  shines  a  collection  of  dilated  bloodvessels.  In  this  case,  the 
disease  is  subcutaneous. 

Prognosis. — Some  neevi,  though  vivid  at  birth,  spontaneously  disappear. 
Those  of  the  venous  sort  especially,  after  having  increased  to  a  certain  degree, 
sometimes  cease  to  enlarge,  or  gradually  wither  and  contract,  till  scarcely  a 
vestige  remains.     Any  means  applied  immediately  before  the  commencement 


190  CURE   OF   N^VUS   BY  PRESSURE   AND   ASTRINGENTS. 

of  such  spontaneous  atrophy,  is  apt  to  get  the  credit  of  having  effected  a 
cure.  Any  severe  illness,  reducing  the  general  powers  of  nutrition,  as 
measles,  hooping-cough,  or  bronchitis  in  infants,  promotes  the  natural  cure. 
Some  nsevi,  having  attained  a  certain  size,  remain  stationai:y  through  the 
rest  of  life,  although  varying  in  intensity  of  color  at  different  seasons,  and 
according  to  different  conditions  of  the  circulation.  Although  abundantly 
supplied  with  blood,  nsevi  often  appear  to  be  endowed  with  a  low  degree  of 
vitality,  so  that  some  slight  injury  will  cause  them  to  ulcerate  and  slough  ; 
and  being  in  this  way  partly  destroyed,  the  remainder  becomes  consolidated, 
and  the  disease  is  thus  prevented  from  increasing.  Another  set  commence 
to  spread,  either  immediately  after  birth,  or  from  incidental  causes,  at  some 
subsequent  period ;  advancing  slowly  but  steadily,  they  form  complicated 
and  dangerous  connections  with  neighboring  parts,  not  at  6rst  involved,  and 
from  small  beginnings,  become  vascular  tumors  of  great  extent,  and  not 
unfrequently  formidable  from  partaking  of  the  nature  of  the  cases  so  well 
described  by  Mr.  John  Bell,  under  the  name  of  aneurism  hy  anastomosis,  apt 
to  burst,  and  to  give  rise  to  impetuous  hemorrhages,  which,  if  they  do  not  prove 
suddenly  fatal,  materially  injure  the  health.^  A  nosvus  on  one  or  other  eyelid 
may  be,  at  birth,  no  bigger  than  a  pin's  head ;  but  in  a  month's  time,  may 
spread  to  the  third  of  an  inch  in  diameter.  Some  very  slight  cause  of  irri- 
tation, as  a  trifling  bruise,  will  sometimes  excite  a  mere  stain-like  speck,  or 
minute  livid  tubercle,  into  an  uncontrollable  state  of  diseased  action.  The 
passive  uebvus  has  been  known  to  assume  the  character  of  the  active,  and 
vice  versa. 

Case  137. — In  a  case  recorded  by  Pauli,  a  ncevus  occupied  the  upper  ej'elid  close  to  the 
external  angle  of  the  eye,  and  at  birth,  was  of  the  size  of  a  lentil.  The  lid,  a  little  red- 
der than  the  rest  of  the  skin,  hung  over  the  eye  ;  but  after  some  days,  it  assumed  its 
proper  situation.  In  nine  months,  the  tumor  was  as  big  as  a  duck-egg.  Towards  the 
third  year,  it  covered  the  eye  almost  completely,  and  went  on  extending  itself  under  the 
skin  in  every  direction.  At  nine  years,  it  occupied  completely  one  half  of  the  face  and 
head,  and  displaced  the  ear  upwards.  Two  years  after,  it  hung  so  much  upon  the  face, 
that  the  little  patient  was  obliged  to  have  it  supported  in  a  bng.  The  cartilage  of  the 
nose  was  twisted  to  the  other  side,  and  the  tumor  was  gaining  upon  the  cavity  of  the 
mouth. 

When  Pauli  saw  the  case,  the  patient  being  15  years  of  age,  the  tumor  was  elastic,  soft, 
bossulated,  and  apparently  fluctuating  ;  it  could  easily  be  compressed,  and  frequently,  on 
placing  the  hand  upon  it,  it  communicated  a  pulsation,  which  diminished  a  little  on  com- 
pressing the  corresponding  arteries,  but  did  not  disappear  completely.  Every  change  of 
weather  affected  the  tumor  with  pain  ;  abrasion  of  it  caused  it  to  bleed. "^ 

Treatment. — Various  methods  of  treating  ntevus  or  aneurism  by  anasto- 
mosis have  been  adopted.  The  principle  of  some  of  them  is  the  obliteration 
of  the  abnormal  structure  by  inflammation ;  that  of  others  is  the  total  destruc- 
tion or  removal  of  the  tumor.  Our  choice  must  be  regulated  by  the  situation 
of  the  growth,  its  size,  and  its  degree  of  activity.  Other  things  being  equal, 
the  methods  which  leave  the  skin  entire,  so  that  no  ectropium  is  likely  to 
ensue,  claim  a  preference  when  the  disease  is  seated  in  the  eyelids. 

If  a  nisvus  is  small,  superficial,  and  not  increasing,  we  may  be  tempted  to 
let  it  alone,  or  to  cover  its  surface  every  second  or  third  day  with  collodion, 
which,  as  it  dries,  causes  a  certain  degree  of  contraction,  or  to  pencil  it  daily 
with  tincture  of  iodine,  or  a  solution  of  lunar  caustic.  If  it  fades  away  under 
such  applications,  the  probability  is,  that  we  are  merely  aiding  in  a  spontane- 
ous cure,  which  would  have  occurred,  even  had  nothing  been  done.*  If  the 
tumor,  on  the  other  hand,  is  evidently  increasing,  there  should  be  no  delay 
in  having  recourse  to  some  ef&cient  mode  of  treatment. 

1.  Abstraction  of  heat,  pressure,  and  astringents. — A  moderately  sized 
naevus  above  the  eyebrow,  or  in  any  other  situation  permitting  it  to  be  emp- 
tied by  pressure  against  a  subjacent  bone,  may,  in  general,  be  cured  by  con- 


CURE   OF   N^VUS   BY   VACCINATION.  191 

tiiiuing  the  pressure  methodically.  This  is  best  effected  by  a  pad,  connected 
with  a  steel  spring  passing  round  the  head.  This  plan  I  adopted  success- 
fully, in  a  case  of  n^vus  situated  between  the  nose  and  the  inner  canthus. 
Boyer  relates  the  case  of  a  child,  of  two  years  of  age,  with  this  disease  in 
the  upper  lip,  the  cure  of  which  was  effected  by  perseverance  in  the  plan  of 
pressure.  The  usevus  extended  from  the  adherent  edge  of  the  lip,  under  the 
nostrils,  and  into  the  septum  narium  ;  so  that  a  complete  extirpation  being, 
in  Boyer's  opinion,  impossible,  he  advised  the  mother  to  bathe  the  tumor 
with  alum  water,  and  with  her  forefinger  placed  transversely  under  the  nose, 
to  compress  the  part  as  often  as  she  could.  This  advice  was  followed  with  a 
degree  of  constancy  which  matei'ual  tenderness  only  could  have  accomplished. 
The  mother  sometimes  passed  seven  hours  continuously,  in  pressing  the  tumor 
with  her  finger  ;  and  this  assiduity  was  attended  with  such  complete  success, 
that  ultimately  no  trace  of  the  disease  remained." 

Mr.  Abernethy,  after  mentioning  the  particulars  of  an  aneurism  by  anas- 
tomosis on  the  forearm,  cured  by  permanent  and  equal  pressure,  and  by 
keeping  low  the  temperature  of  the  limb,  relates  the  following  case: — 

Case  138. — A  child  had  this  unnatural  state  of  the  vessels  in  the  orbit.  They  gradually 
increased  in  magnitude,  and  extended  themselves  into  the  upper  eyelid,  so  as  to  keep  it 
permanently  closed.  The  clustered  vessels  also  projected  out  of  the  orbit,  at  the  upper 
part,  and  made  the  integuments  protrude,  forming  a  tumor  as  large  as  a  walnut.  The 
removal  of  this  disease  did  not  appear  practicable,  and  pressure  to  any  extent  was  evi- 
dently impossible ;  but  the  abstraction  of  heat,  and  consequent  diminvition  of  inflamma- 
tory action,  might  be  attempted.  Mr.  Abernethy  recommended  that  folded  linen,  wet 
with  rose-water  saturated  with  alum,  should  be  bound  on  the  projected  part,  and  kept 
constantly  damp. 

Under  this  treatment,  the  disorder  as  regularly  receded  as  it  had  before  increased.  After 
about  three  months,  the  tumor  had  gradually  sunk  within  the  orbit,  and  the  child  could 
open  its  eye.  Shortly  afterwards  all  medical  treatment  was  discontinued,  and  no  appear- 
ance of  the  unnatural  structure  remained.'' 

In  flat  neevi,  up  to  the  size  of  a  crown  piece,  Dieffenbach  tells  us  that  much 
may  be  done  by  a  careful  employment  of  astringents,  such  as  pure  liquor 
plumbi,  or  a  solution  of  alum,  even  without  pressure.  Lint,  steeped  in  the 
fluid,  is  fastened  over  the  part  with  a  bandage,  and  frequently  wetted,  without 
lifting  it.  After  days,  or  weeks,  the  swelling  becomes  whiter,  flatter,  and 
firmer  5  soon  after,  little  firm  white  spots  form  on  the  surface,  and  the  cure  is 
certain.  By  means  of  solution  of  alum  and  compression,  Dieffenbach  has 
cured  nsevi  so  large,  that  extirpation  Avould  have  been  impossible.  It  may 
be  necessary  to  keep  the  solution  constantly  applied  for  six  months.^ 

From  the  nature  of  the  situation,  the  plan  of  treating  neevus  on  the  eyelids, 
by  pressure  and  astringents  rarely  succeeds ;  and  the  delay  occasioned  by 
giving  it  a  trial,  may  prove  highly  detrimental.  When  a  cure  does  follow 
this  sort  of  treatment,  it  is  probably  accomplished  more  by  nature  than  by 
the  artificial  means  employed.  In  one  case,  in  which  I  used  a  saturated  solu- 
tion of  alum,  the  fluid,  by  getting  into  the  eye,  occasioned  a  pretty  severe 
puro-mucous  ophthalmia.  The  application  was  discontinued,  and  after  some 
months  a  natural  cure  took  place.  Brandy  is  said  to  have  been  tried  with 
good  effect  as  an  astringent  application. 

2.  Vaccination. — Small,  and  sometimes  even  extensive,  cutaneous  na;vi 
have,  in  their  early  stage,  been  cured  by  the  application  of  vaccine  lymph. 
The  principle  upon  which  this  method  of  cure  depends,  is  the  destruction,  by 
suppuration,  of  the  abnormal  tissue.  With  a  lancet  already  charged  with 
the  recent  lymph,  slight  scratches  are  made  upon  the  surface,  and  round  the 
circumference  of  the  mevus,  at  regular  distances  from  each  other.  As  soon 
as  the  bleeding  has  ceased,  additional  lymph  is  to  be  introduced  ;  and  then 
over  the  whole  surface  of  the  tumor,  a  bit  of  linen,  saturated  with  the  same 


192  CURE   OF   N^VUS   BY   INJECTIONS. 

fluid,  is  to  be  applied,  and  retained  for  several  hours.  In  the  usual  time, 
vesicles  appear.  Each  produces  a  degree  of  inflammation,  which  induces  an 
occlusion  of  the  nteval  cells  and  vessels  only  to  a  certain  distance  around  it ; 
and  therefore  it  is  necessary  to  inoculate  the  surface  of  the  tumor  at  such 
close  distances,  that  the  whole  lobes  of  which  it  consists  may  be  involved  in 
the  inflammation.  In  favorable  cases,  the  tumor  gradually  subsides,  leaving 
scarcely  any  mark  behind.  Not  unfrequently  the  cure  is  effected,  however, 
only  after  a  very  tedious  festering  and  ulceration.  If  the  child  has  been  vac- 
cinated in  the  common  Avay,  previously  to  the  neevus  attracting  much  notice, 
this  plan  of  cure  will  rarely  succeed  ;  and  even  in  children  not  previously 
vaccinated,  it  often  fails  to  accomplish  the  object  intended. ^ 

3.  Stimulants. — When  vaccination  has  failed,  or  vaccine  lymph  cannot  be 
procured,  some  other  stimulating  fluid  may  be  tried,  inserting  it  into  the 
niBvus  in  the  same  way  as  we  do  the  lymph.  A  strong  solution  of  tartrate 
of  antimony  may  be  used  for  this  purpose  ;  or  a  pustular  eruption,  affecting 
the  nJBVus  to  a  sufficient  depth,  may  be  excited  by  rubbing  it  with  tartrate 
of  antimony  ointment,  or  covering  it  with  an  antimonial  plaster.  It  is  likely 
that  vaccine  lymph  produces  no  specific  effect  upon  this  sort  of  tumor,  but 
operates  merely  by  inflaming  the  part ;  and  that  any  other  stimulant  of  pro- 
portionate energy,  and  applied  with  equal  care,  would  be  followed  by  the 
same  result,  especially  if  the  disease  were  merely  cutaneous.  Croton  oil 
appears  to  have  answered.'" 

4.  Escharotics. — Both  fluid  and  solid  escharotics  have  been  used,  to  de- 
stroy the  organization  of  noevi.  Some  employ  lunar  caustic.  For  a  small 
cutaneous  ncevus,  painting  the  surface  of  it  with  a  bit  of  wood,  dipped  in 
strong  nitric  acid,  answers  well.  Dr.  Ammon  touches  the  tumor  from  time 
to  time  with  a  solution  of  the  nitrate  of  mercury  in  nitric  acid."  Mr.  Ward- 
rop  has  repeatedly  employed  pure  potash,  applying  it  to  the  ngevus  so  as  to 
produce  an  eschar.  In  some  instances,  the  eschar,  on  falling  out,  has  been 
found  to  comprehend  the  whole  diseased  mass  ;  while,  at  other  times,  the 
separation  of  the  eschar  has  been  followed  by  ulceration,  which  destroyed  the 
remainder  of  the  tumor.'^  These  were  cases,  we  may  presume,  of  the  sub- 
cutaneous or  mixed  kind.  The  potash  is  to  be  rubbed  only  on  the  centre  of 
the  tumor.  Ulceration  follows,  and  spreads,  destroying  the  nsevus.  A  poul- 
tice is  applied,  the  parts  fall  out,  and  cicatrization  takes  place.  The  potash 
may  require  to  be  applied,  however,  four  or  five  times  before  the  object  is 
obtained. 

"  I  have  seen  cases,"  says  Liston,  "in  which  most  profuse  and  alarming 
hemorrhage  had  followed  boring  into  erectile  tumors,  with  strong  potential 
cauteries,  and  in  which,  after  all  the  pain,  danger,  and  delay,  no  benefit 
accrued  from  the  practice."'^  It  is  for  cutaneous  cases  chiefly,  that  escha- 
rotics are  adapted.  When  the  eyelids  are  concerned,  the  contracted  cica- 
trice, which  is  apt  to  be  left  after  the  destruction  of  the  tumor  is  accomplished, 
renders  this  method  of  cure  objectionable. 

5.  Injections. — Mr.  Lloyd'*  proposes  to  inject  into  the  substance  of  the 
noBvus  some  stimulating,  or  even  escharotic,  fluid.  He  tried  a  mixture  of  the 
spirit  of  nitrous  ether  with  nitric  acid.  By  repeated  injections,  one  portion 
of  a  large  nsevus  on  the  face  and  eyelids  was  destroyed  ;  but  the  child  took 
measles  before  the  cure  was  completed,  and  died.  The  injection  did  not 
enter  very  readily ;  therefore,  much  could  not  be  accomplished  at  once.  In 
another  case,  it  passed  freely  into  the  substance  of  the  nosvus,  and  five  injec- 
tions accomplished  a  cure.  The  eff"ect  of  the  injection  was  the  hardening  of 
the  part  into  which  it  entered ;  and  as  the  hardness  subsided,  the  disease 
disappeared. 

A  solution  of  perchloride  of  iron  has  been  recommended  as  a  fit  injection, 


CURE   OF   N^VUS   BY   INCISION.  193 

from  its  power  of  coagulating  the  blood  in  the  vessels ;  and  a  particular  sort 
of  syringe  has  been  invented  for  injecting  it. 

The  point  of  the  syringe  should  be  introduced  through  an  aperture  in  the 
skin,  at  some  little  distance  from  the  disease,  as  it  is  then  easier  to  stop  the 
bleeding  by  compression.  Before  injecting,  the  naevus  should  be  compressed, 
so  as  to  empty  it  of  its  blood,  and  the  pressure  continued  till  the  instant 
when  the  fluid  is  projected  by  the  syringe.  The  fluid  should  be  retained  in 
the  nsBvus  from  five  to  ten  minutes,  by  making  pressure  along  the  track 
which  had  been  occupied  by  the  tube  of  the  syringe. 

Mr.  Lloyd  warns  us  to  make  pressure  around  the  nasvus  during  the  act  of 
injection,  lest  the  fluid  be  forced  into  the  contiguous  cellular  tissue,  where  it 
might  excite  inflammation.  For  making  the  pressure,  he  recommends  the 
cover  of  a  pill-box,  with  a  notch  in  it  for  the  passage  of  the  point  of  the 
syringe. 

A  much  more  serious  accident,  however,  than  the  injection  of  the  cellular 
tissue  is  apt  to  attend  this  method  of  treating  ncevus ;  namely,  the  passage 
of  some  of  the  fluid  into  the  veins,  and  thence  into  the  heart.  There  is  strong 
reason  to  suspect  that  this  was  the  cause  of  instant  death  in  a  child  nearly 
two  years  old,  in  whom  a  ncevus,  situated  over  the  angle  of  the  jaw,  was 
injected  with  diluted  aqua  ammonia. ^^ 

6.  Actual  cautery. — Another  mode  of  producing  inflammation,  and  thereby 
obliterating  the  tumor,  is  by  the  actual  cautery.  The  centre  of  the  tumor  is 
touched  with  the  red-hot  iron ;  or  a  number  of  long  sewing  needles,  heated 
to  a  white  heat,  are  pushed  across  the  tumor  in  different  directions,  so  as  to 
cauterize  every  part  of  it.^^  Platinum  wires  are  put  through  the  naevus  in 
different  directions,  and  heated  to  a  red  heat,  by  being  connected  with  the 
poles  of  a  galvanic  battery.  Small  sloughs  form  at  the  points  where  the 
wires  penetrate  the  skin.     The  operation  may  require  to  be  repeated. ^^ 

7.  Subcutaneous  incision  of  the  vessels  tvithin  the  tumor. — The  danger  of 
ha3morrhagy  from  excision,  the  pain  of  the  ligature,  and  the  extensive  scar 
left  by  vaccination,  induced  Dr.  Marshall  Hall  to  consider  whether  some  less 
objectionable  operation  might  not  be  devised  for  the  cure  of  naevus.  Accord- 
ingly, he  proposed  to  introduce  a  couching-needle  with  cutting  edges,  at  one 
point  of  the  circumference  of  the  nasvus,  close  by  the  adjoining  healthy  skin, 
and  from  this  point  to  pass  the  instrument  through  the  tumor  in  8  or  10  dif- 
ferent directions.  The  first  puncture,  the  only  one  through  the  skin,  is  to  be 
made  in  the  centre  of  the  several  rays  of  incisions,  which  are  effected  by 
merely  withdrawing,  and  again  pushing  forward  the  instrument.  This  ope- 
ration was  tried,  under  Dr.  Hall's  direction,  in  a  case  of  oval  naevus,  rather 
larger  than  a  shilling,  the  situation  of  which,  however,  he  does  not  mention. 
After  the  incisions  were  made  in  the  manner  described,  a  little  pressure  was 
applied  on  the  tumor,  by  means  of  strips  of  adhesive  plaster.  There  was  no 
pain,  nor  hcemorrhagy.  Dr.  Hall  expected  that  inflammation  would  take 
place,  and  that  a  cicatrice  would  be  formed,  which,  from  its  solid  texture  and 
progressive  contraction,  would  obliterate  the  tumor.  For  several  weeks 
there  was  little  or  no  change.  Indeed,  it  was  almost  concluded  that  the 
plan  had  failed.  What  a  short  time,  however,  did  not  effect,  a  longer  period 
accomplished  completely.  Half  a  year  after  the  operation,  the  tumor  was 
found  to  have  disappeared,  and  the  color  of  the  skin  to  be  nearly  natural. 

Dr.  Hall  observes,  that  this  operation  may  be  repeated  at  longer  or  shorter 
intervals,  and  with  more  or  fewer  punctures,  according  to  the  degree  of 
inflammatory  action  necessary  for  the  obliteration  of  the  nasvus.  He  adds 
that  pressure  forms  no  necessary  part  of  the  treatment ;  and  that  the  cure  in 
the  case  detailed  was  gradually  effected,  long  after  pressure  had  ceased  to  be 
employed. ^^ 
13 


194  CURE   OF  N^VUS  BY  THE  LIGATURE. 

8.  Subcutaneous  incision  combined  with  cauterization. — With  a  knife  about 
\  inch  broad,  Sir  B.  C.  Brodie  cuts  up  the  interior  of  the  nsvus,  in  the  mode 
recommended  by  Dr.  Hall,  and  then  introduces  a  silver  probe,  coated  with 
nitrate  of  silver,  into  the  cuts.  This  causes  sloughing  of  the  interior  of  the 
nsevus,  but  does  not  destroy  the  skin.  If  the  tumor  is  large,  the  operation 
will  require  to  be  done  more  than  once.^^  This  is  one  of  the  methods  of  cure 
best  adapted  for  n^vus  of  the  eyelids. 

9.  Seton. — The  cure  of  nsevus  by  the  passage  of  a  seton  through  the  tumor, 
as  proposed  by  Mr.  Fawdington  of  Manchester,  is  tedious.  The  saving  of 
deformity  is  its  great  recommendation,  little  more  remaining  than  the  scars 
produced  by  the  needle. 

In  employing  the  seton,  it  is  necessary  to  secure  two  material  objects  : 
namely,  the  suppression  of  hsemorrhagy  from  the  vessels  divided  by  the 
needle  in  the  first  instance,  and  subsequently  a  degree  of  irritation  sufficient 
to  excite  inflammation  and  suppuration  throughout  the  diseased  mass.  The 
first  of  these  objects  is  accomplished  by  using  a  skein  of  spongy  cotton- 
thread,  large  enough  fully  to  occupy  the  aperture  made  by  the  needle  ;  and 
the  second,  by  a  needle  that  will  admit,  relatively  to  the  dimensions  of  the 
tumor,  a  seton  of  considerable  proportions. 

The  seton  is  commonly  directed  to  be  passed  through  the  tumor ;  but  Mr, 
Lizars  directs  the  tumor  to  be  raised  with  the  fingers,  so  that  the  needle  may 
pass  completely  under  and  free  of  it.  In  this  way,  the  seton  is  more  likely 
to  cause  obliteration  of  the  vessels  leading  to  the  tumor ;  for,  when  passed 
through  the  diseased  mass,  the  vessels  leading  to  it  rapidly  reproduce  that 
which  has  been  destroyed.^ 

In  treating  ntevus  in  the  eyelids  or  their  neighborhood,  with  the  seton, 
several  threads  ought  to  be  passed  through  or  beneath  the  tumor,  parallel 
one  to  another,  and  their  ends  tied  together,  so  as  to  prevent  them  from  slip- 
ping out.  If  the  irritation  which  follows,  seems  insufficient,  thicker  threads 
should  be  passed,  and  additional  ones  may  be  introduced  in  a  transverse 
direction  to  the  first.  When  the  suppuration  becomes  abundant,  the  threads 
should  be  reduced  in  thickness,  to  allow  the  pus  freer  exit.  The  threads  must 
be  persevered  in  till  the  tumor  shrinks,  and  seems  to  be  becoming  consoli- 
dated. The  object  in  view  may  be  promoted  by  occasionally  passing  a  probe, 
coated  with  nitrate  of  silver,  through  the  channels  formed  by  the  threads.^' 

10.  Ligature. — The  ligature  is  employed  in  the  treatment  of  naevus,  either, 
1.  To  excite  inflammation,  and  consolidate  the  parts  only ;  or,  2.  To  destroy 
them  and  make  them  slough.  It  is  used,  also,  either  to  grasp  and  cut  through 
the  skin  as  well  as  the  tumor  ;  or  to  strangulate  and  destroy  the  tumor,  but 
leave  the  integuments  nearly  entire.  It  might  be  supposed,  perhaps,  that 
only  the  latter  mode  of  using  the  ligature  would  be  answerable  when  the  lids 
are  the  seat  of  the  disease,  owing  to  the  contraction  which  must  result  when 
the  skin  covering  the  nsevus  is  destroyed.  I  have  found,  however,  that  nsevi  on 
the  lids,  especially  on  the  upper  lid,  unless  very  extensive,  may  be  treated  with 
the  ligature  in  the  common  way,  without  much  risk  of  producing  ectropium. 

One  mode  of  using  the  ligature  is  the  following :  The  tumor  being  laid 
hold  of  with  the  finger  and  thumb,  so  as  to  raise  it  as  much  as  possible  from 
the  proper  substance  of  the  lid,  two  or  more  slender  pins  are  passed  under  it, 
so  as  to  intersect  each  other ;  the  ligature  is  then  placed  around  the  base  of 
the  tumor,  under  the  pins,  and  being  drawn  tight,  is  tied. 

Another  method  is  to  pass  a  common  curved  needle,  or  a  curved  needle 
fixed  in  a  handle,  and  having  an  eye  near  its  point,  which  is  called  a  nasvus 
needle,  armed  with  a  strong  waxed  linen  thread,  through  the  base  of  the 
tumor,  so  as  to  divide  into  two  portions.  The  thread  being  cut,  and  the 
needle  removed,  each  portion  of  the  tumor  is  to  be  grasped  by  its  own  liga- 


CURE   OF  N^VUS  BY  THE  LIGATURE. 


195 


FiK.  13. 


ture.  If  the  tumor  is  very  large,  it  may  be  divided  into  four  portions,  by 
passing  the  needle,  armed  as  before,  a  second  time,  but  at  right  angles  to  its 
first  direction.  The  ligatures  are  to  be  drawn  tight,  and  secured  by  a  double 
knot.  In  the  following  method,  the  common  needle  may  be  used,  and  there 
is  no  liability  to  mistake  the  threads  to  be  tied  :  Blacken  half  the  length  of 
a  long  white  thread  with  ink,  and  thread  a  wide-eyed  needle  with  it.  Trans- 
fix the  tumor  in  the  common  way,  and  cut  the  bow  so  as  to  keep  the  black 
thread  in  the  needle.  Then  thread  the  needle  also  with  the  white  end,  which 
has  not  passed  through  the  tumor,  and  transfix  the  tumor  at  right  angles  to 
the  former  direction.  Draw  the  white  ends  tight  and  tie  them ;  then,  the 
black.  Each  thread  includes  a  figure  of  8  portion  of  the  tumor,  as  is  shown 
in  Fig.  13.  The  dotted  lines  show  the  course 
of  the  threads  under  the  tumor. 

If  any  part  of  the  tumor  slips  from  the 
grasp  of  the  ligature  intended  to  embrace  it, 
a  needle  must  be  thrust  under  that  part,  and 
held  there  till  the  knot  is  tied,  or  left  till  the 
tumor  separates.  After  the  ligatures  are 
drawn  tight,  but  before  they  are  tied,  it  may 
be  advisable  to  divide  the  skin  round  the  base 
of  the  tumor,  so  as  to  allow  the  ligatures  to 
sink  into  contact  with  the  tumor.  After  the 
ligatures  are  tied,  the  tumor  may  be  punc- 
tured so  as  to  diminish  its  bulk.     Care  must 

be  taken,  in  whatever  way  the  ligature  is  applied,  that  no  part  of  the  tumor 
is  excluded  from  its  embrace,  as  any  small  portion  that  is  left  may  give  rise 
to  a  reproduction  of  the  disease. 

In  the  course  of  48  hours,  the  tumor  will  have  entirely  lost  its  vitality,  so 
that  it  may  be  sliced  off,  and  the  ligatures  removed  ;  or  it  may  be  left  till 
it  turns  black,  shrivels,  and  falls  off,  which,  in  nssvi  of  the  eyelids,  generally 
happens  in  five  or  six  days.  A  poultice  is  then  to  be  applied,  and  continued 
till  the  exposed  surface  granulates  and  heals.  Occasionally,  it  requires  to  be 
touched  with  lunar  caustic. 

Some  very  extensive  and  irregular  nsevi,  stretching  over  the  neighboring 
parts  as  well  as  the  eyelids,  may  require  more  than  two  ligatures.  For  such 
cases,  Mr.  Luke's  method  of  applying  the  ligature  will  sometimes  be  found 
answerable.  He  threads  several  straight  or  curved  needles,  at  distances  from 
each  other  of  about  12  inches,  with  one  long  thread,  the  number  of  needles 
corresponding  to  the  size  of  the  tumor.  The  needles  are  passed  in  a  row, 
under  the  nsevus,  as  is  represented  in 

the  diagram,  Fig.  14 ;  they  are  then  ^ig-  ^^^ 

removed  by  cutting  the  ligature  near 
to  the  eye  of  each  ;  and  the  succession 
of  loops  is  tightened  by  tying  a  with 
a,  h  with  h,  c  with  c,  and  so  on,  till 
the  whole  tumor  is  strangulated."^ 
The  same  thing  may  be  done,  as  Mr. 
Curling  has  shown,  with  the  nsevus 
needle.^"  Besides  the  perfect  strangu- 
lation which  this  plan  affords,  it  lessens 
the  puckering  and  drawing  in  of  the 
surrounding  integuments  which  must 
always,  in  some  degree,  follow  the 
use  of  the  ligature,  but  which  it  is 
material  to  avoid  when  the  eyelids  are  the  seat  of  the  disease. 


196 


CURE   OP   NiEVUS  BY  THE  LIGATURE. 


Fiff.  15. 


If  the  n^evus  is  entirely  subcutaneous,  the  skin,  as  Mr.  Listen^  advises, 
may  be  divided  and  turned  aside,  so  as  to  expose  the  tumor,  to  which  the 
ligatures  are  then  to  be  applied. 

I  may  here  notice  M.  Lallemand's  mode  of  treating  nsevus.  Sometimes 
he  inserts  a  number  of  pins  into  the  tumor,  without  transfixing  it,  and  twists 
a  waxed  thread  around  the  pins.  In  other  cases,  he  transfixes  the  tumor 
with  a  great  number  of  pins,  in  every  direction,  and  then  applies  the  ligature, 
so  as  to  strangulate  the  tumor.  In  whichever  way  they  are  applied,  he  re- 
moves the  pins  and  ligature  in  seven  or  eight  days,  or  when  they  are  thought 
likely  to  have  excited  sufficient  inflammation  to  consolidate  the  morbid  struc- 
ture. In  this  way,  there  is  no  loss  of  integuments.  Occasionally,  he  makes 
an  incision  through  the  whole  substance  of  the  nogvus,  and  immediately 
unites  the  two  lips  of  the  wound  by  needles  and  the  twisted  suture.  The  in- 
flammation and  the  cicatrice  which  follow,  obliterate  the  tumor.^ 

When  we  are  anxious  to  save  the  skin,  the  ligature  may  be  applied  sub- 
cuitaneously.     This  is  done  in  one  or  other  of  two  ways. 

In  the  one  method,  the  ligature  is  passed,  by  means  of  the  common  curved 
needle,  or  the  nasvus  needle,  round  as  much  of  the  basis  of  the  tumor  as  can 
be  conveniently  accomplished  by  a  sweep  of  the  instrument,  as  from  a  to  b 

in  the  diagram,  Fig.  15,  and  brought 
out  through  the  skin  at  B.  Again 
armed  with  the  same  ligature,  the 
needle  is  reintroduced  at  b,  and  carried 
round  either  the  whole  remainder  of 
the  tumor,  or  round  a  portion  of  it 
only,  according  to  its  size.  Suppose  it 
is  carried  round  to  c,  and  there  brought 
out,  the  needle,  again  armed  with  the 
ligature,  is  reintroduced  at  c,  and 
carried  round  to  A,  where  the  two  ends 
of  the  ligature  will  emerge,  after  it  has 
encircled  the  whole  basis  of  the  tumor. 
The  dotted  line  in  the  diagram  shows 
the  course  of  the  subcutaneous  ligature,  which  is  now  to  be  drawn  tight, 
and  secured  by  a  double  knot. 

In  the  other  method,  the  needle,  armed  with  a  ligature,  is  passed  trans- 
versely under  the  tumor,  from  the  one 
side  of  its  base  to  the  other,  as  from  a 
to  B,  in  the  diagram.  Fig.  16.  The 
loop  is  then  cut,  and  the  needle  re- 
lieved. Armed  as  usual  [with  the  ends 
of  the  divided  loop  alternately],  the 
needle  is  now  swept  round,  fii'st,  the 
one-half  of  the  basis  of  the  tumor,  as 
in  the  course  of  the  dotted  line  boa; 
and  then  round  the  other  half,  as  in  the 
course  of  the  dotted  line  b  d  a.  Each 
half  being  now  surrounded  by  its  own 
ligature,  first  the  one,  and  then  the 
other  ligature  is  to  be  drawn  tight,  and 
tied  at  a. 

The    subcutaneous  ligature,  applied 
in  either  of  these  two  methods,  if  it  is 
to  be  left  till  it  comes  away  of  itself, 
requires  to  be  tightened  from  day  to  day.     The  orifice  by  which  it  emerges, 


Fig.  16. 


CURE   OF   ANASTOMOTIC   ANEURISM   BY  EXCISION.  19t 

allows  a  discharge  of  matter  for  some  time,  and  a  slough  is  occasionally  with- 
drawn from  the  cavity  formerly  occupied  by  the  morbid  growth. 

Mr.  Startin  connects  the  ligature  to  a  band  of  A'ulcanized  caoutchouc  ;  and 
through  its  means  exercises  an  elastic  tension,  which  gradually  brings  the 
ligature  away."^ 

Some  practitioners  allow  the  ligature,  whether  it  is  applied  over  or  under 
the  skin,  to  strangulate  the  tumor  only  for  a  day  or  two  ;  they  then  withdraw 
it.  This  temporary  application  suffices,  perhaps,  to  produce  a  certain  de- 
gree of  inflammation,  but  no  slough.  This  plan  is  apt  to  fail,  the  disease 
again  increasing  after  the  irritation  has  subsided.  To  insure  a  cure,  astrin- 
gents and  pressure  should- be  employed,  after  the  ligature  is  removed. 

The  subcutaneous  ligature  has  been  found  to  cure,  not  only  the  subcuta- 
neous variety  of  the  disease,  but  also  the  mixed.  Sometimes  it  fails,  from 
not  sufficiently  interrupting  the  flow  of  blood  into  the  tumor,  through  the 
vessels  of  the  skin.^^ 

11.  Tying  the  vessels  of  supply. — In  cases  of  aneurism  by  anastomosis, 
large  arteries  are  felt  throbbing  strongly  round  the  tumor.  These  vessels  of 
supply  have  often  been  tied,  in  the  hope  of  causing  the  tumor  to  shrink;  but 
the  practice  is  not  to  be  recommended,  as  it  has  generally  proved  totally 
ineffectual.  As  soon  as  one  vessel  is  obliterated,  another  anastomosing 
branch  becomes  enlarged,  and  an  equally  copious  supply  of  blood  is  sent  to 
the  tumor.  Cases  139  and  142  will  illustrate  the  inefficacy  of  this  plan  of 
treatment. 

12.  Excision. — Naevi  and  anastomotic  aneurisms  have  been  removed  by 
excision.  This  is  an  effectual,  but  by  no  means  a  very  safe  mode  of  cure.'^ 
When  the  morbid  growth  itself  is  cut,  a  powerful  gush  of  arterial  blood 
takes  place,  which  can  hardly  be  restrained  ;  and  although  the  knife  keeps 
clear  of  the  tumor,  there  is,  in  general,  very  serious  hsemorrhagy,  so  that  in 
removing  even  small  ntevi  in  this  way,  alarm  has  justly  been  excited  for  the 
life  of  the  patient,  and  the  recovery  of  strength  and  color  has  been  very 
tedious.  Yet,  according  to  Dieffenbach,^''  extirpation  of  noevi,  and  union  of 
the  edges  of  the  wound  by  pins  and  the  twisted  suture,  is  the  best  method  of 
all,  when  astringents  fail.  He  extirpates  the  tumor  totally  or  partially,  ac- 
cording to  its  size.  If  partial  extirpation  is  employed,  an  oval  slip  of  the 
tumor  is  excised  from  the  middle ;  and  when  the  wound  so  produced  has 
healed,  another  piece  is  excised  ;  and  so  on,  till  the  whole  has  been  removed. 
Piecemeal  extirpation,  in  this  way,  may,  perhaps,  answer  in  cases  of  passive 
usevi ;  but  would  be  quite  inapplicable  in  such  an  active  tumor  as  was  present 
in  the  following  case  : — 

Case  139. — A  gentleman  of  about  25  years  of  age,  had  an  aneurism  by  anastomosis 
upon  his  forehead.  It  began  "with  a  small  spot  like  a  pimple,  of  the  size  of  a  pea ;  and 
was,  when  he  consulted  Mr.  .John  Bell,  of  the  size  of  an  egg.  It  was  seated  close  upon 
the  eyebrow,  and  at  its  commencement  was  so  small,  and  so  little  troublesome,  that  it 
was  believed  to  be  a  pimple,  brought  on  by  a  tight  hat.  When  it  had  attained  the  size 
of  a  sparrow's  egg,  the  patient  thought  he  felt  occasional  pulsation  in  it.  He  consulted 
a  surgeon,  who  found  the  pulsation  distinct,  pronounced  it  to  be  an  aneurism,  and  advised 
that  it  should  be  cut  out.  The  patient  delayed,  and  was  recommended  by  some  one  to  try 
pressure.  This  producing  pain  but  no  good  effect,  he  let  the  aneurism  grow  for  five 
years. 

An  operation  was  now  decided  on.  The  tumor  appeared  to  derive  its  blood  from  two 
arteries ;  one,  a  branch  of  the  temporal,  enlarged  and  tortuous,  which  passed  into  the 
upper  end  of  the  tumor,  while  the  other,  coming  from  within  the  orbit,  entered  the  lower 
end.  The  two  arteries  and  the  intermediate  tumor  beat  in  concert,  and  very  strongly. 
Under  the  apprehension  that  the  disease  was  merely  an  enlarged  arter}^  the  surgeon  first 
passed  a  ligature  round  the  arterial  branch  coming  from  the  orbit,  and  tied  it ;  but  this 
did  not  abate  the  pulsation  of  the  aneurism.  He  next  tied  the  temporal  branch,  but  the 
pulsation  remained  unaffected.  The  tumor  was  then  laid  open  in  its  whole  length.  It 
bled  very  profusely.     A  needle,  armed  with  a  ligature,  was  stuck  into  its  centre,  where 


198  CURE   OP  N^VUS   BY  EXCISION, 

there  was  one  artery  larger  than  the  others ;  but  from  all  the  rest  of  the  surface  there 
■was  one  continual  gush  of  blood.  The  htemorrhagy  was  repressed,  and  the  wound  bound 
up  with  a  compress  and  bandage.  It  healed  slowly,  the  ligature  came  away  with  diffi- 
culty, the  pulsation  began  again,  and  by  the  time  the  wound  was  healed,  the  tumor  was 
as  large  as  before  the  operation. 

For  nine  months  the  patient  allowed  the  disease  to  go  on  unmolested,  and  then  con- 
sulted Mr.  Bell.  The  tumor  was  of  a  regular  oval  form,  and  across  the  middle  of  it  ran 
the  scar  of  the  operation.  The  spot  was  not  purple  on  its  surface,  but  was  covered  by  a 
firm  sound  skin.  The  two  arteries  were  felt  pulsating  with  great  force  ;  and  when  the 
patient  was  heated,  stooped,  or  breathed  hard,  the  pulsations  became  very  strong.  By 
this  time  it  was  also  affected  with  pain.  Mr.  Bell  knew,  that  if  he  cut  within  the  active 
circle  of  the  tumor,  he  should  have  innumerable  bloodvessels  to  contend  with.  He  there- 
fore resolved  to  cut  out  this  aneurism,  not  to  cut  into  it.  He  made  an  oval  incision, 
which  comprehended  about  a  fourth  part  of  the  surface  of  the  tumor,  dissected  the  skin 
of  each  side  down  from  it  rapidly,  went  down  to  the  root  of  the  tumor,  and  turned  it  out 
from  the  bone.  It  bled  furiously  during  the  operation,  but  the  moment  it  was  turned 
out,  the  bleeding  ceased.  The  two  arteries  were  tied,  the  eyebrow  was  brought  nicely 
together,  and  the  incision  healed  in  10  days.  The  tumor  appeared  a  perfect  cellular 
mass,  like  a  piece  of  sponge  soaked  in  blood.^ 

This,  then,  is  an  example  of  the  subcutaneous  arterial  aneurism  by  anasto- 
mosis, and  of  the  mode  of  cure  by  excision.  The  following  case,  related  by 
Mr.  Allan  Burns,  furnishes  an  instance  of  the  venous  variety  of  na^vus,  affect- 
ing both  the  skin  and  the  subcutaneous  tissues  : — 

Case  140. — A  middle-aged  stout  man  presented  a  large,  livid,  compressible  tumor,  in 
the  vicinity  of  the  right  orbit.  The  swelling  had  existed  from  birth,  was  sometimes  more 
distended  than  at  others  ;  but  was  seldom  productive  of  pain,  except  when  injured,  on 
which  occasion  it  poured  out  a  considerable  quantity  of  fluid  blood.  It  never  pulsated  ; 
but  during  exertion,  or  walking  in  a  very  hot  or  very  cold  day,  it  became  exceedingly 
tense.  Externally  it  covered  about  one-third  of  the  temporal  extremity  of  the  upper  eye- 
lid, and  occupied  the  whole  extent  of  the  lower  one,  the  folds  of  which  were  separated  to 
such  an  extent,  as  to  produce  an  unseemly  irregular,  and  pendulous  swelling,  which  hung 
down  over  the  cheek.  Towards  the  outer  canthus  of  the  eye,  the  morbid  texture  was 
interposed  between  the  conjunctiva  and  sclei'otica,  to  within  the  eighth  of  an  inch  from 
the  cornea.  It  was  chiefly  in  this  direction  that  the  disease  was  spreading.  From  the 
external  angle  of  the  eye  the  tumor  was  prolonged  both  outwards,  and  doAvnwards.  In 
the  first  direction,  it  extended  to  the  point  of  junction  of  the  temporal  and  malar  bones  ; 
in  the  latter,  it  descended  nearly  half  an  inch  below  the  line  of  the  parotid  duct.  Through 
its  whole  extent,  the  tumor  was  free  from  pulsation ;  no  large  artery  could  be  traced  into 
it ;  by  pressure  it  was  readily  emptied  of  its  contents  ;  but,  on  the  removal  of  the  pres- 
sure, it  was  again  slowly  filled.  When  emptied,  by  rubbing  the  collapsed  sac  between 
the  fingers,  a  doughy  impression  was  communicated  to  them.  On  the  surface  it  was  of  a 
dark  purple  color,  with  a  tint  of  blue  on  those  parts  covered  by  the  skin ;  but  where  in- 
vested by  the  conjanctiva,  it  had  a  shade  of  red.  It  was  cold  and  flabby,  communicating 
to  the  fingers  the  same  sensation  which  is  received  on  grasping  the  wattles  of  a  turkey- 
cock. 

As  the  tumor  was  increasing  and  threatened  to  extend  over  the  eye,  the  patient  was 
anxious  for  its  removal.  Mr.  Burns  began  the  operation  by  detaching  the  lower  eyelid 
along  its  whole  extent ;  he  then  dissected  away  that  part  of  the  tumor  adhering  to  the 
sclerotica,  and  next  removed  that  which  adhered  to  the  upper  eyelid.  This  being  done, 
he  tied  a  pretty  large  artery  which  passed  into  the  tumor  from  the  outer  and  lower  part 
of  the  orbit,  by  the  temporal  side  of  the  inferior  oblique  muscle.  The  next  stage  of  the 
operation  consisted  in  dissecting  off  the  tumor  from  the  aponeurosis  of  the  temporal 
muscle,  the  zygomatic  process,  the  malar  bone,  and  from  over  the  branches  of  the  portio 
dura,  and  the  parotid  duct.  After  the  great  body  of  the  tumor  was  in  this  way  removed, 
Mr.  Burns  found  that  a  part  of  the  spongy  morbid  mass  still  remained  attached  to  the 
parts  behind  the  parotid  duct  and  portio  dura.  He  also  discovered  that  some  of  the 
tumor  dipt  beneath  the  fascia  of  the  temporal  muscle,  which  was  reticulated.  From  these 
parts  there  was  a  general  oozing  of  blood  ;  and  from  the  divided  transverse  facial  artery, 
as  well  as  from  the  arteries  which  perforated  the  malar  bone  and  the  masseter  muscle, 
there  was  a  pretty  profuse  bleeding.  The  vessels  were  secured,  and  then,  with  the  for- 
ceps and  scissors,  Mr.  Burns  cleared  away  the  diseased  matter  from  behind  the  parotid 
duct  and  portio  dura,  both  of  which  were  thus  detached  from  all  connection  with  the 
neighboring  parts.  In  the  same  way,  he  was  obliged  to  cut  away  a  quantity  of  diseased 
substance  from  behind  the  zygoma.  As  the  morbid  parts  were  here  ill  defined,  and  much 
intermixed  with  the  fibres  of  the  temporal  muscle,  a  considerable  part  of  it  required  to  be 


CURE   OF  N^VUS  BY  TYING  THE  CAROTID.  199 

taken  away,  and  in  doing  this,  the  deep-seated  anterior  temporal  artery  was  diyided. 
What  of  the  tumor  remained  on  the  cheek,  adhered  so  firmly  to  the  zygomatic  muscle, 
and  was  so  closely  incorporated  with  its  substance,  that  the  one  could  not  be  separated 
from  the  other.  The  insulated  part  of  the  portio  dura  and  the  parotid  duct  were  now 
laid  back  on  the  masseter  muscle,  and  the  edges  of  the  integuments  brought  into  contact 
over  them,  and  supported  by  means  of  a  single  suture.  Over  the  malar  bone  the  lips  of 
the  wound  could  not  be  made  to  approach,  nor  did  the  oozing  from  the  bone  cease.  A 
fold  of  linen  and  a  layer  of  sponge  were  therefore  laid  into  this  part  of  the  wound,  and 
retained  there  by  a  compress  and  bandage,  applied  so  tightly  as  to  restrain  the  bleeding. 

The  sponge  was  removed  two  days  afterwards,  and  an  attempt  made  to  bring  the  lips 
of  the  wound  nearer  to  each  other.  The  sore  began  to  granulate,  and  threw  out  a  flabby 
red  fungus,  the  growth  of  which  could  not  be  checked  by  the  application  of  sulphate  of 
copper.  By  bringing  the  edges  of  the  sore  together,  it  was  at  length  reduced  to  the  size 
of  a  shilling,  and  was  soon  afterwards  completely  cicatrized. 

Three  years  after  the  operation,  the  patient  continued  free  from  any  return  of  the  dis- 
ease, and  the  cicatrice  was  becoming  smaller.  The  only  inconvenience  which  he  expe- 
rienced, arose  from  the  motion  of  the  upper  lid  being  impaired,  by  its  adhesion  to  that 
part  of  the  sclerotica  from  which  the  tumor  had  been  dissected.  From  the  same  cause, 
the  eye  did  not  possess  the  same  latitude  of  motion  as  formerly.  It  required  a  consider- 
able efl"ort  to  turn  the  pupil  towards  the  nose.*' 

It  will  be  evident  upon  the  slightest  consideration,  how  very  diiferent  in 
activity,  if  not  in  nature,  this  case  of  Mr.  Burns  is  from  that  of  Mr.  Bell ; 
and  how  much  less  the  danger  attending  the  extirpation  of  such  a  passive  or 
venous  aneurism  by  anastomosis,  compared  to  that  which  is  inseparable  from 
every  attempt  to  touch  with  the  knife,  the  active  or  arterial  tumor  of  the 
same  sort. 

13.  Obliteration  of  the  carotid  artery. — The  bold  and  successful  practice  of 
Mr.  Travers,  who,  for  an  aneurism  by  anastomosis  within  the  orbit,  tied  the 
common  carotid  artery,  has  been  followed  by  Mr.  Wardrop  in  several  cases 
of  this  disease  situated  externally.  In  these  cases,  Mr.  Wardrop  went  upon 
the  probability,  that  if  the  current  through  a  nsevus  were  arrested  by  tying 
the  arterial  trunk  supplying  it,  the  blood  contained  in  the  cells  or  parenchyma 
of  the  tumor,  would  undergo  a  process  of  coagulation,  as  the  blood  does  in 
a  common  aneurismal  sac  after  the  artery  has  been  tied,  that  the  coagulated 
blood  would  be  afterwards  absorbed,  and  the  tumor  gradually  shrink.  Mr. 
Wardrop  has  published  the  particulars  of  three  cases  of  naevus  of  the  face,  in 
which  he  tied  the  common  carotid.  All  the  three  patients  were  young  chil- 
dren. Two  of  them  died,  the  circumstances  preceding  the  operation  being 
very  unfavorable. 

Case  141. — A  female  child,  five  months  old,  had  a  large  subcutaneous  na3Yus  on  the 
left  side  of  the  face,  covei-ing  one-half  of  the  root  of  the  nose,  the  eyebrow,  and  the  upper 
eyelid.  The  eyelid  could  not  be  sufficiently  raised  to  expose  the  eyeball,  nor  could  the 
precise  limits  of  the  disease  be  traced  in  the  orbit,  within  which  it  seemed  to  penetrate 
deeply.  The  tumor  was  of  a  pale  blue  coloi',  and  there  were  numerous  tortuous  veins  in 
the  integuments  covering  it.  It  had  no  pulsation,  felt  doughy  and  inelastic,  and  when 
squeezed  became  greatly  diminished ;  on  removal  of  the  pressure,  its  original  size  was 
rapidly  restored. 

As  it  would  have  been  extremely  dangerous,  and  probably  even  impracticable,  to 
remove  the  tumor  with  the  knife,  and  as  it  had  been  rapidly  increasing  since  a  few  days 
after  the  birth  of  the  child,  Mr.  Wardrop  concluded  that  the  only  chance  of  arresting  the 
progress  of  the  disease,  was  by  tying  the  common  carotid  of  that  side  on  which  the  tumor 
was  situated.  The  incision  of  the  integuments  was  made  about  the  middle  of  the  neck, 
along  the  tracheal  edge  of  the  mastoid  muscle,  and  the  rest  of  the  dissection  was  accom- 
plished chiefly  with  a  sharp-pointed  double-edged  silver  knife.  The  operation  was  more 
difi&cult  than  might  have  been  expected  in  a  simple  dissection  amongst  healthy  parts, 
from  the  unceasing  cry  of  the  infant,  which  kept  the  larynx  and  trachea  in  constant 
motion  upwards  and  downwards.  This  not  only  prevented  the  pulsation  of  the  carotid 
from  being  distinguished,  but  when  the  sheath  of  the  vessel  was  distinctly  penetrated  by 
the  point  of  the  knife,  rendered  it  difficult  to  get  the  point  of  Bremner's  aneurismal  needle 
conducted  by  the  finger,  fairly  within  the  sheath.  When,  however,  the  latter  step  of  the 
operation  was  accomplished,  the  needle  passed  around  the  artery  with  great  facility. 
Some  divided  vessels  bled  a  good  deal  during  the  operation,  so  that  the  wound  was  kept 


200      CURE   OF   ANASTOMOTIC   ANEURISM   BY   TYING   THE   CAROTID. 

filled  -with  blood,  and  the  dissection  was  necessarily  conducted  with  the  finger  as  the  only 
giiide.  The  ligature  being  tied,  the  edges  of  the  wound  were  brought  together  by  a 
single  stitch,  and  no  adhesive  plaster  or  bandage  employed. 

The  infant  appeared  pale  and  much  exhausted  after  the  operation,  and  had  a  teaspoon- 
ful  of  the  syrup  of  white  poppies.  A  remai-kable  change  was  immediately  observed  in 
the  tumor.  No  sooner  had  the  carotid  been  tied,  than  the  child  was  observed  to  raise  the 
upper  eyelid  sufficiently  to  expose  the  ej-eball,  which,  until  that  period,  had  never  been 
in  view,  on  account  of  the  swollen  state  of  the  lid.  The  color  of  the  tumor  also  changed, 
losing  its  scarlet  hue,  and  appearing  of  a  much  darker  blue  shade  ;  a  change,  observes 
Mr.  Wardrop,  which  evidently  had  arisen  from  the  collapse  of  the  arteries,  whilst  the 
veins  and  cells  of  the  tumor  remained  filled  with  venous  blood.  Soon  after  the  operation, 
the  child  became  tranquil,  and  in  a  few  hours  was  permitted  to  suck,  care  having  been 
taken  to  keep  the  mother's  mind  easy  by  her  absence  during  the  operation,  and  by  con- 
cealing from  her  the  extent  of  the  wound.  The  child  passed  a  very  quiet  night,  the 
operation  seeming  to  produce  very  slight  excitement  in  the  general  system.  She  con- 
tinued to  suck  as  if  nothing  had  happened,  and  the  wound  inflamed  so  little  as  to  require 
no  dressing.  The  ligature  came  away  upon  the  eleventh  day.  On  the  day  following  the 
operation,  the  tumor  continued  of  the  same  diminished  bulk,  and  of  the  same  dark  purple 
color,  which  it  had  assumed  immediately  after  the  artery  was  tied.  On  feeling  the  tumor, 
it  seemed  either  as  if  the  blood  which  it  contained  had  coagulated,  or  that  it  was  emptied 
of  its  blood;  for  pressure,  instead  of  emptying  its  contents,  now  produced  no  sensible 
alteration.  A  gradual,  though  not  always  regularly  progressive  diminution  followed  ;  by 
degrees,  more  and  more  of  the  eyeball  became  exposed ;  and  ten  months  after  the  opera- 
tion, nothing  of  the  tumor  remained,  more  than  the  membranous  bag  originally  distended 
with  blood. 2^ 

Case  142. — A  fat  comely  girl,  18  years  old,  was  admitted  as  a  patient  into  the  Massa- 
chusetts General  Hospital,  4th  May,  1829.  Little  more  than  a  year  before  that  time,  she 
began  to  experience  a  strange  feeling  in  the  inner  angle  of  the  right  eye,  at  the  anasto- 
mosis of  tlie  facial,  ophthalmic,  and  frontal  arteries.  This  sensation  she  described  as  a 
crowding  feeling  in  the  eye.  It  soon  extended  to  the  head,  and  was  accompanied  with  a 
pain  so  severe,  that  though  otherwise  in  perfect  health,  she  was  obliged  to  give  up  her 
work  as  a  house-servant,  and  had  remained  idle  for  some  months  before  entering  the 
hospital. 

At  this  time,  there  was  a  tumor  at  the  inner  angle  of  the  eye,  just  above  the  lachrymal 
sac,  as  large  as  a  hazel-nut.  It  had  an  active  pulsation,  which  extended  into  the  neigh- 
boring arteries.  The  pulsations  of  the  facial  were  very  strong  ;  and  by  compressing  that 
artery,  the  vibrations  of  the  tumor  were  much  lessened.  Compression  of  the  temporal 
artery  produced  no  change.  The  skin  over  the  tumor  was  slightlj^  reddened,  and  there 
was  an  increase  of  heat.  The  carotid  artery  had  an  augmented  pulsation.  Pressure  on 
this  artery  suspended  the  pulse  of  the  tumor.  The  stethoscope,  applied  over  the  carotid 
and  facial  arteries,  gave  the  saw-mill  sound. 

After  observing  the  case  for  a  few  days.  Dr.  Warren  performed  the  following  operation: 
He  made  a  small  incision,  between  the  tumor  and  the  cavity  of  the  orbit.  The  pulsation 
of  the  anastomosing  branch  of  the  ophthalmic  was  discovered,  and  a  ligature  passed 
round  this  branch.  Next,  an  incision  was  made  across  the  facial  artery,  below  the  tumor ; 
and  after  allowing  about  18  ounces  of  blood  to  flow,  a  compress  was  applied,  including 
the  artery  and  the  tumor.  On  the  division  of  the  facial,  the  pulsation  ceased,  and  the 
patient  was  relieved  from  her  distressing  feelings.  On  removing  tliecomj^ress,  three  days 
after,  a  slight  pulsation  was  perceived.  The  wounds  healed  immediatel^y ;  and  the  patient 
finding  herself  very  comfortable,  was  discharged  on  the  first  June,  although  the  pulsation 
had  not  wholly  ceased. 

Dr.  Warren  was  disposed  to  believe,  that  the  cutting  ofl^  the  supply  from  the  ophthal- 
mic and  facial  arteries  would  be  followed  by  the  disappearance  of  the  tumor.  His 
expectations  were  disappointed.  In  the  latter  part  of  October,  the  patient  returned  to 
the  hospital.  A  verj^  slight  pulsation  was  discernible  in  the  tumor,  and  the  inner  angle 
of  the  left  eye  had  a  pulsation  somewhat  stronger  than  tliat  on  the  right  side.  The  arte- 
ries leading  into  it,  had  strong  pulsations.  The  carotid  on  each  side,  especially  on  the 
right,  throbbed  violently ;  so  that  she  sometimes  said  she  felt  as  if  the  top  of  her  head 
were  flying  off.  The  upper  part  of  the  face  and  the  forehead  were  red  and  swollen ; 
and,  on  the  whole,  there  was  a  great  aggravation  of  the  disease. 

Dr.  Wai'ren  was  at  a  loss  how  to  proceed,  as  the  disease  now  appeared  equally  on  the 
left  and  on  the  right  side,  and  extended  apparently  to  the  whole  arterial  system  of  each. 
He  began  by  trying  the  effect  of  general  remedies.  The  patient  was  ordered  to  be  kept 
perfectly  quiet ;  to  live  as  low  as  possible  ;  to  have  blood  taken  from  the  arm,  and  leeches 
applied  frequently  to  the  head  ;  and  to  take  the  tincture  of  digitalis.  These  measures 
were  followed  by  no  favorable  efi'ect.     Dr.  W.  therefore  laid  bare  and  penetrated  the 


METHODS   OF   TREATING  N^VTJS.  201 

temporal  artery  of  the  right  side,  allowed  it  to  bleed  freely,  and  then  divided  it ;  but  the 
pulsations  remained  unmitigated.  There  seemed  but  one  course  left,  that  of  tying  both 
carotids,  or  rather,  of  tying  one,  and,  if  this  did  not  answer,  the  other. 

On  the  2d  January,  18-30,  Dr.  W.  tied  the  right  carotid.  The  pulsations  on  the  right 
side  were  immediately  relieved.  Those  on  the  left  continued  for  a  time,  then  slowly  sub- 
sided, and  on  the  3d  March,  the  patient  was  discharged  perfectly  well.  Dr.  W.  thinks 
that  the  complete  success,  from  tying  the  right  carotid,  showed  that  the  affection  of  the 
left  side  was  altogether  sympathetic. '^'^ 

As  the  interruption  of  the  current  through  the  facial  and  ophthahnic  arte- 
ries was  not  successful  in  checking  the  disease  in  the  case  just  quoted,  while 
it  was  ultimately  cured  by  tying  the  carotid,  it  might  perhaps  seem  advisable 
in  similar  cases  to  begin  by  securing  the  carotid,  and  not  the  immediate  arte- 
ries of  the  tumor.  Dr.  Warren  states,  however,  that,  this  is  not  the  inference 
he  should  draw.  He  would  not  recommend  the  ligature  of  the  carotid  in 
such  a  case,  in  the  first  instance  ;  because  he  should  expect  that  vessels  so 
small  as  those  passing  into  the  tumor,  and  communicating  so  freely  with 
those  of  the  other  side,  would  be  immediately  supplied  with  blood  from  anas- 
tomosing arteries,  to  a  sufficient  degree  to  keep  up  the  circulation,  and 
maintain  the  morbid  action  in  the  tumor.  He  feels  satisfied  that  tying  the 
carotid  at  first,  would  not  have  accomplished  the  cure  in  the  above  instance. 
The  facial,  temporal,  and  ophthalmic  arteries  had  been  previously  divided, 
and  the  disease  had  felt  the  impression  of  this  measure  ;  the  suspension  of  the 
current  from  the  carotid,  coming  in  aid  of  the  means  already  employed,  was 
sufficient  to  effect  a  cure.  In  support  of  these  views.  Dr.  W.  refers  to  the 
case  of  a  woman,  who  having  fallen  down  stairs,  and  sfruck  the  inner  angle 
of  the  right  eye,  a  pulsating  tumor  arose  there,  which  affected  the  vision  of 
the  eye.  It  extended  into  the  orbit,  so  that  he  could  not  reach  the  ophthal- 
mic branch  within  the  tumor.  He  therefore  tied  the  carotid,  but  without 
any  alleviation  of  the  disease.  He  would  then  have  attempted  the  angular 
arteries  ;  but  the  patient  refused,  and  left  the  hospital.  These  views  of  Dr. 
Warren  are  confirmed  by  a  case  of  nsevus  situated  on  the  vertex,  in  which 
both  carotids  were  tied  by  Dr.  Mussey,  with  little  permanent  advantage,  the 
disease  afterwards  requiring  to  be  extirpated.  This  was  done  six  weeks 
after  tying  the  second  artery,  at  the  expense  of  a  considerable  share  of  hse- 
morrhagy  ;  from  the  consequence  of  which,  however,  the  patient  eventually 
recovered.** 

Mr.  Morgan  tied  the  carotid  in  a  case  of  nsevus  occupying  the  entire  side 
of  the  face,  and  which  had  previously  been  treated  by  ligature  and  the  actual 
cautery.  The  patient  recovered  from  the  operation,  but  the  expected  benefit 
did  not  ensue. ^^ 

With  regard  to  the  various  methods  of  treating  ntevus,  it  has  been  well 
observed  by  Mr.  Philips,  that  each  has  succeeded,  and  all  have  failed.  It 
may  also  be  observed,  that  it  is  often  the  case  that  a  cure,  partially  effected 
by  one  method,  requires  to  be  completed  by  another.  One  method  having 
proved  a  total  failure,  a  cure  is  sometimes  readily  effected  by  a  different 
method.  The  danger  of  exciting  erysipelas  and  phlebitis  by  some  of  the 
methods,  must  not  be  overlooked,  fatal  results  having  followed  from  these 
accidents.  Hemorrhage  also  must  be  guarded  against,  as  exceedingly  likely 
to  follow  some  of  the  plans  of  cure  above  described. 


'  The  disease  here  under  consideration   af-  burgh,  1829.     There  is  also  a  varix  racemostts, 

fects  the  small  vessels,  but  there  is  an  analo-  for  cases  of  which  see  Warren's  Surgical  Ob- 

gous    state  of  the   arterial   trunks,   sometimes  servations  on  Tumors,  p.  427  ;  Boston,  1837. 
called  aneurisma  racemosum.     See  Maclachlan,         ^  On  the   structure  of  nasvus,  consult  Miil- 

Glasgow    Medical    Journal  ;     Vol.    i.   p.   81  ;  ler   on  the   Nature    of    Cancer,    translated    by 

Glasgow,  1828;  Syme,  Edinburgh  Medical  and  West;    PI.  V.  and  YI.  figs.  16,  17;    London, 

Surgical  Journal;    Vol.   xxxi.   p.  66;    Edin-  1840:    Paget,  Lectures    on    Tumors;    London 


202 


(EDEMA   OF   THE   EYELIDS. 


Medical  Gazette;  Vol.  xlviii.  Lect.  8  :  Birkett, 
Medico-Cbirurgical  Transactions  ;  Vol.  xxx.  p. 
193;  London.  1847:  Coote,  Medical  Gazette; 
Vol.  xlv.  p.  412  ;  London,  1850. 

=  Bell's  Principles  of  Surgery  ;  Vol.  i.  p.  456  ; 
Edinburtrh,  1801  :  Bateman's  Synopsis  of  Cu- 
taneous Diseases,  p.  2.39  ;  London,  1819  :  Faw- 
dington,  North  of  England  Medical  and  Surgi- 
cal .Journal;  Vol.  i.  p.  56;  Manchester,  1830  ; 
Philips,  Medical  Gazette;  Vol.  xii.  p.  7;  Lon- 
don, 1833. 

'  Annales  d'Oculistique  ;  1<=''.  Vol.  Supplem. 
p.  26  ;  Bruxelles.  1842. 

'  See  Brainard's  cases,  cured  by  collodion, 
Monthly  Journal  of  Medical  Sicence;  Vol.  x. 
p.  72  ;  Edinburgh,  1850. 

^  Traite  des  Maladies  Chirurgicales ;  Tomo 
ii.  p.  269;  Paris,  1814. 

■"  Surgical  Observations  on  Injuries  of  the 
Head,  and  on  Miscellaneous  Subjects,  p.  228; 
London, 1810. 

^  Dieffenbach,  Operative  Chirurgie;  Vol.  i. 
p.  236  ;  Leipzig,  1845. 

"  ]\Iedico-Chirurgieal  Review ;  Vol.  vii.  p. 
280  ;  London,  1827  :  Lancet;  Vol.  xii.  p.  750; 
London,  1827:  Glasgow  Medical  Journal ;  Vol. 
i.  p.  93;  Glasgow,  1828.  See  Case  of  large 
subcutaneous  Nievus,  cured  by  Vaccination, 
by  Woolcott,  Lancet,  March  13,  1852,  p.  201. 

'°  Medical  Gazette ;  Vol.  xxxv.  p.  786  ;  Lon- 
don, 1845.  » 

' '  Zeitschrift  f iir  die  Opnthalmologio ;  Vol.  i. 
p.  485  ;  Dresden,  1831. 

'-  Lancet;  Vol.  xi.  p.  652;  London,  1827. 

'^  Liston's  Practical  Surgery,  p.  333;  Lon- 
don, 1846. 

"  London  Medical  Gazette;  Vol.  xix.  p.  13; 
London,  1836. 

"  Ibid.  Vol.  xxi.  p.  529;  London.  1837. 

'"  AVarren,  Op.  cit.  p.  418:  Lalleiuand, 
Archives  Generates  de  Medecine,  4«.  Serie, 
Tome  i.  p.  416;  Paris,  1843. 


'■^  See  Case  by  Bernard,  Medical  Times  and 
Gazette,  March  27,  1852,  p.  318. 

'*  Medical  Gazette;  Vol.  vii.  p.  677;  Lon- 
don, 1831 :  Lancet,  Nov.  1837,  p.  353. 

''  Medical  Gazette;  Vol.  xxvii.  p.  605; 
London,  1841. 

^°  Svstem  of  Practical  Surgery;  Part  i.  p. 
118  ;  Edinburgh,  1838. 

^'  Fawdington,  Op.  cit.  p.  66;  Macilwain, 
Medico-Chirurgieal  Transactions;  Vol.  xviii. 
p.  189;  London,  1833:  Bellingham,  Dublin 
Medical  Press,  August  16,  1848,  p.  97. 

^-  Medical  Gazette  ;  Vol.  xii.  p.  581 ;  Lon- 
don, 184S. 

"  lb.  Vol.  xlv.  p.  138;  London,  1850. 

^*  Op.  cit.  p.  335. 

*'  Archives  Generales  de  Medecine;  2*  S6- 
rie.  Tome  viii.  p.  5;  Paris,  1835;  4^  Serie; 
Tome  i.  p.  459  ;  Paris,  1843. 

^^  Medical  Times  and  Gazette;  July  3, 1852, 
p.  22,  and  December  11,  1852,  p.  594. 

^^  On  the  subcutaneous  ligature,  the  sug- 
gestion of  which  is  ascribed  to  M.  Ricord,  see 
Curling,  Op.  cit. :  Birkett,  Guy's  Hospital  Re- 
ports, Second  Series;  Vol.  vii.  p.  294  ;  London, 
1851 :  Broadhurst,  Medical  Times  and  Gazette, 
May  8,  1852.  p.  474. 

'*  Petit,  Traite  des  Maladies  Chirurgicales; 
Tome  i.  p.  266  ;  Paris,  1 790. 

"  Op.  cit.;  Vol.  i.  p.  241. 

"  Bell,  Op.  cit.;  Vol.  i.  p.  461. 

^'  Observations  on  the  Surgical  Anatomy  of 
the  Head  and  Neck,  p.  331 ;  Glasgow,  1824. 

'-  Lancet;  Vol.  xii.  p.  267;  London,  1827. 
Mr.  Wardrop's  unsuccessful  eases  are  contained 
in  the  Medico-Chirurgical  Transactions,  Vol.  ix.; 
and  in  the  volume  of  the  Lancet  now  quoted. 

"  Op.  cit.  p.  400. 

^*  Medical  Gazette;  Vol.  vi.  p.76;  London, 
1830. 

^'  France's  Edition  of  Morgan's  Lectures  on 
the  Diseases  of  the  Eye,  p.  xiv. ;  London,  1848. 


SECTION  XXV. (EDEMA  OP  THE  EYELIDS. 

The  looseness  of  the  cellular  membrane  of  the  eyelids,  and  the  absence  of 
adipose  tissue,  permit  them  readily,  and  to  a  great  extent,  to  become  (Ede- 
matous.    This  affection  may  depend  either  on  local  or  on  general  causes. 

There  is  generally  some  oedema  attending  the  acute  stages  of  the  ophthal- 
miaj.  We  see  the  lids  become  cedematous  from  wounds  and  bruises  ;  from 
erysipelas  ;  from  diseases  of  the  orbit,  as  necrosis ;  or  diseases  -within  that 
cavity,  as  orbital  tumors ;  from  diseases  of  the  nasal  sinuses,  as  polypus ; 
from  the  irritation  of  abscesses  of  the  face  or  scalp  ;  from  the  application  of 
pressure  to  the  lower  parts  of  the  face,  as  after  the  operation  for  harelip  ; 
and  even  from  the  pressure  of  crutches.  When  disease  of  the  orbit,  or  within 
it,  or  disease  of  the  nostril,  is  the  cause,  the  ccdema  often  affects  the  opposite 
lids,  as  well  as  those  of  the  same  side  ;  and  the  like  is  observed  when 
abscesses  about  the  head  are  the  cause.  After  scarlatinous  ophthalmia,  and 
after  the  too  fre(iuent  use  of  emollient  fomentations  and  poultices,  during 
inflammatory  affections  of  the  eyes,  particularly  where  the  poultices  are 
allowed  to  become  cold,  and  to  lie  long  without  Ijeing  changed  or  removed, 
we  not  unfrequently  find  the  lids  puffy  and  ffidematous. 

In  other  cases,  oedema  of  the  lids  is  part  of  a  general  dropsy,  as  in  the 


EMPHYSEMA   OP  THE  EYELIDS.  203 

anasarca  consequent  to  scarlet  fever  ;  or  it  exists  without  any  other  part  of 
the  body  being  dropsical,  in  adults  of  leucophlegmatic  constitution,  or  in 
scrofulous  children.  In  some  cases  it  appears  to  be  a  sympathetic  affection, 
connected  with  disease  in  some  remote  organ.  Dr.  Parry  observed  it  in 
several  instances,  in  connection  with  violent  pain  of  head,  depending  proba- 
bly on  costiveuess.*  Albuminuria  may  be  suspected,  and  the  urine  should 
be  examined,  when  the  lids  long  remain  puffy.  It  rarely  happens  that  this 
affection  occurs  spontaneously,  or  without  some  evident  cause,  in  an  indi- 
vidual otherwise  perfectly  healthy. 

The  eyelids  affected  with  oedema  are  swollen,  smooth,  sometimes  pale, 
sometimes  red,  semi-transparent,  and  soft ;  yielding  easily  to  the  pressure  of 
the  finger,  and  in  some  cases  retaining  the  mark  of  pressure  for  a  time. 
Their  motions  are  impeded,  and  the  eyes  cannot  be  completely  opened. 

(Edema  of  the  eyelids  succeeding  to  a  wound  or  bruise,  to  an  attack  of 
erysipelas,  or  to  the  pressure  of  a  bandage  on  the  lower  parts  of  the  face,  is 
gradually  and  completely  removed,  when  the  cause  which  had  produced  it 
ceases  to  operate.  That  which  appears  in  the  morning  in  persons  of  a  leuco- 
phlegmatic habit,  diminishes  during  the  course  of  the  day,  and  is  not  danger- 
ous. That  which  arises  in  scrofulous  children,  or  in  adults  without  any 
evident  cause,  continues  long,  or  comes  and  goes  at  uncertain  intervals  of 
time. 

Bloodletting  and  diuretics,  in  scarlatinous  dropsy,  and  in  the  inflammatory 
variety  of  Bright's  disease,  prove  effectual  in  removing  the  attending  oedema 
of  the  lids,  in  proportion  as  the  urine  becomes  natural  and  copious.  In 
albuminuria  depending  on  fatty  degeneration  of  the  kidney,  a  mild  diet, 
without  alcohol,  ought  to  be  prescribed,  and  purging  or  mercury  should  be 
avoided. 

In  other  cases,  gentle  stimulants  externally,  and  tonics  internally,  may  be 
used  with  advantage.  Bathing  the  lids  with  rose-water,  or  with  limewater 
sharpened  with  a  little  brandy,  will  be  found  useful.  Bags  of  dried  aromatic 
herbs,  as  chamomile  flowers,  sage,  or  rosemary,  with  a  little  powdered  cam- 
phor, suspended  from  the  brow,  so  as  to  cover  the  lids,  are  highly  recom- 
mended. The  bags  should  be  made  of  old  linen,  quilted,  so  as  to  keep  the 
herbs  equally  spread  out.  When  the  oedema  is  periodic,  and  without  any 
evident  cause,  a  blister  to  the  nape  of  the  neck  will  be  found  advantageous. 
In  scrofulous  and  debilitated  subjects,  chalybeates,  and  the  preparations  of 
cinchona,  are  indicated. 


'  Collections  from  the  unpublished  Medical  Writings  of  C.  II.  Parry,  M.  D.;  Vol.  i.  p.  581 ; 
London,  1S25. 


SECTION  XXVI. — EMPHYSEMA  OP  THE  EYELIDS. 

A  swelling  of  the  eyelids,  produced  by  the  presence  of  air  in  their  cellular 
membrane,  may  either  be  part  of  a  general  emphysema,  arising  from  an  in- 
jury of  the  organs  of  respiration,  in  which  case  the  air,  escaping  from  the 
lungs,  spreads  through  the  whole  body,  and  accumulates  chiefly  where  the 
cellular  substance  is  loose  ;  or  it  may  be  the  consequence  of  such  an  injury 
or  diseased  state  of  the  nasal  parietes,  as  shall  permit  the  air  to  pass  from 
the  cavity  of  the  nose  directly  into  the  cellular  membrane  of  the  eyelids. 

The  following  cases  illustrate  the  second  variety  of  emphysema  of  the  eye- 
lids :^— 

Case  143. — A  young  man  received  a  violent  blow  on  the  nose  in  consequence  of  which 
he  experienced  rather  severe  pain.     Some  hours  after,  while  forcibly  blowing  his  nose, 


204  EMPHYSEMA   OP   THE  EYELIDS. 

he  felt  a  peculiar  sensation  ascending  along  tlie  side  of  it,  to  the  internal  angle  of  the  left 
eye,  and  spreading  to  the  two  eyelids.  These  immediately  became  so  much  swollen,  that 
the  eye  was  entirely  covered.  AVhen  the  patient  was  received  at  the  Hotel-Dieu,  the  lids 
were  very  tense  and  shining,  but  indolent  and  without  any  change  of  color  in  the  skin. 
An  emphysematous  crepitation  was  distinctly  perceived. 

He  was  bled  from  the  arm,  and  compresses,  dipped  in  a  discutient  lotion,  were  applied 
over  the  swelling.  In  four  or  five  days,  the  cure  was  complete.  M.  Dupuytren  supposed 
that  the  blow  received  by  the  patient  had  occasioned  laceration  of  the  pituitary  membrane, 
opposite  the  union  of  the  lateral  cartilage  of  the  nose,  which  had  been  detached  from  the 
lower  edge  of  the  nasal  bone.^ 

Case  144. — A  lad  of  IG  years  of  age,  as  he  was  going  along  the  street,  with  a  load,  ran 
inadvertently  against  a  person  passing  in  the  opposite  direction;  a  scuflSe  ensued,  in 
which  he  received  a  severe  blow  immediately  over  the  right  frontal  sinus.  About  an  hour 
after,  having  occasion  to  blow  his  nose,  the  eyelids  and  parts  adjacent  became  immediately 
inflated,  so  as  completely  to  close  the  eye,  and  he  felt  the  air  rush,  he  said,  into  those 
parts.  On  being  admitted  into  Guy's  Hospital,  under  the  care  of  Mr.  Morgan,  the  eye- 
lids were  much  distended,  and  so  closely  approximated,  that  they  could  not  be  separated 
by  any  voluntary  eliort  of  the  patient;  the  eyebrow  was  also  puffed  up,  and  the  cellular 
membrane  between  the  ear  and  the  orbit  was  in  the  same  state  of  emphysema.  The 
parts  were  not  at  all  painful  on  pressure  ;  they  yielded  a  crackling  sensation  to  the  touch, 
and  were  free  from  discoloration.  The  supposed  seat  of  the  fracture  was  at  a  small  dis- 
tance above  the  superciliary  ridge,  where  a  slight  depression,  but  no  crepitus,  could  be 
felt.     The  globe  of  the  eye  was  perfectly  natural. 

Two  small  incisions  were  made  through  the  integuments,  about  the  eighth  of  an  inch 
behind  the  external  angle  of  the  frontal  bone,  which  allowed  the  air  to  escape.  The 
swelling  subsided  in  twenty-four  hours,  leaving  the  eye  and  surrounding  soft  parts  in  a 
perfectly  healthy  condition.^ 

Case  145. — A  robust  man,  46  years  of  age,  was  brought  senseless  into  the  Hotel-Dieu, 
and  placed  in  one  of  the  surgical  wards  ;  but  as  there  was  profound  stupor,  with  stertor 
and  complete  relaxation  of  all  the  limbs,  without  any  external  lesion,  he  was  removed  into 
one  of  tiae  medical  wards.  On  examining  him  Avith  care,  the  jaws  were  found  strongly 
convulsed,  and  the  muscles  of  the  neck  stiff.  When  the  nose  was  pinched,  so  as  to  inter- 
rupt the  passage  of  the  air,  respiration  was  suspended  during  at  least  half  a  minute, 
■when  a  violent  expiration  being  made,  the  left  upper  eyelid  was  perceived  to  swell  a  little, 
and  the  experiment  being  repeated,  the  same  effect  was  again  produced,  and  the  eyelid 
assumed  a  considerable  size,  with  emphysematous  crepitation.  On  examining  the  eyelid, 
there  appeared  a  slight  abrasion,  and  yellowish  tint  of  the  skin,  from  which  it  seemed 
probable  there  was  a  fracture  of  the  roof  of  the  orbit,  or  of  the  base  of  the  cranium,  per- 
mitting the  air  from  the  ethmoid  or  sphenoid  sinuses,  to  pass  into  the  substance  of  the 
eyelid,  when  an  obstacle  was  presented  to  its  exit  by  the  nose.  Information  was  obtained, 
that  he  had  been  assaulted,  about  twelve  days  before,  by  several  men,  who  hit  him  on 
the  face  with  an  umbrella  and  left  him  lying  senseless  on  the  street.  He  died  the  second 
day  after  his  admission. 

On  dissection,  a  fracture  of  the  roof  of  the  orbit,  with  laceration  of  the  anterior  lobe  of 
the  brain,  extending  to  the  depth  of  eight  lines,  was  discovered.  The  dura  mater  was 
separated  from  the  bone  to  a  great  extent  around  the  fracture,  but  was  not  torn.  One 
of  the  osseous  fragments  extended  to  the  great  notch  of  the  frontal  bone,  and  communi- 
cated with  the  middle  ethmoid  cells,  which  contained  a  small  quantity  of  liquid  blood.* 

I  have  seen  several  cases  of  emphysema  of  the  lids  from  blows.  In  some 
crepitation  was  distinct,  in  others  not.  In  one  case,  the  upper  lid  hung  over 
the  eye,  as  if  palsied.  In  another,  the  eyeball  was  considerably  forced  for- 
wards by  the  presence  of  air  in  the  areolar  tissue  of  the  orbit. 

This  affection  may  arise  altogether  independently  of  a  blow. 

Case  146. — A  scrofulous  girl,  blowing  her  nose  violently,  felt  her  right  eyelids  drawn 
together.  Next  day,  I  found  the  lids  puffy,  but  without  any  crackling.  She  had  no  per- 
ceptible disease  in  her  nose,  but  had  suffered  much  from  scrofulous  ophthalmia.  On  the 
second  day  after  the  accident,  the  swelling  was  less,  but  the  emphysematous  crackling, 
when  I  pressed  the  lids,  distinct. 

Ca.se  147. — A  man  whose  right  nostril  was  nearly  closed  by  a  twist  of  the  septum,  tried 
to  clear  it  by  blowing.  Suddenly  the  right  lids  swelled  with  air,  and  the  eyeball  became 
somewhat  protruded. 

The  application  of  cold  water,  and  a  dose  of  laxative  medicine,  formed  the 
whole  treatment  in  these  two  cases,  both  of  which  probably  depended  on  a 
rupture  of  some  part  of  the  Schneiderian  membrane. 


TWITCHING,    OR   QUIVERING   OP   THE   EYELIDS.  205 

The  plan  of  incision  throngh  the  integuments,  followed  in  Case  142,  is  also 
adopted  when  the  eyelids  are  greatly  distended,  in  cases  of  universal  emphy- 
sema. ■  It  is  merely,  of  com-se,  a  palliative  remedy ;  the  complete  removal  of 
the  disease  depending  on  the  healing  up  of  the  injured  part  of  the  lungs,  or 
windpipe.  Even  in  cases  of  rupture  of  some  portion  of  the  nasal  parietes, 
the  evacuation  of  the  diffused  air  is  merely  palliative,  and  scarcely  worth  the 
while  to  practice.  Till  consolidation  is  effected,  the  emphysema  will  be  liable 
to  return  when  the  patient  blows  his  nose,  against  which  he  is  therefore  to  be 
put  on  his  guard. 


'  A  case  of  emphysema  of  the  eyelid,  from  a  par  Dupuytren;  Tome  i.  p.  128  ;  Paris,  1832. 
gunshot  wound  of  the  frontal  sinus,  is  related         ^  Lancet;  Vol.  x.  p.  31;  London,  1826. 
by  Baudens,  in  his  Clinique  des  Plaies  d'Armes         *  Meniere,  Archives  Generales  da  Medeeine; 

k  Feu,  p.  162;  Paris,  1836.  Tome  xix.  p.  344;  Paris,  1849. 

°  Le§ons   Orales   de    Clinique    Chirurgicale, 


SECTION  XX Vn. — TWITCHING,  OR  QUIVERING  OF  THE  EYELIDS. 

Syn. — Kuvixof  a-TTas-fAOi,  AretcBus.     Tic  non-douloureux,  Fr.     Spasmodic  or  muscular  tic. 

Life-blood,  Vulff. 

I  have  often  been  consulted  by  patients  who  complained  of  a  tremulous, 
quivering,  or  twitching  motion  of  one  or  other  eyelid,  or  of  both,  which  they 
were  unable  to  control  or  to  prevent,  and  which,  from  the  frequency  of  its 
repetition,  had  become  very  annoying,  although  not  attended  with  pain.  In 
many  cases,  the  quivering  of  the  ciliaris  is  so  slight  as  not  to  produce  any  visible 
motion  of  the  affected  lid  ;  the  patient  merely  feels  the  part  moving  ;  but  in 
other  cases,  the  motion  is  very  evident,  and  is  not  confined  to  the  orioicularis 
palpebrarum,  but  extends  to  other  muscles  of  the  face,  and  especially  to  the 
zygomatici,  so  that  while  the  eyelids  are  convulsed,  the  angle  of  the  mouth  is 
drawn  upwards.  In  some  cases,  as  in  those  related  by  M.  Francois,^  the 
whole  of  the  muscles  of  the  face  animated  by  the  portio  dura,  are  convulsed. 
In  one  instance,  even  the  muscles  of  the  velum,  the  stylo-hyoid,  and  the  pos- 
terior belly  of  the  digastric,  seem  to  have  been  affected.^  In  some  cases,  I 
have  seen  the  spasm  spread  to  the  neck  and  to  the  arm,  so  that  these  parts 
were  strangely  agitated  along  with  one  side  of  the  face,  whenever  the  patient 
began  to  speak.  Morbid  nictitation,  and  blepharospasm,  to  be  considered 
in  the  following  Sections,  are  akin  to  twitching  of  the  lids ;  as  is  also  that 
spasmodic  affection  of  the  frontalis,  in  which  the  eyebrows  are  every  other 
minute  drawn  violently  upwards.  These  are  in  general  reflex  diseases  of  the 
portio  dura ;  they  are  spasms,  clonic  or  tonic,  of  muscles  under  its  control. 

Agitation  of  mind  generally  aggravates  twitching  of  the,  lids,  so  that  in 
speaking  to  a  sti*anger,  it  becomes  much  increased.  The  patient  is  conscious 
of  this ;  his  feelings  are  hurt  by  the  knowledge  of  his  being  subject  to  the 
complaint,  and  he  often  becomes  anxious  to  undergo  any  sort  of  treatment 
likely  to  relieve  him,  not  even  excepting  an  operation.  Although,  in  by  far 
the  greater  number  of  cases,  no  pain  attends  the  disease,  it  is  occasionally 
accompanied  by  pain  so  severe  as  to  resemble  tic  douloui'eux. 

Causes. — I  have  generally  found  the  patient's  digestive  organs  deranged, 
and  most  frequently,  from  the  use  of  alcoholic  fluids.  In  one  case  which  I 
saw,  the  disease  was  brought  on  in  a  female  servant,  from  her  sitting  up  in 
the  night,  and  over-fatiguing  her  eyes  in  stitching  fine  linen. 

The  discovery  of  Sir  C.  Bell,  that  the  fifth  nerve  is  the  nerve  of  sensibility, 
and  the  portio  dura  of  the  seventh  the  nerve  of  motion  of  the  face,  leads  us  to 
refer  the  cause  of  such  abnormal  motions  to  a  disordered  influence  of  the 


206  TWITCHING,    OR  QUIVERING   OF   THE  EYELIDS. 

portio  dura.  In  certain  cases,  the  disease  may  perhaps  depend  on  some 
limited  affection  of  one  or  other  of  the  fasciculi  of  the  facial  nerve,  altogether 
exterior  to  the  cranium ;  but,  in  general,  the  nerve  seems  to  be  excited  to 
irregular  action  in  consequence  of  some  remote  disorder,  sufficient  to  disturb 
the  natural  control  of  the  brain  over  the  motions  of  the  face.  The  original 
irritation  seems  to  be  most  frequently  propagated  from  the  stomach  to  the 
nervous  centre,  probably  by  the  nervus  vagus,  whence  it  is  reflected  to  one 
or  more  twigs  of  the  facial,  and  shows  itself  in  clonic  spasms  of  the  lids  and 
face. 

The  state  of  spasm  or  convulsion  on  one  side  of  the  face,  sometimes  pro- 
duces an  appearance  as  if  the  other  side  were  affected  with  palsy.  "  A  lady 
complained  of  pain  in  the  head,"  says  Sir  B.  C.  Brodie,  "and  her  mouth  was 
drawn  to  one  side ;  and  hence  she  was  supposed  to  suffer  from  paralysis  of 
the  muscles  of  one  side  of  her  face.  However,  when  I  was  consulted  respect- 
ing her,  I  observed  that  there  were  nearly  constant  twitches  of  the  cheek  and 
eyelids  on  that  side  to  which  the  mouth  was  drawn ;  and  on  more  minute 
examination,  I  was  satisfied  that  the  distoi'tion  of  the  mouth  arose,  not  from 
the  muscles  on  one  side  of  the  face  being  paralytic,  but  from  those  on  the 
opposite  side  being  in  a  state  of  spasm.  The  case  precisely  resembled  that 
of  a  patient  with  spasmodic  wry-neck,  except  the  disease  influenced  a  different 
set  of  muscles,  namely,  those  supplied  by  the  facial  nerve.  "^ 

Prognosis. — When  the  affection  is  recent,  and  limited  to  the  lids,  and  the 
patient  has  resolution  enough  to  submit  to  a  proper  regimen,  the  prognosis 
is  not  unfavorable.     Otherwise,  the  disease  persists  for  life. 

Treatment. — 1.  The  patient  must  give  up  entirely  the  use  of  wine,  ale, 
spirits,  and  the  like. 

2.  Essential  benefit  results  from  the  use  of  laxative,  alterative,  and  tonic 
medicines.  A  blue  pill  every  night,  or  every  second  night,  and  one  or  two 
compound  rhubarb  pills  every  morning,  for  a  fortnight,  will  generally  be 
attended  with  good  effects ;  after  which,  a  course  of  bitter  infusion,  precipi- 
tated carbonate  of  iron,  or  some  of  the  preparations  of  cinchona,  ought  to  be 
prescribed,  along  with  country  air  and  exercise.  / 

3.  Anodyne  liniments,  rubbed  in  along  the  course  of  the  portio  dura,  have 
been  recommended. 

4.  Continued  pressure,  so  as  to  limit  the  motion  of  the  parts  spasmodically  • 
affected,  has  been  found  advantageous,  tending  to  break  the  hal)it  on  which, 
in  a  great  measure,  the  complaint  depends,  by  what  means  soever  it  may  have 
been  originally  produced. 

5.  The  abstraction  of  blood  from  behind  the  ear,  by  cupping  or  by  leeches, 
is  advisable.  The  lower  lid  being  affected,  I  have  known  much  relief  ob- 
tained from  a  leech  at  the  inner  angle  of  the  eye.  Turberville  had  a  patient 
long  troubled  with  pain  and  convulsions  in  his  cheek ;  the  place  where  the 
pain  was,  could  be  covered  with  a  penny ;  the  convulsions  pulled  his  mouth, 
face,  and  eye  aside.  Turberville  applied  a  cupping-glass  to  the  place,  then 
scarified,  and  cupped  again  ;  after  which  he  put  on  a  plaster,  and  the  patient 
was  perfectly  cured.* 

6.  An  issue  between  the  angle  of  the  jaw  and  the  mastoid  process  has 
proved  decidedly  useful. 

^  1.  Division  of  the  nervous  filaments  of  the  facial  nerve  would  remove  the 
disease,  but  would  substitute  a  paralysis.  In  order  to  avoid  this  evil,  and 
yet  attain  the  same  object,  Dieffenbach,  in  one  case,  performed  a  subcuta- 
neous division  of  the  offending  muscular  fibres.^  This  is  done  by  introducing 
a  narrow  knife  under  the  skin,  turning  its  edge  towards  the  muscle,  and 
dividing  it  as  the  knife  is  withdrawn. 


MORBID   NICTITATION. — BLEPHAROSPASM.  20T 

'  Edinburgh  Medical  and  Surgical  Journal,  thorp's   Abridgment,  Vol.  iii.  part   i.  p.    34; 

Vol.  Ixxv.  pp.  86,  381;  Edinburgh,  1851.  London,  1716. 

*  Ibid.  p.  104.  *  Romberg's  Manual  of  the  Nervous  Diseases 
^  Medical  Gazette ;  Vol.  v.  p.  559 ;  London,  of  Man,  translated  by  Sieveking;  Vol.  i.  p.  297 ; 

1830.  London,  1853. 

*  Philosophical  Transactions ;  No.  164;  Low- 


SECTION  XXVni. — MORBID  NICTITATION. 

While  natural  nictitation  is  accomplislied  so  instantaneously  and  easily  as 
scarcely  to  attract  the  notice  of  ourselves  or  others,  there  is  a  morbid  nictita- 
tion, which  appears  to  be  not  so  much  the  eflfect  of  relaxation  of  the  levator 
palpebrse  superioris,  as  a  convulsive  action  of  the  orbicularis  palpebrai'um, 
too  remarkable  not  to  be  observed  by  others,  and  of  which,  at  last,  the  patient 
himself  becomes  painfully  conscious.  In  the  cases  referred  to,  the  shutting  of 
the  eye,  instead  of  being  performed  only  once,  is  repeated  several  times  in  imme- 
diate succession.  In  some  instances,  the  upper  eyelid  is  principally  affected  ; 
in  others,  the  lower.  Sometimes  one  eye  only ;  generally,  both  eyes  are 
affected.  Analogous  to  the  subject  of  last  section,  although  readily  distin- 
guishable from  it,  the  present  disease  is  aggravated  by  the  same  causes, 
especially  agitation  of  mind,  and  disordered  digestion. 

Sometimes  a  single  eyelash,  growing  inwards  so  as  to  touch  the  eyeball,  is 
the  cause  of  morbid  nictitation.  In  other  instances,  slight  conjunctival  oph- 
thalmia produces  it.  These  causes  being  removed,  the  complaint  will  cease. 
In  many  instances,  morbid  nictitation  seems  merely  a  bad  habit,  or  what  the 
French  term  a  tic.  We  often  see  it  in  children,  whose  eyes  are  overworked. 
Sometimes  it  is  a  sign  of  indigestion.  In  such  cases,  a  treatment  similar  to 
what  has  been  recommended  for  quivering  of  the  eyelids,  should  be  adopted. 
Advantage  is  obtained  from  wearing  a  green  bonnet-shade,  and  using  a  col- 
lyrium,  containing  from  1  to  2  drachms  of  the  tincture  of  belladonna,  in  8 
ounces  of  water.  From  6  to  12  grains  of  rhubarb  powder,  with  from  the 
twelfth  to  the  sixth  of  a  grain  of  tartar  emetic,  each  night,  prove  serviceable. 


SECTION  XXIX. — BLEPHAROSPASM. 


The  reflex  action  by  which  the  eyelids  are  closed,  often  assumes  the  form 
of  tonic  spasm,  and  is  then  termed  blepharospasm.  It  is  generally,  but  not 
always,  accompanied  by  intolerance  of  light,  or  photophobia,  and  often  by 
epiphora.  It  generally  affects  both  eyes  pretty  equally ;  sometimes,  only  one. 
The  stimulus  on  which  the  spasmodic  contraction  of  the  orbicularis  palpe- 
brarum depends,  is  of  course  communicated  through  the  facial  nerve.  The 
exciting  cause  of  the  irritation  resides  sometimes  in  the  organ  of  vision  ; 
sometimes,  in  remote  organs.  In  different  cases,  it  operates  on  the  nervous 
centre  whence  the  facial  nerve  arises,  through  the  fifth  nerve,  through  the 
optic  nerve,  through  the  nervus  vagus,  or  through  the  great  sympathetic  ;  or 
is  derived  immediately  from  some  cerebral  disturbance. 

1.  A  particle  of  dust  adhering  to  the  inner  surface  of  the  upper  eyelid,  an 
inverted  eyelash,  or  some  minute  deposition  in  the  site  of  the  Meibomian  fol- 
licles, is  a  common  cause  of  blepharospasm ;  the  irritation  being  communi- 
cated to  the  nervous  centre  through  the  fifth  nerve.  The  photophobia  and 
spasm  of  the  eyelids  generally  subside  very  soon  after  the  cause  of  irritation 
is  removed. 

2.  In  scrofulous  conjunctivitis,  the  spasm  is  often  continued,  with  slight 


208  BLEPHAROSPASM, 

evening  remissions,  for  months  together.  The  patient,  generally  a  child,  is 
all  that  time  unable  to  bear  the  least  accession  of  light,  or  to  open  the  eyes 
in  the  smallest  degree,  during  the  day.  The  inflammation  during  this  state 
may  be  very  inconsiderable,  so  that  on  forcing  open  the  lids,  scarcely  a  red 
vessel  is  discovered.  Such,  however,  is  the  sympathy  between  the  conjunctiva, 
which  is  the  primary  seat  of  irritation,  and  the  neighboring  parts,  the  retina, 
cerebral  optic  apparatus,  lachrymal  gland,  and  orbicularis  palpebrarum,  that 
the  admitted  light  seems  to  the  patient  to  blaze  like  the  rays  of  the  sun 
reflected  from  a  mirror ;  the  lachrymal  gland  instantly  pours  out  a  tide  of 
tears,  and  the  spasm  of  the  orbicularis  forces  the  lids  together  with  new  vio- 
lence. The  removal  of  the  ophthalmia,  by  the  treatment  hereafter  to  be 
explained,  is  the  only  means  of  obviating  these,  its  reflex  eS"ects. 

3.  In  some  cases  of  severe  blepharospasm  and  intolerance  of  light,  the 
symptoms  have  been  completely  relieved  only  by  the  extraction  of  carious 
teeth,  or  teeth  at  the  roots  of  which  abscesses  existed.  Several  remarkable 
instances  of  this  sort  are  recorded  by  Dr.  Hays  of  Philadelphia,*  showing 
the  propriety  of  examining  with  care  if  such  cause  of  irritation  may  not  be 
in  existence. 

4.  In  a  fourth  set  of  cases,  the  original  irritation  appears  to  be  in  the 
retina,  the  disease  being  the  result  of  over-use  of  the  eyes. 

Case  148. — Sir  C.  Bell  has  recorded^  a  case  of  photophobia  and  blepharospasm,  brought 
on  by  over-exertiou  of  the  eyes  upon  minute  objects,  in  which  the  attacks  came  ou  peri- 
odically, the  patient  losing  all  control  over  the  muscles  of  the  eyelids  and  eyeballs.  The 
complaint  was  attended  with  occasional  pain  extending  round  the  head,  as  if  it  were 
bound  with  a  hoop,  and  a  whizzing  noise  in  the  ears.  Suddenly  the  spasm  would  go  off, 
the  eyes  becoming  open,  and  capable  of  being  fixed  on  the  surrounding  objects,  for  per- 
haps the  space  of  an  hour.  Excitement  of  the  mind  in  conversation  would  produce  this 
temporary  improvement ;  and  what  was  very  remarkable,  the  patient,  an  intelligent  young 
lady,  discovered  that  on  pressing  with  the  point  of  her  finger  on  the  little  pit  before  her 
ear  and  above  the  jugum,  the  eyes  instantly  opened,  and  remained  so  long  as  the  pressure 
was  continued.  Sir  C.  found,  that  when  he  put  the  point  of  his  thumb  under  the  angle 
of  the  jaw,  and  pressed  the  carotid  against  the  vertebra3,  the  same  eflfect  was  produced, 
proving,  he  thinks,  that  the  cessation  of  the  spasm  was  caused  by  some  influence  of  the 
circulation  over  the  nervous  system  of  the  head.  On  pressing  down  the  cartilages  over 
the  left  hypochondriac  region,  so  as  to  affect  the  cardiac  portion  of  the  stomach,  the  eyes 
opened  and  remained  open  while  the  pressure  continued. 

In  cases  of  this  kind,  the  intolerance  of  light  is  often  excessive ;  we  find 
the  patient  in  a  room  totally  dark,  with  his  eyes  tied  up  ;  he  cannot  allow 
them  to  be  examined ;  and  compares  the  sensation  he  experiences  from 
attempting  to  open  his  eyes,  to  what  might  be  felt  on  looking  at  a  sea  of 
molten  gold.  In  one  young  gentleman  in  this  state,  by  whom  I  was  con- 
sulted, the  attempt  to  open  his  eyes  often  seemed  ready  to  throw  him  into  a 
state  of  general  convulsion.  He  was  cured  completely  by  leeches,  blistering, 
and  a  long-continued  course  of  calomel  and  quinine.  I  have  seen  numerous 
cases  of  this  sort,  which  have  resisted  for  years  every  kind  of  treatment,  and 
have  at  length  undergone  a  spontaneous  cure. 

5.  Sometimes,  spasm  of  the  orbicularis  palpebrarum  of  one  side  is  brought 
on  in  consequence  of  a  blow  on  the  head,  or  other  injury,  the  effects  of  which 
have  been  communicated  to  the  brain  or  its  membranes.  The  spasm  con- 
tinues long ;  for  weeks,  perhaps,  or  months ;  and  is  apt  to  be  mistaken  for 
palsy  of  the  levator  of  the  upper  lid.  A  restless  state  of  the  edge  of  the 
upper  lid,  and  the  difiiculty  experienced  in  raising  it  even  with  the  finger, 
will  serve  to  distinguish  this  state  from  palsy. 

Cerebral  congestion,  from  fever  and  other  causes,  apoplexy,  and  various 
other  disorders  of  the  brain,  are  productive  of  blepharospasm.  In  such 
cases,  both  sides  are  generally  affected,  the  intolerance  of  light  is  excessive, 


BLEPHAROSPASM.  209 

exposure  to  strong  sunlight  is  apt  to  produce  violent  and  universal  muscular 
spasms,  and  the  recovery  is  exceedingly  slow. 

6.  The  organic  nerves  of  the  digestive  system  are  sometimes  the  medium 
by  which  an  irritation  is  transmitted  to  the  nervous  centre,  whence  it  is 
reflected  to  the  facial  nerve,  and  the  muscles,  which  it  serves  to  excite,  as  it 
often  is  to  other  nerves  and  other  organs.  The  cure,  when  this  is  the  case, 
will  depend  on  a  judicious  regulation  of  the  diet,  along  with  the  administra- 
tion of  purgatives,  alteratives,  and  tonics.  In  some  cases,  anthelmintics  will 
prove  serviceable,  by  means  of  their  specific  effect. 

T.  Many  cases  of  blepharospasm  are  of  hysteric  origin.  They  are  often 
mistaken  for  palsy  of  the  levator  palpebrte  superioris,  and  erroneously  desig- 
nated by  the  name  of  hysteric  ptosis. 

Case  149. — Dr.  Schon  relates*  the  case  of  a  scrofulous  girl,  of  15  years  of  age,  who 
labored  under  blepharospasm  of  the  right  eye  for  15  months,  not  being  once  nble  during 
the  whole  of  that  time  to  separate  the  lids  from  one  another.  He  employed  all  the  reme- 
dies usually  recommended,  both  internal  and  external,  -without  the  least  effect.  The  left 
eye  continued  well,  and  the  right  never  showed  even  a  trace  of  inflammation.  During 
the  night  of  the  24th  April,  1831,  the  cat^imenia  appeared  for  the  first  time,  and  the  very 
next  morning,  the  patient  could  open  her  eye  with  perfect  freedom,  and  no  longer  saw 
double,  as  was  previously  the  case  when  her  lids  were  separated  by  another  person. 

In  the  case  of  a  lady  by  whom  I  was  consulted,  the  inability  to  open  the 
affected  eye  sometimes  continued  constantly  for  two  or  three  days,  while  at 
other  times  she  had  complete  command  over  the  eye.  In  another  lady,  not 
merely  the  sphincters  of  both  eyes  were  affected,  but  also  the  muscles  of  the 
nose  and  lips,  producing  closure  of  the  eyes,  along  with  a  peculiar  and 
painful  screwing  together  of  the  mouth.  Much  benefit  was  derived,  in  this 
last  case,  from  the  continued  use  of  aloes  and  assafoetida.  A  combination  of 
such  remedies  with  tonics  often  proves  useful  in  hysteric  cases. 

General  treatment. — I  have  already  hinted  at  most  of  the  remedies  to  be 
used  for  the  relief  of  blepharospasm.  The  cause  of  the  original  irritation 
must  first  be  sought  for,  and  against  it  the  treatment  must  be  directed. 

In  cases  of  an  inflammatory  cast,  or  where  the  disease  is  traced  to  an  in- 
jury of  the  head,  bloodletting  from  the  arm,  leeches  to  the  temples,  and  a 
course  of  mercury  are  indicated.  In  gastric  and  hysteric  cases,  purgatives, 
antispasmodics,  and  tonics,  such  as  quinine  and  iron,  are  the  most  available 
remedies.  Belladonna,  internally,  is  often  of  great  service  ;  as  is  the  inhala- 
tion of  ether  or  chloroform,  every  second  or  third  day,  to  the  extent  of  pro- 
ducing slight  insensibility.  Externally,  counter-irritation  is  to  be  employed 
by  means  of  friction  with  volatile  liniment,  tincture  of  cantharides,  and  the 
like,  on  the  forehead  and  temple,  and  behind  and  before  the  ear.  The  appli- 
cation of  blisters  and  the  insertion  of  issues,  are  requisite,  when  milder  means 
are  ineffectual.  Exposing  the  eyes  to  the  vapor  of  opium  or  of  belladonna, 
by  mixing  their  tinctures  with  hot  water  in  a  teacup,  to  be  held  under  the 
eyes,  and  fomenting  them  with  poppy  decoction,  or  a  warm  infusion  of  ex- 
tract of  belladonna,  are  useful.  Poultices,  containing  opium,  hyoscyamus, 
or  coniuni,  are  also  recommended  to  be  applied  over  the  eye.  A  small  con- 
tinued stream  of  cold  water,  or  of  water  impregnated  with  carbonic  acid  gas, 
directed  against  the  eye  by  means  of  a  syringe  or  a  syphon,  is  highly  recom- 
mended by  Dr.  Jiingken.*  The  vapor  bath,  in  some  cases,  has  proved  effi- 
cacious ;  the  cold  shower  bath,  in  others.  The  patient  wearing  a  double 
green  shade,  should  gradually  accustom  his  eyes  to  the  light,  and  not  indulge, 
as  is  often  done,  in  an  increasing  degree  of  obscurity. 


'  Medical  Gazette;  Vol.  xsviii.  p.  617;  Lon-  ^  Ammon's  Zeitschrift  fiif  die  Ophthalmolo- 

don,  1841.  gie;  Vol.  ii.  p.  153;  Dresden,  1832. 

"  Nervous  System  of  the  Iluman  Body;  Ap-  *  Lehre  von  der  Augeukrankheiten,  p.  778  ; 

pendix,  p.  xlvi. ;  London,  1830.  Berlin,  1832. 
14 


210  PALSY  OF  THE   ORBICULARIS  PALPEBRARUM. 


SECTION  XXX. — PALSY  OP  THE   ORBICULARIS  PALPEBRARUM  AND   MUSCLES  OP 

THE  EYEBROW. 

SyA. — Blight,  Vulff.     Palsy  of  the  portio  dura.     Hemiplegia  facialis. 
Fi(/.  Dalrymple,  PI.  XXX. 

In  most  cases  of  palsy  of  the  face,  there  is  a  degree  of  lagophthahnos ;  or 
in  other  ^yords,  the  eyelids  cannot  be  completely  closed,  on  account  of  the 
paralytic  state  of  the  orbicularis  palpebrarum.  The  patient  cannot  wink 
hard,  nor  press  the  eyelids  against  the  eyeball ;  neither  can  he,  from  the  dis- 
ease extending  to  the  epicranius  and  corrugator  supercilii,  elevate  his  eye- 
brow, or  frown,  upon  the  palsied  side.  All  this  is  most  evident  when  the 
patient  keeps  the  sound  eye  open,  and  tries  to  close  the  lids  of  the  palsied 
side.  He  then  finds  that  he  cannot  do  so,  at  least  not  completely ;  but  he 
closes  the  palsied  lids  much  better,  when  he  at  the  same  time  closes  those  of 
the  sound  side.  The  levator  palpebrse  superioris,  retaining  its  power,  raises 
the  upper  lid  to  the  natural  degree,  and  again,  on  its  becoming  relaxed,  the 
lids  fall  to  a  certain  extent,  but  the  two  lids  cannot  be  brought  together. 
They  remain  in  some  cases  four-tenths  of  an  inch  apart.  When  the  patient 
looks  down,  the  levator  is  relaxed,  and  the  lid  falls  considerably  more  than 
when  he  looks  forwards.  The  tears  run  over  on  the  cheek,  from  want  of  the 
action  of  the  lower  lid,  which  hangs  depressed  and  everted  ;  exposed  to  dust 
flying  about,  the  patient  is  distressed  by  its  getting  into  his  eye  ;  and  thus 
inflammation  of  the  conjunctiva  and  opacity  of  the  cornea  may  be  excited.'^ 
The  loss  of  power,  however,  in  the  orbicularis  varies  in  degree.  It  but 
rarely  happens  that  it  exists  to  such  an  extent  as  to  cause  any  material 
injury  to  the  eye,  except  in  infants,  in  whom  the  cornea  sometimes  becomes 
wholly  opaque  or  even  destroyed  by  ulceration.  In  general,  the  lids  merely 
do  not  close  accurately,  and  we  see  the  exposed  eyeball  turn  up,  when  the 
inefi'ectual  effort  is  made  to  bring  the  lids  together.  But  in  other  cases,  the 
lids  gape  widely,  and  the  patient  can  neither  raise  the  lower,  nor  bring  down 
the  upper,  by  any  voluntary  effort.  If  we  push  down  the  upper  lid  with  the 
finger,  it  is  thrown  into  loose  folds,  and  is  immediately  drawn  up  when  we 
cease  to  press  upon  it ;  if  we  draw  down  the  lower  lid,  and  then  let  it  go,  it 
does  not  spring  to  the  eye  as  in  health.  On  the  patient's  falling  asleep,  the 
upper  lid  covers  the  pupil,  the  eyeball  turning  up,  and  the  levator  palpebrse 
relaxing,  but  the  lower  lid  remains  depressed  and  everted.  The  retracted 
lids  are  generally  puffy,  and  the  eyeball  seems  protruded. 

The  other  muscles  of  the  face  are  generally  paralyzed  at  the  same  time, 
and  the  natural  motion  of  the  lips  is  lost,  so  that  the  mouth  opens  most  on 
the  unaffected  side,  and  the  actions  of  whistling,  laughing,  &c.  are  impeded. 
While  the  sound  side  of  the  face  is  rotund  and  full,  or  marked  by  a  dimple, 
the  palsied  is  soft  and  sunk.  If  the  disease  has  continued  long,  there  is  a 
marked  diminution  in  the  thickness  of  the  muscles.  The  cheek  becomes  so 
thin  that,  when  the  patient  speaks,  it  flaps  about  as  if  it  were  only  skin,  and 
the  corrugator  supercilii  and  occipito-frontalis  are  so  wasted,  that  the  bones 
seem  covered  only  by  integuments ;  the  mouth  is  dragged  from  the  palsied 
towards  the  sound  side,  and  even  the  nose  is  twisted.  Sensation  over  the 
face  is  natural,  unless  some  cause  be  present  which  affects  the  fifth  pair,  as 
well  as  the  portio  dura  of  the  seventh.  From  the  exposed  state  of  the  eye, 
and  the  evaporation  which  goes  on  from  its  surface,  the  patient  has  a  feeling 
of  cold  in  it,  which  he  remedies  by  covering  it,  perhaps,  with  his  hand.  At 
first  he  is  apt  to  sleep  with  the  eye  uncovered,  when  the  air  drying  it,  will 
cause  pain ;  but  by  and  by  he  contrives  to  fall  asleep  with  his  fingers  on  his 
lids,  or  turns  half  over  on  his  face,  so  that  the  pillow  presses  the  lids  toge- 


PALSY  OF  THE   ORBICULARIS  PALPEBRARUM.  211 

tlier.  Occasionally  he  complains  of  pain  at  the  root  of  the  ear,  or  in  the 
neighborhood  of  the  stylo-mastoicl  foramen,  from  which  the  portio  dura 
escapes,  to  send  its  branches  over  the  face.  It  is  stated  by  Landouzy,  that 
when  the  cause  is  non-cerebral,  although  above  the  geniculate  ganglion,  ex- 
altation of  hearing  is  present.^  Dulness  of  hearing  is  certainly  not  an  un- 
frequent  symptom,  even  in  non-cerebral  cases ;  and  is  probably  owing,  not 
to  any  affection  of  the  portio  mollis,  but  to  derangement  in  the  movements 
of  the  bones  of  the  tympanum.  Absolute  deafness  would  indicate  that  the 
portio  mollis  was  implicated.  At  the  commencement  of  the  disease,  pain  is 
sometimes  felt,  radiating  along  the  branches  of  the  nerve.  On  looking  into 
the  throat,  the  uvula  is  sometimes  found  to  be  bent  into  an  arc,  and  its  point 
turned  towards  the  palsied  side.  In  some  cases,  both  sides  of  the  face  are 
palsied.^  A  case  of  this  kind,  which  I  saw,  arose  from  a  poor  man  being 
maltreated  on  the  road,  and  kicked  on  the  occiput.  In  such  cases,  the 
patient  experiences  a  degree  of  dysphagia,  speaks  through  his  nose,  and  pre- 
sents other  symptoms  indicating  palsy  of  the  velum.* 

Causes. — Palsy  of  the  face  always  depends  on  some  affection  of  the  portio 
dura ;  but  it  is  of  great  importance  to  distinguish  those  cases  in  which  the 
cause  exists  within  the  cavity  of  the  cranium,  from  those  in  which  the  nerve 
suffers  in  its  passage  through  the  aqueduct  of  Fallopius,  or  after  it  has 
emerged  from  that  canal,  and  is  spreading  itself  to  the  facial  muscles.  Pre- 
viously to  the  discoveries  of  Sir  C.  Bell,  palsy  of  the  face  was  generally 
regarded  as  cerebral  in  its  origin,  and  even  when  the  seat  of  the  disease  was 
altogether  exterior  to  the  cavity  of  the  cranium,  the  patient  was  treated  with 
the  severity  which  a  serious  disorder  of  the  brain  might  properly  demand. 
If  the  uvula  is  drawn  to  the  unaffected  side,  and  there  are  signs  of  a  paralytic 
state  of  the  velum,  it  is  presumed  that  the  cause  is  above  the  geniculate 
ganglion,  which  is  situated  on  the  first  bend  of  the  facial  nerve,  in  the  Fallo- 
pian aqueduct,  and  where  the  facial  communicates  with  Meckel's  ganglion 
by  the  greater  superficial  petrosal  nerve. ^  If  this  deviation  is  absent,  the 
cause  is  presumed  to  be  below  the  ganglion. 

Exposure  to  a  current  of  cold  air  is  the  most  frequent  cause  of  palsy  of 
the  face.  This  cause  probably  operates  by  producing  inflammation  of  the 
portio  dura,  and,  perhaps,  in  some  cases  inflammatory  swelling  of  the  peri- 
osteum lining  the  aqueduct  of  Fallopius,  and  diminution  of  its  calibre,  so 
that  the  trunk  of  the  nerve  suffers  pressure.  According  to  Dr.  Marshall 
Hall,  as  the  inflammatory  affection  of  the  portio  dura  subsides,  the  paralytic 
symptoms  are  transmuted  into  a  spasmodic  state. ^  The  disease  has  been 
known  to  arise  from  the  pressure  of  a  lymphatic  gland  lying  between  the 
mastoid  process  and  the  angle  of  the  jaw,  and  enlarged  in  consequence  of 
inflammation  of  the  mouth  from  the  action  of  mercury.  Dr.  Bennett  relates 
a  case,''  in  which  a  cancroid  tumor  of  the  parotid  was  the  cause.  I  have 
seen  repeated  instances  in  which  palsy  of  the  face  attended  carious  abscess 
of  the  tympanum,  affecting,  no  doubt,  the  aqueduct  of  Fallopius.  In  a  case 
which  came  under  my  observation,  the  disease  followed  a  severe  fall  on  the 
side  of  the  head,  which  produced  a  discharge  of  blood  from  the  auditory 
canal,  and,  it  is  probable,  an  extravasation  of  blood  within  the  cavities  of  the 
temporal  bone.  Division  of  the  portio  dura,  in  any  accidental  wound  or 
surgical  operation,  about  the  angle  of  the  jaw,  will  produce  it.  Mr.  Shaw 
mentions  a  case,*  in  which,  during  the  removal  of  a  tumor  from  before  the 
ear,  the  moment  the  branches  of  the  portio  dura  were  cut,  the  patient  cried 
out,  "Oh!  I  cannot  shut  my  eye."  One  or  other  of  the  temporo-facial 
branches  of  the  nerve  may  in  this  way  be  divided,  and  consequently  one  or 
other  lid  only  may  be  palsied. 

Experience  proves  that  facial  hemiplegia  may  be  produced  by  a  vivid  moral 


212  PALSY  OF  THE   ORBICTJLARIS  PALPEBRARUM. 

affection.  Andral  has  seen  it  after  a  violent  fit  of  anger ;  Bellingeri,  from  a 
fright ;  Frank,  from  the  announcement  of  bad  news ;  Bottu-Desmortiers,  in 
a  young  girl,  from  repeated  crosses  during  profuse  menstruation. ^ 

Facial  palsy  may  depend  altogether  on  cerebral  disease ;  on  pressure  of 
the  nerve,  for  example,  by  congested  vessels  or  by  some  morbid  effusion  or 
formation  within  the  cavity  of  the  cranium,  between  the  origin  of  the  portio 
dura  and  its  exit  by  the  meatus  auditorius  internus.  In  such  a  case,  which 
I  have  known  to  arise  from  fatigue  and  too  much  stooping,  other  cerebral 
symptoms  will  be  present,  as  feelings  of  fulness  and  pain  in  the  head,  giddi- 
ness, sleepiness,  &c.  If  other  nerves  are  implicated,  as  the  sixth,  pressure 
on  the  pons  Varolii  is  likely  to  be  the  cause. 

Occasionally  it  happens  that  palsy  of  the  face,  depending  on  an  affection 
of  the  aqueduct  of  Fallopius,  is  present  along  with  serious  disease  within  the 
cranium  ;  the  latter,  however,  in  nowise  operating  on  the  portio  dura.  la 
other  cases,  the  disease  of  the  temporal  bone,  which  originally  produced  the 
palsy  of  the  face,  goes  on  to  affect  the  dura  mater  and  the  brain,  suppura- 
tion of  these  parts  takes  place,  and  death  speedily  follows.  This  is  especially 
apt  to  happen  in  scrofulous  children.'" 

Treatment. — In  ordinary  cases,  the  treatment  must  be  directed  against 
neither  the  brain  nor  the  eyelids,  but  against  the  portio  dura  and  the  Fallo- 
pian aqueduct.  Antiphlogistic  mean's  of  cure  are  to  be  adopted  in  the  first 
instance,  as  leeches  behind  the  ear,  and  near  the  angle  of  the  jaw,  cupping 
on  the  back  of  the  neck,  and  free  purging.  Calomel  and  opium,  and  the  use 
of  diaphoretics,  may  next  be  had  recourse  to.  A  continued  action  on  the 
digestive  system  by  Pluramer's  pill,  does  good.  A  caustic  issue,  or  a  semi- 
lunar blister  below  the  ear,  and  stimulating  liniments  over  the  course  of  the 
nerves  going  to  the  paralyzed  parts,  will  be  found  of  advantage.  A  succes- 
sion of  small  blisters,  dusted  over  with  strychnia,  is  likely  to  be  useful.' 
Should  these  means  not  prove  effectual,  a  trial  may  be  given  to  electricity, 
galvanism,  or  electro-magnetism.  Each  cheek  may  be  touched  with  a  plate 
of  metal,  and  a  shock  thus  passed,  on  which  the  sound  lids  close,  but  the 
paralytic  remain  unaffected.  Electro-puncture  appears  sometimes  to  have 
been  successful." 

When  caries  of  the  tympanum,  by  affecting  the  portio  dura,  produces  palsy 
of  the  face,  a  perpetual  discharge  should  be  kept  up  behind  the  ear.  The 
diseased  ear  may  be  cautiously  injected  every  second  or  third  day,  with  a 
weak  solution  of  nitrate  of  silver.  The  membrana  tympani  is  always  partially, 
and  often  totally,  destroyed  in  such  cases ;  and  the  indiscriminate  use  of  in- 
jections might  excite  inflammation,  extending  to  the  brain  and  its  membranes. 
If  the  patient  be  a  scrofulous  child,  residence  at  the  sea-side,  and  a  course  of 
sulphate  of  quina,  ought  to  be  prescribed. 

Cerebral  disease,  producing  palsy  of  the  face,  must  be  combated  chiefly  by 
means  of  depletion,  abstinence,  and  counter-irritation. 

To  prevent  the  bad  effects  of  exposure  of  the  eye  to  the  atmosphere,  and 
to  the  particles  of  dust  collecting  on  the  conjunctiva,  the  patient  should  be 
directed  to  foment  the  eye  frequently  with  warm  water,  and  to  move  the  eye- 
lid over  his  eye.  He  should  keep  the  eyelid  down  during  the  night  by  means 
of  a  compress  and  roller. 

In  cases  not  likely  otherwise  to  recover,  the  eversion  of  the  lower  lid  may 
be  remedied  by  tarsoraphia.'^  If  the  upper  lid  is  permanently  elevated, 
Dieffenbach  divides  the  levator  subcutaneously." 


'  See    Sbaw,    Medicn-Chirurgienl    Transac-  ^  See  case  by  Magnus,  Muller's  Archiv  fiir 

tions;  Vol.  xii.  p.  117;  London,  182^1.  Anatnmie,  1837,  p.  258. 

'^  Medical  Gazette;  Vol.  xlvi.  p.  909;  Lon-  *  On  Palsy  of  both  facial  nerves,  consult 
don,  1850. 


PTOSIS. 


213 


Davnine,  Oazette  Medicale  de  Paris,  13  Nov. 
1852.  and  following  Numbers. 

'  CyclopaBdia  of  Anatomy  and  Physiology  ; 
Vol.  iv.  p.  553 ;  London,  1849. 

*  Dublin  Medical  Press;  Vol.  xxiv.  p.  185  ; 
Dublin,  1850. 

'  On  Cancerous  and  Cancroid  Growths,  p. 
83  ;  Edinburgh,  1849. 

"  Op.  cit.  p.  138. 

'  Translation  of  this  work  into  French ;  p. 
viii. ;  Paris,  1844. 

'"  See  case  in  an  adult,  in  Pilcher's  Treatise 
on  the  Structure,  Economy,  and  Diseases  of  the 
Ear,  p.  165 ;  London,  1838.     Palsy  of  portio 


dura  from  fatal  fracture  of  base  of  skull,  see 
Lancet,  January  8,  1853,  p.  24.  Destruction  of 
temporal  bone,  and  of  7th  and  8th  pairs,  see 
Medical  Gazette;  Vol.  xlviii.  p.  927;  London, 
1851.  Palsy  of  right  side  of  face,  and  leftside 
of  body,  from  disease  of  right  side  of  pons 
Varolii,  see  Medical  Times,  Nov.  22, 1851,  p. 
535. 

"  See  case  by  Montault,  Medical  and  Physi- 
cal Journal  ;  A^ol.  Ixiii.  p.  4C3;  London,  1830. 

'^  France,  Lancet,  January  5,  1850,  p.  14. 

'^  Die  Operative  Chirurgie ;  Vol.  i.  p.  743; 
Leipzig,  1845. 


SECTION  XXXI. — PTOSIS,  OR  FALLING  DOWN  OF  THE  UPPER  EYELID. 
nrSo-tf,  from  mTrrt),  I  fall.      Syn. — Blepharoplegia,  a  terin  applicable  oidy  to  the  bth  variety. 
Inability  to  raise  the  upper  eyelid  may  depend  on  a  variety  of  causes ;  as,  a  re- 
dundant state  of  the  integuments,  or  an  injury, 
weakness,  or  palsy  of  the  levator.  Fig.  17. 

§  1.  Ptosis  from  Hypertrophy. 

After  inflammation  of  the  upper  eyelid,  at- 
tended with  considerable  (Edematous  or  san- 
guineous effusion  into  its  substance,  or  treated 
by  the  long-continued  use  of  cataplasms,  we 
tjometimes  find  the  lid  so  much  thickened,  and 
its  integuments  so  much  relaxed,  that  they  form 
a  fold,  hanging  down  over  the  opening  of  the 
lids,  while  the  levator  palpebrag  superioris  is 
unable,  from  the  weight  and  bulk  of  the  lid,  to 
raise  it  so  as  to  uncover  the  eye.  We  perceive 
distinctly  the  endeavors  of  the  muscle,  as  soon 
as  the  patient  is  earnestly  desirous  of  opening 
his  eye ;  but  the  eyelid  is  either  raised  only  to  a 
very  inconsiderable  degree,  or  I'emains  complete- 
ly depressed.  If  we  take  hold,  between  the  fin- 
ger and  thumb,  of  a  transverse  fold  of  the  skin, 
so  as  to  relieve  the  levator  muscle  of  the  addi- 
tional weight  of  integuments,  the  patient  can, 
without  difficulty,  open  his  eye,  showing  that 
the  case  is  not  one  of  paralytic  ptosis  ;  but  as 
soon  as  we  quit  our  hold,  the  eyelid  sinks  to  its 
former  position.  Sometimes  the  relaxation  does 
not  occupy  so  much  the  middle  of  the  eyelid  as 
its  temporal  portion.  It  is  also  occasionally  the 
case,  that  when  the  fold  of  integuments  is  very 
considerable,  it  presses,  by  its  weight,  the  edge 
of  the  lid,  along  with  the  cilia,  inwards,  so  as  to 
produce  a  degree  of  entropium. 

For  the  cure  of  this  variety  of  ptosis,  the 
common  practice  is  to  remove  a  transverse  fold 
of  the  integuments.  In  order  to  perform  this 
with  the  necessary  exactness,  we  take  hold  of 
the  skin,  where  it  appears  most  relaxed,  with  a 
broad  convex-edged  pair  of  forceps,  commonly 
called  entropium  forceps  (Fig.  11),  and  then 
de-sire  the  patient  repeatedly  to  open  and  shut 


214  PTOSIS. 

the  eye.  If  he  be  able  to  do  this,  it  is  a  proof  that  the  forceps  includes  neither 
too  much  nor  too  little  of  the  skin.  If  he  cannot  lift  the  lid,  we  have  taken 
hold  of  too  little,  and  must  apply  the  forceps  again,  so  as  to  include  a  greater 
portion  of  the  skin.  If  he  can,  indeed,  lift  the  lid,  but  not  completely  shut 
it  again,  we  must  let  go  a  little  of  the  skin  from  the  grasp  of  the  instrument. 
It  is  important  also  to  take  care  that  we  do  not  apply  the  blade  of  the  forceps 
too  close  to  the  edge  of  the  lid ;  for  if  this  be  done,  too  little  space  will  be 
left  for  the  application  of  stitches.  As  soon,  then,  as  the  forceps  is  properly 
applied,  we  squeeze  its  blades  together  with  moderate  firmness,  that  the  in- 
teguments may  not  escape,  and  then  remove  the  portion  laid  hold  of,  by  a 
stroke  or  two  of  the  scissors.  The  bleeding  is  inconsiderable,  and  ceases  in 
a  few  minutes  by  the  use  of  cold  water.  Seldom  more  than  two  stitches  are 
necessary  ;  one  is  frequently  sufficient.  Union  is  generally  effected  very 
quickly,  without  any  suppuration,  and  scarcely  leaves  any  perceptible  scar. 
As  soon  as  the  union  is  complete,  the  prolapsus  is  cured. 

§  2.    Congenital  Ptosis. 

I  have  repeatedly  met  with  a  degree  of  depression  of  the  upper  lid,  so 
considerable  as  materially  to  impede  the  function  of  vision,  and  which  had 
existed  from  birth.  In  some  of  these  cases,  the  lid  was  the  reverse  of  being 
swollen  ;  it  rather  appeared  atrophic,  as  if  the  levator  muscle  had  either  been 
originally  deficient,  or  had  wasted  from  disease.  This  sort  of  incomplete 
ptosis  is  sometimes  hereditary,  and  is  occasionally  complicated  with  flatness 
of  part  of  the  superciliary  arch.* 

Removing  a  transverse  fold  of  the  integuments  was  tried  in  several  of  the 
cases  to  which  I  refer,  but  generally  with  little  or  no  advantage.  Perhaps 
better  success  might  attend  the  operation  recommended  by  Mr.  Hunt,  which 
I  shall  immediately  have  occasion  to  explain. 

§  3.   Traumatic  Ptosis. 

In  penetrating  wounds  of  the  upper  lid  (see  p.  150),  the  levator  may  be 
cut  or  torn  across,  or  the  branch  which  it  derives  from  the  third  nerve  may 
be  divided.  The  consequence  will  be  inability  to  uncover  the  eye.  In  such 
a  case,  I  have  known  the  power  of  raising  the  lid  to  be  restored,  probably 
from  the  reunion  of  the  muscular  fibres  which  had  been  divided. 

The  snipping  out  of  a  small  fold  of  the  skin  of  the  lid  can  be  of  no  use 
in  such  cases.  A  close  attention,  however,  to  the  structure  and  healthy  func- 
tions of  the  parts  concerned,  has  led  Mr.  Hunt,  of  Manchester,  to  a  more 
rational  mode  of  operation  for  traumatic  ptosis.  His  method  may  also  be 
useful  when  this  disease  arises  from  congenital  deficiency,  or  from  palsy  of 
the  levator. 

The  operation  recommended  by  Mr.  Hunt,  is  performed  by  dissecting  off 
a  fold  of  integument  from  the  eyelid,  and  the  difference  between  his  operation 
and  the  usual  way  of  proceeding,  consists  in  the  greater  extent  of  the  portion 
removed.  The  upper  incision  is  made  immediately  below  the  eyebrow,  and 
stretches,  each  way,  to  a  point  opposite  the  commissures  of  the  eyelids.  In 
making  the  lower  incision,  no  precise  direction  can  be  given.  It  should 
approach  within  a  short  distance  of  the  tarsal  margin,  and  should  meet  the 
upper  incision  at  both  its  extremities,  so  that  a  portion  of  the  integuments  is 
removed,  of  the  shape  of  an  olive  leaf,  the  extent  of  which  must  vary  accord- 
ing to  the  greater  or  less  degree  of  the  relaxation  of  the  skin,  which  is  the 
same  in  no*two  individuals.  The  divided  edges  should  be  accurately  united 
by  at  least  three  stitches,  and  the  wound  dressed  in  the  usual  manner.  The 
effect  produced,  when  adhesion  is  completed,  is  the  attachment  of  the  eyelid 
to  that  portion  of  the  skin  of  the  eyebrow  upon  which  the  occipito-froutalis 


\ 


PTOSIS.  215 

acts.  By  means  of  that  attachment  we  substitute  the  action  of  this  muscle, 
in  raising  the  eyelid,  for  that  of  the  levator. 

The  deformity  likely  to  be  produced  by  the  removal  of  so  large  a  portion 
of  skin,  in  such  a  conspicuous  situation,  or  the  likelihood  of  substituting  a 
lagophthalmos,  or  eversion,  for  the  ptosis,  may  perhaps  be  urged  as  reasons 
against  this  mode  of  operating.  The  following  case  by  Mr.  Hunt,  affords  an 
answer  to  both  these  objections : — 

Case  150. — In  removing  a  large  and  deeply  seated  tumor  from  the  left  orbit  of  a  patient 
of  the  Manchester  Eye  Institution,  owing  to  the  connection  of  the  levator  palpebraj  with 
the  diseased  mass,  the  muscle  was  so  much  injured,  that,  after  the  patient  had  perfectly 
recovered  in  every  other  respect,  what  then  appeared  an  incurable  ptosis  remained. 
When  the  lid  was  raised  with  the  finger,  the  eye  was  found  to  possess  perfect  vision. 
Anxious  to  remedy  the  evil,  Mr.  Hunt,  when  all  tumefaction  of  the  integuments  had  dis- 
appeared, removed  an  elliptical  fold  of  skin  in  the  usual  way.  The  wound  healed  well ; 
but  although  a  considerable  portion  had  been  included  between  the  incisions,  the  effect 
upon  the  lid  was  hardly  perceptible. 

The  poor  man,  after  waiting  for  some  weeks,  was  very  solicitous  to  have  another  por- 
tion removed ;  and  it  was  more  in  compliance  with  his  desire  than  from  any  expectation 
of  further  benefit,  that  Mr.  Hunt  at  length  consented  to  repeat  the  operation.  Whilst 
deliberating  on  the  portion  to  be  removed,  it  struck  him  that,  if  it  were  sufBciently  near 
the  eyebrow,  the  action  of  the  occipito-frontalis,  which  affects  this  portion  of  the  skin, 
might  also  be  available  for  raising  the  eyelid,  and  fortunately  the  result  fully  justified  the 
conjecture.  The  operation  was  performed  as  is  described  above,  the  wound  united  by  the 
first  intention,  and  the  patient  could  raise  his  eyelid  to  the  same  extent  as  that  of  the 
other  side.  No  deformity  was  produced,  and  the  eye  could  be  as  perfectly  closed  as  before 
the  occurrence  of  the  disease. 

§  4.  Atonic  Ptosis. 

In  some  instances,  we  meet  with  a  depressed  state  of  one  or  both  upper 
eyelids,  dependent  apparently  on  mere  weakness  of  the  levator  muscle. 

In  this  case,  mechanical  support,  by  means  of  a  strip  of  adhesive  plaster, 
assists  in  restoring  to  the  muscle  its  wonted  power.  Applications  of  a 
strengthening  kind  are  to  be  made  to  the  lids ;  sponging  them,  from  time  to 
time,  with  rose-water,  a  solution  of  alum,  brandy,  or  the  spirit  of  nitrous 
ether ;  rubbing  them  gently  with  tinctura  saponis,  and  the  like.  It  is  in  atonic 
cases,  that  such  applications  as  that  with  which  Wenzel  cured  Maria  Theresa, 
Empress  of  Germany,  after  Van  Swieten  and  De  Haen  had  failed,  are  likely 
to  do  good.  He  applied  pledgets  over  the  eyes,  wrung  out  of  a  mixture  of 
lime-water  and  aqua  ammonise.^   Electricity  may  be  tried,  and  general  tonics. 

§  5.  Paralytic  Ptosis. 

Palsy  of  the  levator  of  the  upper  eyelid  is  an  affection  by  no  means  uncom- 
mon. In  one  set  of  cases  it  bears  an  analogy,  in  point  of  cause,  to  the  most 
frequent  instances  of  palsy  of  the  face,  or,  in  other  words,  it  arises  from  cold. 
In  another  set,  the  cause  is  cerebral ;  it  is,  perhaps,  arterial  or  venous  con- 
gestion, sanguineous  or  serous  effusion,  or  some  tumor,  formed  within  the 
"cranium,  and  pressing  on  the  third  pair  of  nerves.  It  is  often  difficult,  espe- 
cially in  the  incipient  stage,  to  distinguish  these  two  sets  of  cases. 

Paralytic  ptosis,  without  any  participation  of  the  muscles  of  the  eyeball, 
is  rare.  We  find  that,  along  with  the  depression  of  the  upper  eyelid,  either 
all  the  muscles  of  the  eyeball  are  paralyzed,  so  that  the  eye  stands  stock-still 
in  the  orbit,  or  much  more  frequently,  that,  from  the  abductor  retaining  its 
power,  the  eye  is  immovably  distorted  towards  the  temple  (luscitas),  while 
from  the  palsied  state  of  the  other  recti,  the  patient  is  unable  to  move  his 
eye  upwards,  downwards,  or  inwards.  In  the  cases  which  are  regarded  as 
rheumatic,  but  which  are  probably  as  often  apoplectic,  one  eye  only  is  gene- 
rally affected,  and  the  abductor  retains  its  power.  In  cases  more  decidedly 
cerebral,  both  eyes  are  apt  to  be  affected  from  the  beginning,  although  some- 
times one  side  is  first  paralyzed,  and  then  the  other. 


216  PTOSIS. 

In  paralytic  ptosis,  the  orbicularis  palpebrarum,  preserving  its  power,  keeps 
the  eyelids  constantly  closed,  so  that  the  patient  sees  none,  unless  he  raises 
the  lid  with  his  finger.  When  he  does  so,  he  sees  double  ;  and  if  he  tries  to 
walk  across  the  room,  is  affected  with  a  great  degree  of  vertigo.  The  double 
vision  and  vertigo  are  owing  to  the  axis  of  the  palsied  eye  no  longer  corre- 
sponding to  that  of  the  sound  one,  and  cease  as  soon  as  the  eyelid  is  allowed 
to  drop.  In  long-continued  cases,  the  attempts  of  the  patient  to  raise  the 
lid  by  calling  the  epicranius  into  action,  causes  the  eyebrow  to  become 
elevated  and  arched,  and  the  skin  of  the  forehead  marked  with  transverse 
furrows. 

The  rheumatic  variety  of  this  palsy  is  brought  on  by  exposure  to  currents 
of  cold  air,  and  the  like.  I  saw  it  induced,  on  both  sides,  in  a  man  who 
walked  about  all  day,  with  his  hat  wet  from  having  dropped  it  into  a  river. 
The  cerebral  variety  is  either  sudden,  or  slow ;  the  sudden,  arising  after 
fatiguing  exertion,  violent  mental  excitement,  exposure  to  the  direct  rays  of 
the  sun,  intoxication,  blows  on  the  head,  concussion  of  the  body,  and  the  like ; 
the  slow,  keeping  pace  with  the  growth  of  scrofulous  tumors,  fungous  excres- 
cences from  the  dura  mater,  and  other  organic  changes  about  the  basis  of  the 
brain.*  The  disease  often  wears  an  apoplectic  aspect.  An  old  gentleman 
walks  quickly  on  a  hot  summer's  day,  along  the  banks  of  a  river,  in  order  to 
reach  a  small  boat,  in  which  he  means  to  cross  to  the  other  side.  He  reaches 
the  small  boat,  sits  down  in  it,  perspiring  much  about  the  head,  and  is  in- 
stantly seized  with  a  chill,  and  palsy  of  all  the  muscles  of  one  eye  under  con- 
trol of  the  motor  oculi.  I  was  called  to  see  a  military  gentleman,  who  having 
spent  the  previous  evening  in  celebrating  the  king's  birthday,  amused  him- 
self next  day  in  rowing  a  boat  on  the  Clyde,  overheated  himself,  threw  off 
his  cap,  but  returned  home  in  perfect  health,  and  went  to  bed,  in  the  evening, 
as  usual.  Next  morning,  on  awaking,  he  was  greatly  alarmed  by  finding  that 
he  could  not  see.  He  had  been  seized  with  complete  double  ptosis ;  both 
eyeballs  were  twisted  to  the  temples,  and  the  pupils  dilated.  Both  these 
patients  recovered  perfectly,  under  anti-congestive  treatment.  In  an  old  man 
whom  I  saw,  double  ptosis,  with  loss  of  speech,  and  weakness  of  the  limbs, 
occurred  suddenly,  and  did  not  yield  to  remedies. 

The  third  nerve  is  more  obnoxious  to  palsy  than  any  other  of  the  cerebal 
nerves.  This  is  perhaps  owing  to  its  position,  as  it  emerges  from  the  brain, 
between  the  posterior  artery  of  the  cerebrum  and  the  superior  artery  of  the 
cerebellum.  Sometimes  the  former  vessel  traverses  the  trunk  of  the  nerve. 
Congestion,  then,  of  these  vessels,  may  readily  cause  palsy  of  the  nerve. 

The  vision  of  the  eye,  which  lies  behind  the  palsied  lid,  may,  or  may  not, 
be  affected.  We  find,  from  the  commencement  of  the  rheumatic  variety,  the 
pupil  dilated,  the  iris  partaking  in  the  paralysis  of  the  other  muscles  supplied 
by  the  third  nerve ;  and  this  dilatation  of  the  pupil  is  accompanied  with  the 
usual  obscurity  of  vision  met  with  in  mydriasis.  Generally  it  happens  in  the 
cerebral  cases,  that  vision  becomes  gradually  affected,  but  sometimes  it  is 
suddenly  so  from  the  first. 

Treatment. — When  palsy  of  the  upper  eyelid  appears  to  arise  either  from 
cold,  or  from  some  sudden  cerebral  affection,  we  employ  general  and  local  blood- 
letting, rest,  the  antiphlogistic  regimen,  and  blistering  of  the  head.  After 
the  use  of  these  means,  we  generally  find  that  the  vertigo  and  other  symptoms 
begin  to  yield.  In  both  cases,  we  employ  mercury  till  the  mouth  is  affected, 
combining  it  in  rheumatic  palsy  with  opium,  that  it  may  act  as  a  sudorific  ; 
in  cerebral  cases  expecting  it  to  prove  useful  as  a  sorbefacient.  Warm 
fomentations  of  the  eye  are  useful.  Sudorifices,  as  guaiac,  and  stimulants,  as 
camphor,  have  been  highly  recommended  in  the  rheumatic  cases.  lu  the 
cerebral  cases,  low  diet  and  the  use  of  iodine  are  indicated. 


PTOSIS.  21t 

Rubbing  the  forehead,  the  temple,  and  the  palsied  lid  with  the  aromatic 
spirit  of  ammonia,  issues  in  the  neck,  blisters  to  the  brow,  the  raw  surface 
being  afterward  dusted  with  strychnia,  and  the  use  of  electricity  or  galvanism, 
are  attended  with  advantage.  Exercise  of  the  eye  does  good.  A  shade 
being  placed  over  the  sound  eye,  the  diseased  one  should  be  forced  into  use. 

In  slow  cerebral  cases,  I  have  seen  almost  every  sort  of  practice  tried  with- 
out effect. 

In  an  Infirmary  patient,  in  whom  the  disease  attacked  first  one  upper  eye- 
lid, and  then  affected  both,  with  a  paralytic  debility  present  also  in  one  side 
of  the  body,  the  internal  use  of  arsenic  appeared  beneficial.  To  enable  this 
patient  to  attend  a  little  to  her  household  affairs,  we  were  obliged  to  keep 
the  eyes  alternately  open  by  a  bit  of  adhesive  plaster,  attached  to  the  lid  and 
fixed  by  its  other  extremity  to  the  brow. 

A  poor  old  Highlander,  who  applied  at  the  Glasgow  Eye  Infirmary  with 
double  ptosis,  had  contrived,  by  tying  a  pretty  thick  twisted  band  round  his 
head,  to  keep  up  both  upper  eyelids  very  well.  Although  both  his  eyes  were 
turned  towards  the  temples,  he  did  not  complain  of  diplopia.  The  neatest 
contrivance  for  elevating  the  upper  eyelid,  in  single  or  double  ptosis,  is  that 
of  Dr.  Mackness.  A  very  thin  and  narrow  piece  of  ivory,  forming  the  seg- 
ment of  a  circle,  is  riveted  upon  a  piece  of  the  mainspring  of  a  watch,  about 
eight  inches  long.  The  loose  end  of  the  spring  being  carried  through  the 
hair  over  the  crown  of  the  head  to  the  occiput,  the  piece  of  ivory  is  placed 
upon  the  eyelid  so  as  to  keep  it  open.  The  piece  of  ivory,  being  very  narrow, 
is  completeiy  hid  in  a  fold  of  the  eyelid,  while  the  spring,  being  accurately 
painted  to  imitate  the  color  of  the  skin,  is  scarcely  observable.  As  the  eye- 
lids occasionally  require  closing,  in  order  to  keep  the  eye  moist,  the  patient 
soon  acquires  a  knack  of  raising  the  spring  to  allow  the  eye  to  wink,  and 
then  replacing  it  again. ^ 

Even  in  favorable  cases,  the  power  of  the  levator  returns,  in  general,  very 
slowly.  We  perceive,  first  of  all,  that  the  lid  does  not  hang  so  flaccid,  or  so 
totally  motionless  as  it  did ;  but  that,  as  the  patient  exercises  his  volition  in 
respect  to  it,  it  is  affected  with  a  tremulous  oscillation,  and  at  length  is  raised 
a  little  from  contact  with  the  lower  lid.  Day  after  day,  the  degree  of  eleva- 
tion is  augmented,  the  iris  comes  into  view,  and  by  and  by  a  part  of  the 
pupil,  so  that  the  sound  eye  being  closed,  the  patient  begins  to  discern  the 
objects  placed  before  him.  Half  the  pupil  is  at  length  uncovered,  and  slowly 
more  and  more  of  the  eyeball  can  be  exposed,  till  the  motion  becomes  as 
extensive  and  as  rapid  as  in  health. 

Mr.  Hunt's  operation  may  be  had  recourse  to  in  cases  of  double  paralytic 
ptosis,  when  no  signs  of  improvement  appear  ;  and  even  in  single  ptosis,  if 
there  be  no  luscitas.  The  epicranius  is  active,  depending  on  the  stimulus  of 
the  facial  nerve,  and  the  plan  of  bringing  the  lid  under  its  influence  deserves 
a  trial.  It  has  been  proposed,  also,  to  divide  the  abductor  in  such  cases,  if 
luscitas  be  present,  an(|  then  perform  Mr.  Hunt's  operation.^ 


'  Alessi,    Annales    d'Oculistique,    1"  Vol.  nal  of  Medical  Science,  September,  1850,  p.  823. 

Suppl.  p.  3S  ;  Bruxelles,  1842.  Case  of  Palsy  of  left  side  of  face,  ptosis,  luscitas, 

'  North  of  England   Medical  and  Surgical  deafness,  and  amaurosis,  from  tumor  in  pons. 

Journal ;  Vol.  i.  p.  166  ;  Manchester,  1830.  with    hardness    and   tumidness   of  3d   nerve  ; 

'  Wenzel,    Dietionnaire    Ophthalmologique,  Edinburgh  Medical  and  Surgical  Journal,  Vol. 

Tome  ii.  p.  6  ;  Paris,  ISOS.  Iviii.  p.  377  ;  Edinburgh,  1842. 

*  See    Case    of    Amaurosis    and    Paralytic  '  Medical  Gazette ;  Vol.  xxviii.  p.  617  ;  Lon- 

Ptoeis,  with  seizures  of  a  mingled  epileptic  and  don,  1841. 

paralytic  character,  in  Bright's  Reports  of  Medi-  "  Curling,  Medical  Gazette;  Vol.  sxviii.  p, 

cal  Cases;  Vol.  ii.  p.  533;  London,  1831.    Case  16  ;  London,  1841.     Hunt,  ibid.  p.  11!.     Holt- 

and  Dissection,  by  Hare,  from  Aneurism  of  left  bouse,  ibid.  p.  152.     Hall,  ibid.  p.  306. 
posterior  communicating  artery,  London  Jour- 


218  LAGOPHTHALMOS. 


SECTION  XXXn. — ^LAGOPHTHALMOS. 

From  Kayk,  hare,  and  ofSaX^woj,  eye  ;  because  it  was  believed  hares  slept  with  their  eyes 

open. 

The  terra  lagophthalmos  is  employed  to  denote  that  state,  in  which  one  or 
other  eyelid,  or  both,  are  shortened  in  their  perpendicular  diameter,  so  that 
they  cannot  be  completely  closed.  (Figs.  4  and  5,  p.  81.)  The  consequence 
is  that  even  during  sleep,  a  part  of  the  surface  of  the  eyeball  remains  exposed 
to  the  action  of  the  air,  and  the  irritation  of  foreign  particles.  In  some 
cases,  even  more  of  the  eye  is  exposed  during  sleep  than  when  the  patient  is 
awake.  This  state  is  generally  the  result  of  the  contraction  attending  the 
cicatrization  of  a  burn  or  other  injury,  or  of  retraction  of  one  or  other  eyelid 
and  adhesion  to  the  edge  of  the  orbit,  in  consequence  of  caries.  In  either 
case,  lagophthalmos  may  or  may  not  be  attended  with  eversion  of  the 
affected  lid. 

I  was,  in  one  instance,  consulted  on  account  of  a  great  degree  of  depres- 
sion and  retraction  of  the  lower  lid,  without  any  eversion.  As  there  was 
neither  destruction  of  its  integuments,  nor  disease  of  the  bone,  I  was  inclined 
to  suspect  that  suppuration  between  the  eyeball  and  the  floor  of  the  orbit, 
had  been  the  cause  of  the  diseased  position  of  the  lid,  but  nothing  of  this 
kind  appeared  from  the  history  of  the  case  to  have  happened.  The  substance 
of  the  retracted  lid  was  much  indurated,  and  ultimately  became  affected  with 
cancerous  ulceration. 

I  have  already  (page  210,)  spoken  of  lagophthalmos  as  the  result  of  palsy 
of  the  orbicularis  palpebrarum. 

A  slight  degree  of  lagophthalmos,  especially  if  the  lower  lid  only  is 
affected,  may  not  be  attended  by  much  inconvenience.  When  more  consi- 
derable, inflammation  of  the  conjunctiva  and  cornea,  opacity  and  abscess  of 
the  cornea,  and  even  staphyloma,  may  be  the  consequences.  The  exposed 
eye  is  incapable  of  the  usual  exertion,  and  is  affected  with  epiphora  and  in- 
tolerance of  light. 

Treatment. — Demosthenes  and  other  ancient  surgeons  attempted  to  relieve 
the  lagophthalmos  which  arises  from  a  cicatrice,  by  making  a  crescentic  inci- 
sion through  the  contracted  integuments,  and  endeavoring  to  keep  the 
edges  of  the  wound  separate,  as  much  as  possible,  by  the  interposition  of 
dressings,  till  the  cure  was  complete.*  This  plan  was  found  to  be  ineffectual, 
as  the  cicatrice  resulting  from  the  very  operation,  necessarily  gave  rise  to  a 
new  degree  of  contraction.  Diefifenbach,  however,  ascribes  the  want  of  suc- 
cess to  the  incision  being  confined  to  the  integuments,  and  recommends  the 
adoption  of  the  following  among  other  operative  means  of  cure  : — 

1.  In  small  irregular  cicatrices  of  the  external  integuments,  excision  of  the 
cicatrice,  the  edges  of  the  wound  being  brought  very  nicely  together. 

2.  In  transverse  cicatrices,  repeated  subcutaneous  division  of  the  whole 
upper  lid,  including  the  cartilage ;  the  lid  to  be  then  strongly  drawn  down, 
and  fixed  by  plasters,  till  the  parts  are  healed. 

3.  In  long,  hard,  elevated,  vertical  cicatrices,  by  which  the  middle  of  the 
lid  is  particularly  shortened,  excision  of  the  cicatrice  by  means  of  two  long 
elliptical  incisions.  The  edge  of  the  shortened  lid  is  laid  hold  of  with  a  pair 
of  toothed  forceps,  and  drawn  well  downwards,  one  blade  of  a  pair  of  small 
sharp  scissors  is  passed  between  the  eyelid  and  the  eyeball,  as  high  as  the 
extremity  of  the  cicatrice,  and  a  long  stripe  of  the  lid  inclosing  the  cicatrice 
is  cut  out.  With  insect  pins,  the  edges  of  the  incision  are  brought  exactly 
together, 

4.  In  cases  of  actual  shortening  of  a  sound  eyelid,  without  any  cicatrice. 


STRANGULATED  ECTROPIUM.  219 

subcutaneous  division  of  the  levator.  A  small  wooden  spatula  being  intro- 
duced under  the  upper  eyelid,  a  small  concave-edged  knife  is  made  to  perfo- 
rate the  eyelid  at  its  temporal  extremity,  and  as  it  is  passed  on  under  the 
skin  to  its  nasal  extremity,  the  muscle  is  divided.^ 

The  lagophthalmos  arising  from  caries  of  the  orbit,  is  occasionally  attended 
(Fig.  2,  p.  76,)  by  a  considerable  transverse  elongation  of  the  edge  of  the 
eyelid,  at  the  same  time  that  it  is  drawn  into  an  angle,  and  immovably  fixed 
in  its  unnatural  position.  Under  these  circumstances,  an  operation  similar 
to  one  or  other  of  those  practised  for  ectropium,  may  sometimes  be  performed 
with  advantage ;  such  as,  after  extirpating  the  cicatrice,  to  extend  from  each 
extremity  of  the  wound,  an  incision  parallel  to  the  edge  of  the  orbit,  dissect 
the  integuments,  on  both  sides,  pretty  extensively,  and  then  transpose  them, 
so  that  the  seat  of  the  cicatrice  is  covered  and  the  lagophthalmos  removed. 
Of  course,  nothing  of  this  sort  should  be  attempted  till  the  bone  has  been 
long  perfectly  healed. 

When,  in  consequence  of  the  exposed  state  of  the  eye,  the  conjunctiva 
becomes  inflamed  in  eases  of  lagophthalmos,  advantage  will  be  derived  from 
the  use  of  the  lunar  caustic  solution,  and  the  employment  of  such  mechanical 
means  as  may  moderate  the  access  of  light  and  air. 


'  Aetil   Cotitraetae   ex   Veteribus    Medieinoe         ''Die  Operative   Chirurgie;  Vol.   i.  p.  472} 
Tetrabiblos  ;  Tretrabib.  11.  Sermo  iii.  cap.  73 ;     Leipsig,  1844. 
p.  360;  Basilese,  1549. 


SECTION  XXXm. — ECTROPIUM,  OR  EVERSION  OF  THE  EYELIDS. 

'extp'jttiov,  Actuarius  ;  from  lx,  out,  and  rfiTrtu,  I  turn. 

There  is  one  acute,  and  there  are  several  chronic  varieties  of  ectropium. 
The  acute  depends  on  swelling  and  protrusion  of  the  conjunctiva ;  the 
chronic  arise  in  consequence  of  morbid  contractions  and  adhesions,  or  of  par- 
tial or  total  destruction,  of  the  skin  of  the  eyelids. 

§  1.  Eversion  from  Inflammation  and  Strangulation. 

Syn. — Acute  eversion.     Ectropium  sarcomatosum. 
Fig.  Vetch,  Tig.  I. 

This  variety  takes  place  only  when  the  conjunctiva  is  in  a  state  of  acute 
puro-mucous  inflammation,  such  as  in  the  Egyptian,  or  any  other  of  the  con- 
tagious ophthalmige.  It  may  affect  either  eyelid,  but  the  upper  is  much 
oftener  affected  than  the  lower ;  rarely  both. 

When  sarcomatous  ectropium  affects  the  upper  lid,  the  protrusion  of  the 
conjunctiva  is  often  enormous,  and  the  surface  of  the  membrane  presents  in 
an  extraordinary  degree,  that  peculiar  degeneration  of  the  papillary  structure 
of  the  conjunctiva,  called  granular  conjunctiva.  The  mode  in  which  this 
protrusion  happens,  has  been  well  explained  by  Dr.  Yetch.'  The  inflamma- 
tory oedema  of  the  eyelids,  which,  in  the  contagious  ophthalmise,  is  for  a  time 
excessive,  beginning  at  length  to  subside,  while  no  proportionate  diminution 
of  the  swelling  of  the  lining  membrane  of  the  lids  has  as  yet  taken  place, 
the  swollen  and  granulated  conjunctiva  loses  that  counterpoise  which  the 
external  swelling  afforded  to  it,  and  is  forced  outwards  by  the  action  of  the 
orbicularis  palpebrarum.  If  the  protrusion  is  not  immediately  returned,  the 
upper  part  of  the  eyelid  and  the  retroverted  cartilage  act  like  a  ligature  on 
the  parts  protruded,  and  as  the  swelling  increases,  the  stricture  becomes  still 
stronger  by  the  natural  but  inefiectual  efforts  of  the  orbicularis  to  bring  tho 


220  STRANGULATED  ECTROPIUM. 

tarsus  into  its  proper  position.  The  protruding  tumor,  therefore,  is  occasioned 
in  a  great  measure  by  strangulation,  like  the  swelling  in  paraphymosis. 

Wiien  this  eversion  occurs  in  children  affected  with  ophthalmia  neonatorum, 
or  some  other  severe  puro-mucous  ophthalmia,  its  origin  is  often  in  a  great 
degree  accidental.  For  example,  the  attendant,  upon  attempting  to  look  at 
the  eye,  or  remove  the  copious  purulent  discharge,  unfortunately  turns  the 
upper  eyelid  inside  out ;  the  child  begins  to  cry  violently,  this  increases  the 
aversion,  and  all  attempts  to  reduce  the  lid  to  its  natural  position  are  found 
ineffectual.  It  is  allowed  to  remain  everted  for  some  hours,  or,  as  I  have 
repeatedly  seen  it  happen,  for  several  days,  and  then  the  child  is  brought  for 
advice.  The  everted  lid  is  by  this  time  greatly  injected  with  blood  ;  some- 
times to  such  a  degree,  that  pressure  fails  to  overcome  the  eversion  ;  or  if  we 
succeed  in  restoring  the  lid  to  its  natural  position,  it  very  probably  returns 
to  the  state  of  eversion,  the  moment  that  the  child  begins  to  cry. 

When  this  variety  of  eversion  affects  the  lower  lid,  there  is  nothing  acci- 
dental in  its  production ;  it  is  entirely  the  result  of  the  swelling  and  protru- 
sion of  the  inflamed  conjunctiva. 

Treatment. — The  great  object  is  to  abate  the  inflamed  state  of  the  con- 
junctiva. If  this  is  effected,  the  eversion  will  speedily  be  removed.  We 
have  recourse,  in  the  first  instance,  to  the  application  of  leeches  to  the  skin 
or  to  the  everted  conjunctiva,  or  we  scarify  the  conjunctiva  with  the  lancet. 
After  the  tumefaction  of  the  eyelid  is  somewhat  reduced  by  the  discharge  of 
blood,  we  are  in  general  able  to  return  it  to  its  natural  position.  For  this 
purpose,  we  lay  hold  of  it  in  such  a  manner,  with  the  thumb  and  forefinger 
of  each  hand,  as  to  express  from  it  as  much  as  possible  of  the  thin  fluid 
effused  into  its  substance,  and  then  suddenly  bend  its  edge  towards  the  eyeball, 
at  the  same  time  that  we  push  back  the  protruded  conjunctiva.  If  the  state 
of  inflammation  is  not  very  acute,  we  ought  to  maintain  the  lid  in  its  natural 
position  by  means  of  a  compress  and  roller.  If  the  ophthalmia  be  still  severe, 
we  must  content  ourselves  with  recommending  great  care  on  the  part  of  the 
attendants  to  avoid  whatever  might  cause  the  child  to  cry,  and  instruct  them 
in  the  manner  of  reducing  the  eversion,  should  it  happen  to  return.  From 
day  to  day,  or  more  frequently  than  once  a  day,  if  this  is  thought  necessary, 
the  eye  is  to  be  examined,  and  the  proper  means  applied  to  the  conjunctiva 
for  removing  the  ophthalmia,  as  lunar  caustic  in  different  forms,  sulphas  cupri, 
red  precipitate  salve,  and  the  like.  Every  other  remedy,  general  or  local, 
likely  to  promote  the  cure  of  the  original  disease,  is  at  the  same  time  to  be 
persevered  in. 

I  have  seen  repeated  instances  in  which  scarification  failed,  or  if  we  suc- 
ceeded by  its  means  in  lessening  the  degree  of  eversion,  it  speedily  returned. 
In  such  cases,  I  have  sometimes  succeeded  in  keeping  down  the  lid  by  means 
of  a  piece  of  strongly  adhesive  plaster,  or  by  collodion  immediately  covered 
with  a  piece  of  thick  cloth  placed  across  the  lids.  The  plaster  or  the  cloth,  which 
is  attached  to  the  upper  lid  first,  should  be  broad,  then  become  narrow,  and  be 
fixed  to  the  lower  lid  and  to  the  cheek.  Being  narrow  over  the  fissura  palpe- 
brarum, it  allows  the  discharge  to  escape.  [Here  the  Donna  Maria  gauze 
and  collodion  will  serve  an  excellent  purpose. — H.]  I  have,  in  other  cases, 
found  a  circular  band  of  vulcanized  caoutchouc  answer  very  well  in  keeping 
the  upper  lid  in  its  proper  situation. 

All  other  means  failing,  we  must  extirpate  a  portion  of  the  diseased  con- 
junctiva. By  means  of  a  ligature,  or  simply  with  a  hook,  or  a  pair  of  toothed 
forceps,  we  raise  up  the  middle  of  the  exposed  and  thickened  portion  of  that 
membrane,  and  remove,  with  the  scissors,  a  fold  of  it  of  the  shape  of  a  myrtle 
leaf.  The  wound  bleeds  profusely,  and  this  assists  in  reducing  the  lid  to  a 
state  favorable  for  replacement.     Strips  of  plaster,  passing  from  the  upper 


ECTROPIUM  FROM  EXCORIATION.  221 

to  the  lower  lid,  and  a  compress  and  bandage,  are  then  applied,  and  are  to  be 
renewed  from  time  to  time  till  the  cure  is  complete. 

Prognosis. — It  is  important  to  observe,  that  although  our  prognosis  in 
every  case  of  this  variety  of  eversion  may  be  favorable,  so  far  as  the  eyelid  is 
concerned,  we  must  pronounce  nothing  regarding  the  future  vision  of  the 
patient,  unless  we  are  able  distinctly  to  bring  the  cornea  into  view.  In  cases 
which  have  been  neglected  for  a  number  of  days,  the  swelling  of  the  everted 
conjunctiva  may  be  such,  that  we  shall  find  it  impossible  to  see  the  cornea, 
on  our  first  examination  of  the  eye ;  and  under  such  circumstances  we  ought 
to  forewarn  the  friends  of  the  patient  that  we  can  promise  nothing  regarding 
sight.  After  the  use  of  scarification  and  other  means,  we  reduce  the  eversion 
and  bring  the  cornea  into  vie\.',  but  perhaps  find  the  eye  staphylomatous, 
and,  of  course,  vision  lost. 

§  2.    Eversion  from  Excoriation. 

Syn. — ChroBic  eversion.     Ectropium  senile. 

Fig.  Ammon,  Zweiter  Theil,  Tab.  V.;  Dalrjmple,  PI.  II.  Fig.  2. 

The  most  common  cause  of  eversion  is  excoriation  of  the  lower  eyelid  and 
cheek,  in  consequence  of  long-continued  catarrhal  ophthalmia,  or  ophthalmia 
tarsi.  In  this  variety,  we  find  the  skin  of  the  affected  lid  contracted,  its 
tarsal  edges  rounded  off,  the  Meibomian  apertures  partially  or  totally  oblite- 
rated, the  cilia  destroyed,  and  a  considerable  portion  of  inflamed  conjunctiva 
permanently  exposed  to  view. 

In  children,  this  eversion  is  the  result  of  neglected  ophthalmia  tarsi ;  in  old 
persons,  of  chronic  catarrhal  ophthalmia.  In  the  former,  the  misplaced  state 
of  the  lid  has  generally  been  preceded  by  considerable  superficial  ulceration 
of  the  skin,  the  cicatrization  consequent  to  which  has  shortened  the  lid,  and 
dragged  it  downwards.  In  old  persons,  again,  there  is  less  appearance  of 
cicatrization,  while  it  would  seem  that  the  orbicularis  palpebrarum  has  lost 
its  power  of  supporting  the  lid,  and  that  the  tensor  tarsi,  being  also  weak- 
ened, allows  the  punctum  lachrymale  to  fall  forwards. 

In  the  commencement  of  the  disease,  the  exposed  conjunctiva  is  swollen, 
presents  a  pale  red  color,  and  possesses  a  natural  degree  of  sensibility  to  the 
touch.  Gradually,  from  the  constant  influence  of  the  air  upon  a  part  not 
intended  to  be  exposed  to  this  excitement,  and  the  occasional  contact  of 
external  bodies,  the  conjunctiva  of  the  everted  lid  assumes  a  redder  and 
firmer  appearance  than  natural,  and  at  last  becomes  almost  insensible  to  the 
contact  of  those  substances  which  formerly  excited  pain  or  brought  on 
bleeding. 

The  consequences  of  this  disease  are  stillicidium  lachrymarum,  and  occa- 
sional attacks  of  inflammation  of  the  eyeball.  Both  these  are  the  unavoid- 
able effects  of  the  interruption  of  the  natural  functions  of  the  lower  eyelid. 
In  the  state  of  eversion,  it  no  longer  covers  completely  and  accurately  the 
inferior  part  of  the  eyeball,  which  consequently  remains  exposed  to  innumer- 
able causes  of  irritation,  from  which  it  ought  to  be  guarded.  In  this  state, 
also,  the  tears  are  no  longer  guided  onwards  to  the  punctum  lachrymale,  nor 
is  the  punctum  kept  in  contact  with  the  eyeball,  as  in  health,  so  that  the  tears 
are  allowed  to  drop  over  on  the  cheek. 

If  nothing  is  done  to  remove  the  eversion,  and  the  cause  in  which  it  has 
originated  is  allowed  to  continue,  the  lid  becomes  transversely  elongated,  so 
that,  were  it  liberated  from  its  unnatural  situation  and  raised  into  contact 
with  the  eye,  it  would  be  found  not  to  fit  exactly,  being  longer  than  sufficient 
to  cover  accurately  the  surface  of  the  eyeball. 


222  ECTROPIUM  FROM  EXCORIATION. 

Eversion  of  the  upper  lid  from  excoriation  rarely  occurs,  and  never  to  any 
great  extent. 

Treatment. — 1.  By  the  use  of  the  appropriate  means,  we  endeavor  to  re- 
move the  remaining  symptoms  of  the  ophthalmia,  which  has  given  rise  to  the 
eversion. 

2.  The  contracted  state  of  the  skin  is  to  be  relieved  as  much  as  possible, 
by  frequently  fomenting  the  lids  with  warm  water,  then  drying  them,  and 
anointing  them  with  oxide  of  zinc  ointment.  This  softens  the  skin  of  the 
everted  lid,  renders  it  more  pliable,  and  protects  it  from  farther  irritation. 

3.  Scarification  of  the  exposed  conjunctiva  is  highly  useful,  as  well  as  the 
keeping  of  the  lid  raised  to  its  natural  position  by  means  of  a  compress  and 
roller,  carefully  applied. 

4.  The  application  of  escharotics  to  the  internal  surface  of  the  lid  is,  in 
general,  an  effectual  means  of  counteracting  the  tendency  to  misplacement  in 
this  variety  of  eversion.  The  sulphate  of  copper,  or  the  nitrate  of  silver, 
solid,  or  in  solution,  will  be  found  to  answer  well.  Some  surgeons^  venture 
on  the  employment  even  of  sulphuric  acid  for  this  purpose. 

The  upper  lid  is  to  be  raised  by  the  finger  of  an  assistant,  and  the  patient 
is  to  look  upwards  ;  then  the  surgeon,  everting  the  conjunctiva  of  the  lower 
lid  as  much  as  possible,  and  wiping  it  dry,  passes  the  nitrate  of  silver  pencil 
along  its  surface,  which  instantly  becomes  white ;  after  which  it  is  to  be 
touched  with  a  little  water,  by  means  of  a  camel-hair  brush. 

If  sulphuric  acid  is  preferred,  a  bit  of  wood  or  the  blunt  end  of  a  common 
silver  probe,  is  to  be  dipped  in  that  fluid,  and  rubbed  upon  the  conjunctiva 
of  the  lid,  carefully  avoiding  the  punctum  lachrymale,  caruncle,  semilunar 
fold,  and  eyeball.  The  portion  of  conjunctiva  touched  by  the  acid  immedi- 
ately ))ecomes  white  ;  and,  in  order  to  prevent  the  acid  from  affecting  the 
eyeball,  a  stream  of  water  should  now  be  directed  over  the  eyelid,  by  means 
of  a  small  syringe.  If  the  acid  does  not  appear  to  have  made  the  conjunctiva 
sufficiently  white,  the  application  may  be  repeated  with  the  same  precautions. 

The  application  of  the  caustic,  or  of  the  sulphuric  acid,  should  be  repeated 
every  fourth  day.  Neither  of  them  causes  a  slough,  but  merely  a  general 
contraction  of  the  part,  and,  after  two  or  three  applications,  an  evident 
diminution  of  the  eversion.  The  escharotic  applications  must  be  continued 
from  time  to  time,  till  the  lid  assumes  its  natural  direction. 

5.  Should  the  means  already  indicated  prove  ineffectual,  a  portion  of  the 
relaxed  and  thickened  conjunctiva  must  be  extirpated.  In  order  to  execute 
this  with  exactness,  it  is  necessary  to  estimate  beforehand  about  what  amount 
of  contraction  of  the  conjunctiva  would  be  sufficient  to  reinstate  the  eyelid 
in  its  natural  position.  If  we  remove  too  little,  a  degree  of  eversion  will 
remain.  If  we  remove  too  much,  we  produce  a  new  disease,  namely,  inver- 
sion, which  is  at  least  as  bad  as  that  which  we  have  been  endeavoring  to 
relieve.  The  operation  and  after-treatment  are  the  same  as  have  already 
been  mentioned  under  the  first  variety  of  eversion.  If  our  calculation  in  the 
quantity  to  be  removed  has  been  correct,  we  find  the  ectropium  cured  as  soon 
as  the  conjunctiva  has  healed. 

6.  In  very  bad  cases  of  this  sort  we  may,  with  advantage,  have  recourse  to 
the  removal  of  a  wedge-shaped  portion  of  the  whole  thickness  of  the  lid ; 
an  operation  we  are  frequently  obliged  to  employ  in  the  third  variety  of 
eversion. 

7.  Dieflfenbach  has  proposed  an  operation,  by  which  the  everted  lid  is  at 
once  brought  into  its  proper  position,  and  the  natural  antagonism,  which 
ought  to  exist  between  the  internal  and  external  structures  of  the  affected 
lid  restored.      He  removes  no  part  of  the  conjunctiva  or  of  the  tarsus. 

The  integuments  being  pinched  up  into  a  fold,  they  are  to  be  divided  by 


ECTROPIUM   FROM  A  CICATRICE,  223 

an  incision,  parallel  to  the  lower  edge  of  the  orbit,  and  a  few  lines  above  it. 
This  incision  is  to  extend  to  two-thirds  of  the  transverse  breadth  of  the  lid. 
The  semilunar  flap,  formed  by  the  incision,  is  to  be  dissected  upwards,  as  far 
as  the  adherent  edge  of  the  tarsus,  which  in  eversion  is  nearer  the  eyeball 
than  the  free  edge,  and  there  the  lid  is  to  be  penetrated,  and  the  conjunctiva 
divided  to  the  extent  of  the  external  wound.  By  means  of  a  hook,  the  con- 
junctiva, along  with  the  tarsus,  is  now  to  be  drawn  into  the  external  incision, 
and  fixed  there  by  the  twisted  suture. 

A  similar  operation  may  be  practised  on  the  upper  lid.^ 

§  3.  Eversion  from  a  Cicatrice. 
Fig.  AmmoD,  Zweiter  Theil,  Tab.  V. 

The  cicatrice  which  operates  in  the  production  of  this  variety  of  eversion, 
is  generally  the  consequence  of  a  wound,  an  abscess,  an  ulcer,  or  a  burn.  In 
such  cases,  though  nature  contrives  to  produce,  in  place  of  the  portion  of 
skin  which  has  been  destroyed,  a  supplementary  substance,  yet  matters  are 
not  restored  exactly  to  their  former  state.  The  ulcer  is  covered,  partly  at 
the  expense  of  the  surrounding  sound  skin,  which  is  drawn  together  and 
contracted  over  the  sore,  and  partly  by  the  formation  of  a  new  membrane, 
which,  though  we  give  it  the  name  of  skin,  possesses  biit  imperfectly  the  pro- 
l^erties  of  the  old  integuments.  It  is  neither  so  large  as  the  piece  of  skin 
which  has  been  lost,  nor  is  it  so  yielding,  nor  so  elastic,  nor  so  movable 
upon  the  part  which  it  covers.  It  is  smooth  and  shining,  and  scarcely  capa- 
ble of  distension  ;  but  above  all,  so  far  as  the  present  subject  is  concerned, 
the  surrounding  original  cutis  is  drawn  towards  this  supplementary  produc- 
tion, is  puckered  and  thrown  into  folds,  and,  to  use  the  homely  comparison 
of  Mr.  Hunter,  the  whole  appears  as  if  a  piece  of  skin  had  been  sewed  into 
a  hole  by  much  too  large  for  it,  and  therefore  it  had  been  necessary  to  throw 
the  surrounding  old  skin  into  folds,  or  gather  the  surrounding  skin,  in  order 
to  bring  it  into  contact  with  the  new. 

A  lacerated  wound  of  either  eyelid,  allowed  to  heal  without  due  attention, 
is  very  apt  to  end  in  eversion.  The  upper  lid  particularly  we  sometimes  see 
completely  everted,  and  peaked  up  into  an  angle,  in  consequence  of  a  neg- 
lected or  mismanaged  laceration. 

From  severe  burns,  the  eyelids  are  generally  much  puckered,  contracted, 
and  indurated  ;  and,  not  unfrequently,  both  the  upper  and  lower  are  affected 
with  ectropiura.  The  skin  having  been  destroyed  from  the  margin  of  the 
eyelid  to  the  eyebrow,  or  to  the  cheek,  the  lid  is  folded  completely  back,  and 
adheres  throughout  its  whole  length  to  the  edge  of  the  orbit.  It  often  hap- 
pens that  the  skin  round  the  everted  eyelids  having  also  suffered,  it  is  replaced 
by  a  hard  unyielding  cicatrice,  stretching  to  the  forehead,  nose,  cheek,  and 
temple. 

The  displacement  being  much  greater  in  cases  of  this  variety  of  eversion 
than  in  that  which  results  from  mere  excoriation,  the  effects  are  still  more 
annoying  to  the  patient.  The  eye  is  more  exposed  to  the  contact  of  foreign 
substances,  suffers  oftener  from  inflammation,  and  is  in  a  greater  degree  dis- 
figured. The  feeling  of  cold  in  the  eye,  from  want  of  the  covering  naturally 
afforded  by  the  lids,  is  often  distressing. 

The  degree  in  which  the  everted  lid  is  dragged  from  the  eye  is  sometimes 
astonishing,  and  the  consequent  deformity  actually  hideous.  For  example, 
Cloquet  notices*  the  case  of  a  patient  in  the  Hopital  Saint-Louis,  who  had 
eversion  of  each  lower  lid,  in  consequence  of  syphilitic  ulcers  of  the  face. 
The  left  lower  lid  was  drawn  down  to  the  outer  part  of  the  upper  lip.  The 
tarsus  had  not  been  destroyed,  but  elongated  ;  and  formed,  on  a  level  with 


224  ECTROPIUM  FROM  A  CICATRICE. 

the  lip,  a  slight-curved  elevation  of  a  whitish  color,  from  which  proceeded 
the  cilia. 

Treatment. — Such  being  the  origin  and  effects  of  this  variety  of  eversion, 
it  comes  to  be  a  question  how  far  it  is  curable,  or,  in  other  words,  whether 
there  be  any  method  of  removing  or  counteracting  the  contraction  arising 
from  cicatrization. 

This  contraction,  so  far  from  diminishing  of  itself,  gradually  increases  for 
some  time  after  the  process  of  cicatrization  appears  completed,  in  consequence 
of  the  absorption  of  the  granulations,  on  which  the  new  skin  is  formed.  Mat- 
ters then  appear  for  a  while  to  remain  stationary ;  but  in  the  course  of  years, 
the  everted  eyelid  will  have  loosened  itself  a  little  from  its  unnatural  situation, 
and  not  quite  so  much  of  the  eyeball  will  be  exposed.  In  consequence  of 
the  mechanical  motion  to  which  the  parts  are  subjected,  a  slight  increase 
talies  place  in  the  flexibility  of  the  cicatrized  surface,  and  it  becomes  some- 
what less  firmly  attached  to  the  subjacent  textures.  The  parts,  which  were 
at  first  matted  immovably  together,  yield  a  little  to  the  motions  impressed  on 
them  by  external  causes,  and  the  absorbents  appear  to  contribute  to  this 
slight  relaxation,  by  removing  some  of  the  adventitious  substance  which 
bound  down  the  integuments.  This  is  all  the  return  which  is  ever  made  to 
the  natural  state  by  the  action  of  the  parts  themselves. 

The  hand  of  art,  however,  has  sought  to  relieve,  not  only  the  present 
variety  of  eversion,  but  similar  consequences  of  cicatrization  in  various  parts 
of  the  body,  by  a  more  speedy  and  effectual  method.  Celsus  gives*  us  an 
account  of  the  operation,  practised  in  his  time,  for  the  cure  of  this  kind  of 
eversion.  It  is  the  same  operation  as  that  employed  by  the  ancients  for  lag- 
ophthalmos,  and  to  which  I  have  referred  in  the  last  section.  When  the 
disease  was  situated  in  the  upper  eyelid,  an  incision  down  to  the  cartilage 
was  made,  in  the  form  of  a  crescent,  the  extremities  of  which  were  turned 
downwards.  When  the  disease  affected  the  lower  lid,  an  incision  of  the  same 
form  was  made  there,  the  extremities  still  pointing  downwards.  The  edges 
of  these  incisions  were  kept  open  as  much  as  possible  by  means  of  lint  put 
into  tlie  wound,  so  that  they  healed  up  by  a  slow  process  of  granulation  and 
cicatrization.  It  was  expected  that  the  space  between  the  edges  would  be 
filled  up  by  new  substance,  that  the  eyelid  would  consequently  be  consider- 
ably elongated,  and  would  return  to  its  natural  position,  or,  in  other  words, 
that  the  eversion  would  be  cured. 

Tills  operation  has  been  frequently  tried  in  later  times;  but,  so  far  from 
permanently  curing  eversion,  it  has  often  been  found  in  the  end  to  increase 
the  very  disease  it  was  intended  to  relieve.  Immediately  after  the  incision, 
indeed,  the  eyelid  can  perhaps  be  brought  nearly,  if  not  altogether,  into  its 
natural  situation ;  and  so  long  as  the  process  of  granulation  is  going  on,  the 
case  continues  at  least  much  better  than  it  had  been  before.  As  soon  as  the 
wound  is  healed,  however,  it  is  found  that  the  eversion  has  begun  to  return, 
and  at  the  end  of  some  months,  matters  are  probably  rather  worse  than  they 
were  before  the  operation. 

1.  Extirpation  of  conjunctiva. — The  following  case,  by  Bordenave,  suf- 
ficiently illustrates  both  the  failure  of  the  ancient  operation,  and  the  good 
effects  of  extirpating  a  portion  of  the  conjunctiva,  in  this  variety  of  ever- 
sion : — 

Case  151. — A  man,  aged  21  years,  had  emersion  of  the  right  lower  eyelid,  from  a  cica- 
trice, the  consequence  of  a  burn  of  the  face,  -which  happened  in  infancy.  The  eversion 
•was  considerable,  the  protruding  part  of  the  eyelid  presented  a  redness  disagreeable  to 
look  at,  and  the  eye  could  not  be  covered  by  the  lids.  Bordenave  found  the  cicatrice 
considerably  flexible,  and  believed  himself  justified  in  hoping  for  a  cure  by  the  ordinary 
operation,  which  he  performed  some  days  afterwards,  according  to  the  prescribed  rules. 

Having  made  a  semilunar  incision  of  moderate  depth,  below  the  tarsus,  he  separated 


ECTROPIUM  FROM  A  CICATRICE.  225 

the  lips  of  the  -wound  with  charpie,  and  kept  them  in  this  state  by  adhesive  plasters,  com- 
presses, and  a  suitable  bandage.  Some  days  afterwards,  suppuration  took  place.  The 
eyelid  appeared  extremely  relaxed,  it  covered  almost  entirely  the  eye,  and  the  cure 
seemed  certain.  But  these  appearances  of  success  were  not  of  long  duration :  the  cica- 
trice being  completed,  and  the  eyelid  no  longer  restrained,  things  returned  to  their  former 
state.  Not  convinced,  however,  of  the  faultiness  of  the  operation,  Bordenave  believed 
that  he  had  not  performed  it  with  sufficient  exactness ;  and  therefore  repeated  it,  but 
with  no  better  success.  He  says  that  he  should  now  have  despaired  of  curing  the  case, 
had  not  the  patient's  eagerness  to  be  relieved  forced  him  in  some  manner  to  try  a  different 
treatment. 

Seeing  that  he  was  unable  to  elongate  the  eyelid,  in  order  to  conceal  the  everted  con- 
junctiva, he  resolved  to  remove  a  portion  of  this  membrane  in  almost  all  its  length.  This 
he  did  with  a  straight  bistoury,  and  found  the  operation  exceedingly  beneficial.  Some 
time  after,  the  conjunctiva  still  protruding  a  little,  he  practised  a  second  excision,  which 
had  all  the  success  desired.  In  proportion  as  the  conjunctiva  cicatrized,  the  eyelid  re- 
turned to  its  proper  direction,  it  applied  itself  more  immediately  upon  the  eye ;  at  last 
the  eye  closed  much  better,  and  the  deformity  became  scarcely  visible.^ 

In  many  cases,  then,  of  eversion,  arising  from  a  cicatrice,  the  simple  ope- 
ration of  removing  the  palpebral  conjunctiva  may  be  sufficient. 

2.  Separation  of  unnatural  adhesions,  and  extii'pation  of  conjunctiva. — 
We  meet  with  cases  of  eversion,  caused  by  an  external  cicatrice,  in  which  the 
dragging  of  the  lid  is  too  great  to  permit  us  to  hope  that  the  counteraction 
of  an  internal  cicatrice  will  of  itself  suffice  to  restore  the  part  to  its  natural 
situation.''  Under  such  circumstances,  it  may  be  proper  to  set  free  the  everted 
lid  from  its  morbid  adhesions,  and  then  to  extirpate  the  conjunctiva.  An 
incision  being  made  through  the  cicatrice,  or  beyond  it,  and  parallel  to  the 
everted  cilia,  the  external  surface  of  the  lid  is  to  be  cautiously  dissected  from 
the  parts  to  which  it  is  bound  down,  so  that  it  may  be  returned  to  its  natural 
position.  More  or  less  of  the  conjunctiva,  according  to  the  degree  of  the 
eversion  is  then  to  be  removed ;  after  which  compresses  and  a  roller  are  to 
be  applied,  to  keep  the  eyelid  in  the  position  to  which  it  has  been  reduced, 
till  the  conjunctiva  heals,  and  the  external  wound  is  cicatrized.^  Professor 
Chelius,  however,  does  not  trust  to  compresses  and  a  roller,  but  to  keep  the 
edges  of  the  wound  apart  till  it  granulates  and  cicatrizes,  he  passes  two  loops 
of  thread  through  the  skin  of  the  eyelid,  near  its  edge,  and  fastens  them  by 
plasters  to  the  cheek,  if  it  is  the  upper  lid ;  to  the  brow,  if  it  is  the  lower  lid. 
Dzondi  dressed  the  wound  with  resinous  ointment  mixed  with  cantharides,  to 
insure  a  sufficiently  copious  process  of  granulation  before  cicatrization  should 
commence.  He  then  applied  lunar  caustic,  in  order  to  heal  the  wound 
quickly,  a  practice  against  which  Chelius  warns  us,  as  exceedingly  likely  to 
cause  absorption  of  the  granulations,  and  thus  to  defeat  the  object  of  the 
treatment. 

It  is  rarely  the  case,  that  one  operation  of  the  sort  now  under  consideration, 
suffices  to  cure  a  bad  ectropium.  Repeated  operations  are  frequently  neces- 
sary, a  farther  amendment  being  accomplished  by  each,  till  the  lid  or  lids  are 
restored  to  their  natural  position. 

3.  Separation  of  unnatural  adhesions,  and  perpendicular  transpositions  of 
a  quadrangidar  flap. — In  cases  of  adhesion  of  the  eyelid  to  the  upper  or 
lower  edge  of  the  orbit.  Dr.  Amnion  proposes  the  following  operation.  The 
integuments,  to  the  distance  of  an  inch  from  the  place  of  adhesion,  being  put 
on  the  stretch,  so  that  the  morbid  connection  of  the  eyelid  to  the  orbit  is 
brought  completely  into  view,  let  an  incision  be  made  parallel  to  the  edge  of 
the  orbit,  and  about  half  an  inch  distant  from  it,  somewhat  more  extensive 
than  the  morbid  adhesion.  From  the  ends  of  this  incision,  carry  two  other 
smaller  incisions  to  the  edge  of  the  orbit.  The  flap,  thus  circumscribed,  is 
now  to  be  dissected  from  the  subjacent  parts,  taking  care  not  to  cut  through 
the  thin  hard  eyelid,  where  it  adheres  to  the  edge  of  the  orbit,  and  avoiding, 

15 


226  ECTROPIUM   FROM   A  CICATRICE. 

in  the  upper  lid,  the  lachrymal  ducts.  The  dissection  being  finished,  and 
the  wound  cleared  of  blood,  the  eye  is  to  be  shut,  and  sutures  applied,  so  that 
the  eyelid  may  remain  in  the  state  of  replacement  and  elongation  to  which  it 
has  been  restored  by  the  operation.^  The  objection  to  this  mode  of  operating 
is,  that  a  large  wound  will  be  left  to  fill  up  by  granulation. 

4.  Perpendicular  transpositioii  of  a  triangular  flap. — The  following  case 
illustrates  a  mode  of  operating,  which  Mr.  Wharton  Jones  has  found  success- 
ful in  eversion  and  shortening  of  the  upper  eyelid,  from  contraction  of  the 
skin  consequent  to  burns.  The  peculiarity  of  the  plan  consists  in  the  two 
following  particulars  :  1.  The  eyelid  is  set  free  by  incisions  made  in  such  a 
way  that,  when  the  eyelid  is  brought  back  into  its  natural  position,  the  gap 
which  is  left  may  be  filled  up  by  approximating  its  edges,  and  thus  obtaining 
immediate  union.  Unlike  the  Celsian  operation,  the  narrower  the  cicatrice 
the  more  secure  the  result.  2.  The  flap  of  skin,  embraced  by  the  incisions, 
is  not  separated  from  the  adjacent  bone,  but  advantage  being  taken  of 
the  looseness  of  the  cellular  tissue  between  the  skin  and  the  bone,  the  flap  is 
pressed  downwards,  and  thus  the  eyelid  is  set  free.  The  success  of  the  ope- 
ration depends  on  the  looseness  of  the  cellular  tissue.  For  some  days  before 
the  operation,  therefore,  the  skin  should  be  often  moved  up  and  down  over 
the  frontal  bone,  to  render  the  cellular  tissue  more  yielding. 

Case  152. — A  woman,  aged  24,'had  her  face  much  scarred.  Both  eyeballs  were  quite 
exposed,  on  account  of  shortening  and  eversion  of  the  upper  ej'elids.  On  the  left  side,  the 
eversion  of  the  upper  eyelid  was  not  so  great  as  on  the  right.  On  this  side,  the  ciliary 
margin  of  the  tarsal  cartilage  corresponded  to  the  edge  of  the  orbit,  and  the  opposite 
margin  of  the  cartilage  occupied  the  usual  position  of  the  tarsal  margin,  so  that  when  an 
attempt  was  made  to  close  the  right  eye,  it  was  the  orbital  margin  of  the  tarsal  cartilage 
which  was  pressed  down.  There  was  some  degree  of  shortening  and  eversion  of  the  left 
lower  eyelid.  The  patient  saw  very  well  with  the  right  eye,  but  with  the  left,  on  account 
of  some  opacity  of  the  cornea,  she  did  not  see  well  enough  to  recognize  a  person.  At  the 
age  of  one  year  and  three  months,  she  fell  into  the  fire,  and  had  her  fiice  severely  burned, 
which  was  the  cause  of  the  state  above  mentioned. 

Two  years  before  coming  under  the  care  of  Mr.  Jones,  she  had  an  operation  performed 
on  the  left  eye,  and  was  improved  by  it.  The  eversion  had  probably  only  been  lessened 
by  the  operation,  for  the  shortening  of  the  upper  eyelid  was  still  very  great. 

On  the  22d  February,  1836,  Mr.  J.  operated  on  the  left  upper  eyelid.  He  made  two 
incisions  through  the  skin,  from  over  the  angles  of  the  eye  upwards.  The  incisions  con- 
verged towards  each  other,  and  met  at  a  point  somewhat  more  than  an  inch  from  the 
adherent  ciliary  margin  of  the  eyelid.  By  pressing  down  the  triangular  flap  thus  made, 
and  cutting  all  opposing  bridles  of  cellular  tissue,  but  without  separating  the  flap  from 
the  subjacent  parts,  he  was  able  to  bring  down  the  eyelid  nearly  into  its  natural  situation 
by  the  mere  stretching  of  the  subjacent  cellular  tissue.  A  piece  of  the  everted  conjunc- 
tiva was  snipped  off.  The  edges  of  the  gap,  left  by  the  drawing  down  of  the  flap,  were 
now  brought  together  by  suture,  and  the  eyelid  was  retained  in  its  proper  place  by  plas- 
ters, compress,  and  bandage. 

During  the  healing  of  the  wound,  a  small  piece  of  the  apex  of  the  flap,  which  had  been 
too  much  separated  from  the  subjacent  parts,  sloughed.  By  the  1st  April,  the  parts 
were  healed,  and  the  eversion  completely  cured.  The  cicatrice,  Avhere  the  part  sloughed, 
was  pretty  broad.  When  the  bandages  were  first  left  off,  the  eyelid  was  so  much  elon- 
gated, that  if  the  lower  lid  had  not  also  been  shortened,  the  eye  would  have  been  entirely 
covered.  After  leaving  off  the  bandages,  some  shortening  took  place,  not  from  contrac- 
tion of  the  cicatrice,  but  of  the  skin.  Being  no  longer  on  the  stretch,  the  skin  assumed, 
as  it  contracted,  more  of  its  natural  appearance. 

About  the  middle  of  March,  Mr.  J.  operated  on  the  right  upper  eyelid.  He  made  the 
incisions  in  a  similar  way,  except  that  they  did  not  meet  in  a  point,  a  space  being  left 
between  their  extremities  of  about  one-sixth  of  an  inch  in  length,  which  was  divided  by  a 
transverse  cut. 

By  the  stretching  of  the  subjacent  cellular  tissue,  Mr.  J.  succeeded  in  drawing  down 
the  flap,  and  thus  elongated  the  eyelid  so  much  as  to  cover  the  eye  entirely ;  but  in  con- 
sequence of  the  long-continued  displacement  of  the  tarsal  cartilage,  the  ciliary  margin  of 
it  did  not  come  into  contact  with  the  eyeball.  He  did  not  interfere  with  this  state  of 
parts,  by  attempting  any  transverse  shortening  of  the  lid.  In  the  operation,  he  removed 
a  piece  of  the  everted  conjunctiva,  and  with  it  a  bit  of  the  tarsal  cartilage.     From  the 


ECTROPIUM  FROM  A  CICATRICE. 


221 


surface  of  this  wound  there  sprung  out  a  small  soft  fungus,  which  was  cut  o£F  with  the 
scissors,  and  the  root  touched  with  the  lunar  caustic  pencil. '" 


Fig.  18. 


Fig.  19. 


F)ff.  IS.  a  a  ConTerging  incisions.  6  Cross-cut 
unitinp;  them.  These  three  incisions  enclose  the 
flap,  which  is  slid  clown  by  the  yielding  of  the  cel- 
lular tissue. 


Fig.  19.  shows  the  parts  when  healed,  a  The 
cicatrice  where  the  gap  was.  b  b  bb  The  marks  of 
the  sutures. 


Fig.  20. 


5.  Separation  of  imnatural  adhesions,  extirpation  of  conjunctiva,  and  ex- 
cision of  a  wedge-shaped  portion  of  the  eyelid. — When  the  edge  of  the  everted 
eyelid  is  much  elongated  from  canthus  to  canthus,  the  integuments  of  the  lid 
destroyed,  and  its  remaining  substance  firmly  adherent  to  the  bones  forming 
the  edge  of  the  orbit,  the  following  plan,  first  practised  by  Sir  William 
Adams,"  may  be  adopted  with  advantage  :• — 

In  ihQ  first  place,  the  everted  eyelid  is  to  be  separated  from  its  unnatural 
adhesions.  In  the  second  place,  the  palpebral  conjunctiva,  especially  if  it  be 
much  thickened,  is  to  be  extirpated.  In  the  third  place,  in  order  to  coun- 
teract the  morbid  elongation  of  the  eyelid  from  the  outer  to  the  inner  can- 
thus,  a  portion  of  the  whole  thickness  of 
the  eyelid,  of  the  shape  of  the  letter  a  (Fig. 
20),  is  to  be  cut  out  with  the  scissors,  after 
which,  the  edges  of  the  last  wound  are  to 
be  brought  together  with  an  insect  pin  or 
two,  and  a  twisted  thread.  This  makes  the 
eyelid  sit  close  upon  the  eyeball,  as  in 
health,  and  completely  cures  the  eversion. 

The  wedge-shaped  portion  has  generally 
been  removed  from  the  middle  of  the  lid  ; 
but  as  the  scar  which  results,  produces 
some  degree  of  deformity,  it  is  preferable 
to  cut  out  the  piece  near  the  temporal  ex- 
tremity, as  here  the  scar  is  less  apparent, 
and  produces  less  interruption  of  the  mo- 
tions of  the  part.  The  size  of  the  piece  to 
be  removed,  depends  on  the  degree  of  the 


228  ECTROPIUM  FROM  A  CICATRICE. 

transverse  elongation  of  the  everted  eyelid,  and  must  therefore  be  left  to  the 
judgment  of  the  operator.  He  must  avoid  cutting  out  too  much,  as,  in  this 
case,  the  parts  will  be  so  shortened,  that  the  edges  of  the  wound  will  not  be 
brought  into  contact  without  stretching  them  so  as  to  produce  ulceration, 
thereby  detaching  the  parts  before  union  is  effected,  and  leaving  them  in  a 
worse  condition  than  they  were  at  first. 

By  the  speedy  union  of  the  edges  of  the  wound  left  by  the  excision  of  the 
wedge-shaped  portion,  the  eyelid  will  be  retained  in  its  place,  and  the  danger 
of  the  integuments  readhering  to  the  orbit  be,  in  a  great  measure,  prevented. 
To  aid,  however,  in  the  cure,  the  eyelid  should  be  covered  with  a  spread 
pledget,  and  supported,  against  the  eyeball,  by  a  compress  and  roller.  The 
opposite  eye  should  be  closed  and  covered,  so  that  it  may  be  kept  at  rest. 
The  following  case  shows  how  the  operation  may  be  sometimes  modified,  and 
the  eyelid  supported  in  a  different  way,  from  that  just  mentioned. 

Case  153. — In  a  case  of  eversion  of  the  lower  eyelid,  Professor  Grlife  first  cut  out  a 
wedge-shaped  portion  of  the  eyelid,  and  united  the  edges  of  the  wound  by  means  of  the 
harelip  suture  ;  but  just  before  twisting  the  thread  round  the  pins,  he  divided  the  skin  of 
the  cheek  to  the  extent  of  1]  inch  by  an  incision  concentric  with  the  edge  of  the  orbit. 
He  then  twisted  the  threads,  drew  the  ends  of  them  upwards,  and  fixed  them  to  the  fore- 
head by  sticking-plaster,  so  that  the  edge  of  the  lower  eyelid  might  be  raised  sufficiently. 
The  incision  through  the  skin  of  the  cheek  was  thus  made  to  gape,  and  in  order  to  heal 
it  with  a  broad  scar,  the  edges  were  kept  separate  by  a  crescentic  plate  of  lead,  which 
■was  pressed  in  between  the  lips  of  the  wound,  and  retained  by  strips  of  plaster.  The 
"wound  of  the  eyelid  was  quite  united  on  the  third  day,  and  that  into  which  the  plate  of 
lead  was  inserted  was  cicatrized  in  the  fourth  week,  the  size  and  situation  of  the  eyelid 
appearing  natural.'^ 

6.  Separation  of  unnatural  adhesions,  excision  of  a  portion  of  the  edge  of 
eyelid,  perpendicular  and  lateral  extension  of  the  eyelid  and  neighboring  in- 
teguments. — When  the  deformity  is  considerable,  in  cases  of  lagophthalmos  or 
ectropium,  produced  by  cicatrization,  both  the  transverse  and  perpendicular 
diameter  of  the  eyelid  are  faulty  in  their  dimensions.  The  perpendicular 
diameter,  or  breadth  of  the  eyelid,  is  shortened;  the  transverse  diameter 
is  elongated.  An  operation  has  been  proposed  by  Professor  Jliger,  of 
Vienna,  the  object  of  which  is  to  increase  the  perpendicular  length  of  the 
eyelid,  as  well  as  to  reduce  its  transverse  elongation. 

Before  proceeding  to  the  operation,  the  difference  in  the  length  of  the 
edge  of  the  everted  lid,  and  of  the  sound  lid  on  the  other  side  of  the  face,  is 
to  be  accurately  measured.  In  the  operation,  the  transverse  length  of  the 
everted  lid  is  to  be  reduced  to  that  of  the  sound  one. 

In  operating  on  the  upper  lid,  the  surgeon  begins  by  taking  hold  of  it 
about  the  centre  of  its  edge,  with  a  hook  or  forceps,  and  drawing  it  down- 
wards so  as  to  put  on  the  stretch  the  cicatrice,  by  which  the  lid  adheres  to  the 
margin  of  the  orbit.  A  horn  spatula  may  be  inserted  between  the  lid  and 
the  eyeball,  so  as  to  protect  the  latter.  With  a  small  scalpel,  a  transverse 
incision  is  now  to  be  made,  about  midway  between  the  edge  of  the  everted 
lid  and  the  superciliary  arch.  The  incision  is  to  be  commenced  and  termi- 
nated in  sound  skin,  and  is  to  be  carried  through  the  whole  thickness  of  the 
lid,  so  as  to  permit  its  edge  to  fall  down,  and  the  eyeball  to  appear  through 
the  slit  which  has  thus  been  formed.  The  length  to  which  the  incision  is  to 
be  carried  must  depend  on  the  circumstances  of  the  case. 

The  narrow  slip  separating  the  natural  rima  palpebralis  from  the  artificial 
opening  formed  by  the  incision  just  described,  is  the  part  in  which  the  reduc- 
tion of  the  ti-ansverse  diameter  of  the  lid  is  to  be  made.  The  size  of  the 
portion  which  ought  to  be  removed,  is  already  known  from  the  measurements 
made  before  the  operation  was  commenced.  The  portion  removed  will  gene- 
rally have  a  quadrilateral  form.  With  forceps  and  scissors,  this  part  of  the 
operation  is  easily  effected. 


ECTROPIUM   FROM  A   CICATRICE,  229 

A  straight  double-edged  scalpel  is  now  to  be  used,  for  separating  any- 
unnatural  adhesions  of  the  lid,  and  for  detaching  the  integuments  from  the 
OS  frontis.  Taking  hold  of  the  upper  lid  of  the  wound  with  the  forceps,  and 
separating  it  a  little  from  the  edge  of  the  orbit,  the  scalpel  is  to  be  intro- 
duced upwards,  between  the  posterior  surface  of  the  orbicular  muscle  and 
the  anterior  surface  of  the  frontal  bone.  The  scalpel  is  now  to  be  carried 
with  a  sawing  motion  towards  the  temple  and  external  canthus,  and  then 
towards  the  middle  line  of  the  forehead,  without  enlarging  the  original  wound 
of  the  lid,  transfixing  the  skin,  or  injuring  the  periosteum.  By  this  process, 
the  skin  and  muscle  covering  the  supra-orbital  region  and  angles  of  the  orbit 
are  loosened  from  the  subjacent  parts,  and  rendered  capable  of  undergoing  a 
change  in  their  position.  The  height  to  which  the  scalpel  will  require  to  be 
carried,  and  the  extent  in  the  transverse  direction  to  which  the  integuments 
ought  to  be  detached,  must  always  be  proportionate  to  the  loss  of  the  palpe- 
bral substance,  and  the  different  degrees  of  mobility  of  the  skin  of  the 
forehead. 

The  wounds  are  now  to  be  united  by  the  interrupted  suture.  In  the  first 
place,  the  bridge  or  narrow  slip  of  the  lid,  whence  the  quadrangular  portion 
was  removed,  is  to  be  united  by  two  stitches.  Then  the  integuments,  which 
have  been  loosened  from  the  supra-orbital  space  and  angles  of  the  orbit,  are 
to  be  pressed  downwards  by  the  assistant,  over  the  eyeball,  so  that  the  edges 
of  the  transverse  wound  of  the  lid  may  be  brought  together.  A  stitch  is  to 
be  inserted  near  the  middle  of  the  transverse  wound,  so  as  to  act  as  a  central 
point  of  traction  upon  the  surrounding  integuments.  Should  the  upper  lip 
of  the  wound  not  much  exceed  the  lower  lip  in  length,  lateral  stitches  may 
be  immediately  inserted ;  and  if,  on  the  other  hand,  it  exceed  to  the  extent 
of  forming  a  fold,  this  must  be  removed  by  the  scalpel  or  scissors,  in  order 
that  the  edges  of  the  wound  may  be  nicely  adjusted.  The  number  of  stitches 
required  cannot  a  priori  be  determined. 

Coaptatioa  of  the  wound  having  thus  been  effected,  the  eyeball  is  covered 
by  integuments  obtained  partly  from  the  supra-orbital  region,  but  chiefly  from 
the  angles  of  the  orbit ;  the  eyebrow,  however,  will  be  somewhat  more  de- 
pressed, and  describe  a  smaller  and  less  convex  arch  than  formerly. 

Professor  Jiiger's  operation  upon  the  lower  eyelid  consists  in  removing  a 
wedge-shaped  piece  from  its  edge,  and  in  detaching  the  integuments  from  the 
margin  of  the  orbit  and  the  cheek,  by  a  similar  process  to  that  already  described 
for  increasing  the  perpendicular  diameter  of  the  upper  lid. 

The  stitches  are  to  be  supported  by  interposing  narrow  strips  of  court- 
plaster.  The  wounds  are  then  to  be  covered  with  small  pieces  of  lint,  and 
graduated  compresses  are  to  be  placed  upon  the  sui)ra-orbital  region,  or  cheek, 
according  as  the  operation  has  been  performed  for  the  restoration  of  the  upper 
or  lower  lid.  Over  the  graduated  compresses  long  strips  of  adhesive  plaster 
are  to  run,  being  applied  in  such  a  manner  as  to  draw  the  integuments  to- 
wards the  lid,  and  approximate  them  to  the  bones.  When  the  upper  lid  has 
been  operated  on,  the  adhesive  plaster  may  extend  from  the  nape  of  the  neck 
to  the  cheek.  A  roller  may  be  applied  to  assist  the  action  of  the  plasters,  if 
it  be  deemed  necessary.  In  the  after-treatment,  nothing  ought  to  be  omitted 
likely  to  effect  union  by  the  first  intention. 

Smart  inflammation,  requiring  active  treatment  for  its  removal ;  nausea  and 
vomiting,  demanding  the  use  of  opium  and  effervescing  draughts ;  premature 
removal,  from  accident,  of  one  or  more  of  the  stitches;  and  ulceration  of  the 
edges  of  the  wounds ;  are  among  the  unfavorable  occurrences  which  occasion- 
ally supervene  to  the  operation." 

7.  Tarsorapkia. — It  occasionally  happens  from  an  extensive  burn,  that 
both  eyelids  are  everted,  and  dragged  towards  the  temple.     In  such  cases, 


230 


ECTROPIUM  FROM  A   CICATRICE. 


^^^\^ 


besides  dividing  the  cicatrice,  removing  part  of  the  exposed  conjunctiva,  and 
perhaps  cutting  out  a  portion  of  the  whole  thickness  of  one  or  of  both  lids, 
it  has  been  found  useful  to  pare  away  a  portion  of  the  edges  of  the  lids  at 
their  outer  angle,  and  then  to  bring  the  two  together  by  a  stitch.  This  tar- 
soraphia,  as  it  has  been  termed,  reduces  the  opening  between  the  lids  to  its 
natural  length,  and  removes  much  of  the  deformity. 

A  somewhat  similar  practice  was  followed  by  Le  Dran,  in  a  case  of  ever- 
sion  of  the  lower  lid,  at  the  inner  angle  of  the  eye.  He  removed  the  thick- 
ened conjunctiva,  extirpated  the  cicatrice,  and  brought  the  edges  of  the 
wound  together  by  two  stitches."  Professor  Walther  has  published'^  a  case 
of  traumatic  eversion  of  the  external  angle  of  the  lids,  cured  by  the  same 
plan. 

8.  Extirpation  of  cicatrice,  and  hringing  together  of  the  integuments  from 
each  side.' — The  lower  lid  being  the  seat  of  the  cctropium,  DieiFenbach  re- 
moves a  triangular  flap  of  skin,  including  the  cicatrice,  of  nearly  three  inches 
in  length,  the  basis  corresponding  to  the  edge  of  the  lid.     With  four  or  five 

pins,  he  brings  the  edges  of  the 
Fig.  21.  Fig.  22.  lower  part  of  the  wound  together, 

in  a  vertical  direction,  and  then 
the  remaining  parts  of  the  wound, 
diverging  from  each  other,  are 
united  in  the  same  way  to  the 
edge  of  the  tarsus.  Zeis  describes 
this  method  somewhat  differently. 
The  triangular  portion  of  integu- 
ments, including  the  cicatrice, 
being  removed,  the  incisions  c  a, 
c  a  (Fig.  21),  are  extended  freely 
on  each  side,  to  allow  of  the  ready 
approximation  of  the  two  sides, 
h,  b.  These  being  fixed  by  sutures,  the  two  edges  a  c,  c  a,  are  now  con- 
nected to  the  corresponding  margin  of  the  lower  lid,  included  between  c  c. 
The  appearance,  after  the  sutures  are  applied,  is  such  as  is  represented  in 
Fig.  22.*^ 

A  similar  operation  was  practised  by  Dieflfenbach  for  eversion,  involving 
both  eyelids  and  their  external  commissure.  He  extirpated  the  commissure, 
along  with  a  triangular  piece  of  the  neighboring  integument,  the  basis  of 
which  was  towards  the  eye,  and  the  apex  towards  the  ear.  One  curved  in- 
cision was  then  carried  above  the  supra-orbitary  arch,  and  another  beneath 
the  lower  orbitary  margin,  towards  the  nose,  each  incision  measuring  about 
\\  inch  in  length.  The  two  crescentic  flaps  thus  formed  were  then  raised, 
and  after  bringing  them  over  the  triangular  wound,  they  were  adapted  as  new 
lids  to  the  remaining  conjunctiva. ''' 

9.  Extirpation  of  cicatrice,  and  lateral  transposition  of  a  triangular  flap . — 
Operations  for  the  relief  of  ectropium,  by  transposing  a  portion  of  skin,  are 
styled  hlepharoplastic.  With  respect  to  such  operations,  in  general,  it  may 
be  remarked,  that  though  we  cannot  pretend  to  make  a  perfect  eyelid  by  the 
transposition  of  a  piece  of  skin,  destitute  of  mucous  lining,  as  well  as  of  cilia, 
lachrymal  apparatus,  cartilage,  and  muscles;  yet  a  new  eyelid,  even  of  mere 
skin,  covers  and  protects  the  eye,  lessens  deformity,  and  frees  the  patient  from 
suffering.  In  attempting  to  supply  a  new  eyelid,  we  should  save  the  con- 
junctiva as  much  as  possible,  cutting  none  of  it  away,  but  separating  it,  if 
necessary,  from  the  diseased  integuments.  We  ought  to  lay  the  flap  of  trans- 
posed skin  on  the  conjunctiva,  so  that  they  may  adhere  together.  We  should 
save,  with  the  same  care,  the  border  of  the  old  eyelid,  with  its  cilia,  and  unite 


ECTROPIUM   FROM   A   CICATRICE. 


231 


it  by  sutures,  to  the  edge  of  the  flap.  The  puncta  and  lachrymal  canals 
ought  also  to  be  spared.  As  it  is  not  likely  that  the  new  eyelid  will  possess 
much  muscular  motion,  we  must  avoid  making  it  either  too  large  or  too 
small. 

Dieffenbach  appears  to  have  tried  many  ways  of  forming  new  eyelids  by 
transposition  of  skin.  The  following  does  not  appear  to  have  ultimately 
retained  his  good  opinion,  as  he  says  nothing  of  it  in  his  latest  work, 
Die  Operative  Chirurgie.  As  it  was  successfully  adopted,  however,  not 
only  by  himself,  but  by  Lisfranc,  Ammon,  Eckstrom,  Blasius,  Fricke,  and 
Chelius,  I  think  it  proper  still  to  describe  it. 

The  cicatrice  is  first  to  be  extirpated,  and  a  triangular  form  given  to  the 
wound,  the  basis  of  the  triangle  being  always  turned  towards  the  eye.  In 
this  part  of  the  operation,  the  ciliary  edge  of  the  eyelid,  if  present,  is  to  be 
preserved;  but  if  the  ulceration  has  destroyed  the  whole  eyelid,  except  the 
conjunctiva,  this  membrane  is  to  be  detached  from  the  parts  to  which  it  ad- 
heres, in  the  course  of  a  line  drawn  from  the  inner  to  the  outer  angle  of  the 
eye,  and  laid  out  upon  the  eyeball.  The  triangular  space  being  thus  pre- 
pared, into  which  the  flap  of  skin  is  to  be  transplanted,  an  incision  is  to  be  made 
from  the  temporal  extremity  of  the  basis 

of  the  triangle,  in  the  direction  of  the  Fig-  23. 

meatus  auditorius,  whether  it  be  the  upper 
or  the  lower  lid  which  is  to  be  supplied. 
This  incision  of  the  skin  should  be  con- 
siderably longer  than  the  basis  of  the 
triangular  wound.  From  the  temporal 
extremity  of  this  incision,  another  is  now 
to  be  carried  upwards,  if  it  is  the  upper 
lid  which  is  to  be  supplied,  downwards,  if 
it  is  the  lower,  and  in  either  case  parallel 
to  the  temporal  edge  of  the  triangular 
wound.  These  incisions  are  the  bound- 
aries of  the  flap,  which,  being  transposed, 
is  to  form  the  new  eyelid.  The  flap  is 
now  to  be  dissected  from  the  subjacent 

parts.     The  bleeding  having  ceased,  and  [From  Lawrence.] 

the   internal   surface   of  the   flap   being 

freed  from  coagulated  blood,  the  flap  is  to  be  drawn  from  without  inwards, 
so  that  its  inner  edge  is  brought  into  contact  with  the  inner  edge  of  the 
triangular  wound.  These  two  edges  are  first  of  all  to  be  steadied  by  a 
stitch  at  the  inner  canthus;  then  the  tarsal  edge  of  the  flap  and  the  conjunc- 
tiva are  to  be  brought  together  by  fine  silk  stitches ;  and  lastly,  the  inner 
edge  of  the  flap  is  to  be  connected  by  Dieffenbach's  suture  to  the  internal  edge 
of  the  triangular  wound.  Except  by  Chelius,  the  temporal  edge  of  the  flap 
is  not  connected  by  sutures.  The  triangular  space  left  by  the  transposition 
of  the  flap  is  generally  covered  with  lint  and  adhesive  plasters,  so  applied 
that  they  serve  also  to  support  the  new  eyelid  in  its  place.  Should  suppura- 
tion  take  place,  in  the  course  of  the  cure,  beneath  the  transposed  flap,  the 
matter  formed  will  escape  from  under  its  temporal  edge.  Cold  applications 
are  recommended,  as  most  likely  to  promote  speedy  adhesion,  and  prevent 
suppuration." 

Case  154. — Mrs.  S.  had  the  misfortune  to  have  her  face  sadly  disfigured  by  syphilis. 
She  lost  her  nose ;  her  upper  lip  was  so  much  shortened,  that  she  could  not  cover  the 
teeth  of  the  upper  jaw  ;  tbe  left  upper  eyelid  was  destroyed,  and  the  lower  in  a  state  of 
complete  ectropium.  Several  extensive  cicatrices  on  the  hairy  scalp  and  forehead  showed 
the  previous  existence  of  necrosis,  with  exfoliations  of  the  outer  table  of  the  skull.  A 
considerable  portion  of  the  upper,  outer,  and  lower  edge  of  the  orbit  had  been  lost  in  this 


232 


ECTROPIUM  FROM  A  CICATRICE. 


way.  The  greater  part  of  the  left  upper  eyelid  -was  so  completely  removed  by  ulceration, 
that  its  remains  surrounded  merely,  without  covering,  the  eyeball.  The  conjunctiva  of 
the  small  portion  which  remained  was  turned  outwards,  and  its  tarsal  edge  very  irregular. 

Fig.  25. 


[From  La-wffence.] 

Dr.  Ammon  began  his  operation  by  insulating  and  separating  from  the  temple  the  flap 
of  skin,  by  which  the  defective  upper  eyelid  was  to  be  supplied ;  he  then  divided  all  the 
adhesions  of  the  old  eyelid,  and  prepared  the  place  for  the  reception  of  the  new  one.  He 
formed  the  flap  by  a  horizontal  incision  two  inches  and  a  half  in  length,  to  which  he 
joined  a  perpendicular  one,  bounding  the  flap  towards  the  temple,  and  then  dissected  it 
off.  He  reduced  the  shrunken  remains  of  the  old  eyelid  with  the  bistoury  ;  but  unfor- 
tunately found  it  impossible  to  separate  enough  of  conjunctiva  from  it,  to  foi-m  a  lining 
membrane^or  the  new  eyelid. 

As  soon  as  the  bleeding  had  ceased,  the  flap  forming  the  new  eyelid  having  been  brought 
into  such  a  position  that  it  covered  the  eye,  it  was  secured  along  its  inner  edge  by  Diefi'en- 
bach's  suture ;  and  thus  ended  the  formation  of  the  upper  eyelid. 

To  remedy  the  ectropium  of  the  lower  eyelid.  Dr.  Ammon  first  of  all  carried  an  incision 
through  the  skin,  parallel  to  the  edge  of  the  lid,  and  then  dissected  it  from  its  unnatural 
adhesions ;  he  next  extirpated  a  horizontal  fold  of  the  exuberant  conjunctiva ;  and  lastly, 
having  made  a  cut  like  a  button-hole  through  the  lid,  about  4  lines  from  its  edge,  by 
means  of  a  ligature,  he  laid  hold  of  that  part  of  the  conjunctiva  which  still  remained 
attached  to  the  tarsal  portion  of  the  lid,  drew  out  the  ligature  through  this  wound,  and 
so  fixed  the  lid  in  its  natural  position. 

At  the  temporal  angle,  the  upper  and  lower  eyelids  were  now  connected  by  the  twisted 
suture,  which,  after  some  hours,  was  removed,  Dr.  Ammon  fearing  that  thereby  the  fissura 
palpebrarum  might  be  made  too  small.  The  wound  on  the  temple,  caused  by  the  trans- 
plantation of  the  new  eyelid,  was  covered  with  charpie,  and  a  thick  compress  wet  with 
water. 

Next  day,  the  transplanted  skin  was  somewhat  swollen,  so  much  so  that  the  fissura 
palpebrarum  was  no  longer  visible,  and  the  eyeball  was  entirely  concealed.  By  injecting 
tepid  water,  Dr.  Ammon  removed  the  matter  which  collected  on  the  eye  ;  but,  notwith- 
standing this  precaution,  a  considerable  oedema  of  the  conjunctiva  took  place.  Union  of 
the  inner  edge  of  the  transplanted  flap  was  not  entirely  efl'ected  by  the  first  intention,  so 
that,  as  the  stitches  were  gradually  withdi-awn,  strips  of  sticking  plaster  were  applied. 
The  wound  on  the  temple  granulated  favorably.  The  cut  through  the  lower  eyelid,  into 
which  the  conjunctiva  had  been  drawn,  closed  perfectly ;  so  that  the  eyelid,  after  the 
oedema  had  subsided,  maintained  its  proper  position. 

The  granulation  of  the  wound  on  the  temple  proceeded,  and  along  with  it  the  formation 
of  the  new  outer  canthus.  Three  weeks  after  the  operation,  the  fissura  palpebrarum 
appearing  too  small.  Dr.  Ammon  slit  up  the  outer  canthus  as  far  as  the  edge  of  the  orbit, 
and  endeavored  to  prevent  reunion  by  the  introduction  of  charpie  between  the  lips  of  the 
wound.  Notwithstanding  this,  he  was  obliged,  two  months  afterwards,  not  only  to  slit 
up  the  outer  canthus  again,  but  to  extirpate  a  stripe  of  skin,  so  as  to  give  to  the  fissura 
palpebrarum  the  proper  degree  of  length  ;  in  which  he  completely  succeeded. 

The  transposed  flap  forming  the  iipper  eyelid,  assumed  more  and  more  of  a  natural 
appearance.  _  The  middle  of  it,  however,  continued  to  be  oedematous  and  of  a  bluish  color, 
till,  on  forming  a  new  nose  for  Mrs.  S.  out  of  her  forehead,  erysipelas  came  on  and  spread 
to  the  new  eyelid ;  after  which  the  oedema  became  greatly  less,  and  at  last  vanished 
entirely. 


ECTROPIUM  FROM  A  CICATRICE.  233 

Seven  months  after  its  formation,  the  new  eyelid  closed  over  the  eyeball,  -without  irri- 
tating it ;  it  could  be  lifted  from  it  like  a  natural  eyelid,  but  generally  hung  over  it  in  a 
state  of  semi-ptosis.  The  cicatrice  on  the  temple  was  very  small,  so  that  it  was  difficult 
to  believe  that  so  considerable  a  portion  of  the  integuments  had  been  taken  from  that 
part. '9 

10.  Transplantation  of  a  crescentic  flap  from  the  temple  or  the  cheeh. — Pro- 
fessor Jtingken  proposed  to  extirpate  the  cicatrice,  and  then  dilate  the 
wound,  so  that  by  giving  the  lid  sufficient  length,  it  might  assume  its  na- 
tural position.  A  piece  of  pastel)oard  was  then  to  be  taken,  of  the  exact 
size  and  shape  of  the  wound,  and  laid  on  the  cheek,  if  the  lower  lid  was  the 
seat  of  the  eversion  ;  on  the  temple,  if  it  were  the  upper  lid.  The  piece  of 
skin  covered  by  the  pasteboard,  except  a  narrow  slip,  which  was  to  be  left 
undivided,  was  now  to  be  insulated  by  an  incision ;  it  was  to  be  dissected 
from  the  parts  it  covered,  with  as  much  cellular  substance  attached  to  it  as 
possible ;  and  then  twisted  round  into  the  wound  left  by  the  extirpation  of 
the  cicatrice.  The  bleeding  was  to  be  stopped  by  the  application  of  cold 
water,  the  clotted  blood  removed,  and  the  edges  of  the  supplementary  piece 
of  skin  connected  with  those  of  the  wound  left  from  the  extirpation  of  the 
cicatrice,  by  means  of  stitches,  strips  of  plaster,  and  a  bandage. 

When  there  was  reason  to  think  that  organic  union  had  taken  place  be- 
tween the  piece  of  skin  and  the  subjacent  surface,  the  connecting  slip  was  to 
be  divided,  and  returned  as  much  as  possible  to  its  original  place.  The 
stitches  were  to  be  removed  at  the  proper  time,  and  the  parts  secured  by 
sticking  plaster  alone,  till  entire  union  and  cicatrization  were  effected.  The 
wound  caused  by  the  abstraction  of  the  piece  of  skin  was  to  be  closed  as 
completely  as  possible  by  sticking  plaster,  that  it  might  heal  with  a  small 
scar.=° 

Professor  Jiingken  twice  adopted  this  method,  in  cases  of  ectropium  of 
the  lower  eyelid ;  but  in  both  cases  it  failed  entirely.'^'  Some  such  method 
appears,  however,  to  have  succeeded  in  the  hands  of  Dr.  Fricke  of  Ham- 
burgh.** 

In  later  years,  the  operation  has  been  frequently  performed,  both  on  the 
upper  and  on  the  lower  lid.  In  general,  it  is  performed  without  twisting  the 
flap,  as  in  the  following  case  : — 

Case  155. — Maria  Connell,  aged  14,  was  admitted  under  my  care  at  the  Glasgow  Eye 
Infirmary,  10th  Aug.  1843.  When  about  IG  months  old,  she  received  an  injury  by  a  gate 
falling  upon  her,  in  consequence  of  which  an  abscess  formed  in  the  left  upper  eyelid,  and, 
bursting  through  the  skin,  discharged  matter  for  many  months.  This  was  followed  by 
ectropium,  to  such  an  extent,  that,  when  the  eyes  are  open,  a  large  portion  of  the  con- 
junctiva is  exposed,  and  the  cilia  tilted  up  so  as  to  be  in  contact  with  the  eyebi'ow.  (Fig. 
26.)  The  ectropium  is  increased  when  the  patient  attempts  to  close  the  eye.  There  is  a 
very  great  deficiency  of  skin  in  the  everted  eyelid,  and  it  feels  as  if  bound  by  a  band  to 
the  inner  surface  of  the  orbit.  The  upper  part  of  the  left  cornea  is  hazy,  and  vision  of 
that  eye  so  imperfect  that  she  with  difQculty  distinguishes  with  it  one  finger  from  another. 
She  keeps  the  eye  constantly  covered,  to  hide  the  deformity. 

The  everted  eyelid  was  divided  transversely  in  the  seat  of  the  cicatrix,  and  the  edges 
dissected  so  as  to  dilate  the  wound  (Fig.  27,  a,  b),  and  allow  the  lid  to  resume  its 
natural  situation.  A  piece  of  pasteboard  was  laid  on  the  temple,  and  the  flap  (6,  c)  was 
insulated  with  the  scalpel,  of  the  exact  size  and  shape  of  the  piece  of  pasteboard.  The 
anterior  edge  of  the  flap  was  continued  into  the  wound.  The  flap  was  now  dissected  off, 
except  at  its  basis  [b),  turned  round  into  the  wound  of  the  eyelid  [b  a),  and  connected 
with  its  edges  by  stitches.  The  edges  of  the  wound  on  the  temple  were  brought  together 
by  stitches.  A  considerable  degree  of  ectropium  still  remained.  Both  eyes  were  covered 
with  spread  pledgets,  and  a  double-headed  roller  applied  from  the  hind-head  forwards. 

13th,  The  external  dressings  were  removed.  There  is  little  or  no  swelling  about  the 
parts  that  were  cut,  and  she  makes  no  complaint  of  pain.  The  lid  appears  more  in  its 
natural  place  than  it  did  immediately  after  the  operation,  owing  probably  to  the  support 
of  the  dressings  and  bandage. 

14th,  Three  of  the  stitches  removed. 


2U 


ECTROPIUM   FROM   A   CICATRICE. 


15th,  Six  more  of  the  stitches  removed,  being  all  those  which  served  to  keep  the  flap 
in  its  new  situation.  Two  stitches  remain  in  the  wound  on  the  temple,  which  appears 
quite  united.  There  is  considerable  motion  in  the  new  eyelid.  Stripes  of  court-plaster 
were  applied  in  place  of  the  stitches  along  the  lid,  and  another  stripe  across  both  upper 
and  lower  lids.     Compresses  and  a  roller  were  applied  over  both  eyes. 


Fig.  26. 


Fig.  27. 


16th,  All  the  stitches  removed,  as  well  as  a  ligature  which  was  applied  on  one  of  the 
branches  of  the  temporal  artery.  Two  stripes  of  court-plaster  applied  across  the  left 
eyelids,  and  both  eyes  covered  with  a  compress  and  roller. 

21st,  All  the  dressings  omitted. 

24th,  On  closing  the  eyes,  without  making  any  particular  effort  to  do  so,  the  left  lids 
do  not  come  together,  but  leave  an  interstice  between  their  edges  of  about  ^^  inch  in 
breadth;  but  on  making  an  effort  to  close  the  eyes,  the  edges  of  the  left  lids  come  together 
perfectly.  On  looking  straight  forwards,  the  left  lids  are  open  almost  exactly  to  the  same 
extent  as  those  of  the  right  eye,  but  the  eyeball  is  a  very  little  directed  more  downward 
than  the  right.  This  seems  the  effect  of  having  long  retained  the  eye  in  that  position 
previously  to  the  operation.  The  cicatrice  by  which  the  upper  edge  of  the  flap  is  united 
to  the  eyelid  forms  a  depression  exactly  in  the  situation  of  the  natural  sulcus,  formed  by 
the  action  of  the  levator  muscle.  The  lower  edge  of  the  flap  is  united  without  any  evi- 
dent cicatrice.  The  line  by  which  the  edges  of  the  wound  on  the  temple  is  united  is 
scarcely  distinguishable ;  and  it  would  be  impossible  to  discover,  by  mere  inspection, 
that  at  B  any  turn  or  change  of  place  had  been  given  to  the  flap.  Not  the  slightest 
eversion  remains. 

From  the  very  great  deficiency  of  integument  in  the  everted  eyelid,  there 
could  be  no  hesitation  as  to  the  choice  of  an  operation  in  this  case.  It  was 
evident  that  a  transplantation  of  skin  only  could  remedy  the  deformity.  Sup- 
pose that  the  tarsus  had  been  drawn  down  into  its  natural  position  by  an 
incision  of  the  cicatrice,  and  an  attempt  made  according  to  Chelius'  plan,  to 
keep  the  edges  of  the  wound  apart  till  it  granulated  and  cicatrized,  months 
would  hare  elapsed. ere  this  could  have  been  accomplished,  and  even  after 
cicatrization  was  finished,  the  granulations  would  have  been  apt  to  be  ab- 
sorbed, and  the  eversion  to  return ;  an  event  completely  prevented  by  the 
blepharoplastic  plan. 

It  does  not  do  to  trust  to  the  eye,  in  estimating  the  size  of  the  flap  which 
is  to  be  insulated  and  detached.     An  exact  measure  of  the  wound,  made  in 


ECTROPIUM   FROM   A   CICATRICE.  235 

dividing  the  cicatrice  and  replacing  the  lid,  must  be  transferred  to  the  piece 
of  pasteboard.  Owing,  however,  to  the  contraction  which  the  skin  suffers, 
both  in  breadth  and  length,  as  soon  as  it  is  raised  from  its  natural  place,  the 
flap  requires  to  be  somewhat  broader  and  longer  than  the  wound  into  which 
it  is  to  be  received.  Fricke  says  it  should  be  one  line  broader  and  longer, 
but  this  would  scarcely  be  sufficient.  At  the  same  time,  by  applying  numer- 
ous stitches  as  close  as  possible  to  the  edges  of  the  wound  and  of  the  flap, 
the  latter  may  be  extended  considerably  after  it  is  adjusted  to  its  new  situa- 
tion, and  by  employing  pretty  thick  compresses  and  a  double-headed  roller, 
it  may  be  prevented  from  shrinking  so  much  as  it  would  otherwise  do. 

[It  might  almost  be  said  to  be  an  axiom  in  plastic  surgery,  that  the  opera- 
tor never  can  make  his  flap  too  large.  If  he  had  dissected  up  a  larger 
portion  than  the  exact  dimensions  of  the  wound  to  be  filled  requires,  it  need 
cause  him  no  alarm,  for  the  tissue  thus  transposed  w^ill  contract  and  accommo- 
date itself  to  the  requirements  of  its  new  position.  This  we  have  seen  occur 
again  and  again. — H.] 

Some  operators  would  dissuade  us  from  bringing  the  edges  of  the  wound 
left  by  displacing  the  flap,  together  by  suture  lest  the  doing  so  should  drag 
too  much  on  the  flap,  and  cause  the  stitches  by  which  it  is  fixed  to  give  way. 
They  would  allow  it  to  heal  by  granulation. 

When  ablepharoplastic  operation  is  to  be  performed,  the  thickened  conjunc- 
tiva should  be  left  untouched,  and  no  part  of  the  skin,  neither  sound,  nor 
hardened  and  contracted  by  previous  cicatrization,  nor  any  portion  of  the 
cellular  substance,  should  in  general  be  removed.  The  incision  of  the  lids 
should  pass  through  the  middle  of  the  cicatrice.  The  transplantation  should 
then  be  accomplished  ;  and  when  the  incisions  are  healed,  it  will  rarely  be 
found  necessary  to  interfere  with  the  conjunctiva,  or  to  shorten  the  lid  trans- 
versely by  the  extirpation  of  any  part  of  it. 

When  the  operation  of  restoring  a  lower  lid  is  attempted,  the  flap  has 
sometimes  been  taken  from  the  cheek ;  but  it 
appears  to  answer  fully  better  to  take  it  from  Fig.  28. 

the  temple,  as  was  done  by  Dr.  Brainard,  in  a 
case  related"^  by  him,  and  of  which  Fig.  28 
shows  the  situation  whence  the  flap  was  taken, 
and  the  adaptation  of  it  by  sutures  to  supply  the 
place  of  the  defective  lid. 

One  of  the  chief  dangers  attendant  on  such 
blepharoplastic  operations  is  gangrene  of  the 
transplanted  flap.  This  may  arise  from  the 
basis   by  which   it  retains   part   of  its  natural 

connections  being  too  narrow,  from  its. not  being  kept  closely  in  contact 
with  the  wound  to  which  it  is  transferred,  or,  on  the  other  hand,  from  being 
too  much  pressed  against  the  bones  by  the  compress  and  roller. 

Another  untoward  event  is  the  flap  not  continuing  to  lie  flat  and  in  contact 
with  the  wound,  but  curling  gradually  up  into  a  globular  mass,  so  that,  as 
Diefifenbach  says,  it  looks  more  like  the  point  of  the  nose  than  an  eyelid. 

The  success  of  a  blepharoplastic  operation  depends  much  on  the  state  of 
the  integuments,  whence  the  flap  is  to  be  taken.  The  prospect  is  good,  if  the 
skin  to  be  transplanted  is  healthy.  In  this  state  it  is  very  extensible,  so  that 
it  may  be  transferred  from  its  natural  place  to  a  degree  that  it  is  scarcely  con- 
ceivable. But  if  the  skin  to  be  transplanted  is  changed  in  structure  from 
inflammation  and  cicatrization,  the  chance  of  success  is  much  reduced. 


236  ECTROPIUM   FROM  CARIES   OF   THE   ORBIT. 

§  4.  Eversion  from  Caries  of  the  Orhit. 

Syn. — Ectropium  symptomaticum. 
Fig.  Dalrymple,  PL  II.  Fig.  3. 

I  have  already  bad  occasion  to  refer  (pages  16  and  81)  to  the  great  degree 
of  shortening  of  the  lid,  with  which  eversion  from  caries  of  the  orbit  is  gene- 
rally attended,  and  to  a  circumstance  which  we  may  remark  more  or  less  in 
every  variety  of  this  disease,  but  which  is  often  very  strikingly  displayed  in 
those  cases  where  the  upper  lid  is  dragged  up  under  the  edge  of  the  orbit, 
from  an  affection  of  the  bone,  namely,  the  degree  of  accommodation  of  the 
lower  lid  to  the  deficient  state  of  the  upper. 

Cases  such  as  those  represented  in  Figs.  1,  2,  and  3  (page  16),  may  often 
be  relieved  by  one  or  other  of  the  operations  recommended  for  the  third 
variety  of  eversion,  and  particularly  by  those  compound  ones  in  which  the 
morbid  adhesions  are  separated,  the  eyelid  and  neighboring  integuments 
extended,  the  thickened  conjunctiva  removed,  and  a  wedge-shaped  portion 
of  the  eyelid  cut  out. 

If  the  distortion,  however,  is  slight,  it  ought  not  to  be  meddled  with,  or 
merely  a  fold  of  conjunctiva  ought  to  be  extirpated,  without  interfering  with 
the  skin,  or  attempting  to  detach  the  cicatrice.  When  the  distortion  is  very 
great,  we  may  be  led  to  attempt  a  blepharoplastic  operation. 

Dr.  Ammon,  in  a  case  of  eversion,  with  adhesion  of  the  cicatrice  to  the 
outer  surface  of  the  edge  of  the  orbit,  surrounded  the  deeply  depressed  cicatrice 
by  an  incision,  left  it  adherent  to  the  bone,  detached  the  neighboring  integu- 
ments all  round  to  such  an  extent  that  the  lid  was  set  at  liberty,  and  the 
patient  could  shut  the  eye,  and  then  closed  the  external  wound  over  the  old 
cicatrice.  The  lid  was  in  this  way  elongated,  a  scarcely  observable  scar 
ensued,  and  the  disagreeable  depression  at  the  edge  of  the  orbit  was  no  longer 
in  view.** 

By  a  still  simpler  operation,  Mr.  Wilde  relieved  a  similar  case,  of  which  he 
gives  a  figure,  not  materially  different  from  Fig.  1,  p.  76: — 

Case  156. — The  parts  above  and  below  the  cicatrice  being  made  as  tense  as  possible, 
Mr.  Wilde  introduced  a  small  narrow-bladed  and  double-edged  knife,  at  the  distance  of 
nearly  an  inch  on  the  outer  side  of  the  cicatrice,  passed  it  obliquely  down  to  the  bone,  and 
under  the  cicati'ice,  and  moving  it  in  a  semicircular  manner  from  above  downwards,  and 
at  the  same  time  pushing  it  forwards,  he  detached  the  entire  adhesion,  and  nearly  an  inch 
on  each  side  of  it,  fully  from  the  bone.  As  soon  as  it  was  found  perfectly  free,  and  that 
the  lid  could  be  restored  to  its  normal  position,  the  knife  was  withdrawn,  and  the  small 
wound  closed  with  adhesive  plaster.  The  effusion  of  blood  which  immediately  took  place 
beneath  the  cicatrice,  caused  a  tumor  where  the  depressions  had  existed,  and  care  was 
taken  that  none  of  this  blood  escaped  through  the  external  wound.  A  ligature  was  then 
passed  through  the  lower  lid,  about  one-quarter  of  an  inch  from  the  ciliary  margin,  and 
the  ends  of  it  di'awn  up  and  attached  to  the  forehead  during  the  next  three  days.  Cold 
applications  were  applied,  and  jSIr.  W.  had  the  satisfaction  to  find  that,  within  a  fortnight 
afterwards,  the  deformity  was  completely  removed,  the  depression  of  the  cheek  filled  up, 
and  the  lid  restored  to  its  natural  position.*^ 


'  Practical  Treatise  on  the  Diseases  of  the  '  See   case  by  Rail,  in  which  extirpation  of 

Eye,  p.  228;  London,  1820.  conjunctiva  was  first  tried,  and  failed;  but  a 

^  See   Guthrie's   Lectures  on   the   Operative  cure  afterwards  effected  by  incision  of  the  lid. 

Surgery  of  the  Eye,  p.  61  ;  London,  1823.  Duncan's  Annals  of  Medicine  j  Vol.  i.  p.  159; 

'  Staub  de  Blepharoplastice,  p.  79;  Berolini,  Edinburgh,  1796. 

1835.  »  See  case  by  Curling,  Medical  Gazette;  Vol. 

^  Pathologic  Chirurgicale,  p.  136:  PI.  x.  Fig.  xxviii.  p.  17  ;  London,  1814. 

17;  Paris,  1831.  ^  Zeitschrift  fiir  die  Ophthalmologie  ;  Vol.  i. 

*  De  Re  Medica ;  Lib.  vii.  Pars  ii.  Cap.  i.  p.  47;  Dresden,  1830. 

Sect.  2.  ">  Medical  Gazette;  Vol.  xviii.  p.  224;  Lon- 

^  Meinoires   de  I'Academie  Royale  de   Chi-  don,  1836. 

rurgie;  Tome  xiii.  p.  170 ;  12mo;  Paris,  1774.  "  Practical  Observations  on  Ectropium,  &c. j 


TRICHIASIS  AND  DISTICHIASIS. 


23t 


London,  1814.  To  Sir  William  Adams  belongs 
the  merit  of  the  operation  described  in  the  test. 
The  reader,  however,  who  has  at  all  turned  his 
attention  to  the  history  of  this  part  of  surgery, 
will  at  once  trace  the  resemblance  of  Sir  Wil- 
liam's operation  to  that  practised  by  Antyllus, 
some  fourteen  or  fifteen  centuries  before.  The 
incision  practised  by  Antyllus.  having  the  form 
of  the  Greek  letter  a,  implicated  only  the 
structures  on  the  inside  of  the  lid,  leaving  the 
skin  undivided.  The  lips  of  the  wound  were 
drawn  together  by  a  suture.  Aetii  Contractse 
ex  Veteribus  Medicinte  Tetrabiblos  ;  Tetrabib. 
II.  Sermo  iii.  cap.  72,  p.  359;  Basilea;,  1549. 

'^  Bericht  liber  das  clinische  chirurgisch- 
augenarztliche  Institut  der  Universitat  zu  Ber- 
lin, fur  1829  und  1830,  p.  9;  Berlin,  1831. 

'^  Dreyer,  NovaBlepharoplastices  Methodus, 
p.  40  ;  Vindobonje,  1831 :  Brown,  London  Me- 
dical Gazette;  Vol.  xvii.  p.  721;  and  Vol.  xviii. 
p.  485, 

"  Memoires  de  I'Academie  Royale  de  Chi- 
rurgie;  Tome  ii.  p.  343;   12rao;  Paris,  1780. 

'^  Grafe  und  Walther's  Journal  der  Chirur- 
gie  und  Augenheilkunde ;  Vol.  ix,  p.  86 ;  Ber- 
lin, 1826. 

"  Review  of  Zeis's  Handbuch  der  plastichen 


Chirurgie,  in  British  and  Foreign  Medical  Re- 
view, for  April,  1839,  p,  406. 

'^  Ibid. 

'^  Ammon's  Zeitschrift  fiir  die  Ophthalmo- 
logic ;  Vol.  iv.  p.  428  ;  Heidelberg,  1835  ;  Staub. 
Op.  cit.  p.  98  :  Chelius,  Handbuch  der  Augen- 
heilkunde; Vol.  ii.  p.  166;  Stuttgart,  1S39. 

'^  Zeitschrift  fUr  die  Ophthalmologic;  Vol, 
V.  p.  313  ;  Heidelberg,  1836. 

^°  Lehre  von  den  Augenoperationen,  p.  267; 
Berlin,  1829. 

"'  Ibid.  p.  9. 

°^  Die  Bildung  neuer  Augenlider;  Hamburg, 
1829.  Delpech  has  published  an  interesting 
case  of  restoration  of  part  of  the  lower  eyelid, 
and  side  of  the  nose,  by  an  autoplastic  opera- 
tion, in  his  Chirurgie  Clinique  de  Montpellier ; 
Tome  ii.  pp.  221,  253;  Paris,  1828.  See  case 
by  Horner,  American  Journal  of  the  Medical 
Sciences;  Vol.  xxi.  p,  105  ;  Philadelphia,  1837. 

^^  American  .Journal  of  the  Medical  Sciences, 
for  October,  1845,  p.  356. 

^■'  Zeitschrift  fiir  die  Ophthalmologie ;  Vol. 
i.  p.  49  ;  Dresden,  1831. 

*'  Dublin  Quarterly  Journal  of  Medical  Sci- 
ence, for  May,  1848,  p.  473, 


SECTION  XXXIV. — TRICHIASIS  AND  DISTICHIASIS, 

Tfixja-a-i?,  from  ^fi^,  hair.     Distichiasis,  from  Jts-Ti;:^^?,  having  tivo  rows. 
Ficj.  Ammon,  Zweiter  Theil.  Tab.  IV.  Figs.  9,  10.    Dalrymple,  PI.  IL  Fig.  4. 

TricMasis  is  an  inversion  of  the  eyelashes ;  distichiasis  means  a  double  row 
of  eyelashes,  the  inner  row,  or  pseudo-cilia,  as  they  are  termed,  being  turned 
in  upon  the  eyeball.  The  fact  is,  however,  that  what  are  called  pseudo-cilia 
in  distichiasis,  although  they  issue  from  the  skin  at  a  wrong  place,  and  grow 
in  a  wrong  direction,  are  seldom,  if  ever,  new  or  supernumerary  productions, 
but  merely  natural  cilia,  the  bulbs  of  which  have  been  displaced  by  pressure 
or  by  disease,  affecting  the  border  of  the  eyelid. 

Symptoms. — We  very  seldom  find  all  the  eyelashes  turned  towards  the  eye- 
ball, except  when  the  trichiasis  is 

merely  a  symptom  of  inversion  of  Fig.  29. 

the  edge  of  the  eyelid,  a  disease 
which  we  leave  out  of  view  for  the 
present,  and  even  when  it  is  a  symp- 
tom of  inversion  of  the  edge  of  the 
eyelid,  the  trichiasis  is  often  partial. 
In  the  same  manner,  the  displaced 
cilia  in  distichiasis  (Fig.  29)  seldom 
occupy  the  whole  length  of  the  eye- 
lid ;  but  in  most  cases  are  strewed 
here  and  there  in  parcels,  between 
the  natural  cilia  and  the  Meibomian 
apertures,  but  generally  nearer  to 
the  latter.  In  some  instances,  we 
find  the  outer  margin  of  the  lid 
rounded   off,   and  the  whole  space 

between  it  and  the  Meibomian  aper-  ' 

tures  covered  with  cilia. 

When  only  one  or  two  small  colorless  eyelashes  are  inverted,  they  are  apt 
to  escape  being  noticed,  and  the  diseased  appearances  of  the  eye,  which  are 


238  TRICHIASIS   AND   DISTICHIASIS. 

owing  to  their  irritation,  are  supposed  to  be  occasioned  by  some  disorder  of 
the  eyeball  itself.  Means  ai'e  even  directed  against  the  effects  while  the  cause 
is  overlooked,  and  the  eye  may  be  seriously  injured,  and  even  vision  lost,  from 
a  derangement  so  minute  that  it  is  apt  to  pass  unobserved.  In  every  case  in 
which  recovery  from  an  attack  of  ophthalmia  proceeds  with  more  than  ordi- 
nary slowness,  the  surface  of  the  cornea  continuing  dim,  and  strewed  with 
bloodvessels,  the  eye  discharging  tears  upon  the  smallest  increase  of  light, 
and  the  patient  complaining  of  the  sensation  of  a  foreign  body  rubbing  against 
the  eye,  we  ought  carefully  to  examine  the  edges  of  the  eyelids,  and  discover 
whether  any  of  the  eyelashes  be  inverted.  In  distichiasis  especially,  the  dis- 
placed eyelashes  are  in  general  so  soft,  short,  and  light-colored,  that  they  can 
be  seen  only  when  the  eyelids  are  opened  wide,  but  at  the  same  time  allowed 
to  remain  in  contact  with  the  eyeball.  The  moment  that  the  edge  of  the  lid 
is  drawn  forwards  from  touching  the  eyeball,  the  displaced  cilia  are  scarcely 
or  not  at  all  visible.  On  again  applying  the  edge  of  the  lid  to  the  eyeball, 
so  that  the  iris,  or  the  pupil,  forms  a  contrasting  background  to  them,  the 
cilia  return  into  view.  Condensing  the  light  upon  them  by  means  of  a  convex 
lens,  assists  in  rendering  them  visible. 

Trichiasis  and  distichiasis  affect  the  upper,  much  oftener  than  the  lower 
eyelid.  This  may,  perhaps,  depend  on  the  natural  disposition  of  the  borders 
of  the  two  eyelids ;  the  border  of  the  upper  being  directed  downwards  and 
inwards,  while  that  of  the  lower  is  turned  upwards  and  outwards. 

Causes. — Trichiasis  and  distichiasis  are  in  an  especial  manner  the  conse- 
quences of  neglected  catarrhal  ophthalmia,  scrofulous  ophthalmia,  and  oph- 
thalmia tarsi.  Smallpox  was  formerly  a  very  abundant  source  of  these  derange- 
ments of  the  cilia.  Burns  of  the  conjunctiva  and  edge  of  the  lid,  and  every 
affection  attended  with  abscesses  and  ulcers  at  the  roots  of  the  eyelashes,  are 
apt  to  give  rise  to  trichiasis  and  distichiasis,  especially  if  the  patient  is  allowed 
to  lie  much  on  the  face,  so  that  the  cilia,  loaded  with  mucus,  or  matted 
together  by  the  diseased  secretion  of  the  Meibomian  follicles,  are  forced  in  a 
constant  direction  towards  the  eyeball.  I  have  seen  a  swollen  state  of  the 
upper  lid  from  syphilitic  inflammation,  caused  by  pressure  of  trichiasis  of  the 
lower  lid. 

The  exciting  causes  of  trichiasis,  such  as  those  now  enumerated,  produce, 
as  Mr.  Wilde  has  pointed  out,*  an  unhealthy  deposit  in  the  interspaces  be- 
tween the  roots  of  the  cilia,  along  with  a  contracted  state  of  the  conjunctiva, 
which  may  be  regarded  as  the  proximate  cause. 

Palliative  cure.  Evulsion. — The  palliative  cure  of  trichiasis  and  distichiasis 
consists  in  removing  one  after  the  other,  all  the  inverted  and  misplaced  cilia, 
by  means  of  a  proper  pair  of  forceps.  (Fig.  30.)     The  best  cilia-forceps  are 

Fig.  30. 


those  without  teeth ;  the  surfaces  which  meet,  to  lay  hold  of  the  hair,  being 
merely  roughened.  Each  eyelash  is  to  be  laid  hold  of  as  close  as  possible  to 
the  skin,  and  pulled  out  in  a  straight  direction,  in  order  that  it  may  not  break. 
Except  when  the  edge  of  the  lid  is  perfect,  and  the  trichiasis  entirely  the 
result  of  the  cilia  having  been  matted  together  by  mucus,  this  operation  must 
be  regarded  as  calculated  to  afford  merely  temporary  relief.  Carefully  and 
frequently  repeated,  it  occasionally  proves,  even  in  cases  of  distichiasis,  espe- 
cially in  young  subjects,  a  radical  means  of  cure  ;  but  on  this  we  cannot  de- 


TRICHIASIS   AND   DISTICHIASIS. 


239 


pend,  and,  therefore,  as  soon  as  the  inverted  or  displaced  cilia  reappear,  they 
must  again  be  extracted.  We  meet  with  patients  who  for  many  years  have 
been  obliged,  every  eight  days  or  oftener,  to  have  this  repeated. 

Radical  cure. — The  constant  repetition  even  of  the  trifling  operation  of 
evulsion  being  found  by  many  extremely  annoying,  we  are  often  asked  whether 
there  is  no  means  by  which  trichiasis  or  distichiasis  can  be  permanently 
removed.     With  this  view,  the  following  plans  have  been  had  recourse  to  : — 

1.  Restoring  to  the  cilia  their  natural  direction. — The  practice  of  turning 
the  distorted  hairs  into  their  proper  direction,  and  cementing  them  to  the 
other  cilia,  or  to  the  skin,  is  not  altogether  to  be  despised.  When  the  dis- 
torted hairs  in  trichiasis  are  long,  by  keeping  them  for  a  fortnight  or  three 
weeks  in  their  natural  direction,  a  cure  may  sometimes  be  effected.  For  this 
purpose,  collodion  may  be  used,  or  strong  shell-lac  varnish.  A  little  of  one 
or  other  of  these  fluids,  taken  up  on  the  point  of  a  bit  of  wood,  is  to  be 
applied  to  the  distorted  hairs,  and  those  beside  them,  so  as  to  mat  them  to- 
gether, and  bind  them  down  to  the  skin.  The  parts  must  be  examined  daily, 
and  retouched,  if  the  crust  formed  by  the  drying  of  the  collodion,  or  the 
varnish,  has  anywhere  given  way.^  This  practice  will  be  of  no  service  in 
distichiasis. 

2.  Extirpation  of  a  fold  of  skin. — In  cases  of  trichiasis,  in  which,  for  a 
considerable  space  along  the  edge  of  either  lid,  the  eyelashes,  instead  of 
standing  out  horizontally  with  their  natural  curve,  are  directed  perpendicu- 
larly, so  as  to  cling  to  the  surface  of  the  eyeball,  and  this  without  any 
irregularity  or  disorganization  of  the  edge  of  the  lid,  we  generally  find  that 
by  laying  hold  of  a  transverse  fold  of  the  skin  of  the  lid,  the  eyelashes  assume 
their  proper  direction.  Estimating,  then,  the  quantity  of  skin  necessary  to 
produce  this  effect,  we  lay  hold  of  it  with  the  entropium  forceps  (Fig.  16,  p. 
213),  clip  it  out  with  a  stroke  or  two  of  the  scissors,  and  bring  the  edges  of 
the  wound  together  with  two  or  three  stitches. 

3.  Cauterization  of  the  skin. — The  same  thing  may  be  effected  by  cauteriza- 
tion, actual  or  potential.     A  smooth  horn  spatula  (Fig.  31),  convex  on  the 

Fig.  31. 


one  side,  and  concave  on  the  other,  and  grooved  transversely  on  its  convex 
side,  a  little  way  from  its  extremity  A,  is  to  be  passed  between  the  eyeball 
and  lid,  in  such  a  way  that  the  edge  of  the  lid  shall  rest  in  the  transverse 
groove,  and  the  lid  be  put  on  the  stretch  by  pressing  the  spatula  a  little 
forwards.  A  small,  flat  cautery,  about  the  twentieth  of  an  inch  in  thickness, 
raised  to  a  white  heat,  is  then  to  be  drawn  along  the  skin  of  the  lid,  parallel 
to  the  eyelashes,  and  at  the  distance  of  about  the  twentieth  of  an  inch  from 
them.  The  same  cauterization  may  be  effected  by  a  pencil  of  pure  potash, 
pointed  by  dipping  the  end  of  it  in  water.  When  the  eschar  separates,  a 
slight  ectropium  will  result  from  the  contraction  of  the  cicatrice,  and  the 
eyelashes  will  resume  their  natural  direction.^ 

The  direction  of  single  inverted  hairs  may  be  corrected,  by  running  the 
point  of  a  lancet  into  the  edge  of  the  lid  immediately  to  the  outside  of  the 


240  TRICHIASIS  AND   DISTICHIASIS, 

root  of  the  hair,  and  inserting  into  this  little  wound  a  speck  of  pure  potash, 
thus  producing  a  small  ulcer,  which,  in  cicatrizing,  alters  the  direction  of  the 
hair. 

4.  Destruction  of  the  bulbs  by  inflammation. — The  eifect  of  inflammation 
in  destroying  the  ciliary  bulbs,  or  hair  capsules,  as  exemplified  in  ophthalmia 
tarsi,  smallpox,  &c.,  which  sometimes  leave  the  lids  affected  with  partial 
madarosis,  or  baldness,  has  suggested  the  plan  of  exciting  artificially  such 
inflammation  in  these  secreting  organs  of  the  cilia  as  shall  be  sufficient  to 
destroy  them,  or  at  least  render  them  incapable  of  continuing  their  function. 
Celsus,  and  even  modern  surgeons,  have  used  the  actual  cautery  for  this 
purpose ;  but,  generally,  inoculation  with  some  irritant  has  been  preferred, 
such,  for  instance,  as  the  tartrate  of  antimony. 

The  parts  being  put  on  the  stretch  by  means  of  a  small  hook,  or  orer  the 
horn  spatula,  the  iDulb  is  to  be  punctured  with  a  lancet,  or  an  iris-knife,  which 
should  be  entered  close  to  the  base  of  the  inverted  cilium,  in  the  direction  of 
its  growth,  to  the  depth  of  ^  inch,  and  moved  about  a  little  so  as  to  widen 
the  bottom  of  the  wound,  and  cut  the  bulb.  The  bleeding  having  wholly 
ceased,  and  the  lid  being  wiped  quite  dry,  the  inoculation  is  to  be  effected 
with  the  point  of  a  small  probe,  or  the  drilled  end  of  a  darning-needle,  slightly 
damped,  and  dipped  in  powdered  tartrate  of  antimony,  inserted  into  the  punc- 
ture, and  held  there  for  a  few  seconds  ;  or  the  same  may  be  done  with  a  bit 
of  platinum  foil,  shaped  like  a  lancet,  heated,  covered  with  a  very  thin  coating 
of  sealing-wax,  and  pushed,  while  hot,  into  powdered  tartar  emetic.  The 
eyelash  is  now  to  be  seized  close  to  its  root,  and  extracted.  Bulb  after  bulb 
is  to  be  treated  in  this  way.  The  inflammation  which  immediately  follows, 
generally  subsides  in  twenty-four  hours  ;  but  if  the  operation  has  been  pro- 
perly performed,  it  recurs  in  a  day  or  two,  with  the  formation  of  small  pus- 
tules, and  though  of  very  limited  extent,  is  sufficient  to  destroy  the  functions 
of  the  bulbs. 

Dr.  James  Hunter,  to  whom  we  are  indebted  for  this  plan  of  curing 
trichiasis  and  distichiasis,  tried  alcohol,  nitric  acid,  aqua  ammonise,  capsicum, 
euphorbium,  and  croton  oil,  for  inoculating  the  bulbs;  but  these  substances 
were  ineffectual.* 

5.  Excision  of  the  edge  of  the  eyelid. — Some  operators  have  contented 
themselves,  in  cases  of  trichiasis,  with  the  simple  plan  of  paring  away  the 
edge  of  the  eyelid,  removing  in  this  way  that  part  of  the  lid  whence  the  cilia 
grow,  as  well  as  the  Meibomian  apertures.^  I  remember  seeing  a  Jew  girl 
in  Vienna,  who  had  been  operated  on  in  this  manner  by  Dr.  C.  Jager.  The 
pain  and  inflammation  of  the  eye,  and  the  opacity  of  the  cornea,  caused  by 
the  inverted  lashes,  were  of  course  removed,  and  the  deformity,  produced  by 
this  curtailment  of  the  lids,  was  very  trifling.  A  perpetual  tendency  to  lip- 
pitudo,  however,  must  follow  the  obliteration  of  the  Meibomian  canals. 

Dr.  Jacob  performs  essentially  the  same  operation,  in  the  following  manner : 
He  passes  the  point  of  a  fine  hook  beneath  the  lid,  and  draws  the  hook  to- 
wards him  till  its  point  shows  through -the  skin,  at  a  distance  of  about  a  line 
from  the  external  angle  of  the  eye.  He,  then,  with  common  straight  scissors, 
cuts  into  the  lid  between  the  point  hooked  and  the  external  angle  of  the  eye, 
continuing  the  incision  by  repeated  clips  along  the  lid,  and  at  a  distance  of 
something  more  than  a  line  from  the  margin,  until  he  comes  to  the  punctum. 
In  fact,  he  clips  away  the  ciliary  margin  of  the  eyelid  from  the  external  angle 
to  the  punctum,  including  skin,  cartilage,  and  roots  of  the  cilia,  not  leaving 
any  notch  at  either  end,  but  sloping  the  incision  as  he  cuts  in  at  the  external 
angle  and  out  at  the  punctum,  thus  obtaining  a  regular  edge,  and  leaving  a 
portion  of  the  cartilage  sufficient  to  preserve  the  form  and  motions  of  the  lid." 

6.  Extirpation  of  a  stripe  of  the  integuments,  including  the  bulbs  of  the 


TRICHIASIS   AND   DISTICHIASIS.  24i 

cilia. — The  operation  proposed  by  Professor  Jilger/  for  the  cure  of  trichiasis, 
is  one  of  the  most  efficient.  It  differs  botli  from  Mr.  Saunders'  extirpation 
of  the  cartilage,  and  from  the  paring  of  the  edge  of  the  lid  just  mentioned. 
It  consists  in  removing  that  portion  of  the  integuments  under  which  lie  the 
bulbs  of  the  cilia,  leaving  the  cartilage,  and  as  far  as  possible,  the  Meibo- 
mian apertures,  entire.  The  bulbs  of  the  cilia  must  be  removed,  the  lachry- 
mal canals  and  puncta  being  preserved  ;  if  the  trichiasis  is  only  partial,  then 
the  operation  is  to  be  limited  to  the  part  where  the  eyelashes  have  a  wrong 
direction. 

The  horn  spatula  (Fig.  31)  being  introduced  beneath  the  eyelid,  and  the 
skin  put  on  the  stretch,  the  skin,  and  orbicularis  are  divided,  with  a  small 
scalpel,  by  a  transverse  incision,  parallel  to,  and  fully  a  line  from,  the  diseased 
cilia;  the  spatula  is  now  withdrawn,  the  ciliary  edge  of  the  wound  laid  hold 
of,  at  its  temporal  extremity,  with  a  pair  of  toothed  forceps*'  (Fig.  32),  and 

i  Fig.  32. 


by  repeated  strokes  of  the  knife,  the  outer  margin  of  the  lid,  along  with  some 
of  the  fibres  of  the  orbicularis,  and  the  whole  bulbs  of  the  cilia,  is  dissected 
off  in  a  stripe.  Dr.  Jiiger  leaves  the  wound  to  cicatrize  ;  Mr.  Wilde  brings 
its  edges  together  with  fine  sutures. 

If  any  of  the  bulbs  of  the  cilia  have  escaped  extirpation,  they  appear  like 
black  points  in  the  wound,  about  the  third  or  fourth  day  after  the  operation. 
Caustic  should  immediately  be  applied  to  them,  so  that  they  may  be  de- 
stroyed. 

"7.  Excision  or  destricction  of  the  bulbs  of  the  cilia. — The  following  opera- 
tion is  recommended^  by  Yacca  Berlinghieri,  of  Pisa  : — 

The  surgeon  having  ascertained  the  number  of  inverted  eyelashes,  and  the 
extent  which  they  occupy,  with  pen  and  ink  traces  a  line  on  the  skin,  parallel 
to  the  margin  of  the  eyelid,  and  at  the  distance  of  a  quarter  of  a  line  from 
it.  The  line,  drawn  with  a  pen,  should  show  upon  the  external  surface  of 
the  eyelid  the  exact  space  occupied  towards  its  internal  surface  by  the  dis- 
torted cilia.  The  horn  spatula  (Fig.  31)  is  now  to  be  introduced  between 
the  lid  and  the  globe  of  the  eye,  so  that  the  edge  of  the  lid  is  placed  on  the 
grooved  part  of  the  convex  surface  of  the  spatula.  With  one  hand,  the 
assistant  holds  the  spatula,  while,  with  the  index  and  mid  finger  of  the  other 
hand,  he  keeps  the  lid  fixed  and  on  the  stretch.  The  surgeon  now  makes 
two  small  vertical  incisions  tl'rough  the  integuments,  with  the  scalpel,  com- 
mencing a  line  and  a  half  from  the  edge  of  the  eyelid,  and  terminating 
exactly  at  its  edge.  These  two  incisions  inclose  the  space  on  which  the  line 
was  marked  with  ink.  A  transverse  incision,  parallel  to  the  line  so  marked, 
is  now  to  unite  the  two  vertical  incisions.  The  flap,  circumscribed  by  these 
three  incisions,  is  to  be  raised  from  the  subjacent  parts,  so  as  to  bring  the 
bulbs  of  the  cilia  into  view.  It  is  not,  however,  always  easy  to  see  and  extir- 
pate them,  partly  from  the  blood  which  conceals  them,  partly  from  the  dense 
tissue  which  surrounds  them  and  renders  it  difficult  to  lay  hold  of  them.  The 
surgeon,  therefore,  must  cleanse  the  wound  well  from  blood,  and  be  provided 
with  a  good  pair  of  fine  forceps,  with  which,  and  a  small  scalpel,  or  scissors, 
he  may  remove  all  that  lies  between  the  everted  flap  and  the  external  surface 
16 


242  TRICHIASIS  AND  DISTICHIASIS. 

of  the  tarsus.     That  being  done,  the  operation  is  finished.     The  flap  is  re- 
placed in  its  natural  position,  and  kept  so  by  a  strip  of  court-plaster. 

Having  repeatedly  performed  this  operation,  I  conceive  a  transverse 
incision,  about  a  line  from  the  margin  of  the  lid,  to  be  sufficient,  without  the 
two  vertical  ones.  The  incision  gapes  sufficiently  to  allow  us  to  go  on  with 
the  extirpation  of  the  bulbs,  without  dissecting  back  any  flap.  The  cellular 
tissue,  surrounding  the  bulbs,  however,  is  too  dense  to  permit  of  being  seized 
with  forceps.  I  use,  therefore,  a  small  sharp  hook,  which  I  pass  beneath  the 
spot  where  I  conceive  the  bulbs  to  lie,  and  raising  the  part  seized  with  the 
hood,  I  snip  it  out  with  scissors.  I  then  seize  another  and  another  bit,  till  I 
think  I  have  accomplished  the  extirpation  of  all  the  faulty  bulbs.  If  I  have 
doubts  about  any  of  them,  I  touch  the  part  with  a  pointed  piece  of  potassa 
fusa.     Next  day  the  wound  is  healed,  without  any  dressing. 

If  the  inverted  cilia  are  placed  at  a  considerable  distance  from  one  another, 
and  in  the  interval  between  them  there  are  cilia  growing  naturgjly,  Yacc^ 
directs  us  to  attack  particularly  the  bulbs  belonging  to  the  distorted  cilia, 
and  not  to  uncover  nor  destroy  the  roots  of  the  natural  ones. 

He  confesses  that  the  extirpation  of  the  bulbs,  in  the  manner  described, 
might  puzzle  one  not  accustomed  to  perform  delicate  operations.  He  tried, 
therefore,  the  plan  of  raising  the  flap  as  before,  and  destroying  the  bulbs  with 
nitric  acid.  This  may  be  better  applied  by  means  of  a  bit  of  wood,  than  by 
the  contrivance  used  by  Vacch. 

The  cilia,  of  which  the  bulbs  have  been  dissected  out,  or  destroyed,  would 
come  away,  about  the  sixth  day  after  the  operation ;  but  it  is  better  to  pull 
them  out  immediately. 

I  have  repeatedly  assisted  my  colleague  Dr.  Rainy,  while  he  performed  the 
following  operation  for  trichiasis  or  distichiasis : — 

Everting  the  eyelid,  and  laying  hold  of  it  with  a  pair  of  forceps,  he  made 
an  incision,  with  an  extraction-knife,  close  and  parallel  to  the  inner  edge  of 
the  border  of  the  lid,  and  then  another  between  the  natural  row  of  cilia  and 
the  inverted  or  displaced  ones.  He  then  extirpated  the  piece  of  the  lid 
intervening  between  these  two  incisions,  including  the  morbid  cilia  and  their 
bulbs.  It  is  difficult  to  make  the  incision  deep  enough,  owing  to  the  firmness 
of  the  cartilage  and  other  textures. 

8.  Excision  of  a  tvedge-shaped portion  of  the  lid. — When  four  or  five  eye- 
lashes, in  a  bundle,  turn  in  upon  the  eye,  we  may  cut  out  a  triangular  or 
narrow  wedge-shaped  piece  of  the  whole  thickness  of  the  lid,  including  the 
faulty  eyelashes,  and  bring  the  edges  of  the  wound  together  by  stitches,  as  in 
the  operation  recommended  by  Sir  W.  Adams  for  the  cure  of  eversion. 

False  eyelashes  are  sometimes  met  with,  growing  from  different  parts  of 
the  conjunctiva,  even  from  the  conjunctiva  cornea?.  Dr.  Monteath  mentions" 
a  case,  in  which  one  exceedingly  strong  hair  grew  from  the  inner  surface  of 
the  lower  lid.  It  was  directed  perpendicularly  towards  the  eyeball,  and  irri- 
tated it.  The  natural  cilia  were  of  a  light  color,  the  pseudo-cilium  jet  black, 
and  double  the  sti-ength  of  the  common  cilia. 

I  once  met  with  an  eyelash  fully  an  inch  in  length,  soft,  and  woolly,  in  a 
patient  who  had  long  suffered  from  ophthalmia. 


'    Dublin    Journal    of   Medical    Science  for  '  Heisteri  Institutiones  Chirurgica;  ,•  Vol.  i. 

March,  1844,  pp.  105,  109.  p.  514;  Amstela;dami,  1750  :  Schreger,  Chirur- 

*  Jacob,  in  Dublin  Hospital  Reports;  Vol.  v.  gische  Versuche;   Vol.  ii.  p.  253;    Nurnberg, 

p.  394;  Dublin,  1830.  1818. 

^  Chirurgie  Clinique  de  Montpellier,  par  Del-  ^  Jacob,  Op.  Cit.  p.  391. 

pech  :  Tome  ii.  p.  295;  Paris,  1828.  ''  Hosp,  DissertatiosistensDiagnosinetCuram 

"  Edinburgh    Monthly    Journal    of  Medical  Radiealem  Trichiasis,  Distichiasis,  nee  non  En- 
Science;  Vol.  i.  p.  259;  Edinburgh,  1849.  tropii;  Viennse;  contained  in  Radius's  Scrip- 


ENTROPIUM. 


243 


tores  Opbthalmologici  Minores;  Vol.  i  p.  199; 
Lipsire,  1826. 

'  The  toothed  forceps,  figured  in  the  text, 
have  at  the  end  of  the  one  blade  a  tooth,  which 
is  received  into  an  interstice  at  the  end  of  the 
opposite  blade.  When  shut,  the  instrument  ap- 
pears like  a  small  probe.     It  differs,  therefore, 


from  Blomer's  forceps,  which  has  two  teeth  pro 
jecting  from  the  one  blade,  and  one  from  the 
other. 

'  Nuovo  Metodo  di  curare  la  Trichiasis,-  Pisa, 
1825. 

'°  Translation  of  Weller's  Manual;  Vol.  i.  p. 
115;  Glasgow,  1821. 


SECTION  XXXV. — ENTROPIUM,  OR  INVERSION  OP  THE  EYELIDS. 

Entropium,  from  Iv,  in,  and  rf'eTrai,  I  turn. 

Fig.  Wardrop,  Vol.  I.  PI.  VII.  Figs.  2,  1.     Dalrymple,  PI.  II.  Fig.  5,  PI.  III.  Fig,  1. 

Exclusive  of  trcmmatic  entropium,  there  are  two  varieties  of  this  disease, 
which  differ  materially  in  their  causes,  symptoms,  and  modes  of  cure.  The 
one  is  acute  or  spasmodic,  the  other  chronic  or  infiamviatory.  The  first  is 
attended  with  little  organic  change  of  the  affected  lid,  the  second  with  much; 
the  first  is  most  frequently  met  with  in  old  persons,  the  second  in  young ;  the 
first  in  healthy,  the  second  in  scrofulous  subjects  ;  the  acute  is  a  disease  chiefly 
of  the  tegumentary,  the  chronic  chiefly  of  the  conjunctival  surface  of  the  lids. 

1.  The  acute  variety  not  unfrequently  takes  its  origin  in  an  attack  of 
ophthalmia,  during  which  the  patient  kept  the  eyelids  long  shut,  perhaps 
covered  with  a  poultice,  or  pressed  inwards  by  a  bandage.  I  have  repeatedly 
seen  it  take  place  during  the  after-treatment  of  extraction  of  the  cataract. 
The  lower  lid  is  almost  exclusively  the  seat  of  this  variety  of  inversion.  The 
skin  of  the  inverted  lid  is  generally  swol- 
len and  puffy.  Its  edge  is  perfectly  regular 
in  form,  not  thickened  nor  indurated,  but 
entirely  rolled  back  towards  the  eyeball,  so 
that  the  eyelashes  are  fairly  out  of  sight 
(Fig.  33),  lying  between  the  eyeball  and 
the  internal  surface  of  the  eyelid.  On  apply- 
ing the  finger  to  the  outer  surface  of  the  lid, 
and  drawing  it  a  little  downwards,  the  eye- 
lashes start  into  view,  clinging  to  the  sur- 
face of  the  eyeball ;  a  little  more  traction 
rolls  the  edge  of  the  lid  completely  into  its 
natural  place,  and  there  is  no  appearance  of 
trichiasis.  The  conjunctiva  is  nowise  contracted,  the  lid  nowise  shortened,  the 
cartilage  nowise  changed  in  structure.  If  we  cease  making  pressure  on  the 
lid,  it  remains  for  a  minute  or  two  in  its  proper  position,  and  then,  with  a 
sudden  jerk,  becomes  inverted  as  before. 

This  kind  of  inversion  appears  to  be  owing  partly  to  the  relaxed  state  of 
the  integuments,  partly  to  an  irregular  action  of  the  orbicularis  palpebrarum. 
The  circumferential  part  of  the  muscle  seems  to  have  lost  its  wonted  power 
of  supporting  the  body  of  the  lid,  while  its  ciliary  portion,  acting  inordinately, 
rolls  the  edge  of  the  lid  into  the  inverted  position.  We  meet  with  this  variety 
of  entropium  almost  exclusively  in  elderly  persons  in  whom  the  skin  has  al- 
ready lost  its  natural  contractility,  so  that  it  falls  into  folds,  particularly  about 
the  eyelids.     A  superabundant  state  of  the  skin  evidently  favors  the  disease. 

[This  form  of  entropium  of  the  lower  lid  is  also  favored  in  old  persons  by  the 
sinking  of  the  eye  in  the  socket  consequent  on  the  absorption  of  the  adipose 
matter,  which  in  the  earlier  periods  of  life,  surrounds  the  optic  nerve  in  the 
bottom  of  the  orbital  cavity,  and  which  causes  the  prominence  of  the  eye  of 
a  person  of  robust  health.  Hence  this  form  of  entropium  may  occur  in 
consequence  of  great  emaciation,  after  a  long  spell  of  illness,  and  disappear 
as  the  health  improves  and  the  patient  recovers  his  former  rotundity. 


244 


ENTROPIUM. 


This  cause  of  entropium  can  only  produce  the  disease  in  the  lower  lid. 
The  reason  of  this  fact  can  readily  be  appreciated  by  a  reference,  in  the 
difference  of  the  movements  of  the  two  lids,  produced  by  the  contraction  of 
the  orbicularis  muscle.  The  upper  lid  descends  in  a  vertical  manner  as  low 
down  (according  to  ScEmraerring)  as  an  eighth  of  an  inch  below  the  inferior 
margin  of  the  cornea  before  it  meets  with  the  lower  lid,  which  is  rather  thrust 
forward  in  a  horizontal  direction  (as  has  been  shown  by  Sir  C.  Bell)  by  the 
action  of  its  portion  of  the  orbicularis;  and  when  the  eye  is  closed,  its  ciliary 
margin  is  completely  overlapped  by  that  of  the  upper  lid.  The  ciliary 
portion,  which  is  the  strongest,  of  the  orbicularis,  always  keeps  the  ciliary 
edges  of  both  lids  in  contact  with  the  ball,  whether  they  be  closed  or  widely 
opened. 

Such  being  the  movements  of  the  two  lids,  and  the  action  of  the  orbicu- 
laris, the  mechanism  of  the  above-mentioned  cause  of  entropium  of  the  lower 
lid  can  readily  be  understood.  The  cartilage  of  this  lid,  which  is  very  nar- 
row, is  diverted  from  its  more  or  less  horizontal  position  and  becomes  some- 
what vertical.  This  it  is  allowed  to  do  by  the  relaxed  condition  of  the 
integuments,  cellular  tissue,  and  the  circumferential  fibres  of  the  orbicularis, 
the  latter  perhaps  favoring  it  more  than  any  of  the  others.  In  this  position 
its  ciliary  border  being  considerably  below  the  horizontal  axis  of  the  eye 
can  readily  be  turned  in  by  the  slightest  rotation  of  the  ball  downwards,  and 
having  once  assumed  an  inverted  position  it  will  be  retained  there  by  the 
ciliary  portion  of  the  orbicularis.  It  can  readily  be  seen  that  such  a  state  of 
things  could  never  occur  in  the  upper  lid  by  the  action  of  this  cause. — H.J 

The  eyeball  is  much  irritated  by  the  eyelashes  rubbing  against  it  in  the  act 
of  winking,  and  hence  the  patient  keeps  the  eye  shut,  and  as  much  as  possible 
at  rest.  He  even  squeezes  the  lids  so  much  together,  as  to  bring  the  skin  of 
the  upper  and  lower  lids  into  contact.  The  eye  waters  much,  and  the  tears 
fret  and  excoriate  the  skin  of  both  lids.  The  cornea  inflames,  and  in  conse- 
quence of  neglect  may  become  totally  opaque. 

This  variety  of  inversion  is  an  occasional  attendant  on  catarrho-rheumatic 
or  arthritic  ophthalmia,  along  with  severe  circumorljital  pain,  and  sometimes 
with  ulceration  of  the  cornea.  In  such  cases  not  only  must  the  entropium  be 
removed,  but  at  the  same  time  venesection,  calomel  with  opium,  and  other 
remedies  must  be  used,  to  cure  the  ophthalmia.  We  occasionally  meet  with 
this  variety  in  children,  along  with  scrofulous  ophthalmia. 

2.  The  chronic  variety  of  inversion  is  the  result  of  long-continued  ophthal- 
mia tarsi,  or  neglected  catarrhal  conjunctivitis.  The  upper  lid  is  as  liable  to 
be  affected  as  the  lower,  and  often  both  are  inverted  at  the  same  time.  The 
edge  of  the  affected  lid  is  thickened,  irregular  and  notched,  and  shortened 
from  canthus  to  can  thus,  so  that  it  presses  unnaturally  on  the  eyeball.^  The 
cartilage  is  indui'ated  as  well  as  inverted.  The  sinuses  of  the  conjunctiva  are 
contracted,  and  its  surface  more  or  less  dry  and  cuticular.  No  degree  of 
traction  which  we  employ,  is  sufficient  to  roll  the  lid  into  its  natural  situation ; 

we  may  drag  it  from  the  eyeball,  and  bring 
the  cilia  into  view,  but  still  the  edge  of  the 
lid  continues  inverted.  (Fig.  34.)  The  cilia 
are  generally  few  in  number,  dwarfish,  and 
themselves  aS'ected  with  inversion,  independ- 
ently of  the  state  of  the  lid,  so  that  there  is 
a  combination  of  trichiasis  with  entropium. 
Notwithstanding  their  being  few  and  small, 
the  cilia  are  sufficient  to  keep  up  constant  suf- 
fering, and  by  the  irritation  which  they  occa- 
sion, to  render  the  cornea  vascular  and  nebu- 


ENTROPIUM.  245 

lous.  The  pain  tliey  induce  by  rubbing  against  the  eye,  deprives  the  patient 
of  the  enjoyment  of  sight;  he  keeps  his  eyes  constantly  shut,  and  avoids 
everything  which  would  produce  motion  of  the  lids  or  of  the  globe  of  the  eye. 
At  length,  the  cornea  becomes  quite  opaque,  and  its  conjunctival  layer  ac- 
quires a  degree  of  morbid  thickness  and  insensibility,  which  renders  the  paiu 
attending  the  disease  less  distressing.  Long  previously  to  this,  however,  the 
whole  conjunctiva  has,  in  general,  lost  its  secretive  power,  and  become  affected 
with  xeroma. 

Irregular  action  of  the  orbicularis  palpebrarum  may  also  have  to  do  with 
the  production  of  this  kind  of  inversion,  but  it  is  evident  that  the  structure 
of  the  lid  is  here  much  more  impaired.  Inflammation  has  altered  the  gland- 
ular organs,  the  conjunctiva,  the  perichondrium,  and  even  the  cartilage  itself. 
Repeated  ulcerations  have  destroyed  the  form  of  the  edge  of  the  lid,  notched 
it  with  cicatrices,  and  permanently  fixed  it  in  the  state  of  contraction  and 
inversion. 

3.  Traumatic  entropium  is  generally  the  result  of  a  scald  or  burn  of  the 
conjunctiva,  or  of  the  intrusion  of  some  caustic  substance,  as  quicklime,  into 
the  sinuses  of  the  eyelids.  It  is  often  conjoined  with  a  degree  of  symble- 
pharon,  and  sometimes  the  cartilage  has  been  partially  destroyed  by  the  injury. 

Prognosis. — This  is  favorable  in  the  acute  variety,  as  it  is  always  curable 
by  proper  applications,  or  by  operation.  Sometimes  the  disease  returns ; 
only  a  temporary  cure  in  either  of  these  ways  having  been  effected.  In  the 
chronic  variety,  the  prognosis  is  much  less  favorable.  Relief  to  the  pain, 
and  other  urgent  symptoms,  may  be  obtained  from  operation,  but  the  lids 
are  apt  to  remain  shrunk,  the  conjunctiva  atrophied,  and  the  cornea  diseased. 
The  i)rognosis  in  traumatic  cases  is  very  variable. 

Treatment. — 1.  The  treatment  of  the  traumatic  variety  will  depend  on  the 
degree  of  the  disease  ;  in  slight  cases,  the  operation  about  to  be  described  as 
suitable  for  acute  inversion  will  be  sufficient ;  in  worse  cases,  a  similar  plan 
of  cure  to  that  pursued  in  chronic  inversion,  may  be  necessary.  As  the  one 
of  these  two  kinds  or  degrees  of  inversion  is  much  less  complicated  in  its 
symptoms  than  the  other,  so  is  the  method  of  cure  for  the  one  simple,  for  the 
other  complex. 

Case  157. — In  consequence  of  a  wound  of  the  upper  lid  witli  some  sharp  instrument, 
and  the  wound  neglected,  in  a  man  who  put  himself  under  my  care,  the  nasal  half  of  the 
lid  was  inverted,  and  the  patient  sadly  tormented  by  the  irritation  of  the  eyelashes.  They 
were  so  much  inverted  as  to  be  fairly  on  the  inside  of  tlie  portion  of  the  lid  to  which  they 
belonged.  I  made  a  vertical  incision  with  a  pair  of  scissors  through  the  lid,  where  the 
nasal  and  temporal  halves  met,  intending  to  snip  out  a  fold  of  the  skin,  and  then  bring 
the  edges  accurately  together  by  the  interrupted  suture.  I  found,  however,  that  it  would 
be  unnecessary  to  remove  any  portion  of  the  skin.  As  soon  as  the  vortical  incision  of 
the  lid  was  made,  the  nasal  portion  came  itself  into  its  place,  so  that  I  had  merely  to 
bring  the  edges  of  the  incision  together  with  two  stitches. 

2.  In  every  case  of  inversion,  acute  or  chronic,  it  is  proper  to  endeavor  to 
remove  the  conjunctival  or  the  tarsal  inflammation,  in  which  the  misplacement 
of  the  lids  has  originated.  This  is  greatly  promoted,  in  most  cases,  by  clean- 
liness, fresh  air,  and  proper  attention  to  diet.  The  ophthalmia  must  be  treated 
with  the  remedies  which  its  peculiar  nature  demands  ;  and  on  this  point,  the 
reader  may  consult  the  sections  on  ophthalmia  tarsi,  catarrhal,  catarrho-rhcu- 
matic,  and  scrofulous  ophthalmias.  We  meet  with  many  cases  in  which  an 
operation  for  entropium  is  the  only  means  which  can  remove  the  ophthalmia, 
and  save  the  eye. 

3.  Acute  entropium  sometimes,  but,  it  must  be  confessed,  very  rarely,  sub- 
sides under  antiphlogistic  means,  aided  by  such  mechanical  contrivances  as 
keep  the  lid  in  its  natural  place.  For  this  purpose,  strips  of  adhesive  plaster 
used  to  be  applied  so  as  to  cross  each  other  upon  the  middle  of  the  lid ;  or  a 


246  ENTEOPIUM. 

small  pad,  sewed  upon  a  piece  of  tape,  was  made  to  press  upon  the  lid,  the 
tape  passing  over  the  nose,  under  the  ears,  crossing  on  the  occiput,  and  tying 
on  the  forehead.  These  means  are  now  supplanted  by  collodion.'^  The  lid 
being  held  in  its  natural  position,  the  whole  of  its  external  surface  is  to  be 
painted  by  means  of  a  smooth  piece  of  stick,  or  camel-hair  pencil,  with  collo- 
dion. This,  drying  instantly,  keeps  the  lid  from  reassuming  the  state  of 
inversion.  The  application  must  be  renewed  every  two  or  three  days,  and 
sometimes  it  proves  a  radical  cure.  Before  I  read  Mr.  Bowman's  paper  on 
the  subject,  I  covered  the  collodion  with  a  bit  of  cloth,  but  this  I  have  laid 
aside. 

In  acute  inversion,  when  we  take  hold  of  a  transverse  fold  of  the  skin  of 
the  inverted  lid,  the  displacement  is  for  the  time  removed,  and  the  patient 
can  open  and  shut  the  eye  without  difficulty,  and  without  any  return  of  the 
inversion.  Having  laid  hold,  then,  of  the  fold  of  skin  with  a  pair  of  broad, 
convex-lipped  forceps  (Fig.  17,  p.  213),  remove  it  with  the  scissors,  bring 
the  edges  of  the  wound  together  by  two  stitches,  and  as  soon  as  union  is 
completed,  the  inversion  will  be  found  to  be  cured. 

So  much  skin  as  is  sufficient  to  overcome  the  inversion,  and  neither  more 
nor  less,  is  to  be  removed.  After  laying  hold  of  the  fold  with  the  forceps, 
the  surgeon  must  observe  whether  the  cilia  appear  in  their  natural  place,  and 
have  their  proper  direction.  If  they  still  incline  inwards,  the  fold  is  too  little, 
and  more  of  the  skin  must  be  laid  hold  of;  if  the  cilia  not  only  incline  out- 
wards, but  the  conjunctiva  is  brought  into  view,  the  fold  is  too  broad,  and 
less  skin  must  be  grasped  with  the  instrument.  In  old  people,  it  is  sometimes 
necessary  to  remove  a  very  broad  piece  of  skin.  Care  must  always  be  taken 
to  leave  sufficient  integument  between  the  cilia  and  the  edge  of  the  wound,  for 
the  insertion  of  the  stitches. 

[We  have  seen  this  operation  for  entropion  with  the  ordinary  form  of 
Himly's  forceps,  as  delineated  at  p.  213,  fail  of  success  more  frequently  from 
the  character  of  the  instrument  used,  than  from  the  principle  on  which  it  was 
performed. 

In  cases  of  slight  inversion,  where  only  the  central  cilia  are  distorted,  the 
instrument  will  answer  very  well ;  but  when  the  entropion  is  more  extended, 
and  generally  when  all  the  cilia  are  turned  in,  the  curve  of  the  blades  is  too 
great,  and  their  length,  from  corner  to  corner,  not  sufficient  for  the  removal  of 
a  fold  of  the  integuments  of  a  proper  size  and  form.  For  such  cases,  we  have 
had  the  instrument  made  Avith  blades  of  a  length  sufficient  to  remove  an 
elliptical  piece,  one  and  a  half  inches  long,  should  it  be  necessary,  instead  of 
nine-tenths  of  an  inch,  the  greatest  length  that  can  be  removed  by  the  original 
form.  And  in  order  that  the  breadth  of  the  piece  thus  removed,  should  not 
be  proportionally  increased,  we  had  the  curve  of  the  blades  changed,  from 
that  corresponding  to  a  segment  of  a  circle  of  three-fifths  of  an  inch  radius, 
the  original  curve,  to  that  of  one  and  a  half  inch  radius.  The  portion  of 
integument  excised  by  the  aid  of  forceps  thus  constructed,  measures  half  an 
inch  in  its  vertical  diameter,  and  corresponds,  in  this  respect,  precisely  with 
the  portion  removed  by  the  original  instrument ;  it,  however,  exceeds  it  in 
its  transverse  or  long  diameter  by  more  than  half  an  inch. 

To  make  the  instrument  hold  more  firmly,  the  blades  should  not  be  bevelled 
and  roughened  on  their  inner  surface,  but  should  be  flat  and  deeply  grooved, 
so  as  to  give  to  each  a  well  defined,  double  biting  edge — not  so  sharp,  how- 
ever, as  to  cut  the  tissues  within  their  grasp.  These  forceps  should  also  be 
provided  with  a  wedge-shaped  sliding  catch,  not  placed,  however,  on  the  inside 
of  the  handle,  but  on  the  back  of  one,  so  as  to  enable  it  to  be  made  lai'ge. 
The  wedge  should  be  triangular  from  above  downwards,  flattened  from  side 
to  side,  near  half  an  inch  long,  one-eighth  wide,  with  a  base  of  one-fifth  of 


ENTROPIUM.  24^ 

an  inch,  and  from  this  it  should  taper  down  gradually  to  a  sharp  edge  ;  the 
handle  on  which  this  slides,  should  have  a  fenestra  in  it  for  the  transmission 
of  the  cross  piece  from  the  opposite  handle,  which  should  have  a  square  hole 
in  itself,  to  receive  the  wedge.  By  this  means  the  blades  can  be  kept  in  any 
degree  of  proximity  with  the  utmost  firmness  and  precision,  and  will  be 
effectually  prevented  from  slipping  by  the  starting  of  the  patient  at  the  first 
stroke  of  the  cutting  instrument. — H.] 

If  this  variety  of  inversion  has  lasted  a  considerable  time,  and  in  addition 
to  the  mere  displacement  of  the  lid,  consequent  to  the  redundant  state  of  the 
skin,  and  irregular  action  of  the  orbicularis,  there  appears  some  unnatural 
disposition  of  the  cartilage  to  turn  inwards,  it  may  be  proper,  after  removing 
the  cutaneous  fold,  to  snip  off"  some  of  the  fibres  of  the  muscle,  so  as  to  form 
a  firmer  cicatrice,  actually  fixed  to  the  cartilage.  Mr.  Haynes  Walton^  insists 
particularly  on  the  removal  of  the  ciliary  portion  of  the  orbicularis,  conceiv- 
ing the  disease  to  depend  on  its  inordinate  action. 

The  portion  of  the  skin  to  be  removed  might  be  destroyed  by  the  actual 
cautery,  or  by  escharotics ;  but  the  operation  just  described  is  much  to  be 
preferred.  The  escharotic  employed  by  Helling*  and  Quadri'*  for  this  pur- 
pose is  concentrated  sulphuric  acid,  which  is  applied  in  the  following  man- 
ner ; — 

The  skin  of  the  inverted  lid,  to  the  breadth  of  about  three  lines,  and  one 
line  from  its  tarsal  edge,  is  to  be  rubbed  with  the  acid,  by  means  of  a  pencil 
of  wood  dipped  in  it,  with  the  precaution  of  not  taking  up  more  than  what 
merely  wets  the  pencil.  After  ten  seconds,  the  part  is  to  be  dried,  and  the 
acid  reapplied,  and  this  even  a  third  or  a  fourth  time,  until  a  sufficient  eschar 
has  been  formed,  or  a  marked  contraction  has  taken  place.  The  part  is  then 
to  be  cai'efidly  washed.  Of  course,  great  care  must  be  taken  that  none  of 
the  acid  gets  into  the  eye.  After  a  time,  it  may  be  necessary  to  repeat  the 
operation. 

Instead  of  a  horizontal,  some  surgeons,  as  Janson,  of  Lyons,  cut  out  a 
vertical  slip  of  skin,  and  bring  the  edges  of  the  wound  together  in  the  usual 
way.^ 

[Janson's  method  will  be  found  particularly  applicable  to  cases  of  entropion 
in  the  old,  which  owe  so  much  of  their  intensity  to  the  relaxation  of  integu- 
ment and  sinking  of  eyeball. — H.] 

4.  In  chronic  entvopium,  neither  the  operation  with  the  scissors,  nor  the 
application  of  escharotics,  is,  in  general,  of  any  use.  In  slight  cases,  however, 
where  the  tarsus  is  but  little  affected,  it  may  be  proper  to  try  the  effect  of 
removing  a  fold  of  skin,  especially  if  it  be  the  lower  lid  which  is  affected. 
Acute  inversion  is  curable  by  an  operation  on  the  skin,  by  shortening  in  fact 
the  skin  of  the  affected  lid,  and  binding  down  the  tarsus  to  the  cicatrice;  but 
in  chronic  inversion,  we  generally  find  that  nothing  done  to  the  skin  merely 
is  of  much  service.  Portion  after  portion  of  it  may  be  removed  in  advanced 
cases  of  this  variety  of  inversion,  but  the  disease  continues  as  before.  The 
altered  condition  of  the  tarsus  prevents  the  lid  from  resuming  its  natural 
position.  The  lid,  then,  must  be  attacked  in  a  different  way.  Saunders''  • 
cut  out  the  tarsus  of  the  upper  lid  altogether,  along  with  the  roots  of  the 
cilia ;  others  have  amputated  the  entire  edge  of  the  lid,  or  extirpated  the 
bulbs,  as  has  been  explained  in  the  preceding  section. 

As  an  evident  shortening  of  tlie  lid  in  the  transverse  direction  attends  the 
inveterate  cases  of  this  kind  of  inversion,  and  produces  a  degree  of  constric- 
tion on  the  eyeball,  an  idea  suggested  itself  to  Ware,  that  the  lid  in  such  a 
state  might  be  relieved  by  a  perpendicular  incision  through  its  whole  thick- 
ness, either  at  its  temporal  extremity,  or  in  its  middle.  Such  an  incision 
would  at  least  release  the  eyeball  from  the  state  of  pressure  caused  by  the 


248  ENTROPIUM. 

contracted  lid;  aud  if  left  to  itself,  to  be  filled  up  by  granulation,  might  allow 
a  permanent  elongation  of  the  lid  in  the  transverse  direction. 

It  was  probably  from  this  hint  of  Mr.  Ware,  that  Sir  P.  Crampton  was 
led  to  devise  the  following  operation  for  the  relief  of  inveterate  cases  of  chronic 
inversion.  Supposing  it  to  be  the  upper  lid  which  is  affected,  it  is  to  be 
divided  perpendicularly,  for  the  length  of  from  a  quarter  to  half  an  inch, 
close  to  its  temporal  extremity,^  with  straight  probe-pointed  scissors.  A 
similar  incision  is  then  to  be  made  at  the  nasal  extremity  of  the  affected  lid, 
taking  care  to  avoid  the  punctum  and  lachrymal  canal. ^  These  incisions 
being  made,  the  eyelid  immediately  feels  unconfined ;  it  can  be  lifted  from 
the  eyeball,  and  the  patient  is  already  freed  from  a  great  part  of  his  uneasi- 
ness. "Were  we  now  to  leave  the  lid  to  itself,  it  would  speedily  resume  its 
former  place,  the  incisions  by  which  we  had  liberated  it  Avould  unite  by  the 
first  intention,  and  no  permanent  relief  would  be  effected.  To  prevent  im- 
mediate union,  Sir  P.  Crampton  employed  an  instrument  similar  to  Pellier's 
speculum  (Fig.  31,  b),  by  which  he  kept  the  eyelid  constantly  suspended,  and 
permitted  only  a  slow  union  by  granulation.  Instead  of  using  the  speculum, 
Mr.  Guthrie  recommended  a  fold  of  the  skin  of  the  afi'ected  lid  to  be  excised, 
exactly  as  in  the  operation  for  acute  inversion  ;  the  edges  of  the  wound, 
made  by  the  removal  of  this  fold,  to  be  brought  together  by  two  or  three 
stitches ;  aud  then,  by  means  of  three  ligatures,  inserted  through  the  edge  of 
the  lid,  and  fixed  to  the  forehead  by  strips  of  plaster,  the  lid  to  be  kept  ele- 
vated for  eight  or  ten  days.  Over  the  everted  lid,  a  bit  of  spread  lint  is  to 
be  applied,  and  a  roller  round  the  head.  The  perpendicular  incisions  slowly 
fill  up  by  granulation;  the  slower  the  better;  we  ought  daily  to  separate  their 
edges  with  the  probe,  and  touch  them  with  sulphate  of  copper,  to  hinder  them 
from  healing  rapidly;  the  union,  when  at  length  completed,  does  not  compre- 
hend the  orbicularis  palpebrarum ;  the  divided  fibres  of  the  muscle  shrink, 
like  the  divided  ends  of  every  other  muscle  ;  the  diseased  cartilage,  in  the 
meantime,  loses  also  much  of  its  induration  and  irregularity,  and  thus  the  lid, 
when  reunited,  is  found  improved  in  structure,  and  almost  natural  in  position.^" 
Such,  at  least,  is  the  hope  held  out  by  the  favorers  of  this  mode  of  cure.  I 
am  sorry  to  say,  that  my  experience  of  this  operation  has  not  been  satisfac- 
tory. Temporary  relief  it  certainly  affords  ;  but  after  the  healing  process  of 
the  vertical  incisions  is  complete,  the  lid  is  generally  found  nearly  in  as  bad 
a  condition  as  it  was  before  the  operation.  On  this  subject  the  reader  may 
consult  with  advantage,  Mr.  Wilde's  paper  on  entropium  and  trichiasis,  in 
the  Dublin  Journal  of  Medical  Science  for  March,  1844.  A  surer  method 
of  relieving  chronic  entropium  will  be  found  in  Jager's  excision  of  the  bulbs 
of  the  cilia,  as  described  in  the  last  Section. 

Mr.  Wharton  Jones  informs  me,  that  in  chronic  cases  of  inversion  of  the 
lower  eyelid,  he  has  performed  the  following  operation,  with  perfect  success. 
Having  made  an  incision  through  the  whole  thickness  of  the  lid,  perpendicular 
to  its  edge,  near  the  outer  canthus,  he  cuts  out  a  piece  of  the  skin,  and,  by 
means  of  the  thread  forming  the  suture,  fixes  the  lid  in  the  everted  position. 


'  See  Ammon  on  Phpiosis  Palpebrarum,  in  ^  Carron  du  Villards,  Guide  Pratique  ;  Tome 

Zeitschrift  fur  die  Ophthalmologie;  Vol.  ii.  p.  i.  p.  320;  Paris,  18.38. 

140  ;^  Dresden,  1832.  "  Treatise  on  some  practical  points  relating  to 

^  See  Bowman,  in  Braithwaite's  Retrospect  the  Diseases  of  the  Eye,  p.  41;  London,  1811. 

of  Medieitio  and  Surgery  ;  Vol.  xxiii.  p.  264:  *  If  the   incision,  as  directed  in  the  te.xt,  is 

Lo^ndnn,  1851.  made  close  to  the   temporal  extremity  of  the 

°  Operative  Ophthalmic  Surgery,  p.  160;  Lon-  lid,  it  will  cut  through  the  glandula;  congre- 

don.1853.  gata,  and  some  of  the  lachrymal  ducts.     Unless 

*  Ilufeland's  Journal,  1815  ;  St.  4,  p.  98.  the    ins-ersion   extends,  therefore,  to  the  very 

'  Aunotazioni  Pratiche  sulle  Malattie    dedi  angle,  it  may  be  proper  to  avoid  these  parts,  by 
Occhi;  Vol.  i.  p.  69  ;  Napoli,  1818. 


PHTHIRIASIS.  249 

keeping  a  line  or  two  from  the  extremity  of  the  of  a  transverse  fold  of  the  integuments.      In 

lid,  and  towards  the  nose.  Mr.  Guthrie's  modification  of  the  operation,  the 

'  Sir  P.  Crampton  cut  through  the  lachrymal  cartilage  is  divided  transversely,  as  well  as  the 

canal;  but  ever  since  I  began  to  give  lectures  conjunctiva. 

on  the  eye,  in  1818,  I  have  directed  this  to  be  '°  Essay  on  the  Entropeon ;  by  Philip  Cramp- 
avoided.  I  have  always  discountenanced  also  ton,  M.  D.;  London,  1806:  Lectures  on  the 
the  transverse  incision  of  the  conjunctiva,  re-  Operative  Surgery  of  the  Eye  ;  by  G.  J.  Guth- 
commended  by  Sir  Philip  ;  and  insisted  par-  rie,  p.  31 ;  London,  1823  :  Jacob,  in  Dublin 
ticularly  on  the  propriety  of  following  up  the  Hospital  Reports;  Vol.  v.  p.  389;  Dublin, 
first  steps  of  this  operation,  by  the  extirpation  1830. 


SECTION  XXXVI.  — ANCHYLOBLEPHARON. 


This,  althongli  strictly  a  disease  of  the  eyelids,  I  shall  consider  along  with 
symblepharon,  in  a  following  chapter,  among  the  diseases  consequent  to  the 
ophthalmise. 


SECTION  XXXVII. — MADAROSIS. 

MaSapaayij,  from  juajjf,  bald. 

Partial  madarosis  is  common  after  hordeolum,  and  after  smallpox,  the 
abscesses  seated  on  the  edge  of  the  eyelid  destroying  the  bulbs  of  the  cilia. 
Neglected  ophthalmia  tarsi  is  apt  to  end  in  a  more  extensive  madarosis  of 
the  same  kind.  The  cilia,  of  which  the  bulbs  have  been  destroyed,  cannot 
be  reproduced. 

Both  the  cilia  and  the  hairs  of  the  eyebrow  are  liable  to  fall  out,  from  dif- 
ferent constitutional  diseases ;  but  in  this  case  they  generally  grow  again. 
The  want  of  the  eyelashes  and  hairs  of  the  eyebrow  is  productive  of  frequent 
nictitation,  in  order  to  moderate  the  glare  of  day,  and  prevent  the  entrance 
of  foreign  particles  into  the  eye. 

Case  158. — I  was  consulted,  some  time  ago,  by  a  man  "who  had  lost  every  hair  of  his 
body.  His  head  was  perfectly  bald,  he  had  no  eyebrows  nor  eyelashes,  his  beard  was 
gone,  no  hair  in  the  armpits,  on  the  pubes,  nor  on  the  limbs.  He  vras  anxious  to  regain 
chiefly  the  eyebrows  and  eyelashes,  as  he  found  his  eyes  much  weakened  by  the  want  of 
them.  He  was  inclined  to  attribute  his  disease  to  some  slight  venereal  complaint,  which 
had  been  cured  by  mercury. 

I  was  consulted  also  by  a  lady,  who  had  sustained  a  similar  loss  of  the 
whole  hairs  of  the  body. 

The  treatment,  both  local  and  general,  already  recommended  for  ophthal- 
mia tarsi,  must  be  carefully  adopted  in  cases  of  threatened  madarosis.  In 
constitutional  cases,  tonics  are  to  be  employed  both  internally  and  exter- 
nally, as  it  is  evident  that  weakness  has  much  to  do  in  the  production  of  the 
disease.  Cinchona  is  particularly  recommended  internally,  and  an  infusion  of 
the  petals  of  the  rosa  centifolia  in  wine,  as  a  collyrium.  When  there  is  a 
suspicion  of  syphilis  being  the  cause,  mercury  and  sarsaparilla  should  be 
tried.  In  such  cases  as  those  to  which  I  have  referred,  artificial  eyebrows 
may  be  applied  with  advantage. 


SECTION  XXXVm. — PHTHIRIASIS  OP  THE  EYEBROW  AND  EYELASHES. 

cSaiptao-ij,  from  <p^i\o,  louse. 
Fig.  Dalrymple,  PI.  VL  Fig.  6. 

Phthiri  or  crab-lice  sometimes  lodge  among  the  cilia  and  eyebrows,  where 
they  keep  up  a  chronic  inflammation,  and  cause  intolerable  itching.     They 


250  DISEASES   or   THE   TUNICA   CONJUNCTIVA. 

are  so  small  that  they  may  escape  observation,  unless  a  lens  is  employed  in 
examining  the  parts.  Their  ova  give  the  cilia  an  appearance  of  being  co- 
vered with  a  black  powder. 

"  A  child  came  to  the  Infirmary,"  says  Mr.  Lawrence,*  "complaining  of 
the  eyes  being  sore,  and  said  they  itched  very  much.  I  looked  at  the  eye, 
and  could  not  see  much  the  matter,  but  I  thought  that  the  cilia  had  rather 
a  thick  appearance,  and  on  a  more  accurate  examination,  I  found  that  this 
was  caused  by  an  infinite  number  of  pediculi  sticking  over  the  hairs.  I 
ordered  the  free  application  of  the  citrine  ointment,  and  wished  to  see  its 
effect ;  but  the  mother,  who  came  with  the  child,  was  so  much  offended  at 
being  told  the  cause  of  the  complaint,  that  she  did  not  bring  the  child  back 
again." 

In  such  cases,  some  mercurial  salve,  as  that  recommended  by  Mr.  Lawrence, 
and  attention  to  cleanliness,  will  generally  be  effectual ;  although  the  disease 
sometimes  resists  mercurial  salves  for  a  considerable  time.  After  rubbing 
the  eyebrow  or  edge  of  the  eyelid  with  mercurial  ointment,  or  bathing  the 
part  with  a  solution  of  two  grains  of  corrosive  sublimate  in  an  ounce  of 
distilled  water,  taking  care  to  avoid  the  eyeball  while  using  the  latter  appli- 
cation, we  should  endeavor  to  dislodge  the  phthiri  with  a  small  spatula  or 
forceps.    This  should  be  repeated  twice  or  thrice  a-day. 


'  Lectures  in  the  Lancet,  Vol.  x.  p.  323  ;  London,  1826. 

CHAPTER    IV. 
DISEASES  OF  THE  TUNICA  CONJUNCTIVA. 


The  principal  morbid  affections  of  the  conjunctiva  fall  under  the  heads  of 
the  Ophthcdmice,  and  Consequences  of  the  Ophihahnice.  There  are,  however,  a 
few  diseases  of  this  portion  of  the  tutamina  oculi,  which,  I  conceive,  it  will 
be  convenient  to  introduce  here.  We  have  considered  the  diseases  of  the 
secreting  lachrymal  organs  ;  the  tears  flow  from  them  over  the  conjunctiva  ; 
this  conducting  organ  of  the  tears  seems,  then,  naturally  to  claim  our  atten- 
tion, before  proceeding  to  the  excreting  lachrymal  apparatus. 

The  conjunctiva  is  a  transition-structure  between  mucous  membrane  and 
skin,  connected  to  the  neighboring  parts  by  areolar  tissue.  This  tissue  is 
liable  to  phlegmonous  inflammation,  inflammatory  oedema  or  chemosis,  and 
to  ecchymosis,  and  emphysema ;  while  the  conjunctiva  itself  is  chiefly  subject, 
on  the  one  hand,  to  blennorrhceal  inflammation,  and,  on  the  other,  to  a  variety 
of  eruptive  diseases.  We  meet  with  fungus,  warts,  and  tumors  of  the  con- 
junctiva. In  some  cases,  its  papillary  structure  is  affected  with  a  morbid 
degree  of  development ;  while,  in  other  cases,  the  conjunctiva  seems  to  lose 
its  faculty  of  secreting  mucus,  and  becomes  dry  and  contracted.  The  com- 
pound nature  of  the  membrane,  expressed  by  the  term  muco-cntaneous,  serves 
as  a  key  to  its  pathology. 


FOREIGN   SUBSTANCES   ADHERING   TO   THE   CONJUNCTIVA.         251 


SECTION  I. — FOREIGN  SUBSTANCES  ADHERING  TO  THE  CONJUNCTIVA. 

1.  Particles  of  dust,  bits  of  straw,  parings  of  the  nails,  the  nibbings  of 
pens,  small  insects,  and  the  like,  getting  into  the  eye,  to  use  the  common 
phrase,  by  which  is  meant  getting  into  one  or  other  of  the  conjunctival 
sinuses,  are  gradually  ejected  by  the  natural  movements  of  the  eyelids,  the 
upper  lid  bringing  them  down  in  the  act  of  nictitation,  while  the  lower 
shoves  them  on  towards  the  nose,  till  they  are  fairly  placed  on  the  caruncula 
lachrymalis,  whence,  perhaps  some  hours  after  their  intrusion,  the  instinctive 
application  of  the  finger  removes  them  entirely.  If  the  foreign  substance, 
however,  adheres  to  any  part  of  the  conjunctiva,  it  then  gives  more  than 
ordinary  uneasiness,  and  the  patient  either  makes  attempts  himself  to  with- 
draw it  immediately,  or  seeks  relief  from  the  hand  of  another.  His  own 
attempts  are  often  fruitless ;  and  it  is  amazing  how  often  medical  practi- 
tioners dismiss,  unrelieved,  those  who  apply  to  them  under  such  circumstances, 
simply  from  not  everting  the  upper  lid,  on  the  inner  surface  of  which,  in  nine 
cases  out  of  ten,  the  foreign  body  will  be  detected.  The  case  being  left  in 
this  way,  the  pain  may  gradually  subside  in  the  course  of  a  day  or  two,  so 
that  the  patient  may  forget  the  accident,  and  not  know  to  what  cause  to 
ascribe  the  inflammation  which  gradually  develops  itself  in  his  eye,  and 
persists  obstinately,  notwithstanding  the  use  of  various  means,  till  the  lid  is 
examined,  and  the  foreign  body  detected  and  removed. 

Blown  into  the  eye  by  the  wind,  foreign  particles,  in  general,  adhere  merely 
to  the  conjunctiva,  often  to  the  conjunctiva  cornete,  and  rarely  penetrate  into 
or  under  that  membrane.  If  they  are  lying  on  the  surface  of  the  ocular 
conjunctiva,  they  are  seen  at  once  on  opening  the  eye,  and  are  easily  removed 
with  the  point  of  a  toothpick,  or  the  edge  of  a  small  elastic  silver  spatula 
(Fig.  35).     The  latter  instrument  answers  extremely  well  for  the  removal  of 

Fig.  35. 


particles  adhering  to  the  surface,  or  imbedded  in  the  epithelium  of  the 
cornea. 

It  is  remarkable  that  those  very  minute  foreign  bodies  of  a  black  color, 
vulgarly  called  fires,  are  never  met  with  over  the  sclerotica,  but  only  on  the 
cornea,  sometimes  just  at  its  edge,  but  generally  near  its  centre  or  on  its 
lower  half.  Notwithstanding  their  general  resemblance,  they  are  not  all  of 
the  same  nature.  Sometimes  they  are  particles  of  iron,  which  have  been 
projected  in  an  ignited  state  against  the  eye,  when  a  person  is  striking  fire 
with  flint  and  steel,  sharpening  iron  instruments  and  the  like.  Dr.  Schindler 
has  shown*  that  they  appear  smooth  and  round,  when  viewed  with  the 
microscope.  They  lie  more  or  less  firmly  in  the  little  pit  they  form  for 
themselves  in  the  cornea ;  and,  even  when  they  remain  there  for  weeks,  may 
leave  no  oxide  behind  them. 

In  other  cases,  the  foreign  bodies  in  question  consist  of  minute,  unignited, 
metallic  splinters,  driven  with  force  against  the  eye ;  as  sometimes  happens 
in  tiling  or  turning  iron.  Being  sharp  and  angular,  they  remain  firmly 
wedged  in  the  epithelium  of  the  cornea  ;  and  their  fine  points,  having  become 
oxidized,  are  apt  to  break  off  when  the  bodies  themselves  are  removed,  and 
leave  a  reddish  brown  stain  of  the  cornea.  After  removing  such  bodies,  we 
find  they  are  not  attracted  by  the  magnet,  till  they  are  allowed  to  dry  ;  then 


252         FOREIGN    SUBSTANCES   ADHERING   TO   THE   CONJUNCTIVA, 

they  spi'ing  to  it.  Their  minuteness  and  fixed  position  in  the  epithelium, 
prevent  theiv  doing  this,  while  attached  to  the  eye. 

Almost  as  common  as  the  above  mentioned  are  little  black  bodies,  not  of 
metallic  origin,  and  often  vegetable.  Sometimes,  on  examining  them  with 
the  microscope,  they  are  discovered  to  be  the  germs  of  grasses ;  in  other 
cases,  particles  of  coke  or  coal.  With  the  naked  eye,  it  is  often  impossible 
to  distinguish  between  these  and  metallic  particles.  It  is  to  be  observed, 
that  it  is  not  necessary  for  a  foreign  particle  to  be  iron,  to  leave  a  rusty  spot 
after  it  falls  off  or  is  removed  artificially.  The  same  thing  may  arise  from 
vegetable,  as  well  as  mineral  or  metallic,  substances.  By  and  by,  the  rusty 
spot  is  thrown  off,  and  no  trace  of  the  injury  left,  unless  ulceration  has  super- 
vened. 

Dr.  Schindler  does  not  think  the  presence  of  such  foreign  bodies  as  have 
just  been  described,  very  productive  of  danger  ;  and  undoubtedly,  the  eye  is 
much  more  frequently  destroyed  by  the  rude  attempts  of  smiths  and  other 
ignorant  people  to  remove  such  bodies  from  the  cornea,  than  when  they  are 
allowed  to  remain  and  drop  out  of  themselves.  That  they  should  always  be 
removed,  however,  is  certain,  and  if  merely  imbedded  on  the  surface  of  the 
cornea,  the  best  instrument  for  the  purpose  is  the  small  spatula  figured  aljove. 
The  operator  raises  the  upper  eyelid  with  his  thumb,  taking  care  not  to  touch 
the  lower  eyelid  nor  the  cilia  of  either  eyelid  ;  he  now  tells  the  patient  to  look 
at  him,  and  with  the  edge  of  the  spatula  the  foreign  body  is  in  general  easily 
unseated.  This  is  not  the  method  recommended  by  Dr.  Schindler,  who  uses 
a  camel-hair  pencil  for  the  purpose  ;  a  safer  instrument,  certainly,  than  the 
extraction-knife,  but  which  in  many  cases  would  be  found  insufficient  to  effect 
the  object  in  view. 

It  sometimes  happens  that  the  irritation  does  not  attract  sufficient  atten- 
tion, so  that  the  foreign  substance  is  left  adhering  to  the  conjunctiva  for 
days,  or  even  for  weeks,  or  months,  bringing  on  inflammation,  or  even  ulcera- 
tion, without  any  attempt  being  made  to  discover  the  cause,  or  to  remove  it. 
On  the  surface  of  the  cornea,  this  may  give  rise  to  a  permanent  speck  or 
opacity. 

2.  Foreign  substances,  adhering  to  the  eye,  not  unfrequently  simulate  the 
appearances  of  pustules,  specks,  &;c.,  as  the  following  cases  will  show  : — 

Case  159. — Daniel  Newton,  aged  14,  from  Paisley,  applied  at  the  Glasgow  Eye  Infirm- 
ary, on  account  of  considerable  pain  and  inflammation  of  the  left  eye,  which  had  con- 
tinned  for  two  months,  notwithstanding  the  application  of  a  salve,  a  sugar  of  lead  poultice 
over  the  lids,  leeches,  and  repeated  blistering.  There  was  a  small  semi-opaque  elevation, 
running  nearly  in  a  vertical  direction,  and  occupying  the  centre  of  the  cornea.  Its  figure 
being  different  from  that  of  any  ordinary  pustule  or  speck,  I  touched  it  with  the  convex 
side  of  a  small  hook,  when  it  instantlj^  separated  from  the  cornea,  and  proved  to  be  what, 
in  Scotland,  is  known  by  the  name  of  a  meal-seed,  that  is,  a  fragment  of  the  husk  of  a 
grain  of  oats,  about  the  sixth  of  an  inch  in  length,  and  the  fortieth  of  an  inch  in  breadth. 
The  cornea,  where  the  foreign  substance  had  adhered,  appeared  slightly  nebulous.  Eight 
days  after,  the  inflammation  was  completely  gone,  the  cornea  natural,  and  vision  perfect. 

Case  160. — A  child  of  three  months  was  brought  to  me  by  its  mother,  who  said  that 
one  of  the  eyes  had  been  inflamed  for  six  weeks,  and  that  a  speck  had  grown  on  it.  Dif- 
ferent remedies  had  been  tried,  and  a  blister  recommended.  On  examining  the  eye,  I 
found  one-half  of  the  husk  of  a  phalaris  seed  adhering  to  the  cornea,  a  little  below  the 
level  of  the  pupil,  simulating,  to  an  inexperienced  or  careless  observer,  a  speck  or  pus- 
tule.    It  was  easily  removed  with  the  point  of  a  toothpick. 

Case  161. — An  infant,  ten  weeks  old,  was  brought  to  me  by  its  mother,  who  said  there 
was  a  speck  on  one  of  its  eyes,  for  which  she  had  been  using  a  solution  of  caustic,  given 
by  her  medical  attendant.  She  had  observed  the  speck  for  three  weeks,  but  knew  no 
change  in  its  appearance.  It  had  exactly  the  color  of  a  thin  leucoma,  and  did  not  seem 
in  the  least  elevated;  but  as  it  was  square-shaped,  I  immediately  suspected  it  to  be  the 
fragment  of  some  seed,  and  lifted  it  off  with  the  spatula. 

Case  162. — A  child  was  brouglit  to  me  with  severe  inflammation  of  one  of  its  eyes,  and 
puriform  secretion  from  the  conjunctiva.     From  under  the  edge  of  the  upper  lid  there 


FOREIGN   SUBSTANCES   ADHERING   TO   THE   CONJUNCTIVA.  253 

projected  a  black  roundish  body,  -vvliich,  at  first  view,  I  was  afraid  might  be  a  protrusion 
of  part  of  the  iris  through  an  ulcer  of  the  cornea.  The  parents  were  of  opinion  that  the 
eye  was  gone,  and  evidently  labored  under  some  notion  of  the  same  kind  as  that  which 
occurred  to  myself,  when  I  laid  down  the  child  to  examine  the  exact  state  of  disease. 
How  great  was  my  surprise  when,  on  raising  cautiously  the  upper  eyelid,  I  found  this 
was  a  case,  not  of  figurative,  but  of  real  myocephalon !  A  common  house-fly  was  fairly 
lodged,  and  had  been  so  for  eight  days,  between  the  eyeball  and  the  upper  eyelid ;  its 
head  only  projecting  in  the  manner  described,  and  producing  an  appearance  as  if  the  eye 
were  disoi-ganized. 

3.  It  is  remarkable  how  tenaciously  a  foreign  substance  will  adhere  to  the 
surface  of  the  eye.  The  surrounding  vessels  become  distended  with  blood, 
and  the  portion  of  conjunctiva  covered  by  the  foreign  body  soon  puts  on  a 
fungous  appearance. 

Case  163. — A  child  of  ih  years  was  brought  to  me  from  the  country,  with  a  black  sub- 
stance firmly  adhering  to  the  conjunctiva  covering  the  sclerotica.  It  was  supposed  to  be 
a  bit  of  coal,  and  several  attempts  had  been  made  to  remove  it.  Laying  the  child  on  its 
back,  fixing  its  head  between  my  knees,  and  steadily  elevating  the  upper  eyelid,  I  laid 
hold  of  the  foreign  substance  with  a  pair  of  forceps.  It  came  away,  leaving  the  portion 
of  conjunctiva  which  it  had  covered,  in  an  inflamed  and  fungous  state.  On  examination, 
it  proved  to  be  half  the  husk  of  a  hemp  seed,  which  had  stuck  to  the  eye  by  its  concave 
surface,  and  had  become  blackened  by  imbibing  moisture  from  the  conjunctiva.  It  had 
remained  for  seven  days  in  the  situation  in  which  I  found  it. 

4.  If  the  foreign  body  is  not  visible  on  the  surface  of  the  eyeball,  it  will 
sometimes  come  into  view,  on  drawing  down  the  lower  lid.  If  nothing  is 
discovered  in  the  lower  sinus  of  the  conjunctiva,  then  the  upper  is  to  be  ex- 
amined. This  is  done  by  making  the  patient  lean  his  head  back  and  look 
towards  the  ground,  while  we  raise  the  lid  and  look  under  it ;  or  we  at  once 
evert  the  upper  lid,  in  the  following  manner.  We  lay  hold  of  the  eyelashes 
with  the  finger  and  thumb  ;  and  whilst  by  this  means  the  edge  of  the  lid  is 
drawn  outwards  and  upwards,  a  slight  counterpoise  is  to  be  made  with  the 
round  end  of  the  small  spatula,  on  the  outer  surface  of  the  lid,  opposite  to 
the  upper  edge  of  its  cartilage.  Between  these  two  forces  the  lid  is  readily 
everted,  so  that  its  internal  surface  is  exposed. 

[A  simpler,  and  often  (when  done  with  skill)  a  much  less  painfiil  method 
of  everting  the  upper  lid  is  that  described  by  M.  Desmarres,  though  it  is  not 
original  with  that  gentleman.  It  consists  in  depressing  the  lid  from  above 
downwards  by  means  of  the  index  finger  (of  the  left  hand  for  the  right  eye 
and  vice  versa)  placed  a  little  above  the  adherent  margin  of  the  cartilage. 
This,  after  bringing  the  ciliary  margin  of  both  lids  in  contact,  will  cause  the 
upper  to  slide  forward,  and  over  the  lower.  Continuing  this  pressure  on  the 
upper  lid  its  free  edge  will  look  towards  you,  and  the  cartilage  will  become 
almost  horizontal.  Then  placing  the  thumb  on  this  free  edge  and  in  contact 
with  its  mucous  surface,  you  force  it  up,  and  at  the  same  time  continue  the 
downward  pressure  on  the  adherent  margin.  This  double  movement,  as  it 
were,  of  sliding  the  two  fingers  over  each  other,  by  an  opposite  motion,  with 
the  lid  interposed  between  them,  will  completely  effect  its  eversiou,  and  will 
require  but  a  second  of  time  for  its  performance.  It  is,  indeed,  astonishing 
with  what  facility  (after  a  little  practice)  it  can  be  accomplished.  The  ad- 
vantages which  M.  Desmarres  claims,  and  which  we  have  experienced  in  the 
use  of  this  means  of  evulsion,  are  its  facility  of  execution,  requiring  no  instru- 
ment whatever  to  aid  you,  its  not  giving  rise  to  any  traction  on  the  cilia, 
and,  thus  avoiding  the  risk  of  their  removal,  the  not  unfrequent  result  of  the 
method  above  described,  particularly  in  cases  of  conjunctivitis  complicated 
with  tarsal  inflammation  ;  and  then  again  it  avoids  all  unnecessary  alarm  to 
patients,  particularly  children,  who  often  dread  even  the  approach  of  an 
ordinary  lead-pencil  to  the  eye,  lest  it  might  contain  some  concealed  instru- 
ment.— H.] 


254         FOREIGN    SUBSTANCES   ADHERING   TO   THE   CONJUNCTIVA. 

In  many,  indeed  in  most  cases  in  which  a  particle  of  dust  lodges  in  the 
eye,  a  single  black  point  will  be  observed  adhering  to  the  inside  of  the 
everted  lid,  and  can  readily  be  removed.  The  foreign  particle,  however, 
may  be  a  minute  fragment  of  some  transparent  substance,  and  may  not  be 
detected,  unless  with  the  spatula  or  the  point  of  the  finger  we  go  over  the 
surface  of  the  conjunctiva.  The  intolerable  pain,  and  violent  spasm  of  the 
orbicularis  palpebrarum,  which  generally  attend  the  presence  of  a  foreign 
particle  fixed  on  the  inside  of  the  upper  lid,  subside  almost  immediately  on 
its  being  removed.  The  turgidity  of  the  capillaries  of  the  conjunctiva, 
resulting  from  the  increased  attractive  force  of  the  irritated  tissue  on  the 
blood,  also  speedily  disappears. 

If,  after  the  foreign  substance  has  been  removed,  the  spasm  of  the  orbicu- 
laris palpebrarum  should  still  continue,  which  is  particularly  apt  to  be  the 
case  when  the  conjunctiva  has  been  both  mechanically  and  chemically  injured, 
the  patient  ought  to  remove  to  a  dark  room,  lie  in  bed,  paint  the  eyelids 
with  extract  of  belladonna,  and  keep  a  pledget,  wet  with  cold  water,  over 
the  eye. 

The  whole  of  the  upper  conjunctival  sinus  cannot  be  brought  into  view  by 
eversion,  so  that,  if  we  have  any  reason  to  think  that  a  foreign  body  is  lodged 
in  the  remote  part  of  the  fold,  we  must  wash  it  out  by  means  of  a  syringe  and 
tepid  water,  or  employ  the  spatula  in  searching  for  it,  and  bringing  it  down. 

5.  It  is  remarkable,  that  while  the  smallest  particle  of  dust,  fixed  on  the 
internal  surface  of  either  eyelid,  but  especially  the  upper,  generally  gives  rise 
to  intolerable  uneasiness,  foreign  bodies  of  considerable  size  may  lodge  in  the 
deeper  and  looser  part  of  the  conjunctival  folds  for  many  weeks,  without 
inducing  any  violent  symptoms.  The  conjunctiva,  in  such  circumstances, 
inflames  and  is  apt  to  throw  out  a  fungous  growth,  which  may  completely 
envelop  the  foreign  substance,  so  as  to  hide  it  from  view,  and  lead  the  prac- 
titioner to  adopt  a  false  notion  of  the  case.  Not  suspecting  the  presence  of 
any  foreign  body,  he  may  be  led  to  think  that  he  has  to  do  with  hypertrophy 
or  polypus  of  the  conjunctiva. 

Case  1G4. — A  young  girl  bad  a  soft  red  fungus  growing  out  of  the  eye,  as  large  as  a 
filbert.  It  was  of  some  weeks'  standing,  and  was  attributed  to  a  hurt  inflicted  by  a  straw 
striking  the  eye.  The  fungus  originated  in  the  conjunctiva  where  it  is  reflected  from  the 
lower  eyelid  to  the  eyeball.  It  was  cut  away;  but  in  three  weeks  was  as  large  as  ever. 
It  was  again  removed;  and  at  the  angle  of  reflexion  of  the  conjunctiva,  a  bit  of  straw, 
half  an  inch  in  length,  was  observed  and  extracted.  The  cure  was  complete  in  a  few 
days.2 

Case  165. — A  man  consulted  Dr.  Monteath  on  account  of  an  inflamed  state  of  his  eye, 
induced  by  a  fall,  five  months  before,  among  some  bushes  in  descending  a  steep  mountain. 
He  felt  some  part  of  his  eye  wounded  at  the  moment,  and  had  never  enjoyed  freedom  from 
a  tender  state  of  it,  from  that  period,  though  he  had  applied  a  great  variety  of  medicines. 
On  everting  the  upper  eyelid,  a  fungous  state  of  the  conjunctiva  was  discovered  very  high 
up  in  the  angle  of  reflexion  of  that  membrane,  and  on  examination  with  the  probe,  it  was 
evident  that  a  foreign  body  remained  there.  It  was  laid  hold  of,  and  extracted  with  the 
forceps,  and  proved  to  be  a  portion  of  a  twig  of  a  bush,  fths  of  an  inch  in  length,  and 
nearly  as  thick  as  a  crow-quill.  This  substance  had  remained  in  the  upper  fold  of  the 
coniunctiva  for  five  months,  and  had  got  into  that  situation  without  wounding  the  eye.^ 

Case  166. — A  boy  ten  years  of  age,  having  lain  during  the  night  on  a  sheet  upon  which 
ears  of  corn  had  been  thrashed,  awoke  in  the  morning  with  his  left  eyelids  swollen  and 
painful.  Notwithstanding  the  use  of  topical  emollients,  an  abscess  formed  in  the  upper 
lid,  which  burst  below  the  eyebrow  towards  the  temple,  and  left  an  opening  which  could 
not  be  closed  by  any  of  the  means  which  were  employed.  In  process  of  time,  the  lid 
began  to  turn  itself  outwards,  its  membrane  swelling  and  protruding,  till  at  length  the 
eversion  was  enormous. 

About  eight  months  from  the  first  appearance  of  any  disease,  the  fungous  excrescence, 
formed  by  the  internal  membrane  of  the  lid,  covered  a  considerable  part  of  the  upper 
hemisphere  of  the  eyeball,  and  kept  the  lid  so  much  everted,  that  its  margin,  especially 
towards  the  temple,  was  almost  close  to  the  eyebrow.    Pressed  upon  with  the  point  of  the 


DACRYOLITHS.  255 

finger,  the  lid  yielded  readily,  and  appeared  as  if  it  would  have  descended  to  cover  the 
eye,  had  it  not  been  for  the  intervention  of  this  fungus,  formed  by  its  internal  membrane. 

As  the  fungus  was  dry  and  indurated,  Scarpa  ordered  it  to  be  covered  for  24  hours  with 
a  bread  and  milk  poultice ;  and  then  removed  the  whole  of  it  with  a  stroke  of  the  curved 
scissors,  carefully  avoiding  the  punctum  lachrymale. 

After  the  extirpation,  a  piece  of  straw,  about  an  inch  long,  and  half  a  line  thick,  was 
discovered  in  the  fold  of  the  fungus.  The  whole  of  the  superfluous  part  of  the  internal 
membrane  being  now  removed,  the  lid  descended  over  the  eye,  so  as  to  cover  it  properly. 
The  operation  was  not  followed  by  any  remarkable  symptom,  and  the  boy,  ten  days  after- 
wards, left  the  hospital  so  far  cured  that  no  other  defect  remained,  except  a  slight  eleva- 
tion of  the  lid  near  the  external  angle,  where  the  abscess  had  burst.  ^ 

6.  The  eggs  of  insects  are  sometimes  deposited  between  the  eyelids,  and 
may  produce  very  serious  mischief,  as  is  well  illustrated  by  the  following  case, 
related  by  M.  Cloquet : — 

Case  167. — A  man,  about  50,  following  the  double  business  of  public  singer  and  rag- 
gatherer,  fell  asleep  in  the  open  fields  in  a  complete  state  of  intoxication.  Flies  of  the 
species  musca  caniaria  deposited  their  eggs  in  the  entrances  to  the  different  natural  open- 
ings of  his  body,  between  the  eyelids,  in  the  nostrils,  in  the  ears,  and  in  the  prepuce.  The 
eggs  being  hatched,  the  larvae  passed  into  the  nose,  the  ears,  the  orbits,  &c.  Under  the 
integuments  of  the  cranium  they  formed  large  cavities,  pieixed  with  ulcerated  openings, 
by  which,  on  pressure,  they  escaped  in  thousands. 

All  the  larvte  were  extracted  by  the  second  day  after  the  patient's  entering  the  IlOpital 
Saint  Louis.  The  eyes  were  totally  destroyed,  and  when  the  larvae  were  removed  through 
the  perforations  of  the  cornece,  the  crystalline  lenses  escaped.  The  integuments  of  the 
upper  part  of  the  cranium  fell  into  a  gangrenous  state,  and  the  patient  died  a  month  after 
his  admission,  in  a  complete  state  of  dementia,  believing  himself  constantly  pursued  by 
assassins.  The  bones  of  the  vault  of  the  cranium  were  in  part  necrosed,  and  the  dura 
mater  and  arachnoid  inflamed.  ^ 


'  Ammon's  Zeitschrift  fiir  die    Ophthalmo-  *  Scarpa,  Trattato  delle  principali  Malattie 

logie;  Vol.  v.  p.  64;  Heidelberg,  1835.  degli  Occhi;  Vol.  i.  p.  170;  Pavia,  1816. 

^  Monteath's  Translation  of  Waller's  Manual  '  Pathologie  Chirurgicale,  par  Jules  Cloquet, 

of  the  Diseases  of  the  Human  Eye;  Vol.  i.  p.  p.  60;  Paris,  1831.     For  other  eases  of  larvse 

9;  Glasgow,  1821.  under  the  eyelids,  see  Bouilhet,  Annales  d'Ocu- 

'  Ibid.  listique;  Tome  xv.  p.  133;  Bruxelles,  1846. 


SECTION  n. — DACRYOLITHS,  OR  LACHRYMAL  CALCULI,  IN  THE  SINUSES  OF  THE 

CONJUNCTIVA. 

Several  cases  are  recorded  of  depositions  of  calcareous  matter  from  the 
tears,  forming  concretions  in  the  sinuses  of  the  conjunctiva.  From  the  large 
size  of  the  masses,  and  their  frequent  recurrence,  doubts  have  been  entertained 
of  the  reality  of  the  disease,  the  suspicion  naturally  arising  that  the  substances 
extracted  had  for  some  sinister  purpose  been  introduced  into  the  eye.  The 
chemical  analysis,  however,  of  the  concretions,  and  the  characters  of  the 
observers  for  exactness,  remove  this  doubt. 

Case  168. — In  1811,  a  small  bit  of  lime  fell  from  the  ceiling  of  a  room  into  the  left  eye 
of  a  healthy  young  woman.  Professor  Walther  removed  the  foreign  body,  and  the  eye 
appeared  to  have  sustained  no  injury.  In  February,  1813,  the  patient  was  first  attacked 
with  severe  toothache,  both  in  the  upper  and  lower  jaw.  Several  decayed  molares,  in 
which  the  pain  was  particularly  violent,  were  extracted,  but  with  merely  temporary  relief. 
Soon  after  this  she  had  an  attack  of  rather  obstinate  constipation,  with  other  symptoms 
of  colic ;  but  by  clysters,  fomentations,  &c.,  it  was  removed.  Towards  the  end  of  July  of 
the  same  year,  she  began  to  complain  of  a  burning,  stinging  sensation  in  the  left  eye, 
most  severe  when  the  eye  or  eyelids  were  moved,  or  when  she  was  exposed  to  bright  sun- 
shine. On  closely  examining  the  organ,  a  white  angular  concretion  was  discovered  between 
the  eyeball  and  the  lower  eyelid,  towards  the  external  angle  of  the  eye.  It  was  about  the 
size  of  a  pea,  and,  when  removed  from  the  eye,  was  readily  rubbed  down  between  the 
fingers  into  a  greasy  sandy  powder.  Although  the  patient  firmly  denied  that  any  foreign 
body  had  fallen  into  her  eye,  Walther  at  first  supposed  that  the  substance  removed  was  a 


256  INJURIES   OF   THE   CONJUNCTIVA. 

piece  of  lime  which  had  just  got  into  it.  He  was  not  a  little  surprised,  however,  when 
the  patient  returned  to  him,  three  days  afterwards,  with  a  calculus  exactly  like  the  first, 
lying  in  the  very  same  place.  The  eye  was  now  considerably  inflamed,  the  pain  not  being 
confined  to  the  eyeball,  but  extending  in  the  direction  of  the  supra-orbitary  nerve.  There 
was  a  proportionate  sensibility  to  light,  and  increased  flow  of  tears.  The  inflammation 
of  the  eye  had  commenced  the  preceding  evening,  accompanied  by  a  violent  paroxysm  of 
fever,  with  shivering,  succeeded  by  heat.  Although  the  newly-formed  calculus  was  im- 
mediately and  easily  removed,  still,  on  the  following  morning,  after  a  restless  and  dis- 
tressful night,  the  violence  of  the  inflammation  was  much  increased,  and  in  the  lower  fold 
of  the  conjunctiva,  another  white  crumbling  concretion  was  perceived,  which,  by  the  suc- 
ceeding day,  had  attained  as  large  a  size  as  the  former.  The  upper  eyelid  was  inflamed, 
and  the  margins  of  both  swollen.  The  inflammation  was  so  violent  as  to  require  blood- 
letting, and  other  antiphlogistic  remedies.  By  these  some  alleviation  was  eS'ected ;  but 
four  days  afterwards,  another  bleeding  was  necessary,  from  an  increase  of  the  inflam- 
matory symptoms.  In  the  mean  time,  the  formation  of  calculi,  at  the  same  place  in  the 
aflTected  eye,  not  only  proceeded,  but  larger  concretions  were  produced,  and  with  greater 
rapidity.  The  calculi  were  now  removed  twice  a  day,  and  at  length  three  times  a  day, 
from  the  eye. 

Reasoning  from  the  good  efi'ects  of  potash  in  calculous  affections  of  the  kidney,  Walther 
prescribed  a  solution  of  a  drachm  and  a  half  of  carbonate  of  potash  in  4  ounces  of  cinna- 
mon water,  with  half  an  ounce  of  syrup.  Of  this  solution,  half  a  tablespoonful  was  taken 
four  times  a  day ;  and  along  with  this  the  patient  drank  copiously  of  an  infusion  of  the 
viola  tricolor.  After  using  these  remedies  for  six  days,  during  which  time  the  urine  was 
muddy  and  foetid,  and  deposited  a  copious  sediment,  the  activity  of  the  disposition  to  form 
calculi  greatly  diminished.  In  the  course  of  24  hours,  there  was  but  one  small  concretion 
formed,  and  at  length  merely  a  white  crumbling  powder,  no  longer  consolidated  into  a 
mass,  and  which  required  to  be  removed  only  every  second  day.  But  while  the  disease  in 
the  left  eye  decreased  and  disappeared,  it  attacked  the  right,  and  at  the  same  part  of  the 
conjunctiva,  between  the  eyeball  and  lower  eyelid.  Its  course  here  was  exactly  the  same 
as  before ;  at  first,  the  calculi  formed  in  fewer  numbers,  and  more  slowly,  afterwards  more 
rapidly,  and  in  greater  numbers ;  the  inflammation  of  the  right  eye  was  at  first  moderate, 
and  afterwards  more  severe,  rendering  repeated  venesection  necessary.  Nevertheless,  the 
disease  never  attained  the  same  height,  and  was  of  shorter  duration  than  in  the  left  eye. 
It  gradually  decreased  as  it  had  increased ;  the  concretions  appearing  at  longer  intervals, 
becoming  smaller,  and  at  length  entirely  ceasing.  The  whole  course  of  the  disease  occu- 
pied nearly  ten  weeks. 

The  patient's  chest  seemed  to  suffer  in  some  degree,  from  the  repeated  bloodletting, 
altered  manner  of  life,  and  perhaps  from  the  continued  use  of  alkaline  medicine ;  she  had 
a  troublesome  cough,  with  considerable  expectoration,  particularly  in  the  morning,  and 
an  altered  appearance.  AValther,  therefore,  ordered  her  an  infusion  of  lichen  Islandicus, 
and  better  diet.     In  three  weeks,  she  had  perfectly  recovered. 

Some  years  after  this,  however,  she  was  again  attacked  with  the  same  disease.  Con- 
cretions of  the  former  color,  size,  and  other  properties,  formed  in  the  left  eye ;  at  first, 
they  lay  between  the  eyeball  and  under  eyelid,  and  afterwards  between  the  eyeball  and 
upper  eyelid.  In  the  course  of  a  few  days  the  formation  of  calculi  began  in  the  right  eye. 
On  this  occasion  both  ej-es  were  less  severely  inflamed,  and  the  disease  was  likewise  of 
shorter  duration.  Walther  immediately  ordered  her  the  solution  of  potash.  The  number 
of  calculi  which  were  daily  generated,  soon  diminished,  and  the  whole  process  ceased  in 
shorter  time. 

On  analysis  the  concretions  were  found  to  be  composed  of  carbonate  of  lime,  which 
formed  the  greatest  part  of  their  weight;  traces  of  phosphate  of  lime;  and  coagulable 
lymph  or  albumen.  They  consequently  resembled  salivary  calculi,  and  the  tartar  deposited 
on  the  teeth.' 


'  Grafe  und  Walther's  Journal  der  Chirurgie  und  Augenheilkunde  ;  Vol.  i.  p.  163  ; 

Berlin,  1820. 


SECTION -in. — INJURIES  OF  THE  CONJUNCTIVA. 

§  1.  Mechanical  Injuries. 

1.  Incised  wounds  of  the  conjunctiva  rarely  present  themselves,  without 
the  sclerotica  being  also  divided.  I  have  seen,  however,  several  cases  of 
this  kind.     In  one  of  them  the  wound  was  inflicted  with  a  sharp  bit  of 


INJURIES   OP   THE   CONJUNCTIVA.  25T 

glass.     It  healed  readily,  although  the  lips  gaped  more  than  I  could  have 
anticipated. 

2.  I  have  seen  many  cases  of  severe  pain  and  lachrymation,  following  slight 
scratches  of  the  epithelium  of  the  cornea,  by  the  finger  nails  of  infants  carried 
in  arms.  The  feeling  which  the  patient  experiences  is  that  of  a  particle  of 
sand  behind  the  upper  lid.  The  excessive  uneasiness  is  often  remarkably 
alleviated,  in  the  course  of  a  few  minutes,  by  painting  the  extract  of  bella- 
donna over  the  eyelids  and  eyebrow.  Cold  water  cloths  should  be  laid  over 
the  belladonna.  In  two  or  three  days,  the  epithelium  is  regenerated,  and  the 
eye  perfectly  well. 

Somewhat  similar,  only  much  more  serious  in  their  effects,  are  abrasions 
of  the  cornea,  happening  to  reapers,  during  harvest,  from  the  ears  of  corn. 
My  experience  as  to  the  danger,  in  cases  of  this  sort,  agrees  with  that  of  Pro- 
fessor Walther,  who  states^  that  in  the  Isar  district  of  Bavaria  alone,  from 
50  to  60  eyes  are  annuaUy  lost  from  the  inflammation  originating  in  this  kind 
of  injury  during  harvest.  The  patients  in  this  part  of  Scotland  are  chiefly 
females,  and  much  of  the  bad  effects  is  no  doubt  attributable  to  neglect. 
The  internal  textures  of  the  eye  inflame,  the  cornea  becomes  infiltrated  with 
pus,  and  bursting,  gives  rise  to  staphyloma.  The  symptoms  altogether  bear 
a  close  resemblance  to  those  of  catarrho-rheumatic  ophthalmia,  and  the  most 
active  measures  are  required  to  save  the  eye.  Depletion  and  mercurialization 
are  necessary,  together  with  the  use  of  belladonna. 

3.  A  foreign  body,  if  hard  and  angular,  may  penetrate  through  the  sclerotic 
conjunctiva,  and  either  be  driven  under  the  membrane  for  a  considerable  way, 
at  once,  by  the  projectile  force  with  which  it  was  sent  against  the  eye,  or 
afterwards  be  gradually  insinuated  under  it  by  the  pressure  of  the  eyelids. 
In  such  cases,  it  is  sometimes  necessary  to  raise  a  portion-  of  the  conjunctiva 
with  the  toothed  forceps,  and  snip  it  off  along  with  the  foreign  substance. 
If  this  is  not  done,  the  conjunctiva  heals  over  the  foreign  body,  and  the  irri- 
tation ceases.  Mr.  Wardrop^  tells  us,  that  in  one  case  he  found  a  piece  of 
whinstone,  inclosed  in  a  sac  of  cellular  membrane,  lying  close  to  the  sclerotic 
coat,  where  it  had  remained  for  ten  years  prior  to  the  person's  death,  without 
his  experiencing  the  least  uneasiness,  or  even  suspecting  its  presence.  The 
same  author^  quotes,  from  Loder's  Journal,  the  following  instance  of  a  foreign 
body,  which,  having  penetrated  the  sclerotic  conjunctiva,  gradually  advanced 
to  the  central  part  of  the  cornea : — 

Case  169. — A  priest  requested  assistance  for  a  dai-k  speck  on  the  cornea  of  his  right 
eye,  which  greatly  impaired  his  vision.  Two  years  before,  he  suddenly  experienced  a 
little  pain  in  that  eye,  and  on  examination,  remarked  on  the  white  of  it,  below  the  upper 
lid,  a  black  spot,  which  not  hurting  his  sight,  and  the  pain  soon  going  away,  he  took  no 
further  notice  of  the  accident.  After  some  time,  he  was  aware  that  the  spot  had  changed 
its  situation,  and  appeared  at  the  union  of  the  cornea  with  the  sclerotic.  The  speck  con- 
tinued its  progress  very  slowly,  but  uninterruptedly ;  it  came  forwards  on  the  cornea,  and 
at  last  covered  a  portion  of  the  pupil.  There  was  a  prominent  hard  spot  upon  the  cornea, 
equalling  in  size  a  small  lentil,  but  longer  than  it  was  broad.  Many  small  red  vessels 
appeared  like  streaks  around  it.  The  patient  had  no  pain.  The  hardness  of  the  speck, 
and  other  circumstances,  made  the  surgeon  suspect  that  a  foreign  body  was  fixed  on  the 
eye.  He  made  an  incision  over  it,  and,  with  the  assistance  of  a  magnifying  glass,  saw  a 
black  body,  which  he  removed  with  the  point  of  the  knife,  from  the  small  cavity  it  had 
formed  for  itself  in  the  cornea.     It  proved  to  be  the  hard  wing-case  of  a  beetle. 

The  change  of  place,  in  such  cases,  is  to  be  attributed,  I  presume,  to  the 
pressure  of  the  eyelids  in  the  act  of  nictitation. 

4.  The  stings  of  insects  sometimes  fix  in  the  conjunctiva,,  and  are  to  be 
carefully  removed,  either  by  a  pair  of  forceps  or  the  point  of  a  cataract 
needle. 

17 


258  INJURIES   OF   THE   CONJUNCTIVA 

§  2.  Burns  and  other  Chemical  Injuries. 
Fig.  Wardrop,  Vol.  I.  PI.  V.  Fig.  3. 

1.  Lime,  whetber  in  the  state  of  quicklime,  or  slaked  lime,  or  mixed  with 
sand  so  as  to  form  mortar,  acts  very  injuriously  on  the  conjunctiva.  It  is  also 
apt  to  affect  violently  the  proper  substance  of  the  cornea,  and  sometimes 
totally  destroys  the  eye.  One  of  the  first  effects  observed  to  arise  from  the 
intrusion  of  lime,  in  any  of  the  above-mentioned  states,  is,  that  the  sclerotic 
and  palpebral  portions  of  the  conjunctiva  become  white,  swell,  and  peel  off, 
being  in  fact  decomposed  by  the  caustic  action  of  the  substance.  The  corneal 
epithelium  suffers  a  similar  change.  This  decomposition  of  the  conjunctiva 
is  produced  very  rapidly,  so  that  it  can  very  rarely  be  prevented  by  a  removal 
of  the  lime.  When  the  corneal  conjunctiva  has  peeled  off,  in  only  a  small 
portion  of  its  extent,  a  shallow  depression  is  visible  on  the  surface  of  the 
cornea,  with  irregular  edges.  If  the  whole  has  separated,  the  proper  sub- 
stance of  the  cornea  appears  perfectly  smooth,  and  presents  more  or  less  of 
a  blue  pearly  whiteness.  The  eye  may  be  destroyed,  although  no  part  of  the 
conjunctiva  has  peeled  off. 

The  ultimate  effects  arising  from  the  intrusion  of  lime  into  the  eye,  depend 
on  the  degree  of  causticity,  the  quantity,  and  the  length  of  time  that  the  sub- 
stance has  been  allowed  to  remain  in  contact  with  the  conjunctiva.  Common 
mortar  falling  into  the  eye,  and  quickly  removed,  generally  acts  only  as  a 
severe  stimulant,  causing  increased  redness,  pain,  and  epiphora,  followed  by 
a  puro-mucous  discharge  from  the  conjunctiva.  But  even  when  quickly  re- 
moved, I  have  seen  mortar  cause  swelling  of  the  conjunctiva,  whiteness  and 
bursting  of  the  cornea,  and  loss  of  vision.  In  one  case,  the  cornea  became 
gradually  thin  and  disorganized,  and  burst  three  weeks  after  the  injury. 
Allowed  to  remain  for  days  in  the  conjunctival  folds,  I  have  seen  mortar 
followed  by  sloughing  of  the  conjunctiva,  permanent  nebula  of  the  cornea, 
and  partial  symblepharon.  Slaked  lime,  thrown  into  the  eyes,  acts  more 
powerfully,  and  is  apt  to  be  followed,  especially  if  not  speedily  removed,  by 
complete  opacity  of  the  cornea,  or  even  by  suppuration  of  that  part,  and 
staphyloma. 

Case  170. — A  child  two  years  old,  was  brought  to  the  Glasgow  Eye  Infirmary,  who, 
three  weeks  before,  had  fallen  among  quicklime,  which  had  intruded  into  both  eyes.  A 
poultice  had  been  applied  immediately  after  the  injury,  and  no  attempt  made  to  remove 
the  lime,  or  counteract  its  effects.  On  examination,  I  found  the  right  cornea  totally 
opaque,  small,  and  deformed.  There  was  no  appearance  of  cornea  in  the  left  eye,  which 
had  shrunk  to  a  very  small  flat  stump. 

Case  171. -^Robert  Gray,  aged  13,  a  slater,  was  admitted  at  the  Glasgow  Eye  Infirmary, 
3d  September,  1838. 

On  the  28th  ult.  a  quantity  of  mortar  was  thrown  into  his  left  eye.  The  skin  of  the 
left  eyelids  and  cheek  is  inflamed,  and  the  eyelids  swollen.  He  is  unable  to  open  the  eye, 
except  to  about  half  its  usual  extent.  The  conjunctiva  covering  the  eyeball,  and  that 
lining  the  upper  eyelid,  presents  a  white  scarred  appearance  ;  that  lining  the  lower  eye- 
lid is  more  natural.  Shreds  of  the  conjunctiva  are  coming  away  in  a  sloughy  state.  A 
considerable  quantity  of  mortar  is  still  lodged  between  the  eyeball  and  the  upper  eyelid, 
being  impacted  between  the  two  surfaces.  The  conjunctiva  cornece  looks  as  if  it  had 
been  immersed  in  boiling  water,  especially  the  upper  half  of  it.  Vision  of  the  injured 
eye  is  very  dim ;  although  he  can  read  with  it  the  large  letters  on  the  Infirmary  card. 
The  first  day  after  the  injury,  the  eye  was  alFected  with  severe  burning  pain,  which  sub- 
sided after  the  application  of  a  poultice.  At  present,  he  does  not  make  much  complaint 
of  pain.  He  says  his  master  removed  a  quantity  of  the  mortar  immediately  after  the 
accident.  When  the  eye  is  held  open  for  a  few  minutes,  the  cornea  appears  to  become 
quite  dry,  and  when  viewed  through  a  lens,  presents  the  appearance  of  cuticle.  Imme^ 
diately  on  being  shut,  it  becomes  bedewed  with  tears,  and  assumes  a  less  opaque  appear- 
ance. 

The  remainder  of  the  mortar  was  carefully  removed  when  he  came  to  the  Eye  Infirmary ; 


INJURIES   or   THE   CONJUNCTIVA.  259 

the  solution  of  nitrate  of  silver  was  applied  to  the  conjunctiva  ;  and  eight  leeches  to  the 
eyelids. 

Sept.  4th,  A  good  night.  Opens  the  eye  better.  He  was  ordered  a  purging  powder; 
the  red  precipitate  salve  to  the  edges  of  the  eyelids  at  bedtime ;  a  collyrium  with  wine  of 
belladonna ;  and  a  blister  behind  the  ear. 

5th,  Conjunctiva  looks  rather  better.  Moves  the  eye  more  freely.  He  had  a  dose  of 
sulphate  of  magnesia. 

6th,  Cornea  rather  clearer. 

10th,  Three  leeches  to  the  left  lower  eyelid. 

12th,  Lower  half  of  cornea  considerably  clearer. 

19th,  Three  leeches  to  the  inner  angle  of  the  eye.     Blister  repeated. 

22d,  Diluted  wine  of  opium  substituted  for  the  solution  of  nitrate  of  silver. 

29th,  A  considerable  part  of  the  conjunctiva  cornese  appears  to  have  separated.  Whole 
cornea  more  opaque.     Conjunctiva  less  inflamed. 

Oct.  7th,  An  evident  deficiency  in  the  conjunctival  covering  of  the  cornea.  Cannot  tell 
one  finger  from  another  with  left  eye. 

28th,  Left  cornea  smooth  and  clearer. 

Nov.  4th,  Continues  to  improve. 

11th,  A  conjunctival  frcenum  extending  between  the  upper  eyelid  and  margin  of  the 
coi'nea,  towards  inner  angle.  Cornea  still  very  nebulous.  Genei'al  appearance  of  eye 
more  healthy. 

April  7th,  1839,  Cornea  much  clearer,  except  towards  its  upper  inner  margin,  in  the 
vicinity  of  the  symblepharon.     Reads  a  small  type  with  left  eye. 

In  whatever  state  tlie  lime  may  have  been,  which  has  intruded  into  the  eye, 
it  ought  instantly  to  be  removed.  For  this  purpose  the  eye  is  to  be  opened, 
the  lids  everted  one  after  the  other,  and  with  the  finger  nail,  or  the  small 
spatula,  every  particle  of  the  foreign  substance  picked  out.  It  often  adheres 
pretty  firmly  to  the  conjunctiva,  so  that  the  aid  of  forceps  is  necessary  to 
detach  it.  After  so  much  has  been  removed  in  this  way  as  seems  possible,  a 
continued  stream  of  cold  water  should  be  sent  over  the  eyeball  and  inside  of 
the  lids,  by  means  of  a  syringe,  so  as  to  wash  away  every  particle  of  the 
lime. 

The  patient  should  now  go  to  bed,  the  eyelids  and  eyebrow  should  be 
painted  over  with  the  extract  of  belladonna,  and  a  compress,  wrung  out  of 
cold  water,  laid  over  the  eye.  The  solution  of  the  nitrate  of  silver  (gr.  iv-x 
to  ^i  of  distilled  water)  operates  favorably  in  abating  the  puro-mucous  con- 
junctivitis which  follows,  but  the  more  serious  inflammatory  symptoms  must 
be  combated  by  bleeding,  calomel  and  opium,  and  counter-irritation.  Solu- 
tion of  acetate  of  lead  must  carefully  be  avoided,  as  the  lead  will  be  precipi- 
tated on  the  excoriated  parts,  and  form  opaque  scales,  which  can  seldom  be 
removed. 

If  the  inflammation  which  follows  is  moderate,  the  epithelium  of  the  cornea, 
in  those  cases  where  it  peeled  off,  is  slowly  regenerated,  and  vision  may  be 
perfectly  restored.  If  the  lime  has  acted  more  deeply,  or  severe  inflamma- 
tion ensued,  the  cornea  may  never  regain  its  transparency*,  although  it  still 
retains  its  form. 

2.  Particles  of  potash,  nitrate  of  silver,  and  other  caustic  substances,  must 
immediately  be  extracted  from  the  eye,  with  the  forceps,  or  any  other  instru- 
ment which  is  at  hand.  The  mixture  of  the  tears  with  such  substances 
increases  their  destructive  effects. 

I  once  saw  severe  inflammation  of  the  conjunctiva,  with  considerable 
sloughing  in  the  lower  fold  of  that  membrane,  from  red  precipitate  in  powder, 
which  an  ignorant  pretender  had  applied,  to  cure  a  slight  ophthalmia.  The 
sloughy  conjunctiva  came  away  in  firm  white  pieces,  leaving  a  raw  surface. 
By  care,  symblepharon  was  prevented. 

3.  Hot  and  caustic  fluids,  such  as  boiling  water,  melted  tallow,  sulphuric 
acid,  and  the  like,  blister  the  conjunctiva,  and  bring  on  inflammation  of  a 
highly  dangerous  character.^     Indeed,  after  sulphuric  acid  has  been  thrown 


260  INJURIES   OF   THE   CONJUNCTIVA. 

into  the  eyes,  a  piece  of  diabolical  malice,  the  effects  of  which  I  have  repeatedly- 
had  occasion  to  witness,  the  conjunctiva  almost  appears  scarred,  being  white, 
soft,  and  swollen.  It  afterwards  peels  off,  while  the  cornea  rapidly  becoming 
disorganized  by  infiltration  of  pus,  ulceration,  and  sometimes  sloughing,  a 
raw  surface  is  left  both  on  the  ball  and  on  the  inside  of  the  lids,  ready  to 
unite  and  close  the  eye  by  an  incurable  and  almost  total  symblepharon.  In 
other  cases,  partial  symblepharon  is  the  result.  A  stream  of  tepid  water,  or 
of  a  solution  of  four  grains  of  subcarbonate  of  soda  to  the  ounce  of  water, 
injected  over  the  whole  surface  of  the  conjunctiva,  is  the  remedy  to  be  had 
recourse  to  in  the  first  instance.  The  inflammation  which  follows  is  to  be 
combated  by  general  and  local  blood-letting,  calomel  and  opium  internally, 
and  the  use  of  belladonna  externally.  Every  care  is  to  be  taken  to  prevent 
anchyloblepharon  and  symblepharon,  by  opening  wide  the  lids  from  time  to 
time,  and  anointing  them  with  tutty  salve.  A  curious  effect  of  a  burn  of  the 
conjunctiva,  which  I  have  sometimes  witnessed,  is  an  ecchymosed  state  of  the 
cornea,  near  the  burned  or  scalded  part  of  the  conjunctiva,  blood  being 
effused  into  the  proper  substance  of  the  cornea.  This  appearance  is  very 
slow  of  removal. 

4.  Yinegar,  ardent  spirits,  and  other  stimulating  fluids,  thrown  into  the 
eye,  occasion  severe  inflammation  of  the  conjunctiva.  From  whiskey,  I  have 
seen  an  inflammation  of  the  conjunctiva,  sclerotica,  and  cornea  arise,  very 
difficult  to  be  overcome ;  and  the  same  from  the  miserable  trick  of  putting 
snuff  into  a  person's  eyes  while  asleep. 

5.  Dr.  Ammon  quotes"  the  case  of  a  man,  who,  smearing  the  roof  of  the 
entrance  to  his  house  with  melted  pitch,  had  the  misfortune  to  let  a  drop  of 
that  substance  fall  directly  on  the  cornea,  where  it  stuck  so  fast  that  the 
surgeons  who  were  called  were  unable  to  loosen  it,  either  by  the  application 
of  instruments,  or  the  use  of  an  eye-water.  The  patient  was  advised  to  drop 
olive  oil  into  his  eye,  and  to  cover  it  with  a  compress  steeped  in  that  fluid, 
the  effect  of  which  was  that  the  pitch  was  speedily  loosened,  and  quitted  the 
eye  without  leaving  any  visible  injury. 

6.  In  consequence  of  the  cornea  being  touched  with  a  burning  fragment  of 
wood,  Avith  a  piece  of  hot  iron,  or  with  melted  iron  or  lead,  we  see  the  epi- 
thelium of  the  cornea,  whitened,  coagulated  like  a  layer  of  albumen,  raised 
into  a  blister,  and  separated.  The  effects  are  slight  in  some  cases,  and  severe 
in  others.  Belladonna  extract  is  applied  to  soothe  the  pain,  and  cold  water 
is  used  as  a  lotion.  Next  day,  the  eye  sometimes  seems  perfectly  well,  the 
epithelium  being  already  regenerated.  In  other  cases,  the  restoration  is  more 
slow.  If  the  burn  has  extended  to  the  anterior  elastic  lamina  of  the  cornea, 
the  effects  are  much  more  serious,  including  tedious  ulceration.  In  children, 
the  effects  are  generally  very  dangerous,  the  cornea  suppurating  and  giving 
way,  so  as  to  leave  the  eye  staphylomatous.  The  palpebral  and  ocular  con- 
junctiva suffer  more  or  less  severely  from  burns,  such  as  from  melted  iron 
projected  into  the  eye.  Sloughing  and  symblepharon  are  common  results  of 
such  an  injury. 

T.  Gunpowder  exploded  into  the  eye  fixes  in  the  conjunctiva,  and  in  the 
cornea,  and  must  be  carefully  picked  out  with  the  small  spatula,  or  the  point 
of  a  cataract  needle,  else  the  membrane  will  close  over  the  grains,  so  that 
they  will  remain  indelible,  and  injure  the  transparency  of  the  cornea. 

8.  Other  substances  sometimes  leave  an  indelible  stain  of  the  sclerotic 
conjunctiva,  unless  carefully  removed,  along  with  the  injui'ed  portion  of  the 
membrane.  I  have  seen  an  injury  with  a  piece  of  coal  produce  a  permanent 
black  mark;  and  Dr.  Jacob  mentions^  that  he  had  more  than  once  seen  the 
same  thing  arise  from  the  thrust  of  a  charred  stick. 

9.  The  conjunctiva  often  becomes  indelibly  stained^  from  the  misapplica- 


INJURIES  OF   THE   CONJUNCTIVA.  261 

tion  of  nitrate  of  silver  in  solution ;  a  remedy  much  abused  by  half-educated 
practitioners,  who,  unable  to  discriminate  the  proper  occasions  for  its  use,  and 
too  careless  to  apply  it  themselves,  and  watch  its  effects,  hand  it  over  to  the 
patient,  with  a  recommendation  to  employ  it  daily,  till  a  cure  of  some  inflam- 
mation of  the  eye,  or  some  opacity  of  the  cornea,  is  effected.  At  the  end  of 
some  weeks,  the  conjunctiva  acquires,  from  this  application,  a  light  ochre  hue. 
If  the  solution  has  been  strong,  and  used  for  months,  the  stain  is  much  deeper, 
coloring  not  only  the  conjunctiva  of  the  eyeball,  but  also  that  of  the  under 
eyelid,  of  a  dirty  olive,  or  even  black  color,  productive  of  permanent  and  very 
obvious  deformity.  To  remove  such  discoloration  of  the  conjunctiva,  a  so- 
lution of  iodide  of  potassium,  or  of  hyposulphate  of  soda,  of  the  strength  of 
1  to  10. of  water,  has  been  recommended.  Nitrate  of  silver,  decomposed,  and 
the  oxide  thrown  down,  sometimes  becomes  incorporated  in  a  cicatrice  of  the 
cornea,  and  produces  a  black  stain  ;  but  this  event  is  rare. 

10.  If  a  solution  of  acetate  of  lead  be  applied  to  any  part  of  the  con- 
junctiva in  an  excoriated  or  ulcerated  state,  the  acetate  is  decomposed,  and  a 
white  precipitate  is  deposited,  which  adheres  tenaciously  to  the  conjunctiva, 
and,  as  the  membrane  heals,  becomes  incorporated  with  the  cicatrice.  If 
this  takes  place  on  the  surface  of  the  cornea,  it  may  greatly  impede  the  vision 
of  the  patient.  The  appearance  produced  by  deposition  of  lead  on  the  con- 
junctiva cannot  be  mistaken,  its  chalk-like  impervious  opacity  easily  dis- 
tinguishing it  from  the  densest  cicatrice  resulting  from  mere  ulceration. 

Case  172. — In  a  schoolmaster,  whiskey  being  thrown  into  one  eye,  brought  on  ulcera- 
tion of  the  cornea.  Sugar  of  lead  water  was  applied,  and  an  opaque  cicatrice  followed, 
of  a  triangular  shape,  and  presenting  three  laminse  of  different  degrees  of  opacity.  The 
centre,  where  the  ulcer  had  been  deepest,  was  chalky,  the  next  layer  less  white,  and  the 
next,  the  most  extensive,  still  less  so,  presenting  altogether  a  resemblance  to  the  section 
of  an  agate. 

Solution  of  nitrate  of  silver,  10  grains  to  1  ounce  of  distilled  water,  applied 
daily  to  such  deposits  of  lead,  sometimes  removes  them  entirely,  where  the 
ulcer  has  not  been  deep. 

In  one  case,  I  succeeded  in  separating  a  scale  of  lead  which  had  been 
deposited  on  the  cornea ;  but,  in  general,  the  lead  is  so  incorporated  with 
the  cicatrice  as  to  be  immovable. 

The  inflammation  which  follows  the  various  injuries  we  have  considered  in 
this  section  not  only  varies  much  in  degree,  but  is  by  no  means  of  uniform 
character.  When  it  confines  itself  to  the  conjunctiva,  it  is  sometimes  puro- 
mucous,  sometimes  eruptive.  But  it  frequently  affects  the  proper  textures 
of  the  eyeball ;  such  as  the  cornea,  the  sclerotica,  or  the  iris.  Of  course, 
rest,  and  the  antiphlogistic  regimen,  are  necessary  in  every  case  of  injury  of 
the  eye.  The  local  applications  must  be  regulated  by  the  peculiar  symptoms 
excited,  and  even  the  internal  remedies  to  be  employed  are  not  of  that  uniform 
sort  with  which  inflammation,  in  less  complicated  parts  of  the  body,  is  usually 
treated.  The  grounds  of  this  doctrine  will  be  more  fully  explained  under 
the  head  of  Traumatic  Ophthalmice. 

In  almost  all  the  injuries  of  which  we  have  been  speaking,  the  external  use 
of  the  extract  of  belladonna  ought  to  be  adopted,  not  for  the  purpose  so 
much  of  dilating  the  pupil  as  for  acting  as  an  anodyne  on  the  branches  of 
the  fifth  nerve,  which  it  does  in  a  very  remarkable  manner. 

Before  quitting  this  subject,  it  is  right  to  state,  that  recovery  from  the 
immediate  effects  of  many  of  the  injuries  described,  not  unfrequently  takes 
place,  to  be  followed,  after  an  interval  of  some  weeks,  by  very  serious  internal 
inflammations  of  the  eye,  embracing  the  cornea,  the  iris,  and  even  the  retina. 


*  Merkwiirdige  Heilung  eines  Eiterauges,  p.        *  Essays   on    the   Morbid   Anatomy   of  the 
25  ;  Landshut,  1810.  Human  Eye;  Vol.  i.  p.  70  ;  London,  1819. 


262  SUBCONJUNCTIVAL  PHLEGMON. 

^  Ibid.  °  Zeitschrift  fiir  die  Ophthalmologie  ;  Vol.  ii. 

*  Jacob,  Dublin  Journal  of  Medical  Science ;  p.  155  ;  Dresden,  1832. 

Vol.  ix.  p.  755  Dublin,  1836;  Wardrop,  Op.  cit;  '  Dublin  Hospital  Reports;  Vol.  v.  p.  371; 

Vol.  i.  p.  160.  Dublin,  1830. 

»  On  opacity  of  the  cornea,  produced  by  sul-  *  Ibid.   p.    365  ;    Solomon,  Medical   Times, 

phuric  acid,  see  Thomson,  Lancet,  Oct.  31, 1840,  October  4,  1851,  p.  350, 
p.  209, 


SECTION  IV. — SUBCONJUNCTIVAL  ECCHYMOSIS. 
Fifj.  Dalrymple,  PI.  VIL  Fig.  1. 

Extravasation  of  blood  into  the  subconjunctival  areolar  tissue,  occurs  from 
various  causes,  as  blows  on  the  eye,  blows  on  the  eyebrow,  gunshot,  and  other 
wounds  of  the  head  or  face,  fits  of  coughing,  fits  of  epilepsy,  &c.  I  have  seen 
a  slight  blow  on  the  forehead  produce  ecchymosis  beneath  the  conjunctiva  of 
both  eyes.  In  some  cases,  no  evident  cause  appears  why  the  vessels  should 
have  opened ;  for  the  patient,  on  awaking  in  the  morning,  finds  the  conjunc- 
tiva of  a  deep  red  color,  without  any  pain  being  present,  or  anything  having 
happened  likely  to  produce  such  an  effect.  The  vessels  which  have  given 
way,  sometimes  continue  to  give  out  blood  under  the  conjunctiva,  for  days  or 
weeks,  so  that  the  whole  subconjunctival  areolar  tissue  is  injected,  and  the 
conjunctiva  elevated  by  dark  coagulated  blood.  Under  these  circumstances, 
the  iris  sometimes  assumes  a  greenish  color.  Subconjunctival  ecchymosis 
has  sometimes  been  observed  in  Asiatic  cholera.  It  occurs  in  purpura  and 
in  scurvy ;  and  hojmorrhagy  occasionally  takes  place  from  the  conjunctiva  in 
these  diseases. 

Jn  ordinary  cases,  the  extravasated  blood  is  gradually  absorbed,  the  con- 
junctiva becoming  first  yellow,  and  then  resuming  its  natural  appearance,  A 
slightly  astringent  coUyrium  generally  forms  the  whole  treatment. 


SECTION  V. — SUBCONJUNCTIVAL  EMPHYSEMA. 

We  have  already  (p.  203)  explained  how,  in  cases  of  fracture  of  the  nasal 
parietes,  the  eyelids  are  subject  to  emphysema,  the  air  passing  from  the 
nostril,  through  the  fractured  bone,  into  their  areolar  tissue.  From  similar 
injuries,  extending  between  the  nostril  and  the  orbit,  the  areolar  tissue  which 
connects  the  conjunctiva  to  the  neighboring  parts,  is  sometimes  filled  with  air. 

Should  the  swelling  from  the  effused  air  prove  so  great  as  to  give  rise  to 
pain,  or  impede  the  motion  of  the  eyeball  or  eyelids,  the  conjunctiva  may, 
from  time  to  time,  be  punctured,  so  as  to  let  the  air  escape,  till  the  fracture 
is  supposed  to  be  consolidated.  The  patient  ought  to  avoid  forcible  blowing 
of  the  nose,  by  which  this  emphysema,  as  well  as  that  of  the  eyelids,  is  apt  to 
be  induced. 


SECTION  VI. — SUBCONJUNCTIVAL  PHLEGMON. 
Fig.  Sichel,  PI.  V.  Figs.  4,  5,  6. 

The  subconjunctival  areolar  tissue  is  occasionally  the  seat  of  phlegmonous 
inflammation.  The  affected  part  of  the  conjunctiva  is  injected  with  red 
vessels,  much  thickened,  and  after  some  days,  presents  a  prominence  about 
the  size  of  a  split  pea,  which  rarely  goes  the  length  of  suppuration.  This 
disease  will  easily  be  distinguished  from  any  of  the  ophthalmise. 

In  one  case,  I  observed  an  appearance  resembling  conjunctival  phlegmon, 


PTERYGIUM.  263 

precede  an  attack  of  syphilitic  iritis.  In  another  case,  a  similarly  thickened 
and  inflamed  patch  of  conjunctiva  occurred,  along  with  a  syphilitic  eruption  ; 
and  in  several  instances,  I  have  seen  the  same  appearance,  investing  an  at- 
tenuated portion  of  the  sclerotica,  with  protruding  choroid.  In  all  of  these 
cases,  the  symptom  in  question  yielded  to  mercury.  Such  cases  might  readily 
be  mistaken  for  phlegmon.  They  will  easily  be  distinguished  from  syphilitic 
chancre  of  the  conjunctiva. 

We  might  suppose  slight  injuries  to  be  the  most  probable  causes  of  sub- 
conjunctival phlegmon  ;  but,  like  phlegmonous  inflammation  in  many  other 
situations,  it  generally  arises  without  any  evident  cause. 

Bloodletting  of  any  kind  is  scarcely  ever  necessary  in  this  complaint.  The 
patient  should  be  purged.  Warm  fomentations  to  the  eye  are  to  be  used.  If 
the  phlegmon  goes  on  to  suppuration,  it  is  to  be  opened  with  the  lancet. 


SECTION  VII. SUBCONJUNCTIVAL  (EDEMA. 

Subconjunctival  oedema  sometimes  occurs  in  small  patches,  especially  on 
the  temporal  side  of  the  eyeball ;  producing  a  feeling  as  if  some  foreign 
body  were  lodged  in  the  eye,  and  proving,  in  this  way,  very  annoying.  The 
cedematous  patches  generally  shrink  under  the  application  of  stimulants,  such 
as  a  solution  of  nitrate  of  silver,  or  the  wine  of  opium.  If  this  treatment 
does  not  succeed,  the  cedematous  bit  must  be  snipped  off.  The  wound  heals 
in  a  few  days,  and  the  disease  is  not  apt  to  return.  Sometimes  the  cedema- 
tous little  fold  degenerates  into  a  hard  and  almost  cartilaginous  state,  causing 
constant  watering  and  inflammation  of  the  eye,  and  rendering  the  snipping 
of  it  away  still  more  necessary. 

An  cedematous  state  of  the  conjunctiva  sometimes  occurs  more  diffusedly, 
in  old  people  of  a  relaxed  habit  of  body.  In  one  case,  it  came  on  in  an  old 
woman  after  an  overdose  of  rum-punch,  and  continued  for  months.  I  have 
repeatedly  seen  it  accompanied  by  an  unnatural  prominence  of  the  eyeballs, 
as  if  they  were  pressed  out  by  a  swollen  state  of  the  orbital  areolar  tissue,  or 
effusion  into  the  ocular  capsule.  I  have  also  met  with  subconjunctival 
oedema  as  an  attendant  on  hemicrania  and  circumorbital  neuralgia. 

In  the  last  mentioned  cases,  the  patients  derived  benefit  from  venesection, 
calomel  with  opium,  and  sarsaparilla.  Leeches  round  the  eye,  mercurial 
purges,  red  precipitate  salve  to  the  eye,  and  temperance  appeared  useful  in 
some  of  the  other  cases. 

The  conjunctiva  is  affected  with  an  inflammatory  oedema  in  many  of  the 
ophthalmiae  ;  in  none  so  much  as  in  that  which  arises  from  phlebitis.  In 
cases  of  this  kind,  the  membrane  becomes  in  the  course  of  a  few  hours  greatly 
distended  by  a  colorless  effusion  of  fluid,  apparently  sero-gelatinous.  ^  This 
is  attended  with  severe  pain  in  the  eye,  and  the  speedy  extinction  of  vision, 
as  I  shall  have  occasion  to  state  more  fully  hereafter. 


SECTION  Vm.  —  PTERYGIUM. 


Ureciyiov,  from  mepov,  wing.      (Syn.— Unguis,  Celsiis.     Web  of  old  English  surgeons. 
Onglet,  Fr.     Das  Flugelfell,  Ger. 

Fis:  Wardrop,  PI.  III.  Fi^s.  2.  3.     Beer,  Vol.  II.  PI.  IV.  Fis?.  4.  5.     Ammou,  Thl.  I.  Tab.  I. 
Figs.  12, 13,  14.     Dalrymple,  PI.  III.  Fig.  2. 

The  term  jiterygium  is  applied  to  a  disease  which  consists  chiefly  in   a 
thickened  and  elevated  portion  of  the  conjunctiva  of  the  eyeball,  of  a  trian- 


264 


PTERYGIUM. 


Fig.  36. 


gular  form,  its  base  generally  turned  to  the  caruncula  lachrymalis,  while  its 
apex,  which  is  white  and  opaque,  advances  over  the  edge,  or  even  as  far  as 
the  middle  of  the  cornea.  In  some  cases,  the  base  of  the  pterygium  is 
towards  the  temporal  angle,  and  occasionally  both  sides  of  the  eye  are 
affected  with  the  disease. 

Although  pterygium,  in  most  cases,  affects  the  conjunctiva  only,  we  some- 
times observe  a  part  of  it  evidently  seated  beneath  that  membrane.  This 
deep-seated  portion  presents  a  glistening,  tendinous  appearance,  especially 
towards  the  apex  of  the  triangle,  and  probably  belongs  to  the  tunica 
tendinea. 

The  form  generally  assumed  by  a  pterygium  is  represented  in  Fig.  36,  but 

occasionally  the  upper  and  lower  edges 
of  the  thickened  part  are  not  straight, 
but  run  in  a  curved  form  towards  the 
sinuses  of  the  conjunctiva ;  and  al- 
though the  apex  is,  in  general,  nar- 
row, yet  we  sometimes  see  the  disease 
advance  over  the  edge  of  the  cornea, 
with  a  broad  rather  than  a  pointed  ex- 
tremity. 

One  variety  of  pterygium  is  semi- 
transparent,  and  thinly  strewed  with 
bloodvessels.  This  is  the  pterygium 
teniie.  Another  variety  presents,  from 
the  size  and  course  of  its  bloodves- 
sels, almost  the  appearance  of  a  thin  muscle.  This  is  the  pterygium  eras- 
sum.  We  can  lay  hold  of  each  of  these  varieties  with  a  pair  of  forceps, 
without  much  difficulty,  and  without  giving  the  patient  any  pain,  and  raise 
it,  not  merely  from  the  sclerotica,  but  sometimes  even  from  the  cornea.  We 
can  do  this  with  greater  ease,  when  the  patient  turns  his  eye  towards  the 
side  whence  the  pterygium  originates.  A  pterygium  sometimes  assumes  a 
great  degree  of  thickness,  becomes  fleshy,  and  rugous  on  its  surface,  and 
looks  somewhat  like  a  carcinomatous  growth.  If  this  occurs,  as  I  have  seen 
it  do,  at  the  nasal  angle  of  each  eye,  its  occurring  on  both  sides  removes  the 
suspicion  of  its  malignancy.  This  state  of  the  pterygium  is  the  result  of 
chronic  catarrhal  ophthalmia,  supervening  on  a  common  pterygium,  and  en- 
tirely neglected  or  improperly  treated. 

Pterygium  sometimes  proceeds  even  to  its  complete  development  without 
giving  any  pain,  and  even  almost  without  any  disagreeable  feeling  in  the  eye, 
so  that  the  patient  perhaps  receives  the  first  intimation  of  his  disease  from 
some  other  person,  or  from  examining  his  eye  in  a  glass,  or  from  the  disease 
gaining  that  part  of  the  cornea  which  is  opposite  to  the  pupil,  and  thereby 
obstructing  vision. 

The  great  number  of  pterygia  which  have  their  base  turned  towards  the 
nasal  angle  of  the  eye,  in  comparison  with  the  few  which  arise  from  any  other 
part  of  the  circumference  of  the  eyeball,  might  naturally  lead  us  to  suspect 
that  this  disease  consisted  in  an  elongation  of  the  semilunar  fold  of  the  con- 
junctiva, or  that  it  took  its  origin  from  the  caruncula  lachrymalis  ;  and  on 
carefully  examining  a  pterygium  on  the  nasal  side  of  the  eye,  it  will  appear 
evident,  that  the  membrana  semilunaris  is  generally  involved  in  the  disease. 
We  have,  however,  the  occasional  occurrence  of  pterygium  on  the  temporal, 
and  even  on  the  superior  and  inferior  sides  of  the  eye  ;  whence  it  is  evident 
that  this  disease  is  not  always  a  prolongation  of  the  semilunar  membrane. 

Pterygium  on  both  sides  of  the  same  eye  had  occurred  only  twice  to  Beer. 
In  these  cases,  they  met  in  the  centre  of  the  cornea,  and  almost  entirely  de- 


PTERYGIUM.  265 

prived  the  patient  of  sight.  In  one  case,  Beer  found  three  pterygia  on  the 
same  eye.  Mr.  Wardrop  mentions  having  seen  two  pterygia  on  each  eye  of 
the  same  individual. 

Schmidt  gives^  an  account  and  figure  of  an  extraordinary  pterygium,  which 
so  strongly  resembled  a  muscle  in  its  structure,  that  one  might  have  almost 
believed  the  rectus  superior  oculi  to  have  been  misplaced.  Taking  its  origin 
from  behind  the  upper  eyelid,  it  passed  over  the  eyeball  to  the  edge  of  the 
cornea,  exactly  in  the  form  of  a  layer  of  muscular  fibres.  At  the  edge  of  the 
cornea,  it  became  thicker  and  almost  tendinous,  and,  opposite  to  the  pupil, 
interwove  itself  with  the  cornea  in  the  same  manner  as  the  straight  muscles 
do  with  the  sclerotica.  This  pterygium  was  successfully  removed  by  ope- 
ration. 

Mr.  Travers  has  represented'^  two  cases  of  pterygium,  each  of  which  occu- . 
pied  the  upper  part  of  the  eye.  One  of  them  was  membranous  and  transpa- 
rent, the  other  fleshy.  The  subject  of  the  latter  was  a  female,  about  21  years 
of  age,  who  had  experienced  repeated  attacks  of  scrofulous  ophthalmia,  in 
one  of  which  the  cornea  gave  way,  and  the  iris  prolapsed  near  its  ciliary 
margin.  A  pterygium  then  formed,  originating  from  beneath  the  whole  base 
of  the  upper  eyelid;  it  was  triangular,  extended  to  the  lower  margin  of  the 
cornea,  was  of  sarcomatous  density,  about  a  line  thick,  and  formed  a  fold 
when  the  eye  was  directed  upwards.  It  was  completely  cured  by  the  opera- 
tion of  dividing  and  detaching  it  at  its  basis.  The  patient  recovered  her 
sight,  and  ultimately  no  vestige  of  the  disease  remained. 

Such  sarcomatous  pterygia  as  those  mentioned  by  Schmidt  and  Travers 
bear  some  resemblance  to  symblepharon,  and  the  latter  disease  has  sometimes 
been  operated  on,  as  if  it  had  been  a  mere  pterygium.  The  history  of  the 
disease,  however,  as  well  as  the  appearances  of  the  eye,  will  readily  enable 
the  surgeon  to  discriminate  between  these  two  diseases.  In  symblepharon,  a 
probe  may  often  be  passed  behind  the  thickened  fold  of  conjunctiva,  never  in 
pterygium.  If  what  appears  as  a  pterygium  is  not  only  sarcomatous,  but  is 
attended  with  more  than  ordinary  pain,  it  may  be  suspected  to  be  of  a  malig- 
nant nature.^ 

Causes. — Beer  scouts  the  idea  adopted  by  many  writers,  that  pterygium 
ought  to  be  regarded  as  a  consequence  of  ophthalmia.  He  grants  that  tedious 
or  neglected  ophthalmia,  or  ophthalmia  treated  with  many  relaxing  external 
applications,  is  apt  to  leave  the  conjunctiva  of  the  eyeball  so  loose,  that  on 
every  motion  of  the  eye,  it  falls  into  a  number  of  folds,  but  asserts  that  such 
cases  never  appear  to  terminate  in  pterygium. 

I  have  met  with  several  cases,  in  which  pterygium  was  combined  with 
chronic  catarrhal  ophthalmia,  and  I  am  led  to  believe  that  the  former  disease 
had  originated  in  the  latter.  I  have  also  seen  pterygium  produced  by  scro- 
fulous ophthalmia.  In  one  case,  I  found  a  pterygium  on  the  nasal  side  of 
each  eye,  in  a  person  laboring  under  elephantiasis,  who  had  been  long  in  the 
West  Indies.  In  two  other  individuals  from  the  West  Indies,  I  have  met 
with  pterygium  on  the  nasal  side  of  each  eye.  I  have  seen  a  particle  of  gun- 
powder, which  had  been  lodged  for  years  under  the  conjunctiva,  at  last  cause 
pterygium.  I  have  also  known  a  cut  of  the  edge  of  the  upper  eyelid  and  of 
the  conjunctiva,  and  burns  of  the  conjunctiva  and  of  the  edge  of  the  cornea, 
by  melted  iron  projected  into  the  eye,  to  bring  on  this  disease.  In  such  cases, 
the  pterygium  is  very  tough,  and  adheres  more  closely  to  the  cornea  and  scle- 
rotica than  in  ordinary  cases.  In  many  cases,  it  is  impossible  to  trace  this 
disease  to  any  exciting  cause.  Of  this,  however,  I  am  certain,  that  often  the 
disease  begins  by  the  formation  of  what  ultimately  forms  its  apex,  close  to  the 
edge  of  the  cornea,  before  any  thickening  or  unnatural  vascularity  of  the  con- 
junctiva is  observable. 


266  PTERYGIUM. 

Beer*  came  to  the  conclusion,  that  pterygium  most  frequently  owed  its 
origin  to  the  influence  of  lime  or  fine  stone-dust  upon  the  conjunctiva,  by  far 
the  greater  number  of  patients  who  had  been  under  his  care  with  this  com- 
plaint, being  day-laborers,  who  are  extremely  exposed  to  this  cause.  Mr. 
Lawrence^  has  seen  pterygium  most  frequently  in  persons  who  had  lived  long 
in  hot  climates,  which  agrees  also  with  my  experience.  "Pterygium  is  so 
common,"  says  Dr.  Heineken,^  speaking  of  Madeira,  "as  almost  to  deserve 
the  term  endemic ;  at  a  very  rough  and  faulty  estimate  of  course,  I  should 
think  that  one-tenth  of  the  peasants  and  boatmen  were  more  or  less  affected 
with  it;  and  although  they  never  submit  to  an  operation,  and  it  in  most  in- 
stances encroaches  greatly  upon  the  cornea,  yet  I  have  never  seen  nor  heard 
of  a  single  case  of  blindness  occasioned  by  it.  Its  prevalence  may  probably 
arise  from  those  classes  of  men  being  especially  exposed  to  the  full  and  con- 
stant power  of  the  sun,  with  no  other  covering  for  the  head  than  a  small 
cloth  cap  {carapiiga),  which  does  not  give  the  slightest  shade  or  protection 
to  the  eyes." 

Prognosis. — Pterygium  rarely  disappears  of  itself,  and  the  duration  of  the 
cure  is  exceedingly  various,  depending  on  whether  the  operation  be  imme- 
diately submitted  to  by  the  patient,  and  be  performed  without  leaving  any 
part  of  the  pterygium  behind,  or  whether  we  content  ourselves  with  alternate 
scarifications  and  stimulating  applications,  till  the  pterygium  is  removed  by 
a  tedious  process  of  organic  change  of  substance.  If  the  cornea  has  become 
partially  opaque  from  the  presence  of  a  pterygium,  it  may  be  long  of  clearing, 
or  may  never  clear. 

Mr.  Raleigh  relates^  a  case,  in  which  a  thick  pterygium,  occupying  the 
nasal  side  of  the  eye,  and  encroaching  about  a  line  on  the  cornea,  was  entirely 
absorbed  after  the  operation  of  extraction  of  the  lens,  the  section  being  made 
on  the  temporal  side  of  the  cornea. 

Treatment. — I  have  found  the  solution  of  nitrate  of  silver  useful  in  ptery- 
gium, even  when  the  disease  approached  to  the  state  styled  crassum,  especially 
when  it  was  attended  by  catarrhal  conjunctivitis.  In  several  cases,  I  have 
known  a  cure  effected  by  this  means ;  as  also,  by  vinum  opii. 

Should  these  means  fail,  it  will,  in  general,  be  sufficient,  in  cases  of  ptery- 
gium tenue,  not  yet  reaching  to  the  cornea,  to  lay  hold  of  the  pterygium  with 
a  small  pair  of  forceps,  and  snip  a  bit  of  it  away.  After  this,  it  shrinks  and 
disappears.  In  the  mean  time,  the  pai't  maybe  touched  daily  with  the  vinous 
tincture  of  opium,  or  the  red  precipitate  salve. 

With  regard  to  pterygium  crassum,  it  has  generally  been  thought,  that  the 
best  plan  is  to  remove  it  completely  by  operation.  If  the  patient  refuse  to 
submit  to  this,  we  may  try  the  effect  of  dividing  the  pterygium  by  two  or 
three  vertical  scarifications,  and  then  touching  it  daily  with  vinum  opii.  The 
probability,  however,  is,  that  the  patient  will  tire  of  a  mode  of  cure  so 
tedious ;  and  there  is  also  a  danger,  that  the  pterygium,  instead  of  disap- 
pearing, may  become  more  luxuriant  and  extensive. 

Mr.  Wardrop  describes,^  under  the  name  oi  fleshy  pterygium,  what  appears 
by  his  account  to  have  been  a  common  triangular  pterygium,  improperly 
treated  by  repeated  scarifications,  which,  instead  of  causing  its  diminution, 
made  it  grow  more  rapidly,  till  at  last  it  projected  from  between  the  eyelids, 
and  involved  the  semilunar  membrane  and  caruncula  lachrymalis. 

If  it  is  thought  advisable  to  proceed  to  the  extirpation  of  the  pterygium, 
it  is  to  be  performed  in  the  following  manner  :  The  patient  being  laid  _  on 
his  back  on  a  table,  the  assistant  takes  charge  of  both  eyelids,  separating 
them  so  as  fully  to  expose  the  eyeball.  The  patient  is  to  look  outwards  or 
inwards,  according  as  the  pterygium  is  on  the  nasal  or  temporal  side  of  the 
eye,  so  as  to  put  it  on  the  stretch.     With  the  toothed  forceps,  the  operator 


CONJUNCTIVAL   WARTS.  26Y 

seizes  the  pterygium  about  its  middle,  raises  it  from  the  sclerotica,  and  then 
snips  oif  the  fold  thus  formed,  with  a  pair  of  curved  scissors.  Any  remains 
of  the  pterygium  are  now  to  be  laid  hold  of,  and  removed  in  the  same  way. 
Mr.  Lawrence  transfixes  the  pterygium  with  a  knife,  and  then  shaves  it  oif 
as  far  as  the  edge  of  the  cornea.  On  the  following  day,  the  whole  surface  of 
the  wound  is  found  in  a  state  of  superficial  inflammation  and  suppuration. 
Cicatrization  quickly  follows,  and  the  cure  is  generally  completed  in  twelve 
or  fourteen  days. 

The  operation  is  very  apt  to  be  followed  by  the  formation  of  frsena  between 
the  lids,  especially  the  lower  lid,  and  the  eyeball.  These  impede  the  move- 
ments of  the  eye,  and  cause  a  feeling  of  dragging,  much  more  irksome  than 
any  uneasiness  usually  caused  by  a  pterygium  ;  so  that,  on  the  whole,  I  am 
inclined  to  dissuade  from  the  operation.  At  any  rate,  the  extirpation  must 
not  be  prolonged  too  much  in  the  direction  of  the  canthus. 

[In  a  case  of  symblepharon  following  a  too  extensive  extirpation  of  a 
pterygium,  Dr.  Hays  performed  a  plastic  operation  at  the  Wills  Hospital, 
in  1843,  of  which  he  has  given  a  full  account  in  his  edition  of  Lawrence,  to 
which  we  would  refer  the  reader. ^ — H.] 


'  Ophthalmologische  Bibliothek  von    Himly  *  Treatise   on   the  Diseases  of  the   Eye,  p. 

and  Schmidt,-  Vol.  ii.  p.  57;  Jena,  1803.  365;  London,  1833. 

*  Synopsis  of  the  Diseases  of  the  Eye;  PI.  ^  Medical  Repository;  Vol.  xxii.  p.  15;,Lon- 

vi.  figs.  3  and  4,  p.  424;  London,  1820.  don,  1824. 

^  See  case  of  pterygium-like  growth,  ending  "  Transactions  of  the  Medical  and  Physical 

in  cancer,  by  Browne,  Dublin  Quarterly  Jour-  Society  of  Calcutta;  Vol.  iv.  p.  357;  Calcutta, 

nal   of  Medical    Science,    February,    1851,  p.  1829. 

226.  '  Morbid  Anatomy  of  the  Human  Eye;  VoL 

■*  Lehre  von  den  Augenkrankheiten  ;  Vol.  ii.  i.  p.  155;  London,  1819. 

p.  638;  Wien,  1817.  '  Hays'  Lawrence,  p.  335;  Phila.,  1854. 


SECTION  IX. — PINGUECULA. 
[Fiff.  Beer,  Vol.  IL  PI.  IV.  Fig.  6. 

The  little  tumor  caWed  pingiiecula,  and  sometimes  pterygium  pingue,  ap- 
pears to  have  its  seat  partly  in  the  conjunctiva  of  the  eyeball,  partly  in  the 
areolar  tissue  connecting  the  conjunctiva  to  the  sclerotica.  It  presents  in 
the  greater  number  of  cases,  a  small,  yellowish,  well  defined  elevation, 
situated  close  to  the  edge  of  the  cornea,  over  which  it  very  rarely  advances, 
and  never  to  such  a  degree  as  to  interfere  with  vision.  It  is  sometimes 
situated  on  the  temporal,  sometimes  on  the  nasal,  side  of  the  eye.  Weller 
assures  us,  that  this  little  tubercle  contains  no  fat.  It  seldom  gives  rise  to 
any  inconvenience.  If  it  does,  it  is  to  be  laid  hold  of  with  the  toothed 
forceps,  and  removed  with  the  scissors. 


SECTION  X. — WARTS  OP  THE  CONJUNCTIVA. 

Warts,  red,  fleshy,  and  somewhat  granulated,  single,  or  in  clusters,  are 
met  with,  growing  from  every  part  of  the  conjunctiva,  not  excepting  the 
surface  of  the  cornea.  One  begins  to  grow,  perhaps,  from  the  semilunar 
membrane,  and  others  follow,  till  a  large  portion  both  of  the  palpebral  and 
ocular  conjunctiva  is  affected.  Mr.  Travers  compares  them  to  the  warts 
which  arise  from  the  inside  of  the  prepuce,  and  attributes  their  origin  to  a 
similar  cause,  namely,  irritation  from  a  diseased  secretion.  We  generally 
find  that  they  are  attended  by  a  puro-mucous  inflammation  of  the  con- 
junctiva. 


268  NJ3VUS   MATERNUS   OF  THE   CONJUNCTIVA. 

I  once  saw  a  case,  in  whicli  the  removal  of  a  small  wart  from  the  external 
surface  of  the  lower  eyelid  was  followed  by  a  crop  of  warts  on  the  conjunc- 
tiva of  the  eyeball.  They  disappeared  spontaneously,  but  left  partial  sym- 
blepharon  of  both  upper  and  lower  eyelid.  In  another  case  I  saw  a  wart, 
growing  by  a  narrow  neck  from  the  conjunctiva  scleroticoe,  so  large  as  to 
cover  the  eyeball,  and  presenting  an  appearance  which  might  readily  have 
been  mistaken  for  fungus  h^matodes  of  the  eye.  By  pressing  the  tumor 
aside,  the  sound  cornea  was  brought  into  view,  and  on  careful  examination 
the  root  of  the  wart  was  found  to  be  exterior  to  the  sclerotica,  and  movable 
on  the  eyeball.  Conjunctival  warts  must  not  be  confounded  with  the  fungus 
which  grows  round  a  foreign  body  lodged  in  the  conjunctival  folds,  nor  with 
the  fungous  diseases  of  the  conjunctiva  afterwards  to  be  described. 

Although  the  progress  of  these  excrescences  is  slow,  they  cause  consider- 
able irritation  and  inflammation,  sometimes  extending  to  the  cornea,  and 
ought  therefore  to  be  immediately  removed  with  the  scissors.  Escharotics 
appear  to  have  scarcely  any  power  in  diminishing  their  bulk,  although  they 
may  perhaps  delay  their  progress. 

Mr.  Wardrop  has  described  a  congenital  warty  excrescence  of  the  corneal 
conjunctiva.  He  mentions  that  it  was  firm  and  immovable,  with  a  rough 
granulated  appearance  externally,  and,  from  its  brownish  color,  did  not  ap- 
pear very  vascular.  It  was  small  when  first  observed,  and  increased  in  size 
in  proportion  with  the  other  parts  of  the  body.^  Mr.  Bowman  relates^  a 
case  of  warty  opacity  of  the  cornea,  its  surface  being  rough,  like  that  of  a 
soft  corn.  By  shaving  it  off,  he  reduced  the  prominence  and  improved  the 
siffht. 


'  Morbid  Anatomy  of  the  Human  Ej'e ;  Vol.        *  Lectures   on  the   parts    concerned   in   the 
i.  p.  .32  ;  London,  1819.     Two  cases  of  a  similar     Operations  on  the  Eye ;  p.  122  ;  London,  1849. 
kind  are  figured  by  Mr.  AVardrop;  Vol.  i.  PI. 
i,  figs.  1  and  2. 


SECTION  XI. — ^POLYPUS  OF  THE  CONJUNCTIVA. 

Mr.  Lawrence  tells  us,*  that  he  has  seen  small  polypi,  analogous  to  those 
of  the  Schneiderlan  membrane,  growing  from  the  conjunctiva.  In  one  case, 
the  tumor  was  as  large  as  a  pea,  and  was  connected  to  the  inner  surface  of 
the  upper  eyelid  by  a  slender  stalk.  It  had  a  smooth  mucous  surface.  In 
snipping  it  off,  Mr.  L.  found  the  peduncle  hard,  so  as  to  require  some  force 
in  dividing  it.  The  tumor  was  found  to  be  fibro-cartilaginous  and  hard  inter- 
nally, while  externally  it  was  formed  of  conjunctiva.  The  complaint  had 
existed  for  15  years,  and  had  caused  trichiasis  of  one  quarter  of  the  upper 
eyelid. 

'  Treatise  on  the  Diseases  of  the  Eye,  p.  366;     Translation  of  this  work,  p.  x.;  Paris,  1844. 
London,  1835.     For  a  similar  case,  see  French 


SECTION  Xn. — NiEVUS  IVIATERNUS  OF  THE  CONJUNCTIVA. 
Fig.  Ammon,  Thl.  III.  Tab.  VI.  Fig.  7. 
It  has  already  (p.  189)  been  noticed,  thatnsevus  sometimes  implicates  both 
surfaces  of  the  eyelids.     In  other  cases,  the  disease  affects  the  conjunctiva 
alone,  of  which  Ammon  has  recorded  a  remarkable  instance.* 

Early  extirpation  by  the  ligature  seems  the  most  likely  plan  of  cure. 


Zeitschrift  fiir  die  Ophthalmologie;  Vol.  t.  p.  84;  Heidelberg,  1835. 


FUNGUS   OF   THE   CONJUNCTIVA,  269 


SECTION  Xni. — FUNGUS  OF  THE  CONJUNCTIVA. 

Sarcosis  bulbi.     Scliwammichte  Exophthalmie,  Ger. 
Fig.  Ammon,  Thl.  II.  Tab.  I.  Figs.  5,  6,  7. 

The  conjunctiva  is  subject  to  two  diiferent  fungous  diseases,  neither  of  which 
is  a  sequela  of  the  specific  diseases  to  which  we  appropriate  the  name  of  oph- 
thalmia. The  one  has  been  described  and  figured  by  Beer,  under  the  name 
of  exoplithalmia  fungosa.^  The  other  fungous  state  of  the  conjunctiva  I  have 
not  found  described  by  any  author.     Both  are  rare  diseases.^ 

Symptoms. — ll\ie  first  variety  of  fungus  of  the  conjunctiva  is  of  a  deep  red 
color,  inclining  to  livid ;  it  aff"ects  chiefly  the  conjunctiva  covering  the  scle- 
rotica, over  which  it  is  elevated  in  irregular  soft  smooth  masses ;  it  sometimes 
rises  from  the  inside  of  the  lids,  but  never  from  the  surface  of  the  cornea. 
The  fungus  is  pressed,  however,  by  the  eyelids,  over  the  edge  of  the  cornea, 
and  sometimes  to  such  ^  degree  as  to  hide  it  completely.  Unattended  by 
pain,  this  disease  goes  on  increasing,  till  it  projects  from  between  the  lids, 
and  prevents  them  from  closing.  If  neglected,  it  may  reach  to  a  great  size, 
and  is  liable  to  be  confounded  with  the  last  stage  of  spongoid  tumor  of  the 
eyeball.  By  exposure  to  the  influence  of  the  air,  the  secretion  from  the  sur- 
face of  the  fungus  becomes  encrusted,  while  the  irritation  of  the  foreign  sub- 
stances which  come  into  contact  with  it,  renders  it  tender,  and  apt  to  bleed. 
The  edge  of  the  fungous  growth  sometimes  becomes  affected  with  ulceration, 
presenting  a  white  sloughy  appearance,  and  in  this  way  portions  of  it  are  apt 
to  perish.  The  disease  is  a  very  slow  one,  and  the  subjects  of  it  are  of  a 
decidedly  scrofulous  habit.  For  a  time,  the  firmness  of  the  cornea  and  scle- 
rotica is  sufficient  to  resist  the  effects  of  the  pressure  of  the  fungous  mass  by 
which  they  are  surrounded,  and  which  makes  way  for  itself  chiefly  by  pro- 
jecting and  dilating  the  eyelids ;  but  at  length  the  eyeball  begins  to  suffer 
from  the  pressure,  inflames,  and  bursts,  or  the  ulcerative  process  spreads  from 
the  fungus  to  the  sclerotica,  and  destroys  the  eye. 

The  second  variety  of  fungus  of  the  conjunctiva  is  almost  of  a  gelatinous 
consistence,  and  of  a  light  yellow  or  brownish  color ;  it  is  met  with  chiefly  on 
the  inside  of  the  lids,  especially  of  the  upper,  and  in  the  superior  fold  of  the 
conjunctiva.  It  sometimes  attains  a  very  considerable  size ;  and  although 
soft,  and  destitute  of  red  vessels,  is  apt  to  prove  destructive,  by  the  pressure 
which  it  exercises  on  the  eyeball. 

On  the  supposition  of  neither  of  these  fungous  affections  of  the  conjunctiva 
being  malignant,  it  is  evident  that,  by  their  mere  mechanical  effects,  they  may 
prove  destructive,  not  only  of  vision,  but  of  life.  Even  after  the  eyeball  has 
been  destroyed  by  their  pressure,  they  may  go  on  to  increase,  affect  the  bones 
of  the  orbit,  and  wear  out  the  patient  by  pain  and  fever.  I  have  sometimes 
been  led  to  doubt  whether  the  second  variety  was  not  cancerous.^  The  exu- 
berant growth  and  loose  textures  of  the  fungous  mass  sufficiently  distinguish 
it  from  epithelial  cancer  of  the  conjunctiva,  in  which  the  membrane  becomes 
warty,  the  eyelid  thickens  and  inflames,  and  the  part  at  length  ulcerates. 

Treatment. — In  the  early  stage  of  the  fungous  diseases  of  the  conjunctiva 
above  described,  leeches  to  the  conjunctiva  would  probably  be  useful ;  and 
benefit  might  perhaps  be  derived  from  the  application  of  the  vinous  tincture 
of  opium,  or  of  gentle  astringents  in  solution.  At  a  later  period,  escharotics 
are  naturally  thought  of,  especially  the  solid  nitras  argenti.  In  a  case  of  the 
first  variety,  which  has  been  for  years  under  my  observation,  benefit  appears 
to  have  been  derived  from  the  internal  use  of  cod-liver  oil.  Should  the  dis- 
ease still  advance,  extirpation  of  the  fungus  ought  not  to  be  delayed  ;  and  in 
both  varieties,  it  will  be  found  of  advantage  to  commence  the  operation  by 


2Y0 


CONJUNCTIVAL   AND   SUBCONJUNCTIVAL   TUMORS. 


separating  the  eyelids  at  their  temporal  angle,  by  an  incision  carried  towards 
the  temple,  so  as  to  allow  the  whole  of  the  diseased  conjunctiva  to  be  exposed 
to  view.  The  extirpation  will  now  be  accomplished  with  comparative  ease, 
by  means  of  the  toothed  forceps  and  a  small  scalpel,  with  the  occasional  aid 
of  the  scissors.  The  first  variety  of  fungus,  when  we  attempt  to  dissect  it 
from  the  sclerotica,  bleeds  profusely,  so  that  the  assistant  must  be  prepared 
to  clear  away  the  blood  as  the  operator  proceeds,  by  injecting  cold  water 
over  the  eye.  After  the  whole  of  the  fungus  is  removed,  the  eyelids,  where 
they  have  iDeen  disunited,  are  to  be  brought  together  with  a  stitch.  The  sur- 
face exposed  by  the  removal  of  the  disease  will,  in  a  day  or  two,  be  covered 
with  purulent  matter,  and  slowly  become  invested  by  a  pseudo-conjunctiva. 
Any  tendency  to  reproduction  must  be  prevented  by  the  use  of  nitras  argenti, 
and  symblepharon  guarded  against  by  frequent  motion  of  the  eye,  and  the 
introduction  of  a  little  mild  salve  into  the  folds  of  the  conjunctiva.* 

"When  fungus  of  the  conjunctiva  has  been  allowed  to  proceed  in  its  course 
till  the  eyeball  is  destroyed  by  its  pressure,  it  will  be  difficult  to  remove  the 
fungous  growth  by  itself,  and  it  is  quite  unnecessary  to  attempt  to  do  so. 
In  such  cases,  we  must  have  recourse  to  extirpation  of  the  eyeball,  taking 
care  also  to  remove  any  part  of  the  fungus  arising  from  the  inside  of  the 
eyelids. 


'  Lehre  von  den  Augenkrankheiten ;  Vol.  ii. 
pp.  223,  XXX.;  PI.  ii.  fig.  6;  Wien,  1817. 

*  See  two  cases  by  Scarpa,  in  his  Trattato 
delle  principali  Malattie  degli  Occhi;  Vol.  ii. 
p.  303;  Pavia,  1810. 

^  Canstatt  Uber  Markschwamm  des  Auges 
und  amaurotisches  Katzenauge,  p.  11 ;  Wiirz- 
burg,  1831. 


''  See  case  of  vascular  excrescence  of  the 
conjunctiva,  extirpated  by  Mr.  Lawrence,  Lan- 
cet, January  26,  1850,  p.  12G.  The  excrescence 
is  said  to  have  been  malignant.  Case  by  Rau, 
Jones'  Ophthalmic  Medicine  and  Surger}',  p. 
459;  London,  1847. 


Fig.  37. 


SECTION  XIV. — CONJUNCTIVAL  AND  SUBCONJUNCTIVAL  TUMORS. 

Various  tumors  take  their  origin  in  the  conjunctiva,  or  in  the  areolar  tissue 
which  connects  it  to  the  neighboring  parts.  Some  of  them  are  congenital, 
others  arise  in  after-life. 

1.  The  annexed  figure  represents  a  case  described*  by  Professor  Gnife, 
under  the  name  of  trichosis  hulbi.  I  extirpated 
a  tumor  of  the  same  appearance,  and  exactly  in 
the  same  situation.  It  was  firm  and  white,  and 
had  a  number  of  fine  hairs  growing  from  it,  like 
a  mole.  It  had  long  kept  up  an  inflamed  state  of 
the  conjunctiva,  which  entirely  subsided  after  the 
tumor  was  removed.  It  was  so  incorporated  with 
the  sclerotica,  that  its  root  was  left,  but  died  away 
under  the  use  of  nitrate  of  silver  solution. 

[Tumors  of  this  form  examined  by  Virchow, 
presented  more  or  less  completely  the  structure 
of  the  cutis.     The  formation  of  hairs  is  not  con- 
stant in  them.     They  are,  according  to  this  ob- 
server, apparently  of  congenital  origin,  and  do 
not  become  fully  developed  until  in  after-life.    They  may  grow  partly  from  the 
sclerotic  and  partly  from  the  cortiea,  though  their  most  frequent  seat  is  in  the 
former  structure. — H.] 

In  a  girl  who  applied  at  the  Glasgow  Eye  Infirmary,  there  was  a  fixed 
trichosis  at  the  inner  margin  of  the  cornea,  and  a  movable  tumor  at  the 
outer  commissure.     Mr.  White  Cooper  records  a  case  of  trichosis  both  at  the 


I 


CONJUNCTIVAL  AND   SUBCONJUNCTIVAL  TUMORS.  211 

nasal  and  temporal  edge  of  the  cornea.^  A  fatty  tumor,  which  I  extirpated 
from  a  young  lady's  eye,  had  one  hair  growing  from  it.  On  the  same  side, 
she  had  pendulous  congenital  tumors  on  the  auricle. 

Mr.  Wardrop  has  described  and  figured  a  tumor,  about  the  bulk  of  a 
horsebean,  of  which  a  small  part  seemed  to  grow  from  the  cornea,  while  the 
rest  was  situated  on  the  sclerotica,  next  the  temporal  angle  of  the  eye.  Its 
surface  was  smooth,  and  covered  by  the  conjunctiva.  Upwards  of  twelve 
very  long  and  strong  hairs  grew  from  its  middle,  passed  through  between  the 
eyelids,  and  hung  over  the  cheek.  The  patient,  at  this  time  upwards  of  50 
years  old,  remai'ked  that  these  hairs  did  not  appear  until  he  had  advanced  to 
his  sixteenth  year,  at  which  time  also  his  beard  grew.^ 

2.  We  sometimes  meet  with  gelatinous-like  tumors,  clear  and  transparent ; 
and  small,  very  hard,  vesicular  tumors,  attached  to  the  conjunctiva.  They 
are  to  be  snipped  off. 

Case  173. — Mr.  Wharton  Jones  communicated  to  me  the  case  of  a  patient,  who  came 
to  him  with  a  small  vesicular  tumor  under  the  conjunctiva,  between  the  semilunar  fold 
and  the  inner  margin  of  the  cornea.  It  could  be  made  to  slide  in  the  subconjunctival 
areolar  tissue.  With  a  fine  forceps,  Mr.  Jones  raised  a  fold  of  the  conjunctiva  over  the 
tumor,  and  snipped  it  across  with  scissors ;  whereupon  the  yesicle  slipped  out,  and  was 
received  on  the  edge  of  the  lower  lid.  On  placing  it  on  the  palm  of  his  hand,  and 
examining  it,  he  found  it  egg-shaped ;  with  a  long  diameter  of  about  two  lines,  whitish 
like  a  hydatid,  but  without  any  head.  On  minute  examination,  he  found  its  tissue  not 
the  same  as  that  of  a  hydatid.  Its  wall  was  composed  of  a  finely  granulous  membrane ; 
its  contents,  a  fluid  with  flat  nucleated  cells,  like  epithelium  cells,  some  free,  some  aggre- 
gated together  in  a  membranous  form. 

Cysticerci  and  other  entozoa,  as  I  shall  hereafter  have  occasion  to  state, 
are  sometimes  met  with  under  the  conjunctiva. 

3.  Other  conjunctival  or  subconjunctival  tumors  are  adipose,  sarcomatous, 
or  even  cartilaginous,  and,  in  most  cases,  are  easily  extirpated,  for,  in  general 
they  are  but  loosely  attached  to  the  sclerotica. 

In  some  individuals,  a  fatty  deposition  forms  beneath  the  conjunctiva  at  the 
inner  canthus,  stretching  upwards  behind  the  upper  eyelid,  and  attended  with 
an  amplification  of  the  semilunar  fold.  The  bulk  of  the  deposition  is  seldom 
such  as  to  demand  any  operation. 

A  not  uncommon  situation  for  fatty  growths  is  behind  the  upper  fold  of 
the  conjunctiva  towards  the  temple,  or  between  the  rectus  externus  and  the 
lachrymal  gland.  I  have  removed  a  congenital  fatty  tumor  from  this  situ- 
ation, drawing  it  outwards  with  forceps  and  snipping  it  away  with  scissors. 

4.  I  have  seen  several  cases  of  what  seemed  scrofulous  tuljercles,  growing 
from  the  sclerotica,  and  elevating  the  conjunctiva.  Such  tumors  are  of  a 
whitish  or  yellowish  color ;  they  appear  as  if  about  to  suppurate,  but  con- 
tinue firm,  slowly  increase  to  perhaps  the  size  of  a  hazel-nut,  burst  through 
the  conjunctiva,  but  do  not  come  to  suppuration.  In  one  case,  a  child  pre- 
sented a  tubercle  imbedded  in  the  cheek,  similar  to  the  one  growing  from  the 
eye.  Dr.  A.  Anderson  was  so  kind  as  to  examine  for  me  microscopically,  a 
portion  of  a  growth  of  this  sort,  taken  from  the  eye.  He  found  it  slightly 
nodular,  or  faintly  lobulated  externally.  Its  texture  did  not  break  short, 
but  tore  up  under  the  needles,  and  was  distinctly  fibrous.  The  fibres  were 
very  fine,  not  very  intricately  interwoven,  and  could  easily  be  separated 
into  bundles,  in  which  they  ran  parallel  to  one  another.  They  were  loaded 
with  minute  cells,  which  separated  on  breaking  up  the  mass  in  a  drop  of 
water.  They  are  probably  similar  growths,  which,  contained  within  the  eye, 
constitute  what  I  shall  describe  in  a  subsequent  chapter  as  non-malignant 
tumors.  Such  cases,  left  to  themselves,  are  apt  to  end  in  disorganization 
and  atrophy  of  the  eyeball.  If  extirpation  is  attempted,  the  diseased  mass 
is  found  to  be  soft  and  easily  torn. 


2T2  OONJUNCTIVAL   AND   SUBCONJUNCTIVAL   TUMORS. 

5.  Miiller  makes  mention  of  a  tumor  of  the  conjunctiva  palpebrarum,  as  large 
as  the  fist.  It  was  made  up  almost  entirely  of  caudate  corpuscles,  arranged 
in  a  fibrous  manner.  The  growth  was  lobulated ;  it  could  be  broken,  and 
presented  a  fibrous  fracture,  fasciculi  appearing  to  radiate  towards  the  peri- 
phery from  one  common  centre.  He  regards  it  as  belonging  to  the  category 
of  benignant  albuminous  sarcoma.  It  was  extirpated  thrice,  but  returned 
after  each  operation,  having  been  cut  into  rather  than  excised.  After  having 
been  extirpated  for  the  last  time,  on  which  occasion  the  eye  was  also  removed, 
it  ceased  to  return,  and  the  patient  recovered  completely.  It  proceeded 
entirely  from  the  conjunctiva,  the  globe  of  the  eye  being  perfectly  sound.* 

6.  Mr.  Abernethy  refers^  to  a  curious  case,  published  in  London,  by  Dr. 
Bouttatz,  of  Moscow,  of  a  tumor  which  grew  beneath  the  conjunctiva,  and 
pushed  it  out  from  between  the  eyelids.  It  was  seven  inches  long,  and  three 
inches  and  a  half  in  circumference ;  and,  on  extirpation,  weighed  two  pounds 
and  a  half.  The  structure,  Mr.  Abernethy  considers  to  have  answered  correctly 
to  what  he  has  denominated  pancreatic  sarcoma.  It  had  also  the  ordinary 
characters  of  that  diseased  structure,  which  are  those  of  slowly  and  regularly 
increasing,  not  being  prone  to  inflammation,  nor  tending  to  suppuration. 
The  tumor  was  closely  connected  with  the  conjunctiva,  against  which  it  pressed, 
but  did  not  involve  the  cornea,  which  still  retained  its  natural  transparency. 

7.  Not  only  is  the  palpebral  conjunctiva  subject  to  cancerous  ulceration 
(see  p.  16t),  but  we  meet  with  cancerous  tumors  growing  over  the  sclerotica. 

Case  174. — I  was  consulted  by  a  man,  aged  50,  on  account  of  a  tumor,  about  the  size 
of  a  small  bean,  growing  midway  between  the  external  canthus  and  the  junction  of  the 
sclerotic  with  the  cornea.  It  was  of  a  bright  red  color,  and  had  a  smooth,  glistening, 
lobulated  surface.  It  had  been  repeatedly  extirpated,  but  always  grew  again.  I  advised 
extirpation  of  the  eyeball,  Avhich,  I  understand,  was  performed  by  Mr.  Syme.* 

8.  Melanosis  not  unfrequently  commences  in  or  under  the  conjunctiva. 
We  see  small  melanotic  depositions  at  the  edge  of  the  cornea.  In  other 
cases,  a  pendulous  mass  hangs  from  the  conjunctiva. 

Case  175. — In  a  case  of  this  kind,  in  a  patient  of  the  Glasgow  Eye  Infirmary,  a  mela- 
notic tumor  protruded  at  the  inner  canthus,  and  elevated  the  upper  eyelid.  It  grew  by 
a  pedicle,  and  was  about  the  size  of  half  a  small  filbert.  It  was  snipped  oif,  grew  again, 
and  was  again  snipped  off.  Ultimately,  it  spread  extensively  over  the  eyeball,  and  so 
affected  even  its  interior,  that  the  organ  required  to  be  extirpated. 

Case  176. — Mr.  Travers  relates  the  case  of  a  lady,  in  whom  the  cornea  was  concealed 
by  a  tumor,  of  a  dark  purple  color,  protruding  to  such  an  extent  between  the  eyelids,  as 
to  occasion  great  inconvenience  and  deformity.  It  had  the  appearance  of  being  disposed 
in  lobes,  somewhat  resembling  a  bunch  of  currants,  of  unequal  size.  Mr.  Travers  ex- 
tirpated, in  this  case,  the  anterior  hemisphere  of  the  eyeball.  On  examination  of  the 
tumor,  the  cornea  and  sclerotica  proved  to  be  entire,  and  the  morbid  growth,  lying  upon 
and  adhering  to  the  cornea  and  a  small  portion  of  the  sclerotica,  had  acquired  the  lobu- 
lated appearance,  as  if  by  degeneration  of  the  investing  conjunctiva.  Delicate  white 
bands,  the  only  vestiges  of  this  membrane,  were  seen  intersecting  the  lobules  at  irregular 
distances,  in  the  form  of  septa.  The  substance,  on  dissection,  was  found  to  be  partly 
firm,  partly  pulpy,  of  a  dark  color,  here  and  there  mottled  with  white,  and  measured  a 
quarter  of  an  inch  in  thickness  from  the  external  surface  of  the  cornea.'' 

Had  Mr.  Travers  been  aware  of  the  external  seat  of  this  tumor,  perhaps 
he  might  have  endeavored  to  extirpate  it  without  sacrificing  any  part  of  the 
eyeball.  In  the  explanation  of  the  two  figures  which  he  has  given  of  the 
tumor,  he  tells  us  that  when  he  first  saw  the  case,  he  formed  the  idea  that  it 
was  a  fungus  originating  from  the  iris  or  choroid,  consequent  to  a  slough  of 
the  cornea.  The  patient  recovered  quickly  from  the  operation,  and  the  re- 
maining part  of  the  eyeball  collapsed.  From  the  dark  color  and  partly  pulpy 
consistence  of  the  morbid  growth,  may  we  not  suspect  it  to  have  been  of  the 
nature  of  melanosis  ?  Mr.  Travers  mentions  that  the  surface  of  the  cornea 
was  rough,  and  had  a  brownish  tint,  as  if  beginning  to  degenerate  into  the 
morbid  mass  which  lay  above  it. 


INFLAMMATION   OF   THE   CARUNCULA   LACHRYMALIS.  213 

The  figure  whicli  Mr.  Travers  has  given  of  the  external  appearance  of  the 
tumor  is  very  similar  to  the  eye  of  a  gentleman  by  whom  I  was  consulted  some 
years  ago,  and  who  submitted  by  ray  advice  to  have  the  interior  half  of  the 
eyeball  extirpated,  as  in  Mr.  Travers'  case.  Dr.  Monteath  being  consulted, 
approved  of  and  performed  the  proposed  operation ;  but  on  examining  the 
portion  of  the  eye  which  was  removed,  we  found  the  melanotic  degeneration 
to  occupy  the  whole  place  of  the  vitreous  humor,  so  that  the  rest  of  the  eye 
was  immediately  extirpated.  Recovery  was  speedy,  and  I  heard  of  no  return 
of  the  disease, 

1  Journal  de  Chirurgie  und  Augenheilkunde  ;  dres,  1801.     Burgmann  and  Blumenbach  have 

Vol.  iv.  p.  137;  Berlin,  1822.     See  Kuppius,  in  each  described   a  case   of   extraordinary  ^jro- 

Ammon's  Zeitscbrift  fiir  die  Opbthalmologie ;  lajistis   conjunctirce,  observed  by  the  former  in 

Vol.  ii.  p.  345  ;  Dresden,  1831:  Jones' Ophthal-  the  head  of  a  man  who  was  hanged,  and  by  the 

mie   Medicine   and   Surgery,  p.  458,  fig.   82;  latter  in  that   of  a  man  who  was  beheaded. 

London,  1847.  Some  analogy  has  been  supposed  to  exist  be- 

^  Medical  Gazette;  Vol.  xxix.  p.  278;  Lon-  tween  Bouttatz's  case  and  the  prolapsus  con- 
don,  1841.  junctivse  in  these  two  instances.     See  Amnion's 

^  Morbid  Anatomy  of  the  Human  Eye ;  Vol.  Zeitscbrift  flir  die  Ophthalmologic ;  Vol.  i.  p. 

i.  p.  32;  London,  18J9.  411 ;   Dresden,  1831. 

'  MUller  on  the  Nature  of  Cancer,  translated  ^  Dobie,  Monthly  Journal  of  Medical  Science, 

by  West;  p.  19;  PI.  iv.  fig.  10;  London,  1840.  Oct.  1853,  p.  309,  where  figures  are  given  of  the 

s  Surgical   Observations    on   Tumors,  &c.  p.  eye,  and  of  the  cancer  cells  of  the  tumor. 

43;     London,    1811;    Bouttatz,    Observations  'Synopsis   of   the  Diseases  of  the  Eye,  pp. 

pratiques  sur  diflerentes  Maladies,  p.  1 ;  Lon-  102,  349 ;  London,  1820. 


CHAPTER   V. 


DISEASES  OF  THE  SEMILUNAR  MEMBRANE,  AND 
CARUNCULA  LACHRYMALIS. 


SECTION  I. — ^INFLAMMATION  OP  THE  SEMILUNAR  MEMBRANE  AND  CARUNCULA 

LACHRYMALIS. 

Symptoms. — The  semilunar  membrane  and  caruncula  lachrymalis,  when 
inflamed,  become  much  enlarged,  and  of  a  bright  red  color,  and  affected  with 
considerable  pain,  especially  when  the  lids  are  moved.  The  inflammation 
extends  in  some  degree  to  the  conjunctiva,  of  which,  indeed,  the  semilunar 
membrane  is  a  portion,  and  by  which  the  caruncula  is  invested.  A  sensation 
as  if  some  foreign  body  was  lodged  in  the  inner  angle  of  the  eye  attends  the 
disease,  the  absorption  of  the  tears  is  obstructed,  and  an  increased  secretion 
of  mucus,  sometimes  puriform,  flows  from  the  Meibomian  follicles,  conjunc- 
tiva, and  caruncula.  In  some  cases,  suppuration  takes  place  in  the  substance, 
perhaps  in  the  follicles,  of  the  caruncula,  the  redness  and  swelling  increasing 
for  a  time,  till  matter  forms,  when  the  swelling  points,  breaks,  and  discharges 
itself.  Fungous  excrescences  are  apt  to  follow,  and  sometimes  a  permanent 
distortion  of  the  caruncula;  while,  in  other  instances,  this  part  is  entirely 
destroyed  by  the  suppuration. 

Causes. — The  influence  of  cold  may  cause  the  inflammation.  I  had  an  in- 
stance of  this  in  a  patient  who  caught  cold  while  recovering  from  dysentery. 
Slight  injuries  may  also  induce  this  disease.  Foreign  bodies,  such  as  a  par- 
ticle of  iron,  lodging  behind  the  semilunar  membrane,  or  so  fixed  as  to  irritate 
the  caruncula,  may  also  be  the  cause.  A  little  girl  was  brought  to  me,  with 
an  inflammatory  enlargement  of  the  caruncle,  which  had  been  observed  for 
18 


274         N^VUS   MATERNUS   OF   THE   CARUNCTJLA  LACHRYMALIS. 

some  weeks,  and  was  still  increasing.  By  the  side  of  the  swelling,  between 
it  and  the  eyeball,  I  noticed  something  like  a  white  thread,  which  I  pushed 
out  with  my  finger.  It  was  an  awn  of  barley,  |  inch  long.  Dr.  Monteath 
mentions'  his  having  seen  this  disease  in  two  instances,  produced  by  a  loose 
eyelash,  the  root  or  thick  end  of  which  had  fairly  entered  the  upper  punctum 
and  lachrymal  canal;  its  other  extremity  consequently  pointed  downwards  to 
the  caruncula,  which  it  constantly  irritated.  The  troublesome  irritation, 
which  had  been  excited  in  both  instances,  immediately  subsided  on  removing 
the  eyelash  from  the  lachrymal  canal.  This  little  accident  I  have  met  with 
in  a  number  of  instances ;  in  some  of  which,  the  eyelash  was  in  the  lower 
punctum,  and  in  others  in  the  upper.  In  one  case,  the  patient,  with  the 
view  of  relieving  the  uneasiness  which  he  felt,  had  made  the  eyelash  be  cut 
across  with  a  pair  of  scissors,  which  only  served  to  fret  the  caruncle  the 
more.  I  have  also  seen  an  eyelash  sticking  in  one  of  the  Meibomian  aper- 
tures, and  fretting  the  eye.  From  the  smallness  of  the  aperture,  this  occurs 
much  more  rarely. 

Prognosis. — Inflammation  of  the  semilunar  membrane,  and  carunculalachry- 
malis,  if  neglected,  may  give  rise  to  watery  eye,  and  ultimately  to  inflamma- 
tion of  the  lachrymal  passages. 

Treatment. — The  removal  of  the  cause  when  that  is  known  and  removable, 
bathing  the  parts  frequently  with  tepid  water,  touching  them  once  a  day  with 
the  lunar  caustic  solution,  and  the  use  of  laxatives,  make  up  the  general  treat- 
ment. Should  the  swelling  go  on  increasing,  a  leech  may  with  propriety  be 
applied  to  the  inflamed  caruncula  ;  and  if  suppuration  threatens,  a  bread  and 
water  poultice,  in  a  thin  linen  bag,  is  to  be  laid  over  the  inner  angle  of  the 
eye.  The  suppurated  caruncula  is  to  be  opened  with  the  lancet.  Should  it 
threaten  to  throw  out  fungous  granulations,  we  must  endeavor  to  repress  them 
by  the  vinous  tincture  of  opium,  or  the  application  of  sulphas  cupri,  or  nitras 
argenti.  If  these  means  are  insuflBcient,  the  fungus  must  be  removed  with 
the  scissors. 


Translation  of  Weller's  Manual;  Vol.  i.  p.  191;  Glasgow,  1821. 


SECTION  n. — POLYPUS  OF  THE  CARUNCULA  LACHRYMALIS. 

I  have  repeatedly  seen  a  soft  red  tumor  growing  by  a  pedicle  from  the 
caruncula,  and  bleeding  profusely  on  being  touched.  On  laying  hold  of  it, 
the  greater  part  of  it  comes  away  in  the  grasp  of  the  forceps,  and  looks  exactly 
like  the  soft  polypus  of  the  Schneiderian  membrane.  In  other  cases,  I  have 
met  with  a  firmer  sort  of  polypus,  springing  from  the  semilunar  fold  and  sur- 
face of  the  caruncula,  of  a  granular  or  lobulated  structure,  and  requiring  to 
be  snipped  away.  Both  varieties  are  apt  to  be  reproduced.  Their  root  should 
be  touched  from  time  to  time  with  nitrate  of  silver,  sulphate  of  copper,  or  a 
saturated  solution  of  carbonate  of  soda. 


SECTION  rn. — N^VUS  MATERNUS  OP  THE  CARUNCULA  LACHRYMALIS. 

Ammon  represents*  a  case  of  telangiectasia  of  the  caruncula,  connecting 
itself  with  the  lower  lid,  covering  almost  the  whole  eye,  and  hanging  down 
almost  to  the  mouth. 


Klinische  Darstellungen  des  Krankheiten  des  menscLlichen  Auges;  Vol.  ii.  Tab.  ix.  fiff.  10  ; 
Berlin,  1838. 


LITHIASIS   or   THE   CARUNCULA   LACHRYMALIS.  215 

SECTION  IV. — ENCANTHIS. 
Fig.  Demours,  PI.  LXIV.  Fig.  1.     Ammon,  Thl.  11.  Tab.  IX.  Figs.  6,  7,  8,  9. 

This  term  is  applied  to  a  chronic  enlargement  of  the  caruncula  lachrymalia 
and  semilunar  membrane,  but  especially  of  the  former.  Encanthis  henigna 
has  been  distinguished  from  encanthis  maligna;  the  former,  a  merely  hyper- 
trophied  state  of  the  parts,  and  probably  of  the  conjunctiva  more  than  of  the 
caruncula,  the  effect  of  simple  inflammation,  and 
disappearing  under  the  use  of  the  remedies  already  Fig.  38. 

enumerated ;  the  latter,  a  scirrhous  affection  of 
the  glandular  substance  of  the  caruncula,  dege- 
nerating, if  neglected,  into  cancerous  ulceration. 

Symptoms. — In  scirrhous  encanthis,  the  carun- 
cula presents  the  appearance  of  a  hard,  irregular 
swelling.  It  involves  the  semilunar  fold,  and  ex- 
tends to  the  conjunctiva  lining  the  lids,  and  even 

to  the  sclerotica    and    cornea.       It    is    at    first  of    a  [Encanthis.— From  MiUer.] 

uniform  red  color ;  but  after  it  has  attained  a  con- 
siderable bulk  beyond  the  natural  size  of  the  caruncula,  it  becomes  here  and 
there  of  a  whitish  color,  with  varicose  vessels  ramifying  over  its  surface.  It 
is  the  seat  of  lancinating  pain.  It  impedes,  by  its  size,  the  functions  of  the 
eyelids  and  excreting  lachrymal  passages.  The  lids,  especially  the  lower,  are 
everted  and  excoriated.  The  hairs  growing  from  the  caruncula  become  much 
stronger  than  natural.  Its  surface  is  easily  excited  to  bleed.  At  last  it 
ulcerates,  the  edges  of  the  sore  become  everted,  and  the  discharge  is  thin  and 
acrid,  irritating  and  excoriating  the  neighboring  parts.  If  allowed  still  tO' 
proceed  in  its  course,  the  cancerous  ulceration  spreads  to  the  lids,  lays  open 
the  lachrymal  passages,  attacks  even  the  eyeball,  and  in  fact  runs  a  course 
similar  to  that  of  cancer  of  the  lids,  as  already  described. 

Treatment. — The  scirrhous  encanthis  requires  to  be  extirpated.  For  this 
purpose  a  curved  needle,  armed  with  a  linen  thread,  is  to  be  passed  through 
the  tumor,  by  means  of  which  it  may  be  drawn  out  from  the  neighboring 
parts,  while,  with  a  small  scalpel  or  the  scissors,  it  is  completely  separated 
from  its  connections.  It  is  probable,  that  the  removal  of  the  caruncula  and 
semilunar  fold,  will  be  followed  by  incurable  stillicidium  lachrymarum ;  but 
even  if  this  should  happen,  it  is  not  to  be  compared  with  the  dangers  attend- 
ing a  scirrhous,  or  cancerous  affection  of  these  parts,  left  to  itself.  If  the 
lids,  or  the  eyeball,  are  involved,  these  parts  must  be  removed.  If  the  ope- 
ration is  followed  by  granulations  of  an  exuberant  or  unhealthy  character, 
they  must  be  touched  with  the  nitrate  of  silver.^ 


'  On  Encantliis,  consult  Carron  du  Villards,  rurgia  Curiosa,  translated  by  Sprengell,  p.  59,,; 
Guide  Pratique;  Tome  i.  p.  454;  Paris,  18.38.  London,  1706:  Bouchacourt,  Revue  Medicale, 
For  cases  of  Extirpation,  see  Purmann's  Chi-    Avril,  1842,  p,  6. 


SECTION  V. — LITHIASIS  OF  THE  CARUNCULA  LACHRYMALIS. 

Under  this  title,  Himly*  refers  to  Blasius,  Sandifort,  Schmucker,  and 
Riberi,  for  cases  of  concretions  lodged  in  the  cryptse  of  the  caruncula.  They 
are  to  be  picked  out  with  a  needle. 


Die  Krankheiten  und  Missbildungen  des  menschlicben  Auges,  Vol.  i.  p.  266;  Berlin,  1843, 


2T6  INJURIES   OF   THE   LACHRYMAL   CANALS. 


CHAPTER   VI. 
DISEASES  OF  THE  EXCRETING  LACHRYMAL  ORGANS. 


SECTION  I. — INJURIES  OP  THE  EXCRETING  LACHRYMAL  ORGANS. 
§  1.  Injuries  of  the  Pimcta  and  Lachrymal  Canals. 

In  the  1st  Section  of  Chapter  III.,  I  have  spoken  of  the  obliteration  of 
the  puncta  by  burns.  The  intrusion  of  loose  eyelashes  into  the  puncta,  has 
been  mentioned  in  the  1st  Section  of  Chapter  Y. 

If  the  canals  which  lead  from  the  puncta  lachrymalia  to  the  lachrymal  sac 
are  injured,  it  becomes  a  question,  how  far  the  eyelids  are  likely  to  be  dis- 
torted, and  the  integrity  of  the  canals  destroyed,  by  the  cicatrice  which  fol- 
lows, or  the  suppurative  inflammation  which  is  to  be  dreaded.  When  the 
wound  has  been  occasioned  by  a  clean  cutting  instrument,  we  may  hope  for 
a  cure,  without  either  distortion  of  the  eyelids  or  permanent  interruption  of 
the  function  of  the  canals.  "When  the  part  is  torn  or  bruised,  it  may  be 
destroyed  by  the  consequent  inflammation  and  suppuration ;  and  if  both 
canals  are  included  in  the  injury,  an  irremediable  stillicidium,  or  discharge  of 
tears  and  mucus,  from  the  nasal  angle  of  the  eye,  seems  likely  to  ensue. 

In  lacerated  wounds,  then,  our  prognosis  must  be  doubtful.  Yet  even 
such  wounds  are  sometimes  happily  cured.  Schmidt  relates^  the  case  of  a 
person,  who,  in  a  game  at  blindman's  buff,  was  laid  hold  of  by  the  finger  of 
one  of  the  party,  exactly  in  the  nasal  angle  of  the  eye,  and  had  the  under 
eyelid  torn  away  to  the  length  of  half  an  inch  from  the  upper.  Mohrenheim, 
who  happened  to  be  in  the  company,  pronounced  an  unfavorable  prognosis ; 
but  by  Schmidt's  care  the  case  was  cured  in  eight  days,  without  the  slightest 
stillicidium  or  ectropium.  He  omits,  however,  to  mention  whether  he 
sounded  the  lower  canal  with  Anel's  probe  after  the  cure,  so  as  to  ascertain 
that  it  was  patent.  In  a  drunken  brawl,  a  man  met  with  an  injury  exactly 
similar  to  what  Schmidt  describes,  and  for  which  he  applied  at  the  Glasgow 
Eye  Infirmary.  The  wound  healed  after  a  good  deal  of  trouble  to  keep  the 
lid  in  its  place,  left  very  little  deformity,  and  no  stillicidium.  I  thought  it 
very  unlikely,  from  the  nature  and  situation  of  the  injury,  that  the  lower 
canal  could  have  continued  patent,  and  on  passing  Anel's  probe,  I  found  it 
totally  closed  about  the  middle  of  its  course.  In  case  135  (p.  1*72),  both 
canals  were  totally  removed  in  an  operation  for  cancer,  and  yet  no  stillici- 
dium ensued.  Either  little  lachrymal  secretion  is  formed  in  such  cases,  the 
conjunctiva  absorbs  more  of  it  than  it  does  in  general,  or  it  is  more  readily 
dissolved  in  the  air.  The  observations  of  Gunz  and  Zinn,  indeed,  would 
lead  us  to  suppose,  that,  besides  the  two  canals,  there  are  other  smaller 
channels  from  the  conjunctiva  into  the  lachrymal  sac.^ 

In  cases  of  wounds  of  the  canals,  our  object  is  to  bring  the  separated  parts 
into  apposition,  and  then  to  keep  them  so.  This  is  best  effected  by  the 
introduction  of  a  stitch,  and  the  application  of  slips  of  plaster  supported  by 
a  compress  and  roller.     The  patient  must  be  careful  to  keep  the  eyes  at  rest, 


INJURIES   OF   THE   NASAL  DUCT,  2tT 

till  the  wound  is  perfectly  united.  It  might  perhaps  aid  us  in  procuring  a 
perfect  union,  to  pass  a  bristle  by  the  punctum,  through  the  divided  canal, 
and  through  the  lachrymal  sac  into  the  nasal  duct,  and  keep  it  there  till  the 
wound  heals. 

If  the  wounded  canal  does  not  unite,  but  each  end  cicatrizes  separately, 
little  is  to  be  hoped  from  making  raw  the  edges  of  the  wound,  and  again 
trying  to  bring  them  together  with  greater  accuracy.  "  I  have  met  with 
several  such  cases,"  says  Mr.  Travers,  "  and  have  tried  in  vain  to  heal 
them.'" 

I  saw  a  boy  at  the  Glasgow  Eye  Infirmary,  in  whom  a  wound,  received 
eight  years  before,  had  divided  each  lachrymal  canal,  about  the  fifth  of  an 
inch  from  the  puncta.  The  openings,  thus  produced,  nearest  to  the  puncta, 
remained  patent,  while  those  next  the  lachrymal  sac  had  completely  closed. 
A  troublesome  stillicidium  lachrymarum  was  the  result.  There  was  an  an- 
chyloblepharon,  also,  at  the  inner  angle  of  the  eye. 

§  2.   Injuries  of  the  Lachrymal  Sac. 

The  lachrymal  sac  is  pretty  well  protected  from  injury.  It  is  occasionally, 
however,  laid  open  both  by  incised  and  lacerated  wounds.  These  must  be 
treated  with  care,  lest  they  degenerate  into  fistulte  of  the  sac.  If  the  wound 
is  extensive,  and  perhaps  the  tendon  of  the  orbicularis  divided,  a  stitch  or  two 
will  be  necessary.  Should  the  opening  into  the  sac  contract  to  a  small  size, 
and  its  edges  threaten  to  become  callous,  they  should  be  touched  with  lunar 
caustic,  or  a  redhot  wire.  The  introduction  of  a  style  will  only  give  tempo- 
rary relief,  by  conveying  the  tears  into  the  nostril. 

Case  177. — A  female  applied  at  the  Glasgow  Eye  Infirmary,  in  whom  the  sac  had  been 
laid  open  by  a  stroke  with  the  sharp  end  of  a  shuttle,  thrown  out  suddenly  from  a  steam- 
loom.  Two  stitches  had  been  immediately  used,  but  the  wound  had  not  healed.  Tears 
flowed  from  it,  on  pressing  the  upper  part  of  the  sac. 

A  blow  over  the  sac  will  sometimes  rupture  it,  without  the  skin  being 
divided,  and  emphysema  of  the  eyelids  will  ensue  on  blowing  the  nose. 

Lacerated  and  gunshot  wounds,  implicating  the  sac,  are  followed  by  great 
swelling  of  the  eyelids,  and  are  apt  to  end  in  sloughing.  Care  must  be  taken 
to  obviate  ectropium  in  such  cases. 

§  3.  Injuries  of  the  Nasal  Duct. 

Injuries  of  the  membranous  nasal  duct  must  happen  not  unfrequently  in 
operations  for  the  relief  of  dacryocystitis  and  fistula  lachrymalis,  especially  in 
passing  probes  and  other  instruments  through  the  duct,  either  from  above  or 
from  below.  Attempts  to  open  a  passage  for  the  tears  by  a  series  of  probes, 
entered  by  the  puncta,  must  often  be  attended  by  laceration  and  penetration 
of  the  walls  of  the  duct.  Even  in  introducing  a  style,  there  is  reason  to 
believe  that  it  is  often  pushed,  not  in  the  calibre,  but  through  the  sides  of 
the  duct,  into  contact  with  the  periosteum  or  the  bone,  causing  htemorrhagy 
from  the  nostril.  Such  injuries  must  often  prevent  the  success  of  operations 
for  the  cure  of  dacryocystitis,  or  bring  about  a  relapse. 

The  osseous  canal,  through  which  the  duct  passes,  is  sometimes  shattered, 
and  its  sides  pressed  in  by  severe  blows  on  the  face.  I  once  saw  a  case  in 
which  this  had  followed  a  kick  from  a  horse,  received  on  the  side  of  the  nose. 
The  consequence  was  complete  obliteration  of  the  passage  for  the  tears,  from 
the  lachrymal  sac.  The  lachrymal  canals  and  the  sac,  being  uninjured,  served 
to  collect  the  tears,  which,  having  no  exit,  caused  frequent  inflammations  of 
the  sac,  which  ended  in  abscesses,  bursting  through  the  skin.  The  patient 
was  admitted  into  the  Glasgow  Eye  Infirmary,  under  the  care  of  the  late  Dr. 


218  ACUTE   DACRYOCYSTITIS. 

Monteath,  who,  as  he  found  it  impossible  to  effect  any  new  passage  for  the 
tears,  not  even  through  the  os  unguis,  attempted  by  caustics  of  various  kinds, 
and  even  by  the  actual  cautery,  to  obliterate  the  sac  and  canaliculi,  but  with- 
out success.  Under  such  circumstances,  by  cutting  across  the  canaliculi,  the 
tears  might  be  prevented  from  reaching  the  sac. 

Dr.  Rognetta  suggests*  that  in  every  case  of  fracture  of  the  nose,  in  which 
there  is  reason  to  dread  closure  of  the  nasal  duct,  we  should  sound  the  duct 
from  the  inferior  aperture,  with  the  probe  of  Laforest,  improved  by  Gensoul, 
and  leave  it  in  the  duct  for  at  least  a  day. 


'  Ueber  die  Krankheiton  des  Thranenorgans,  ^  Sj'nopsis  of  the  Diseases  of  the  Eye,  p.  238; 

p.  215;  Wien,  1803.  London,  1820. 

^  Zinn,  Descriptio  Anatomica  Oculi  Humaui,  *  Traite  Philosopbique  et  Clinique  d'Ophthal- 

p.  233;  Gcettingce,  1780.  mologie,  p.  125;  Paris,  ISii. 


SECTION  n. — ACUTE  INFLAMMATION  OF  THE  EXCRETING  LACHRYMAL  ORGANS. 

Si/n. — Dacryocystitis  acuta. 
Fig.  Ammon,  Thl.  IL  Tab.  VIII.  Fig.  9. 

Symptoms. — There  is  a  circumscribed  swelling  in  the  situation  of  the  lachry- 
mal sac,  hard,  very  sensible  to  the  touch,  and  accompanied  by  a  feeling  of 
obtuse,  deep-seated  pain,  extending  to  the  nose  and  to  the  eye.  This  swelling 
gradually  becomes  red,  and  the  least  touch  is  insupportable.  The  papillae 
are  shrunk,  the  puncta  scarcely  visible,  the  absorption  and  conveyance  of  the 
tears  into  the  lachrymal  sac,  and  through  the  nasal  duct  into  the  nose,  com- 
pletely stopped,  and  a  stillicidium  lachrjanarum  is  present.  The  nostril  on 
the  affected  side  is  at  first  uncommonly  moist ;  but  it  soon  becomes  dry, 
the  inflammation  extending  to  the  mucous  membrane  of  the  nostril.  A  degree 
of  sympathetic  inflammation  affects  the  caruncula  lachryraalis,  the  conjunc- 
tiva, and  the  eyelids.  The  redness  about  the  nasal  angle  of  the  eye,  extending 
with  some  degree  of  swelling  even  to  the  cheek,  gives  to  the  parts,  when 
viewed  at  a  distance,  an  appearance  as  if  the  integuments  were  attacked  by 
erysipelas  ;  but  on  a  nearer  examination,  the  characteristics  of  phlegmonous 
inflammation  are  recognized,  and  in  the  midst  of  the  diffused  discoloration 
and  tumefaction,  the  circumscribed  swelling  of  the  lachrymal  sac  is  evident, 
not  merely  to  the  touch,  but  even  to  the  view. 

The  primary  and  chief  seat  of  this  disease  is  the  mucous  membrane  of  the 
whole  of  the  lachrymal  passages,  from  the  puncta  to  the  nose.  When  the 
stage  of  pure  inflammation  has  reached  its  highest  degree,  and  is  about  to 
pass  into  the  suppurative  stage,  the  mucous  membrane  of  the  lachrymal  canals 
and  nasal  duct  becomes  so  much  swollen,  that  these  tubes  cease  to  be  per- 
vious. The  tumefaction  extends  also  to  the  parietes  of  the  sac.  The  nasal 
duct,  being  inclosed  in  an  osseous  canal,  cannot  become  tumefied  by  inflam- 
mation, and  at  the  same  time  leave  a  free  passage  to  the  tears.  The  anterior 
side  of  the  sac,  on  the  other  hand,  being  covered  only  by  soft  parts,  is  gra- 
dually distended,  so  as  to  form  the  tumor  already  mentioned,  which  becomes 
much  more  considerable  when  the  disease  is  so  far  advanced  that  the  mucus 
secreted  is  of  an  inordinate  quantity,  and  puriform.  The  pressure  from  within 
the  sac  produces  progressive  absorption,  so  that  the  matter  comes  gradually 
towards  the  surface, "while  the  thickening  of  the  mucous  membrane  behind 
serves  to  secure  the  deeper-seated  parts.  Mr.  Hunter  has  repeatedly  refer- 
red' to  the  fact  of  the  matter  within  the  sac  not  following  the  shortest  way, 
which  would  be  directly  into  the  nose,  but  coming  to  the  external  surface,  as 


ACUTE   DACRYOCYSTITIS.  219 

an  illustration  of  the  instinctive  provision  wliich  exists  in  the  body  for  bring- 
ing; extraneous  and  morbid  substances  to  the  skin  for  their  exit.  Occa- 
sionally, however,  the  means  of  protection  becomes  a  cause  of  future  evil,  for 
there  sometimes  takes  place  such  a  change  in  the  texture  of  the  parietes  of 
the  canals,  sac,  and  duct,  that  they  can  scarcely  ever  return  to  their  natural 
state ;  but  one  or  more  of  these  parts  are,  in  a  greater  or  less  extent,  con- 
stricted, or  even  obliterated. 

Towards  the  end  of  the  inflammatory  stage,  the  patient  complains  of  head- 
ache, and  has  other  symptoms  of  febrile  disturbance  of  the  constitution. 
The  pain  in  the  parts  primarily  affected  is  often  very  severe,  in  consequence, 
no  doubt,  of  the  unyielding  nature  of  the  surrounding  structures.  The  whole 
head  suffers,  and  the  fever  is  not  unfrequently  attended  with  delirium  during 
the  night. 

As  happens  with  all  mucous  membranes  in  a  state  of  inflammation,  a  very 
abundant  morbid  secretion  of  mucus  takes  place  at  the  transition  of  the  first 
into  the  second  stage.  This  fluid  collects  in  such  a  quantity  within  the 
lachrymal  sac,  that  the  tumor  is  strikingly  increased  in  size,  and  is  felt  dis- 
tinctly to  fluctuate.  The  accumulated  mucus  cannot  escape  in  any  consider- 
able quantity  from  the  sac  into  the  nose,  on  account  of  the  swollen  state  of 
the  lining  membrane  of  the  nasal  duct.  From  the  same  cause,  the  accumu- 
lated mucus  cannot  be  regurgitated  through  the  lachrymal  canals.  Besides, 
though  the  tears  are  more  plentifully  secreted  than  during  health,  they  are 
not  absorbed  and  conveyed  into  the  sac,  where  they  might  have  the  effect  of 
diluting  this  morbid  mucous  secretion. 

It  rarely  happens,  after  the  sac  is  once  filled  with  muco-purulent  fluid,  that 
the  symptoms  begin  to  subside,  without  the  skin  giving  way.  If  they  do,  a 
discharge  of  matter  takes  place  from  the  puncta,  the  swelling  falls,  and  the 
passage  into  the  nose  becomes  patent.  In  general,  the  tumor  increases,  the 
redness  becomes  darker,  the  skin  more  glistening,  the  fluctuation  more 
distinct.  The  sac,  and  the  parts  by  which  it  is  covered,  altered  by  inflam- 
mation, are  incapable  of  any  further  distension.  The  skin  sometimes 
mortifies  and  sloughs;  but  more  commonly  in  the  middle  of  the  swelling,  a 
yellowish,  soft  point  is  observed,  generally  below  the  tendon  of  the  orbicularis, 
but  in  some  rare  cases  above  it,  and  which  soon  gives  way.  The  collection 
of  puriform  mucus,  left  to  itself,  works  a  passage  through  the  orbicularis 
palpebrarum,  and  through  the  integuments  ;  but  by  this  opening,  the  thinner 
parts  merely  of  the  puriform  secretion  will  be  discharged,  and  the  tumor 
will,  at  least  for  some  time,  be  but  inconsiderably  diminished. 

By  and  by,  we  observe,  when  we  press  upon  the  superior  part  of  the  sac, 
that  it  is  not  altogether  puriform  mucus  which  is  discharged  by  the  opening, 
but  occasionally  a  quantity  of  pure  tears,  a  proof  that  the  action  of  the 
puncta  and  canaliculi  is  re-established.  After  a  time,  the  puriform  discharge 
ceases,  and  healthy  mucus  comes  to  be  secreted.  It  is  in  general  transparent, 
although  for  a  while  it  may  present  occasional  streaks  of  a  white  color. 
These  at  last  entirely  disappear,  and  the  mucus  becomes  thinner  in  conse- 
quence of  a  due  intermixture  of  tears.  The  opening  of  the  sac  now  heals 
either  spontaneously,  or  by  the  assistance  of  art.  Most  frequently  it  begins 
with  contracting  to  a  small  aperture,  by  which,  if  the  nasal  duct  has  not 
returned  to  its  natural  dilatation,  tears  and  mucus  are  discharged.  Should 
this  opening  close,  and  the  duct  still  continue  impervious,  the  patient  is  obliged 
several  times  in  the  day  to  press  upon  the  sac,  that  the  mucus  and  tears  which 
it  contains  may  be  discharged  through  the  puncta. 

Causes. — Among  the  causes  of  this  disease,  exposure  to  cold,  and  con- 
tusions on  the  side  of  the  nose,  are  those  most  frequently  noticed  by  patients. 
I  have  known  long-continued  weeping  bring  on  acute  dacryocystitis,  when 


280  ACUTE   DACRYOCYSTITIS. 

there  appeared  no  predisposition  to  the  disease.  Beer  mentions  the  case 
of  a  child  of  four  years  old,  in  whom  it  arose  from  the  irritation  of  a  large 
pea,  which  had  been  thrust  so  deep  into  one  of  the  nostrils  that  it  was  with 
difficulty  extracted.^ 

Prognosis. — In  every  instance,  this  is  a  sudden  and  rapid  disease,  termi- 
nating its  course  in  ten  or  twelve  days.  The  prognosis  is  always  more  favor- 
able than  in  the  chronic  affection  of  the  same  sort,  which  has  probably  been 
long  preceded  by  imperfect  transmission  of  the  tears  into  the  nose. 

When  this  disease  arises  from  no  considerable  injury  of  the  sac,  but  from 
some  slight,  perhaps  unknown  cause,  the  prognosis  is  very  favorable  during 
the  first  stage ;  that  is,  before  the  secretion  of  puriform  mucus  has  com- 
menced. If  the  disease  has  reached  the  suppurative  stage,  we  have  to  con- 
tend indeed  with  a  blennorrhoea,  or  morbid  secretion  and  accumulation  of 
mucus ;  but  under  proper  treatment  these  symptoms  may  disappear.  When 
the  inflammation  is  from  the  beginning  severe,  or  the  case  has  been  neglected 
or  mistreated,  the  nasal  duct  and  lachrymal  canals  run  the  risk  of  obliteration ; 
and  it  is  to  be  accounted  fortunate  if  the  duct  is  obliterated  at  its  lower  ex- 
tremity only,  or  the  canals  merely  at  their  termination  in  the  sac.  The  whole 
length  of  the  duct  may  be  converted  into  a  ligamentous,  almost  cartilaginous 
substance,  which  baffles  every  attempt  again  to  render  it  pervious ;  and  in 
this  case,  both  the  lachrymal  canals  and  the  sac  itself  may  become  obliterated. 
The  possibility  of  such  events  must  be  borne  in  mind,  when  we  are  called  in 
even  during  the  first  stage. 

The  prognosis  during  the  second  or  suppurative  stage  is  extremely  dubious. 
No  surgeon,  however  great  his  experience,  can  know  how  far,  during  the  first 
stage,  the  permeability  of  the  canals  has  been  affected ;  nor  can  he  at  this 
period  attempt  to  ascertain  by  probes  the  state  of  the  parts,  without  exposing 
them  to  essential  injury.  If  we  are  called  in  just  as  the  suppuration  has 
commenced,  our  treatment  may  perhaps  moderate  that  process  ;  and,  at  least, 
we  have  it  in  our  power  to  open  the  sac  at  the  proper  time,  and  in  the  proper 
place.     If  we  are  later,  we  probably  have  a  fistula  to  contend  with. 

Treatment. — It  is  by  combating  the  inflammation  that  we  are  to  cure  this 
disease,  and  not  by  attacking  merely  one,  or  even  several  of  the  symptoms. 
Dilatation,  for  instance,  by  the  introduction  of  probes  through  the  canaliculi 
into  the  sac,  and  down  even  into  the  nose,  would  only  be  subjecting  the 
inflamed  parts  to  a  new  cause  of  irritation,  and  might  thus  produce  effects 
which  would  render  a  complete  cure  difficult,  if  not  impossible. 

The  method  of  treatment,  before  the  process  of  suppuration  has  com- 
menced, is  sufficiently  simple.  In  mild  cases,  it  consists  in  observing  the 
antiphlogistic  regimen,  and  in  carefully  applying  to  the  inflamed  parts  a 
piece  of  folded  linen,  moistened  with  an  evaporating  lotion.  In  severe  cases, 
bleeding  at  the  arm,  immediately  followed  by  the  application  of  leeches  over 
the  swelling,  or  to  the  mucous  membrane  of  the  nostril,  ought  to  be  em- 
ployed. The  bowels  are  to  be  freely  opened,  and  a  gentle  degree  of  perspi- 
ration maintained  by  the  use  of  some  of  the  common  diaphoretics.  Our 
object  is  to  arrest  the  process  of  inflammation,  and  to  prevent  it  from  passing 
into  suppuration.  Where  this  is  impossible,  and  the  symptoms  show  that 
the  process  of  suppuration  has  commenced,  the  cold  lotion  should  give  way 
to  a  warm  emollient  poultice. 

Should  our  hopes  of  checking  the  disease  be  still  disappointed,  and  the 
secretion  of  puriform  mucus  go  on  augmenting,  the  sac  must  be  opened  with 
the  knife  as  soon  as  it  is  so  overfilled,  and  the  parts  which  cover  it  so  far 
disorganized,  that  the  middle  of  the  tumor  becomes  soft  and  yellowish,  point- 
ing like  an  abscess.     We  make  our  incision  in  the  direction  of  the  longer 


ACUTE   DACRYOCYSTITIS. 


281 


diameter  of  the  tumor,  and  as  we  withdraw  the  lancet,  enlarge  the  opening 
downwards  through  the  integuments,  that  the  matter  may  have  a  free  exit. 

[Most  wi'iters  on  surgery  direct,  in  this  operation,  that  the  cartilages  of  the 
eye  should  be  first  made  tense  by  pulling  the  lids  outward  to  indicate  the 
point  of  puncture  to  reach  the  lachrymal  sac  ;  but  well  as  this  may  answer  on 
the  dead  subject,  it  will  not  always  succeed,  particularly  in  cases  of  acute 

Fig.  39. 


[From  T.  W.  Jones.] 

abscess  where  all  the  surrounding  tissues  are  inflamed  and  infiltrated.  Under 
such  circumstances,  our  only  guide  is  the  edge  of  the  orbit  in  front  of  the 
bony  canal,  and  the  point  at  which  we  should  aim  to  make  the  aperture  is  to 
the  inside  and  a  little  below  the  lower  punctum.  The  patient  should  be  seated 
on  a  chair  with  the  head  well  supported.  A  narrow,  sharp-pointed,  straight 
bistoury  is  to  be  inserted  (with  the  edge  turned  out)  over  the  index  finger  of 
the  left  hand  placed  on  the  edge  of  the  orbit,  as  above  indicated,  and  passed 
inwards  a  little  until  its  point  reaches  beyond  the  edge  of  bone  ;  the  handle 
of  the  knife  is  then  to  be  elevated  to  a  point  on  the  brow  corresponding  to 
the  supraorbital  notch;  the  instrument  is  then  to  be  thrust  downwards  and 
backwards  with  the  handle  held  in  this  slightly  oblique  position. — H.] 

We  may  now  introduce  a  common  silver  probe  into  the  sac,  and  direct  it 
downwards  into  the  nasal  duct.  We  shall  almost  always  find  that  it  descends 
freely  into  the  nostril.  With  tepid  water  and  the  lachrymal  syringe,  we  next 
wash  out  the  parts,  and  this  is  to  be  repeated  daily.  A  common  poultice  is 
now  to  be  applied,  inclosed  in  a  thin  linen  bag,  and  after  the  opening  has 
continued  for  several  days,  and  the  matter  has  been  freely  evacuated,  if  the 
sac  should  continue  hard,  a  warm  poultice  of  cicuta  leaves  with  camphor  is 
recommended  for  discussing  the  induration.  A  mercurial  plaster  is  also  found 
useful  for  this  purpose. 

As  soon  as  the  object  of  these  applications  is  gained,  the  wound  is  to  be 
dressed  with  simple  cerate.  Under  this  treatment,  the  process  of  suppuration 
diminishes,  and  the  matter  discharged  begins  to  lose  more  and  more  the 
character  of  pus,  and  to  approach  to  that  of  mucus. 

Should  the  unnatural  secretion  threaten  to  become  habitual,  a  weak  solution 
of  sulphate  of  zinc  (gr.  ii  to  5i  of  water),  made  lukewarm,  is  to  be  dropped, 


282  CHRONIC  DACRYOCYSTITIS. 

once  or  twice  a  day,  into  tlie  nasal  angle  of  the  eye,  and  injected  through  the 
wound  into  the  sac. 

At  this  period,  if  the  treatment  has  been  properly  conducted,  we  most  fre- 
quently find  that  the  canaliculi  and  the  nasal  duct  have  of  themselves  become 
permeable,  the  secretion  of  mucus  natural  in  quantity  and  quality,  and  mixed 
duly  with  the  fluids  absorbed  from  the  lacus  lachrymarum.  We  therefore 
cover  the  opening  into  the  sac  with  a  bit  of  adhesive  plaster,  or  apply  such 
dressings  to  it  as  may  induce  it  to  close.  If  we  have  any  doubt  of  the  com- 
plete permeability  of  the  lachrymal  canals  and  nasal  duct,  we  have  recourse  to 
that  examination  of  the  parts  which  I  shall  describe  in  the  ninth  and  tenth 
sections  of  this  chapter. 

'  Hunter  on   the    Blood,  Inflammation  and        *  Praktiscbe    Beobachtungen   iiber    Augen- 
Gunshot  Wounds;  Vol.  ii.  pp.  298,  331;  8vo ;     krankheiten,  p.  32;   Wien,  1791. 
London,  1802. 


SECTION  ni. — CHRONIC  INFLAMMATION  Or  THE  EXCRETING  LACHRYMAL  ORGANS. 

Syn. — So  long  as  the  sac  remained  entire,  the  ancients  called  this  disease  anchylops ;  after 
it  burst,  segilops.  Dacryocystitis  chronica.  Blennorrhoea  sacci  lachrymalis.  Watery 
eye,  Ware.     Flusso  palpebrale  puriforme,  Scarpa. 

Fig.  Demours,  PI.  XX.  Figs.  I,  2,  3.     Dalrymple,  PL  VL  Figs.  1,  2,  3. 

This  disease,  by  far  the  most  common  to  which  the  excreting  lachrymal 
organs  are  subject,  occurs  more  frequently  in  women  than  in  men.  Occasion- 
ally we  see  it  even  in  infants,  depending,  as  there  is  reason  to  believe  it  often 
does  also  in  adults,  on  a  congenital  narrowness  of  the  nasal  duct.  It  presents 
five  different  stages. 

1st  Stage — Watery  Eye The  symptom  which,  in  general,  first  attracts 

the  patient's  attention,  is  weakness  of  the  eye,  from  the  tears  gathering  at  the 
inner  canthus.  Whenever  he  begins  to  read,  or  look  earnestly  at  any  minute 
object,  he  finds  a  tear  standing  in  the  eye,  and  ready  to  drop  over  on  the 
cheek.  Within  doors,  and  in  warm  dry  weather,  he  is  less  troubled  with 
this  stillicidium ;  it  is  much  increased  when  he  exposes  himself  to  a  cold 
moist  atmosphere.  To  relieve  himself  of  the  inconvenience,  he  either  simply 
applies  his  handkerchief  to  absorb  the  superabundant  moisture,  or  puts  his 
finger  upon  the  sac,  and  forces  its  contents  down  into  the  nostril.  He  goes 
on,  in  this  way,  for  perhaps  months  or  years ;  but,  by  and  by,  he  finds  that 
the  contents  of  the  sac  can  no  longer  be  made  to  descend  into  the  nostril, 
but,  on  pressure,  regurgitate  through  the  puncta.  This  however,  still  affords 
relief,  and  the  patient  probably  persists  in  the  practice  for  a  great  length  of  time. 

This  stage  of  the  disease  is,  in  general,  attended  with  no  pain  ;  but  on 
comparing  the  diseased  side  with  the  healthy  one,  we  may  always  observe  an 
additional  degree  of  fulness  at  the  inner  canthus.  The  canaliculi,  caruncle, 
and  integuments  are  thickened,  and  somewhat  inflamed,  and  the  orbicularis 
palpebrarum  and  tensor  tarsi  are  incapable  of  acting  so  completely  as  in  health. 

2c?  Stage — Blennorrhoea. — As  the  second  stage  approaches,  the  patient  feels 
pain  around  the  sac,  attended  with  an  additional  degree  of  redness  and  swell- 
ing, at  the  inner  canthus.  On  pressing  the  sac  in  his  usual  way,  for  the  pur- 
pose of  emptying  it,  he  now  observes  that  it  is  not  pure  tears,  or  a  transparent 
mucus  which  is  discharged,  but  an  opaque  fluid.  If  he  becomes  alarmed  at 
this,  and  seeks  advice,  we  find  that  whenever  we  press  pretty  strongly  on  the 
sac,  a  quantity  of  puriform  mucus  wells  out  through  the  puncta,  and  overflows 
the  eye.  Rarely,  however,  can  our  pressure  empty  the  sac  of  its  contents 
through  the  nasal  duct,  its  permeability  being  for  the  most  part  suspended 
by  general  tumefaction  of  the  mucous  membrane,  or  by  stricture  at  some 


CHRONIC   DACRYOCYSTITIS.  283 

particular  point.     Hence  the  patient  almost  always  complains  of  dryness  of 
the  nostril,  in  this  stage  of  the  disease. 

The  extent  of  the  blennorrhojal  inflammation  is  various.  The  lining  mem- 
brane of  the  sac  is  its  chief  seat.  In  many  cases,  we  have  reason  to  suspect 
that  the  whole  excretory  passages  are  affected ;  while  in  others,  it  is  evident 
that  one  or  other  of  the  lachrymal  canals  only  is  the  source  of  the  discharge. 
I  had  under  my  care  a  lady  in  whom  the  upper  lachrymal  canal  only  seemed 
affected.  The  surgeon  in  the  country,  under  whose  care  she  had  been,  treated 
the  case  as  one  of  inflammation  of  the  conjunctiva ;  there  was  no  lachrymal 
tumor;  the  matter,  oozing  from  the  upper  punctum,  inflamed  the  conjunctiva; 
and  it  was  not  till  after  repeated  examinations,  that  I  detected  how  limited 
was  the  seat  of  the  disease. 

The  accumulated  mucus,  also,  varies  much  both  in  quantity  and  quality. 
For  instance,  it  accumulates  more  rapidly  and  is  much  thicker  after  taking 
food  than  at  other  times.  The  secretion  of  it  is  very  plentiful,  but  thinner 
than  usual,  when  the  patient  continues  long  in  a  moist  and  cold  atmosphere. 
In  this  case,  the  overfilling  of  the  sac  sometimes  takes  place  so  rapidly,  that 
the  compression  of  the  orbicularis  palpebrarum  in  the  act  of  winking,  is  suf- 
ficient to  evacuate  it  through  the  canals  to  such  a  degree,  that  the  surface  of 
the  eyeball  is  overflowed,  and  the  puriform  fluid  runs  down  upon  the  cheek. 
After  the  patient  remains  for  a  short  time  in  a  warm  and  dry  atmosphere,  the 
morbid  secretion  becomes  sparing  and  ropy.  We  find  that  this  blennorrhcea 
almost  disappears  in  many  individuals  during  warm  weather,  upon  which  the 
yet  inexperienced  patient  is  apt  to  express  a  premature  joy,  for  on  the  very  first 
change  to  cold  and  wet  weather,  the  disease  most  frequently  returns  as  before. 

3d  Stage — Abscess. — It  is  evident,  from  what  has  been  said,  that  the  in- 
flammation with  which  chronic  dacryocystitis  commences,  is  seldom  consider- 
able. In  scrofulous  patients  especially,  the  purely  inflammatory  stage  is  not 
unfrequently  overlooked,  and  no  advice  asked  till  puro-mucus  has  consider- 
ably distended  the  sac.  The  external  signs  of  inflammation  in  different  cases 
of  the  disease,  and.  even  in  the  same  case  at  different  times  are  very  various. 
Sometimes  we  find  the  integuments  free  from  discoloration,  and  merely  ele- 
vated by  the  distended  sac.  At  other  times,  they  are  severely  inflamed,  exqui- 
sitely tender  to  the  touch,  thinned  by  the  pressure  of  the  puriform  mucus,  and 
ready  to  give  way.  In  fact,  the  longer  the  disease  has  lasted,  the  more  liable 
does  the  sac  become  to  attacks  of  inflammation,  which,  though  repeatedly 
dissipated,  generally  end  at  last  in  the  sac  pointing  like  an  abscess,  bursting, 
and  discharging  the  puriform  fluid  which  it  contains.  After  this,  the  opening 
in  the  skin  may  heal  up,  the  disease  return  to  the  blennorrhoeal  stage,  or  even 
to  that  of  mere  watery  eye ;  and  for  years  the  patient  may  in  this  way  suffer 
from  repeated  abscesses  of  the  sac,  without  submitting  to  any  efficient  treat- 
ment.    The  stage  of  abscess  is  attended  with  hemicrania  and  fever. 

ith  Stage — Fistula. — If,  in  the  stage  of  abscess,  the  collection  of  puriform 
mucus  be  left  to  itself,  it  will  form  a  passage  through  the  fibrous  membrane 
by  which  the  sac  is  covered,  the  orbicularis 
palpebrarum,  and  the  integuments.    The  open-  Fig.  40. 

ing  thus  formed  may  not  close,  but  merely  con- 
tract after  the  contents  of  the  sac  are  evacuated, 
manifest  no  disposition  to  heal,  and  degenerate 
into  a  fistula  of  the  sac.  Through  such  an 
opening,  a  great  portion  of  the  mucus  and  tears 
taken  up  by  the  puncta  are  discharged,  very 
little,  or  none,  going  down  through  the  nasal 
duct.  This  is  a  sort  ofnatural  cure  of  the  disease. 

It  rarely  happens  that  the  opening  through      [Rstuia  Lachrymaiis.— From  Muier.] 


284  CHRONIC  DACRYOCYSTITIS. 

the  anterior  part  of  the  sac  is  directly  opposite  to  that  which  has  been 
wrought,  by  the  process  of  suppuration,  through  the  fibrous  layer  of  the 
lower  eyelid,  the  orbicularis  palpebrarum,  and  the  integuments ;  and  it  is 
sometimes  the  case,  that  though  there  be  but  one  opening  into  the  sac,  the 
matter  forms  beneath  the  skin  several  sinuses,  which  open  by  small  orifices  at 
different  places,  more  or  less  remote  from  one  another.  This  complicated 
kind  of  fistula  is  most  apt  to  occur  in  patients  of  bad  constitution,  and  is 
generally  the  result  of  often  renewed  attacks  of  inflammation  during  the  course 
of  this  tedious  disease.  I  have  seen  the  irritation  of  a  fistula  of  the  sac  com- 
municate itself  to  the  preauricular  lymphatic  gland,  causing  it  to  swell. 

bth  Stage — Caries. — In  those  patients  who  have  suffered  from  frequent 
abscess  of  the  sac,  and  in  whom  the  external  opening  has  degenerated  into  a 
fistula,  we  sometimes  find  on  introducing  a  probe,  for  the  purpose  of  ascer- 
taining the  state  of  the  nasal  duct,  that  it  comes  immediately  into  contact 
with  bare  rough  bone,  or  even  that  in  consequence  of  the  disorganized  state, 
not  merely  of  the  soft  parts,  but  of  the  bones  by  which  these  are  surrounded, 
instead  of  passing  with  difficulty  in  the  course  of  the  nasal  duct,  it  can  be 
turned  in  various  directions  with  little  or  no  opposition.  The  os  unguis 
and  inferior  turbinated  bone  are  particularly  subject  to  this  carious  state,  but 
it  sometimes  extends  also  to  the  ethmoid  and  superior  maxillary. 

There  is  reason  to  think  that,  in  such  cases  of  carious  fistula,  not  merely 
has  inflammation  spread  from  the  lachrymal  sac  to  the  periosteum  to  which  it 
is  attached,  but  that  the  matter  collected  within  the  sac  has  drained  through 
its  posterior  wall  as  well  as  perforated  its  anterior,  and  in  this  way  induced 
the  disorganization  of  the  bones. 

Carious  fistula  seldom,  if  ever,  occurs,  except  in  long-neglected  cases,  or 
when  the  individual  is  affected  with  scrofula,  syphilis,  or  some  other  constitu- 
tional disease. 

Causes. — The  general  cause  of  the  train  of  symptoms  above  detailed,  is 
undoubtedly  inflammation  of  the  mucous  membrane  of  the  excreting  lachrymal 
passages.  This,  at  least  in  many  instances,  and  at  an  early  period,  induces 
stricture  of  the  nasal  duct ;  an  effect  which  in  its  turn  operates  powerfully 
in  continuing  the  disease. 

Congenital  smallness  of  some  part  of  the  nasal  duct  is  probably  an  occa- 
sional cause  of  chronic  dacryocystitis.  I  operated  on  two  twin  sisters,  the 
one  at  the  age  of  44,  and  the  other  at  45,  in  whom  the  disease  was  in  all 
likelihood  owing  to  a  congenital  tendency  to  stricture. 

Chronic  dacryocystitis  is  not  unfrequently  complicated  either  locally  or 
constitutionally. 

Locally,  it  may  be  connected  with  catarrhal  inflammation  of  the  Schnei- 
derian  membrane,  or  continued  disorder  of  the  Meibomian  glands  and  con- 
junctiva ;  although  certainly  the  doctrine  of  Scarpa,  that  the  general  cause  of 
this  disease  is  the  absorption  of  puro-mucous  fluid  from  the  lids  by  the  puncta, 
is  incorrect. 

It  will,  in  many  cases,  be  found,  that  chronic  dacryocystitis  is  modified  by 
some  faulty  state  of  the  general  health,  and  often  by  scrofula.  There  are 
other  portions  of  the  mucous  system,  the  inflammation  of  which  is  strikingly 
modified  by  this  latter  cause.  Mr.  Hunter  "  suspected  that  there  was  some- 
thing scrofulous  in  some  gleets  ;"^  and  with  gleet,  or  chronic,  periodic,  puro- 
mucous  inflammation  of  the  urethra,  this  affection  of  the  lachrymal  passages 
presents  a  striking  analogy.  Indeed  it  may  be  asserted  in  general,  that  the 
effect  of  scrofula  upon  any  inflammatory  disease,  is  to  prolong  its  second  stage, 
and  to  render  it  chronic.  In  other  cases,  chronic  inflammation  of  the  excre- 
ting lachrymal  organs  appears  to  depend  upon  the  weakly  constitution  of  the 
patient,  although  he  be  free  from  scrofula ;  and  in  others,  it  is  evidently  kept 


CHRONIC   DACRYOCYSTITIS.  285 

up,  and  in  some  it  appears  to  be  produced,  by  the  disordered  state  of  the 
digestive  organs.  Smallpox,  measles,  and  scarlet  fever,  frequently  call  into 
action  an  occult  scrofulous  disposition,  and  at  the  same  time  give  rise  to  the 
particular  local  disease  which  forms  the  subject  of  this  section. 

As  occasional  causes  of  the  relapses  which  take  place  in  the  course  of  this 
disease,  we  may  mention  the  influence  of  cold  while  the  individual  is  perspir- 
ing, long-continued  weeping,  and  much  stooping. 

Prognosis. — It  is,  in  general,  easy  to  afford  great  relief  in  chronic  dacryo- 
cystitis, or  even  to  remove  the  symptoms  almost  completely,  so  long  as  the 
remedial  means  are  in  use ;  but  to  cure  it  thoroughly  and  permanently,  so 
that  we  can  say  that  the  lachrymal  passage  is  again  as  good  as  ever,  is  what 
is  very  rarely  accomplished,  so  rarely,  indeed,  that  many  practitioners  make 
no  pretensions  to  do  so,  but  at  once  announce  to  the  patient  the  necessity  of 
employing,  for  life,  some  mechanical  contrivance,  by  the  aid  of  which  the 
tears  shall  reach  the  nostril. 

In  children,  the  disease  often  subsides,  and  that  rapidly  and  unexpectedly, 
towards  the  period  of  puberty,  the  osseous  passage  becoming  then  completely 
developed.  Witness  the  case  of  Marguerite  Perier,  the  niece  of  the  cele- 
brated Pascal,  whose  cure  was  so  sudden  that  it  was  deemed  miraculous,  and 
ascribed  to  the  adoration  of  a  relic  !^ 

The  oftener  the  disease,  already  become  in  some  measure  habitual,  has  been 
attended  with  new  attacks  of  acute  inflammation,  the  less,  in  general,  is  our 
hope  of  completely  curing  it.  If,  in  consequence  of  these  relapses,  a  fistula  of 
the  sac  should  form,  there  sometimes  follows  almost  a  total  closure  of  the  nasal 
duct,  while  the  mucous  surface  of  the  sac  itself  becomes  so  hypertrophied  that 
it  is  almost  impossible  to  restore  it  to  a  healthy  condition. 

If  the  sac  during  this  disease  be  not  carefully  and  frequently  emptied  by 
pressure,  its  spontaneous  evacuation  will  take  place  more  and  more  seldom, 
the  sac  will  become  over-distended,  the  swelling,  even  after  the  most  com- 
plete evacuation,  will  merely  subside  and  not  disappear,  and  an  obvious  laxity 
remain  in  the  anterior  part  of  the  sac,  and  in  the  parts  by  which  it  is  covered. 
This  is  a  particular  state,  of  which  I  shall  treat,  in  a  subsequent  Section, 
under  the  name  of  relaxation  of  the  sac. 

In  a  case  of  long-continued  blennorrhcBa,  with  stillicidium,  I  observed  the 
pupil  of  the  eye  of  the  affected  side  become  expanded  and  fixed,  and  vision 
dim,  while  on  the  other  side  no  amaurotic  tendency  was  manifest.  By  adopt- 
ing proper  measures  for  the  relief  of  the  blennorrhoea,  the  amaurosis  was 
removed. 

Local  treatment. — The  local  treatment  necessarily  varies  according  to  the 
particular  symptoms  which  are  present,  their  severity,  and  their  duration. 
The  object  in  view  is,  by  removing  the  inflammation,  puriform  discharge,  and 
swollen  state  of  the  lining  membrane  of  the  passages,  to  restore  the  tears  to 
their  natural  course.  In  every  stage  of  the  disease,  we  require  to  bear  in 
mind  the  inflamed  state  of  the  mucous  membrane,  and  the  probability  of 
stricture  existing  in  the  nasal  duct.  The  principal  points,  therefore,  of  the 
local  treatment,  fall  under  the  head  either  of  antiphlogistic  remedies,  or  of 
such  mechanical  means  as  are  likely  to  restore  the  nasal  duct  to  its  natural 
diameter. 

1.  Leeches. — Even  in  the  stage  of  xoatery  eye,  when  the  external  signs  of 
inflammation  are  not  such  as  attract  much  attention,  great  advantage  may  be 
derived  from  the  repeated  application  of  leeches  over  the  sac,  or  to  the 
mucous  membrane  of  the  nostril.  In  the  blennorrhoea!  stage,  and  especially 
during  a  renewed  attack  of  inflammation,  the  pain,  redness,  and  swelling  of 
the  integuments  will  still  more  evidently  demand  the  employment  of  this  re- 
medy.    Some  surgeons  attempt,  in  this  disease,  to  pass  up  a  bent  probe,  or 


286  CHRONIC   DACRYOCYSTITIS. 

lachrymal  sound,  from  the  nostril,  through  the  nasal  duct,  into  the  sac;  an 
operation  always  difficult,  and  often  impossible  to  perform ;  but  the  bleeding, 
produced  by  the  attempt,  seems  sometimes  useful.  I  have  even  known  it 
followed  by  a  complete  disappearance  of  the  symptoms. 

2.  Lotions — Fomentations. — Refrigerant  lotions  and  emollient  fomenta- 
tions, applied  by  means  of  a  piece  of  sponge  or  folded  linen,  over  the  sac,  are 
useful  in  abating  the  inflamed  state  of  the  parts.  Bathing  the  part  with 
brandy  and  water,  or  even  with  pure  brandy,  is  often  useful.  Fomentations 
with  chamomile  tea,  or  poppy-head  decoction,  give  relief.  Astringent  lotions 
are  also  employed,  especially  in  the  blennorrhoeal  stage,  in  the  hope  that  they 
may  be  taken  up  by  the  puncta,  and  conveyed  through  the  canaliculi,  into  con- 
tact with  the  lining  membrane  of  the  sac  and  duct,  an  object  more  certainly 
effected  by  means  of  Anel's  syringe.  A  solution  of  one  grain  of  muriate  of 
mercury,  with  six  grains  of  muriate  of  ammonia,  in  eight  ounces  of  water, 
may  be  used  for  this  purpose ;  or  a  solution  of  from  one  to  four  grains  of 
nitrate  of  silver,  in  one  ounce  of  distilled  water.  The  sac  is  to  be  emptied 
by  pressure;  then,  a  little  of  one  or  other  of  these  solutions  is  to  be  poured 
into  the  nasal  angle  of  the  eye,  the  patient  lying  on  his  back,  until  the  fluid 
is  supposed  to  have  reached  its  intended  destination.  If  the  passage  be  pa- 
tent, the  solutions  will  be  tasted  in  the  throat,  in  the  course  of  a  few  minutes. 

3.  Salves. — When  the  disease  is  complicated  with  disordered  Meibomian 
follicles  and  conjunctiva,  the  red  precipitate  of  mercury  salve  is  often  of 
advantage ;  not  merely  correcting  the  affection  of  the  lids,  but  acting  favor- 
ably upon  the  state  of  the  lachrymal  passages.  About  the  bulk  of  a  hemp- 
seed  melted  on  the  end  of  the  finger,  is  introduced  on  the  inside  of  the  lids, 
and  rubbed  along  their  edges  and  into  the  neighborhood  of  the  puncta 
lachrymalis,  once  or  twice  a  day.  When  there  is  much  hardening  at  the 
inner  angle  of  the  eye,  friction  with  diluted  mercurial  ointment,  or  with  a 
salve  containing  calomel,  or  iodide  of  potassium,  is  useful. 

4.  Forced  expiration  and  inspiratio7i. — The  patient  ought  to  be  directed 
to  blow  his  nose  frequently,  and  immediately  afterwards  to  endeavor  to  empty 
the  sac,  down  into  the  nostril,  by  pressure  with  his  finger.  He  ought  to  be 
warned  against  emptying  it  through  the  puncta,  as  by  doing  so  he  must  indi- 
rectly aid  the  tendency  to  stricture  of  the  nasal  duct.  He  ought  to  snifif 
frequently ;  and  occasionally  closing  the  mouth  and  nostrils,  inspire  strongly, 
thus  exhausting  the  air  from  the  nostril,  and  nasal  duct  opening  into  it,  and 
consequently  removing  their  contents.  These  simple  auxiliary  means  of 
keeping  the  passage  free  are  not  to  be  despised.  If  the  lachrymal  pas- 
sages be  perfectly  free,  and  the  secretion  of  tears  abundant,  as  it  is  in  raw 
weather,  inspiring  and  expiring  suddenly  and  strongly,  undoubtedly  empties 
the  sac  and  duct.  Dr.  Jacob  tells''  us  of  an  infant,  cured  of  watery  eye,  by 
the  nurse  sucking  the  nose.  Sternutatories  may  do  good  by  exciting  forcible 
expiration. 

5.  Counter-irritation. — As  a  remedy  of  considerable  use  in  chronic  dacryo- 
cystitis, I  may  mention  blisters  and  issues  behind  the  ears  and  on  the  nape  of 
the  neck.  The  employment  of  sternutatories  may  also  be  serviceable  by 
means  of  their  derivative  effect  on  the  mucous  membrane,  as  well  as  by  excit- 
ing forcible  expiration. 

6.  Electricity  has  sometimes  proved  useful.  The  method  of  employing  it 
is,  to  insulate  the  patient,  and,  with  a  wooden  point,  draw  the  electric  fluid 
from  the  neighborhood  of  the  lachrymal  sac,  either  in  a  stream,  or  in  sparks. 
This  is  to  be  continued  for  three  or  four  minutes  every  day.  When  an  ob- 
struction of  the  nasal  duct  is  suspected,  shocks  may  be  passed  down  the  duct, 
by  placing  one  director  upon  the  sac,  and  another  up  the  nostril.*  Galvanism 
or  electro-magnetism  may  be  employed  in  the  same  way. 


CHRONIC   DACRYOCYSTITIS.  281 

T.  AneVs  probes. — In  the  first  and  second  stages,  benefit  may  often  be 
derived  from  the  passage  of  small  probes,  such  as  were  first  recommended  by 
Anel,  through  the  puncta  and  canaliculi,  and  down  the  sac  and  duct,  into  the 
nostril.  A  set  of  gold  or  silver  probes,  six  in  number,  varying  from  Jj  to  J^ 
inch  in  thickness,  is  to  be  provided  for  this  purpose.  They  must  be  perfectly 
round  and  smooth  at  their  extremity,  but  need  not  be  bulbous,  and  are  not 
to  be  conical.  The  eyelid  is  to  be  put  on  the  stretch,  by  pressing  it  some- 
what towards  the  temple,  with  the  fingers  of  the  hand  which  does  not  hold 
the  probe,  and  its  edge  drawn  a  little  forward,  so  as  to  bring  the  punctum 
into  view.  If  we  intend  to  pass  the  probe  by  the  superior  canal,  we  first  of 
all  introduce  it  perpendicularly  into  the  punctum  from  below  upwards  until 
it  reaches  the  angle  of  the  canal,  and  then  turn  it  in  a  circle,  until  its  point 
comes  to  be  directed  obliquely  downwards  and  inwards,  while  at  the  same 
time  we  draw  the  lid  somewhat  upwards  as  well  as  outwards.  If  we  are  about 
to  pass  the  probe  by  the  inferior  canal,  we  introduce  it  perpendicularly  into 
the  punctum  from  above  downwards,  and  then  lower  the  handle  of  the  instru- 
ment to  a  horizontal  direction.  If  the  canals  are  patent,  by  continuing  to 
press  the  probe  onwards  in  the  directions  described,  it  enters  the  sac,  so  that 
we  come  to  touch  the  nasal  side  of  that  cavity  with  the  point  of  the  instru- 
ment. Drawing  back  the  point  a  little,  to  prevent  it  being  entangled  in  the 
lining  membrane  of  the  sac,  we  now  turn  it  in  the  direction  of  the  nasal  duct, 
viz  :  downwards  and  a  little  backwards,  and  press  it  slowly  onwards  till  it 
strikes  the  floor  of  the  nostril,  or  till  we  meet  with  such  opposition  as  may 
lead  us  to  conclude  that  the  duct  is  closed,  or  much  contracted.  In  doing 
all  this,  the  danger  of  penetrating  the  walls  of  the  duct  must  be  borne  in 
mind. 

The  introduction  of  the  probe  is  to  be  repeated  from  day  to  day,  and 
though  it  is  plainly  impossible,  even  by  a  succession  of  probes  of  different 
sizes,  to  restore  the  nasal  duct  to  its  natural  diameter,  yet,  by  this  means,  in 
combination  with  others,  and  particularly  injections,  the  obstructed  state  of 
the  duct  may  often  be  so  far  overcome,  that  the  tears  and  mucus  shall  again 
pass  into  the  nostril. 

8.  Itijections. — I  have  occasionally  succeeded  in  completely  curing  slight 
incipient  cases  by  injections  with  Anel's  syringe,  but  much  more  frequently 
I  have  failed.  The  sac  is  first  to  be  emptied,  and,  if  possible,  downwards 
into  the  nostril.  The  syringe,  with  its  piston  accurately  fitted  to  the  cylinder, 
and  stuffed  if  necessary  with  lint,  its  point  being  screwed  off,  is  to  be  filled 
with  tepid  water.  Its  point,  being  now  screwed  on,  is  to  be  passed  through 
one  or  other  punctum,  into  the  sac,  in  the  manner  already  described  for  the 
introduction  of  the  probe.  The  piston  is  now  to  be  very  slowly  pressed 
down ;  the  sac  becomes  filled ;  and,  if  the  duct  is  free,  the  water  flows  from 
the  nostril,  or  into  the  back  of  the  throat.  If  the  duct  is  not  free,  the  sac  is 
left  distended.  "We  now  endeavor  to  press  the  fluid,  with  which  it  is  filled, 
down  into  the  nostril,  placing  the  finger  for  this  purpose  between  the  puncta 
and  the  sac,  and  pressing  from  the  puncta  towards  the  nose.  Whether  the 
water  has  reached  the  nostril,  or  has  been  prevented  from  doing  so  by  the 
obstructed  state  of  the  nasal  duct,  we  now  take  up  with  the  syringe  the  medi- 
cated injection,  and  use  it  in  the  same  manner. 

It  is  by  no  means  indifferent  what  is  selected  for  a  medicated  injection. 
In  a  case  of  blennorrhoea  of  the  lachrymal  passages,  with  much  inflammation 
of  the  conjunctiva,  I  first  of  all  tried  water,  without  getting  any  of  it  to  flow 
into  the  nostril.  In  the  course  of  four  or  five  days'  trials,  I  employed,  first 
a  solution  of  lapis  divinus,  of  which  a  drop  or  two  reached  the  fauces  ;  then 
greatly  diluted  muriatic  acid,  of  which  a  good  deal  flowed  into  the  nostril; 
then  greatly  diluted  nitric  acid,  which  flowed  very  freely.     The  inflammation 


288  CHRONIC   DACRYOCYSTITIS. 

of  the  conjunctiva  and  the  blennorrhoea  of  the  sac,  greatly  abated  under  this 
plan,  in  which,  no  doubt,  each  injection  prepared  the  way  for  the  favorable 
effect  of  the  next.  On  the  whole,  I  have  found  diluted  aqua  potassse  the 
best  injection.  For  this  purpose,  from  Jss  to  Ji  may  be  mixed  with  §vi  of 
water.  It  always  causes  a  large  discharge  of  mucus  from  the  interior  of  the 
sac,  and  often  in  a  few  days  removes  the  blennorrhoea,  even  when  profuse. 
It  seems  to  possess  a  much  greater  power  of  correcting  the  inflamed  state  of 
the  mucous  membrane  of  the  lachrymal  passages,  and  changing  the  secretion 
of  its  follicles,  than  the  solutions  of  sulphate  of  zinc,  or  nitrate  of  silver. 

Whatever  medicated  injection  is  chosen,  it  ought  to  be  repeated  once  every 
day,  or  every  second  day.  Injections  may  either  be  tried  alone,  or,  according 
to  Anel's  plan,  in  combination  with  the  use  of  the  probe. 

Sir  William  Blizard  proposed^  to  treat  this  disease  in  its  early  stages,  by 
filling  the  sac  with  quicksilver ;  but  this  must  be  regarded  more  as  a  test  of 
the  state  of  the  duct,  than  a  remedy  for  dacryocystitis. 

9.  Probes  and  injections  introduced  from  the  nostril. — The  method  of 
Laforesf^  consisted  in  introducing  probes  into  the  nasal  duct  from  the  nostril, 
and  in  throwing  injections  up  into  the  sac  through  tubes  passed  in  the  same 
way.  In  some  subjects,  it  might  be  easy  to  do  this ;  but  the  difficulties 
generally  found  to  attend  the  introduction  of  a  probe  or  a  tube  from  the 
lower  meatus  of  the  nostril  into  the  nasal  duct,  caused  the  practice  to  be 
abandoned  for  many  years.  It  has  again  been  revived  in  France,  however, 
by  Gensoul,  Yerpillat,  and  others,'  and  in  England  by  Morgan.^ 

10.  Poidtices. — The  remedial  measures  hitherto  spoken  of,  presume  the 
lachrymal  passages  to  be  entire.  If  the  patient  suffers  from  a  renewed  attack 
of  inflammation,  and  we  fail  in  reducing  it  by  the  means  already  pointed  out, 
we  must  proceed  as  in  acute  dacryocystitis,  apply  an  emollient  poultice,  and 
wait  till  suppuration  advances. 

11.  Incision  of  the  sac — Daily  passage  of  a  prohe. — As  soon  as  the  fluctu- 
ation of  the  abscess  is  distinct,  we  lay  the  sac  open  as  has  been  directed  in 
the  last  section.  Even  in  cases  where  the  swelling  is  small,  we  shall  be  sur- 
prised at  the  large  quantity  of  matter  which  is  discharged.  On  proceeding 
to  examine  the  nasal  duct  with  a  common  probe,  we  almost  uniformly  find  it 
contracted  at  one  or  several  points  of  its  extent,  so  that  it  often  requires 
very  considerable  force  to  press  the  probe  through  the  duct,  till  it  touches 
the  floor  of  the  nostril.  To  remedy  this  state  of  contraction,  as  well  as  to 
relieve  the  other  symptoms,  the  daily  passage  of  the  probe  sometimes  answers 
well.  The  opening  into  the  sac  continues  patent,  in  general,  for  three  or 
four  weeks,  if  the  probe  is  passed  regularly  every  day.  By  pressure  the 
probe  aids  in  promoting  the  absorption  of  the  substance  infiltrated  into  the 
submucous  tissue,  and  which  causes  stricture  of  the  duct.  A  thicker  and  a 
thicker  probe  may  be  used,  as  the  cure  proceeds.  The  probe  interferes  in  no 
degree  with  the  employment  of  other  means,  such  as  injections,  inunction 
with  mercurial  salve,  and  the  like.  I  consider  the  probe  much  to  be  pre- 
ferred to  the  style,  in  children. 

[We  believe,  that  very  many  of  the  cases  operated  on  for  obstruction  of  the 
puncta,  lachrymal  sac  or  nasal  duct,  might  be  cured  by  the  use  of  a  series 
of  probes  as  recommended  by  Mr.  Travers  and  Dr.  Hays. 

We  have  employed  the  probes  used  by  Dr.  Hays  with  perfect  success,  both 
in  private  and  hospital  practice,  in  cases  which  seemed  at  first  to  preclude  all 
possibility  of  a  cure,  except  by  the  use  of  the  knife.  We  should,  therefore, 
recommend  their  trial,  before  a  resort  to  the  introduction  of  the  style. 

For  a  detailed  account  of  the  mode  of  using  these  pi'obes,  we  would  refer 
the  reader  to  Dr.  Hays'  valuable  edition  of  Lawrence,  published  by  Blan- 
chard  &  Lea H.] 


CHRONIC   DACRYOCYSTITIS. 


289 


Fig.  42. 


12.  Introduction  of  a  style. — The  introduction  of  a  style  is  a  very  useful 
method  of  treating   chronic   dacryocystitis,  not   merely  after  a  renewal  of 
inflammation,  terminating  in  abscess  of  the  sac,  but  in  every  stage 
of  the  complaint,  except  the  first.     The  style  is  a  nail-headed  piece  Fig.  41. 
of  silver  wire,  about  1;^  inch  long,  and  2V  inch  thick.     The  head 
should  be  plano-convex,  with  its  edge  rounded  off,  lest  by  pressure  it 
cut  the  skin,  and  the  neck  should  form  an  angle  of  about  130°  with 
the  body,  as  is  represented  in  Fig.  41.    The  surgeon  requires  to  have 
a  series  of  styles  by  him,  of  different  lengths  and  degrees  of  thick- 
ness.    The  inclination  of  the  neck  requires  also  to  be  changed  ac- 
cording to  the  form  of  the  orbit,  and  the  distance  of  the  lachrymal 
sac  from  the  surface,  circumstances  which  vary  remarkably  in  different 
subjects.     The  style  is  an  instrument  which  generally  may  be  worn 
for  an  unlimited  time,  not  only  without  annoyance  to  the  patient,  but 
with  a  great  degree  of  comfort. 

The  probe,  which  was  passed  immediately  after  opening  the  sac, 
being  withdrawn,  and  a  little  tepid  water  injected,  the  style,  previously  put 
through  a  bit  of  adhesive  plaster,  is  introduced  from  the  sac  into  the  duct, 
and  pushed  down  so  that  the  bit  of 
plaster  comes  into  contact  with  the 
integuments.  The  plaster  serves  to 
bring  the  edges  of  the  incision  as  much 
together  as  the  presence  of  the  style 
will  permit,  and  prevents  the  style  from 
sinking  through  the  wound  into  the  sac. 
As  an  additional  means  of  preventing 
this  accident,  a  bit  of  thread  may  be 
tied  round  the  neck  of  the  style,  and 
fixed  to  the  forehead  with  a  drop  of 
collodion.  The  wound  closes  gradually 
round  the  style,  which  is  not  to  be 
entirely  taken  out  for  the  first  four  or 
five  days,  but  to  allow  the  parts  to  be 

cleaned,  is  merely  to  be  raised  a  little  daily,  as  is  represented  in  Fig.  42,  and 
immediately  pushed  down  again.  After  the  wound  has  healed  so  much  that 
the  opening  closely  embraces  the  style,  this  is  to  be  taken  out  every  morning, 
the  nasal  duct  injected  with  tepid  water,  or  some  weak  astringent  solution, 
and  the  style  replaced.  The  aperture  through  the  integuments  into  the  sac 
soon  becomes  fistulous,  having  no  disposition  to  close. 

During  the  time  that  the  style  is  worn,  the  previous  symptoms  disappear 
almost  completely.  The  style  dilates  the  duct,  in  the  same  way  as  a  bougie 
dilates  the  urethra.  The  tears  and  mucus,  absorbed  by  the  lachrymal  canals, 
appear  to  be  attracted  between  the  surface  of  the  style  and  the  lining  mem- 
brane of  the  nasal  duct,  and  thus  the  function  of  the  parts  being  restored, 
the  inflammation,  watery  eye,  and  blennorrhoeal  discharge  quickly  subside. 

Although  a  style  be  worn,  and  the  nasal  duct  be  perfectly  free,  tears  some- 
times continue  to  distil  from  the  puncta,  or  by  the  head  of  the  style.  This 
may  arise  from  an  inactive  state  of  the  puncta  and  canaliculi ;  or  it  may  be 
owing  to  the  style  being  too  slender,  so  that  capillary  attraction  is  not  suffi- 
ciently accomplished  between  its  surface  and  that  of  the  mucous  membrane. 

It  frequently  happens  that  a  patient,  after  wearing  a  style  for  three  or  four 
months,  has  it  withdrawn,  thinking  the  disease  cured.  After  a  time,  how- 
ever, the  blennorrhoea  returns,  the  style  is  reintroduced,  and  the  symptoms 
again  subside.  After  three  or  four  months  more,  it  again  becomes  a  question, 
whether  the  style  should  be  removed.  The  patient  often  objects  to  its 
19 


■^'■^^J^^J//'' 


290  CHRONIC   DACRYOCYSTITIS. 

removal.  He  knows  the  inconvenience  of  the  disease,  and  the  little  trouble 
of  the  remedy,  and  prefers  continuing  the  use  of  the  style,  rather  than  run 
the  risk  of  the  blennorrhoea  returning.  I  have  known  even  ladies  object  to 
giving  up  the  style,  having  once  experienced  a  relapse  from  its  removal. 

To  prevent  it  from  becoming  oxidized,  the  silver  style  is  sometimes  gilt ; 
but,  I  presume  from  some  galvanic  effect,  such  a  style  gives  rise  to  a  disa- 
greeable feeling,  from  which  the  use  of  a  common  silver  one,  or  one  entirely 
of  gold,  is  exempt.  The  head  of  the  style  may  have  its  head  enamelled  of  a 
skin  color,  so  that  it  shall  scarcely  be  observed,  or  blackened  with  sealing- 
wax,  so  as  to  look  like  a  little  patch.  Styles  are  made  of  gutta  percha,  and 
various  other  materials.  An  extemporaneous  one  may  be  made  of  a  bit  of 
leaden  wire.  On  no  account  must  the  style  be  left  without  regular  removal 
and  replacement.  A  patient  in  the  lower  ranks  of  life  called  upon  me,  with 
a  silver  style,  which  had  been  introduced  by  the  late  Dr.  Monteath,  and 
which  had  not  been  taken  out  for  more  than  six  months.  It  was  all  but 
corroded  through,  about  a  quarter  of  an  inch  below  the  head,  the  silver  being 
converted  into  a  sulphuret,  by  the  sulphur  present  in  the  secretions  from 
the  mucous  membrane. 

In  one  instance,  I  witnessed  profuse  bleeding  from  the  nostril,  during  the 
day  and  night,  after  pushing  down  a  style.  A  short  one  had  been  worn,  but 
not  reaching  the  nostril,  a  longer  one  was  introduced,  and  was  followed  by 
this  eft'ect. 

It  is  important  to  remark  that  the  style  itself  is  occasionally  a  cause  of 
irritation.  It  often  is  so,  for  some  days  after  it  is  first  introduced.  We  are 
obliged  to  apply  an  emollient  poultice  over  the  sac,  or  even  to  withdraw  the 
style.  Months  after  it  has  been  introduced,  and  proved  highly  serviceable, 
we  sometimes  find  that  the  patient  complains  of  matter  being  still  discharged 
by  the  side  of  the  style.  In  such  cases,  we  should  consider  how  far  the  style 
itself  is  a  cause  of  this  discharge ;  and  if  the  Meibomian  follicles,  conjunc- 
tiva, and  lachrymal  passages,  appear  in  every  other  respect  sound,  except 
only  in  the  puro-mucous  discharge  by  the  side  of  the  style,  let  it  be  gradually 
shortened,  and  at  length  removed,  and  a  trial  made  whether  everything  will 
not,  now  that  the  passage  is  patent,  go  on  as  it  ought  to  do. 

By  shortening  the  style  bit  by  bit,  we  try  the  state  of  the  lower  portion  of 
the  duct.  If  matters  go  on  well  with  a  short  style,  we  may  conclude  that 
the  passage  is  healthy,  and  think  of  removing  it  entirely;  but  if  the  disease 
returns  under  the  use  of  the  short  style,  we  must  reintroduce  one  of  the  ori- 
ginal length.  When  we  withdraw  the  style,  with  the  intention  of  no  longer 
replacing  it,  the  edge  of  the  opening  through  the  integuments  should  be  made 
raw;  for  if  this  is  not  done,  it  is  apt  to  contract  to  an  almost  capillary  fistula, 
very  difficult  to  close.  This  I  shall  notice  more  fully  in  the  next  section. 
Sometimes,  indeed,  this  minute  callous  opening  may  in  itself  furnish  a  pallia- 
tive cure^  for  chronic  dacryocystitis.  A  lady  consulted  me,  who  had  long 
been  under  the  care  of  Dr.  Monteath,  for  blennorrhoea  and  relaxation  of  the 
sac.  She  had  worn  a  style  for  a  length  of  time,  but  without  a  cure  being 
effected.  Dr.  Monteath  proposed  laying  open  the  sac  and  stuffing  it,  as  is 
recommended  in  certain  cases  by  Scarpa;  but  the  patient  declined  this.  The 
style  was  removed,  the  opening  did  not  close,  but  continued  patent  for  years; 
mucus  continued  to  collect  in  the  sac,  and  kept  it  greatly  dilated ;  the  eye  was 
strong,  and  the  patient  thought  nothing  of  the  inconvenience  of  being  obliged, 
several  times  a-day,  to  press  out  the  mucus  through  the  callous  orifice. 

The  long-continued  wearing  of  a  silver  style  is  apt  to  dye  the  skin  per- 
manently, round  the  opening  into  the  sac,  of  a  blackish  hue.  Among  the 
bad  effects  of  the  style,  I  must  mention  also  that,  especially  in  children  and 
young  people,  if  used  during  a  lengthened  period,  it  is  apt  to  be  followed  by 


CHRONIC   DACRYOCYSTITIS.  291 

atrophy  of  the  sac,  with  a  sunken  state  of  the  integuments,  which  continues 
after  the  style  is  removed  and  the  aperture  into  the  sac  closed.  In  some  rare 
cases,  we  see  ectropium  of  the  inner  half  of  the  lower  eyelid  produced  by  the 
style. 

13.  Escharotics. — When  the  sac  is  laid  open,  for  the  purpose  either  of 
merely  evacuating  the  matter  pent  up  within  it,  or  of  following  out  the  cure 
by  the  daily  passage  of  the  probe  or  the  introduction  of  a  style,  we  have  an 
opportunity  of  applying  escharotics  to  the  internal  surface  of  the  sac  ;  a  practice 
at  one  time  carried  to  excess,  but  which  may  sometimes  be  necessary.  When 
the  lining  membrane  of  the  sac  is  greatly  thickened,  stuffing  it  with  lint,  dipped, 
as  Scarpa  l'ecommends,*°  in  a  liniment  consisting  of  red  precipitate  and 
mucilage  of  gum-arabic,  or  touching  the  inside  of  the  sac  with  lunar  caustic, 
may  be  proper. 

Lallemand  tells  us"  that  a  method,  long  used  in  Italy,  is  to  puncture  the 
sac,  and  introduce  into  it  a  small  bit  of  lunar  caustic ;  then  a  little  stripe  of 
amadou  is  pressed  into  contact  with  the  caustic,  to  prevent  it,  when  melted, 
from  flowing  out  by  the  opening.  Acute  inflammation  follows;  but  diminishes 
next  day,  and  ceases  in  two  or  three  days.  The  swollen  parts  fall,  and  resume 
their  natural  color,  and  the  wound  closes.  One  such  application,  it  is  stated, 
usually  suffices  to  cure  the  disease;  but  sometimes  two  or  three  applications 
are  necessary.  This  plan  operates  by  removing  the  chronic  inflammation  of 
the  mucous  membrane  of  the  sac  and  duct,  in  the  same  way  as  lunar  caustic 
cures  inflammation  of  the  conjunctiva. 

14.  Introduction  of  a  tube. — This  old  practice,  which  was  revived  and  ex- 
tensively employed  by  Dupuytren,  has  often  been  brought  forward  anew,  and 
again  allowed  to  fall  into  neglect.  The  objections  urged  by  Mr.  Ware"  and 
others,  against  the  introduction  of  a  gold  or  silver  tube  down  the  nasal  duct, 
there  to  be  left  for  life  or  for  an  indefinite  period  of  time,  have  chiefly  been, 
either  that  it  sank  down  through  the  duct  into  the  nostril,  or,  exciting  in- 
flammation, was  pushed  upwards,  by  the  swelling  of  the  mucous  membrane, 
so  as  to  project  under  the  skin  covering  the  sac,  and  required  to  be  removed. 
These  objections  may,  no  doubt,  in  a  great  measure  be  obviated  by  employing 
a  tube  of  an  appropriate  form  and  size.  Instances  are  recorded,  in  which, 
with  attention  to  those  points,  such  an  instrument  has  remained  in  the  nasal 
duct  for  many  years, ^^  and  appeared  to  afford  a  complete  cure. 

It  may  fairly  be  doubted  whether  the  tears  actually  flow  through  the  metal- 
lic canal,  furnished  to  them  by  this  contrivance,  or  descend  merely  on  the 
outside  of  the  tube,  as  they  do  along  the  surface  of  a  style.  The  tube  prob- 
ably operates  more  in  dilating  the  duct,  than  in  affording  a  channel  for  the 
tears ;  and  I  am  disposed  to  think  that  a  gold  style,  furnished  with  a  round 
head  of  such  thickness  as  to  allow  it  to  sit  easily  in  the  lachrymal  sac,  but  to 
prevent  it  from  sinking  down  the  duct,  and  over  which  the  sac  and  the  skin 
should  be  healed,  and  which  should  be  worn  for  life,  might  answer  the  purpose 
just  as  well  as  a  tube,  or  better. 

If  a  tube  is  to  be  used,  the  sac  is  to  be  freely  laid  open,  from  the  tendon 
of  the  orbicularis  downwards  and  upwards,  and  the  state  of  the  duct  examined 
with  a  probe.  If  sufficiently  wide  for  the  reception  of  the  tube,  this  may  be 
introduced  immediately;  if  contracted,  it  must  be  dilated,  by  a  series  of  styles, 
or  pieces  of  catgut  of  increasing  thickness.  The  tube  (Figs.  43  and  44) 
ought  to  be  from  2  inch  to  1  inch  long,  and  taper  gently  from  its  upper  to 
its  lower  extremity  ;  the  former  is  furnished  with  a  projecting  rim,  measuring 
I  inch  in  diameter,  whilst  the  latter  measures  -^^  inch.  Fashioned  in  one 
piece,  without  any  soldering,  of  gold  or  platinum  rather  than  silver,  the  tube 
is  to  be  slightly  curved  in  correspondence  with  the  curvature  of  the  nasal 
duct,  that  is  to  say,  with  its  convexity  forwards  and  its  concavity  backwards, 


292 


CHRONIC   DACRYOCYSTITIS. 


and  its  lower  extremity  is  to  be  truncated  obliquely,  so  that  its  oval  orifice 
shall  look  downwards  and  backwards.  The  instrument  for  introducing  the 
tube  into  the  duct  is  a  stylet  (Fig.  45),  with  a  handle  joining  it  at  an  obtuse 


Fig.  45. 


Fig.  43.     Fig.  44. 


angle.  The  stylet  fits  into  the  tube  so  loosely  that  it  may  be  easily  withdrawn 
after  the  tube  is  fixed  in  its  situation.  Mounted  on  this  instrument,  then,  the 
tube  is  to  be  introduced  into  the  sac,  and  thence  down  into  the  duct ;  such  a 
degree  of  pressure  being  exercised  upon  it,  as  to  push  the  projecting  rim  to 
the  bottom  of  the  sac.  The  stylet  is  now  withdrawn,  and  the  lips  of  the 
wound  being  accurately  adjusted,  they  are  to  be  kept  together  by  a  drop  of 
collodion,  or  a  bit  of  court-plaster. 

It  occasionally  happens  that  the  presence  of  the  tube  produces  so  much 
irritation  that  it  is  necessary  to  withdraw  it.  This  is  sometimes  difficult  to 
effect.  In  order  to  be  provided  against  such  a  possibility,  it  is  recommended 
that  in  the  original  construction  of  the  tube  a  groove  should  be  sunk  along 
the  inside  of  its  head,  so  that  it  may  be  laid  hold  of  by  means  of  a  bifurcated 
stylet,  the  blades  of  which  have  a  catch  at  their  extremity,  and  by  their  elas- 
ticity separate  from  each  other,  unless  kept  together  by  a  sliding  ring.  The 
sac  being  laid  open  by  an  incision,  this  instrument,  with  its  blades  closed 
(Fig.  46)  by  the  sliding  ring,  is  to  be  pushed  down  the  tube,  the  edge  of 
which  forces  up  the  sliding  ring,  and  the  blades  (Fig.  47)  diverge.     By  now 

Fig.  47. 


Fig.  46. 


drawing  up  the  stylet,  the  catches  at  the  end  of  its  blades  hook  against  the  edge 
of  the  groove,  and  by  this  means  the  surgeon  gets  such  ahold  of  the  tube,  that 
it  can  he  withdrawn  in  a  perpendicular  direction.     For  the  same  purpose, 


CHRONIC  DACRYOCYSTITIS.  293 

Mr.  Listen  recommended  a  probe,  formed  into  a  screw.  Introduced  into  the 
tube,  the  screw  is  fixed  in  it  firmly  by  a  few  turns,  and  thus  the  tube  is  ex- 
tracted." It  is  almost  impossible  to  lay  hold  of  the  tube  with  a  pair  of 
forceps. 

In  the  following  case,  a  lachrymal  tube  having  eifected  a  perfect  cure  of 
chronic  dacryocystitis,  took  its  leave  in  a  manner  as  inconvenient  as  unex- 
pected : — 

Case  178. — A  •woman  called  on  me,  4th  July,  1840,  to  complain  of  something  growing, 
as  she  said,  from  the  roof  of  her  mouth.  On  examination,  I  found  a  metallic  substance 
projecting  through  the  left  side  of  the  palate.  On  inquiring  into  her  history,  I  found 
that  my  colleague.  Dr.  Nimmo,  had  operated  on  her  for  fistula  lachrymalis,  at  the  Glasgow 
Eye  Infirmary,  six  years  before;  but  without  informing  her  that  any  instrument  was  left 
in  the  passage.  Seizing  the  piece  of  metal  with  pincers,  I  extracted  it  apparently  from 
the  antrum.  It  descended  in  a  vertical  direction,  as  I  drew  it  out.  It  proved  a  silver 
lachrymal  tube  of  the  usual  size,  not  much  corroded,  but  its  calibre  filled  apparently  with 
food,  its  lower  orifice,  by  projecting  for  some  time  into  the  mouth,  having  allowed  this. 
The  opening  in  the  palate  speedily  closed,  and  the  patient  continued  free  from  any  lach- 
rymal complaint. 

[The  circumstance  of  the  great  variety  in  the  form  and  material  of  the 
styles  and  tubes  employed  in  the  treatment  of  this  troublesome  affection,  is 
very  significant  of  the  fact  that  no  unexceptionable  method  or  instrument  has 
yet  been  proposed  to  meet  the  requirements  of  all  cases.  At  the  Wills  Hos- 
pital we  have  employed  the  solid  style  of  as  large  a  size  as  could  be  intro- 
duced in  preference  to  all  other  means  yet  offered — being,  however,  free  to 
admit  that  it  is  not  all  that  we  could  desire.  Some  surgeons  have  employed 
tubes  of  ivory  in  preference  to  those  of  metal ;  but  they  are  open  to  the 
objection  of  becoming  corroded,  and  then  of  giving  rise  to  unnecessary  irrita- 
tion, which  will  require  their  removal.  Dr.  Pancoast,  of  this  city,  has  been 
in  the  habit,  for  the  last  three  years,  of  employing  tubes  of  ivory,  from  which 
the  earthy  matter  has  been  removed  by  maceration  in  dilute  muriatic  acid. 
After  this  maceration,  they  require  to  be  dried  on  a  mandrin  or  cylinder,  so 
that  they  have  their  proper  form,  and  they  are  to  be  introduced  into  the  nasal 
duct  by  means  of  a  probe  previously  placed  in  the  opening  made  in  the  sac. 
A  tube  of  this  kind,  becoming  rapidly  imbued  with  the  moisture  in  the  sac, 
will  swell,  and  become  very  flexible.  No  inconvenience,  however,  follows 
from  the  swelling,  owing  to  the  fact  that  the  body  is  a  hollow  cylinder. 

The  chief  object  to  be  obtained  from  the  extraction  of  the  earthy  material 
is  that  it  enables  the  whole  tube  to  be  removed  by  disintegration  and  absorp- 
tion, after  the  lapse  of  a  period  sufficiently  long  for  its  presence  to  have 
effected  the  cure  of  the  stricture. 

To  avoid  the  inconvenience  of  this  tube  rising,  care  should  be  taken  not  to 
have  it  made  as  conical  as  is  the  custom  of  forming  them  by  some  instrument 
makers.  In  no  one  instaijce,  except  from  this  cause,  has  Dr.  P.  seen  any 
inconvenience  follow  its  use,  and  in  all  cases  where  he  has  used  it,  he  tells  us 
it  has  been  adequate  to  the  cure  of  the  disease. — H.] 

General  treatmeiit. — However  well  chosen  and  carefully  conducted  our 
local  treatment  of  this  tedious  and  troublesome  disease,  we  shall  probably 
find  it  to  have  comparatively  little  eff'ect,  unless  we  at  the  same  time  employ 
every  means  we  possess  of  improving  the  patient's  general  health. 

Chronic  dacryocystitis,  in  scrofulous  children,  who  sometimes  present  the 
disease  on  both  sides  of  the  face,  is  often  attended  with  extensive  destruction 
of  the  integuments  round  the  fistulous  opening  communicating  with  the  sac, 
and  is  not  unfrequently  connected  with  caries  of  the  bones  forming  the  osseous 
canal  for  the  transmission  of  the  nasal  duct.  In  such  subjects  the  style  is 
difficult  to  manage,  is  not  productive  of  the  same  amount  of  benefit  as  in 
adults,  and  not  unfrequently  must  be  laid  aside,  on  account  of  the  irritation 


294  FISTULA   OF   THE   LACHRYMAL   SAC. 

it  occasions.  On  the  other  hand,  constitutional  remedies  are  of  much  greater 
utility  in  cases  of  scrofulous  inflammation  of  the  sac  in  children,  than  in  the 
chronic  dacryocystitis  of  adults.  I  have  seen  a  complete  cure  effected  by  the 
use  of  the  iodide  of  potassium,  without  any  manual  interference  with  the 
parts." 

In  scrofulo-syphilitic  cases,  I  have  found  the  administration  of  equal  parts 
of  cinchona  and  sarsaparilla,  in  powder,  very  useful. 

In  weakly  persons,  whether  scrofulous  or  not,  the  employment  of  the  pre- 
parations of  iron  and  cinchona  will  be  found  highly  beneficial.  When  the 
prolongation  of  the  disease  depends  on  derangement  of  the  digestive  organs, 
it  will  be  necessary  to  begin  by  restoring  these  to  a  healthy  state.  This  will 
be  best  effected  by  small  doses  of  blue  pill  at  bedtime,  followed  by  a  laxative 
in  the  morning,  as  has  been  recommended  by  Mr.  Abernethy.*^  I  have  known 
a  smart  dose  of  calomel  and  jalap  remove  all  the  symptoms,  even  when  the 
sac  was  filled  with  matter.  In  almost  every  case,  advantage  will  be  reaped 
from  cold  bathing,  country  air,  and  regular  exercise.  Change  of  climate  has 
been  known  of  itself  to  effect  a  cure.*'' 


'  Treatise  on  the  Venereal  Disease,  p.  159  j  "°  Trattato  delle  Malattie  degli  Occhi,  Vol.  i. 

London,  1810.  p.  39;  Pavia,  1816. 

*  Bossut,  Discours  sur  la  Vie  et  les  Ouvrages  "  Des  Partes  Seminales  Involontaires,  Tome 
de  Pascal.  iii.  p.  418  ;  Paris,  1842. 

'  Dublin  Hospital  Reports,  Vol.  v.  p.  377;  '*  Observations    on    the    Treatment  of  the 

Dublin,  1830.  Epiphora,  or  Watery  Eye,  &c.,  p.  74  ;  London, 

*  Cavallo  on  Electricity;  Vol.  ii.  pp.  149, 167,  1818. 

186;  London,  1795.  '"  Ansiaux,   Clinique    Chirurgicale,  p.  115; 

'  Philosophical  Transactions  for  1780  ;  VoL  Liege,  1829. 

Ixx.  part  i.  p.  239.  "  Lancet,  July  13,  1844,  p.  481. 

'  Memoires  de  I'Academie    Royale  de  Chi-  "  London  Medical  Gazette;  vol.  x.  p.  I'.'O  ; 

rurgie  ;  T.  v.  p.  79  ;  12mo;  Paris,  1787.  London,   1832.      Seo    Manson's    Medical    Ke- 

'■  Journal   Hebdomadaire    des    Progrfes    des  searches  on  the  Effects  of  Iodine,  p.  273;  Lon- 

Sciences    Medicales;  Tome  i.  p.  114;    Paris,  don,  1825. 

1836.  "  Surgical  Observations    on   the    Constitu- 

*  Lectures  on  Diseases  of  the  Eye,  p.  220;  tional  Origin  and  Treatment  of  Local  Diseases. 
London,  1839.  '^  Haynes  Walton's    Operative  Ophthalmic 

'  See  Practical  Observations  on  the  Diseases  Surgery,  p.  213  j  London,  1853. 

of  the  Inner    Corner  of  the  Eye,  by  Joseph  , 
Reade ;  London,  1811. 


SECTION  IV. — FISTULA  OF  THE  LACHRYMAL  SAC. 
Fig.  Ammon,  Thl.  IL  Tab.  VIIL  Figs.  11,  12,  13,  14,  15.    Dalrymple,  PI.  VL  Fig.  4. 

It  must  be  apparent,  from  what  has  already  been  said,  that  fistula  of  the 
sac  is  usually  the  consequence  of  neglect  in  acute  inflammation  of  the  ex- 
creting lachrymal  organs,  or  of  reiterated  attacks  of  inflammation  during  the 
course  of  chronic  dacryocystitis.  If  the  inflamed  sac  be  not  opened  at  the 
proper  time,  but  the  collection  of  puriform  mucus  be  left  to  itself,  it  will  form 
a  passage  through  the  fibrous  layer  by  which  the  sac  is  covered,  the  orl^icu- 
laris  palpebrarum,  and  the  integuments.  The  opening  thus  formed  may  close 
soon  after,  and  everything  go  on  well.  But  in  many  cases,  the  opening 
merely  contracts,  manifests  no  disposition  to  heal,  and  degenerates  into  a 
fistula  of  the  sac,  through  which  a  great  portion  of  the  mucus  and  tears  taken 
up  by  the  puncta  are  discharged,  little  or  none  going  down  through  the  nasal 
duct.  Lachrymal  fistula  is  occasionally  complicated  with  a  hypertrophied 
state  of  the  lining  membrane  of  the  sac,  and  generally  with  stricture  of  the 
nasal  duct. 

Prognosis. — The  least  disagreeable  circumstance  which  takes  place  when 
inflammation  of  the  sac  has  ended  in  fistula,  is  an  external  cicatrice  more  or 


CARIES   OF   THE   BONES   AROUND   THE   LACHRYMAL   SAC.  295 

less  visible.  In  general,  tlie  cicatrice  is  pretty  deep,  and  may  even  produce 
a  degree  of  ectropium.  If  the  fistula  be  allowed  to  continue  for  a  length  of 
time,  contraction  or  even  obliteration  of  the  nasal  duct,  from  disuse,  is  likely 
to  be  the  consequence.  The  prognosis  is  favorable  when,  on  pressing  the 
sac,  tears  issue  along  with  the  morbid  mucous  secretion,  although  not  mixed 
with  it ;  for  this  proves  that  the  absorption  of  the  tears  by  the  puncta,  and 
their  conveyance  into  the  sac,  by  the  canals,  are  restored.  The  restoration 
of  the  nasal  duct  only  now  remains  doubtful. 

Treatment. — Whatever  be  the  conditions  under  which  a  fistula  of  the  sac 
presents  itself,  whether  it  be  simple,  and  open  directly  into  the  sac,  or  com- 
plicated, so  that  several  apertures  perforate  the  skin  at  different  distances 
from  the  sac,  and  communicate  with  it  by  sinuses  placed  at  different  depths 
under  the  integuments,  the  practice  to  be  followed  is  one  and  the  same ;  viz: 
to  lay  open  the  sac  in  the  usual  manner,  introduce  a  style  down  the  nasal 
duct,  secure  the  style  from  slipping  into  the  sac,  and  apply  an  emollient 
poultice.  This  is  the  plan  to  be  followed,  even  should  it  happen  that  the 
fistula  is  so  deeply  situated,  that  a  portion  of  the  superior  maxillary  bone, 
over  which  it  runs,  has  been  laid  bare  or  become  carious.  When  this  is  the 
case,  the  fistulous  opening  is  surrounded  by  fungous  granulations,  an  ichorous 
matter  is  discharged,  the  integuments  around  are  of  a  deep  red  color,  and  the 
dehuded  or  carious  bone  is  felt  with  the  probe. 

By  means  of  the  style,  the  tears  are  conveyed  along  their  natural  channel, 
and  the  fistulous  track  or  tracks  readily  close,  without  any  other  application 
than  the  poultice,  which  is  to  be  discontinued  as  soon  as  the  hardness  of  the 
diseased  parts  has  subsided.  The  style  is  not  to  be  removed  entirely,  till  the 
surgeon  has  made  a  careful  examination  of  the  lachrymal  canals  and  nasal 
duct,  and  satisfied  himself  of  their  permeability  and  effectiveness. 

There  is  a  particular  variety  of  fistula,  which  must  be  noticed,  viz  :  that 
which  results  from  the  wearing  of  a  style.  The  purpose  for  which  this  in- 
strument was  employed  being  answered,  by  a  dilatation  of  the  nasal  duct 
to  its  natural  diameter,  the  style  is  removed,  and  the  orifice  through  the  skin 
contracts,  but  sometimes  does  not  close.  We  try  to  close  it  by  making. its 
edges  raw  with  the  lancet,  and  touching  it  from  time  to  time  with  lunar 
caustic.  Some  touch  it  with  a  red  hot  wire.  These  means  occasionally 
succeed,  but  in  other  cases  they  fail,  and  tears  continue  to  trickle  from  the 
minute  opening,  and  inflame  the  cheek.  In  such  a  case,  two  small  concave 
incisions  may  be  made  around  the  fistulous  opening,  the  intervening  piece  of 
skin  extirpated,  and  the  lips  brought  together  by  a  stitch.  So  troublesome 
have  such  cases  proved,  that  recourse  has  sometimes  been  had  to  the  trans- 
plantation of  a  flap  of  skin.^ 


'  Journal  Complementaire  des  Sciences  Me-     Zeitschrift  fiir  die  Ophthalmologie ;  Vol.  i.  p. 
dicales;  Tome  xl.  p.  388;  Paris,  1831;  Amnion's     405;  Dresden,  1831. 


SECTION  V. — CARIES    OP  THE  BONES   AROUND  THE   LACHRYMAL   SAC  AND   NASAL 

DUCT. 

Fig.  Ammon,  Thl.  II.   Tab.  VIII.  Fig.  17. 

It  cannot  be  denied  that  carious  fistula  occasionally  arises  in  the  manner 
described  in  the  third  section.  Neither  is  there  any  doubt  that  the  os  unguis 
and  neighboring  bones  sometimes  become  affected  with  inflammation  from 
scrofula  or  syphilis,  and  that  the  inflammation  in  these  cases  may  terminate 
in  caries. 


296  RELAXATION  OF  THE  LACHRYMAL  SAC. 

In  caries  of  the  os  unguis  from  constitutional  causes,  the  swelling  is  more 
deeply  seated,  and  the  symptoms  of  disease  in  the  excretory  apparatus  of  the 
tears  more  slowly  developed,  than  in  primary  affections  of  the  lachrymal  sac. 
For  some  time  after  the  obscure  tumefaction  has  continued,  with  very  con- 
siderable pain,  in  the  neighborhood  of  the  os  unguis,  the  excreting  lachrymal 
organs  continue  to  execute  their  functions ;  whereas,  when  the  mucous  mem- 
brane is  the  part  first  affected,  the  conveyance  of  the  tears  into  the  nostril  is 
much  sooner  impeded.  At  length,  the  lachrymal  sac  and  nasal  duct  becoming 
inflamed,  the  symptoms  bear  a  nearer  resemblance  to  those  described  in  the 
preceding  sections.  The  posterior  part  of  the  sac  becomes  ulcerated,  and 
unless  some  successful  plan  of  treatment  be  adopted  against  the  constitutional 
disease,  the  caries  of  the  bones  and  the  ulceration  of  the  soft  parts  continue, 
the  integuments  give  way,  a  fetid  ichor  is  discharged,  and  the  excretory 
lachrymal  passage  may  be  destroyed. 

General  treatmejit. — In  such  cases,  if  the  local  affection  depends  upon 
syphilis,  the  proper  remedies  against  that  disease  are  to  be  exhibited.  A 
tonic  plan  of  treatment  must  be  followed,  if  the  caries  appears  to  be  of  scro- 
fulous origin,  and  a  course  of  iodine  will  be  found  advantageous. 

Local  treatment. — No  interference  with  the  diseased  bone  can  be  of  any 
use,  either  while  the  scrofulous  or  syphilitic  action  is  going  on,  or  afterwards. 
On  the  contrary,  such  interference  would  in  all  likelihood  exasperate  the  dis- 
ease. The  introduction  of  a  style,  and  the  cautious  injection  of  a  solution  of 
nitras  argenti,  make  up  the  local  treatment.  The  former  serves  to  attract 
the  tears  along  their  natural  course,  v.-hile  the  latter  corrects  the  blennorrhoeal 
discharge,  and  represses  the  tendency  to  fungous  granulations. 

It  sometimes  happens  that  the  style  drops  from  the  lachrymal  passage  into 
the  antrum,  or  into  the  mouth  through  a  carious  aperture  in  the  palate.  This 
may  happen  not  only  in  syphilitic,  but  in  scrofulous  cases,  followed  by  ulcera- 
tion spreading  round  the  eye,  and  affecting  the  septum  and  ala)  of  the  nose ; 
the  vomer  comes  away  with  pieces  of  the  superior  maxillary  bone,  and  the 
nose  falls  in.  In  scrofulous  cases  of  this  sort,  I  have  found  sarsaparilla 
eminently  serviceable. 


SECTION  VI. — RELAXATION  OF  THE  LACHRYftLAL  SAC. 

Syn. — Hernia  sacci  laclirymalis,  Beer. 
Ficj.  Ammon,  Thl.  II.  Tab.  YIII.  Fig.  6. 

The  lachrymal  sac  is  sometimes  protruded  from  its  natural  situation,  with- 
out much  unnatural  dilatation,^  a  state  of  parts  which  has  been  called  hernia  ; 
but,  in  general,  this  term  has  been  applied  to  the  affection  of  the  sac  I  am 
now  about  to  describe. 

Symptoms. — The  sac  presents  a  tumor,  of  the  shape,  and  generally  about 
the  size,  of  a  horse-bean ;  sometimes,  however,  much  larger ;  the  integuments 
covering  it  are  scarcely  or  not  at  all  discolored,  it  is  not  painful,  and  it  yields 
more  or  less  easily  to  the  pressure  of  the  finger.  These  symptoms  are  suffi- 
ciently characteristic  to  distinguish  relaxation  from  mucocele. 

Upon  pi'essure,  the  contents  of  the  sac  in  the  state  of  relaxation  are  gene- 
rally discharged  either  by  the  canals  and  puncta,  or  by  the  nasal  duct,  accord- 
ing to  the  direction  in  which  the  pressure  is  applied.  Sometimes,  however, 
the  sac  can  be  evacuated  only  down  the  nasal  duct.  The  fluid  is  usually 
transparent,  or  presents  merely  a  streak  of  whitish  matter;  but  occasionally, 
from  the  presence  of  blennorrhoea,  it  is  entirely  yellowish  and  opaque.  Upon 
evacuation  of  the  sac,  the  tumor  is  almost  completely  removed,  but  its  integu- 


RELAXATION  OF  THE  LACHRYMAL  SAC.  29t 

ments  remain  folded  and  wrinkled,  and  it  very  soon  becomes  filled  again.  If 
the  fluid  does  not  consist  of  mucus  duly  mixed  with  tears,  but  presents  whitish 
streaks,  or  if  it  consists  entirely  of  a  catarrhal  matter,  we  feel  a  little  elasticity 
in  the  sac  after  the  evacuation,  and  there  remains  some  degree  of  swelling, 
owing  to  the  tumefaction  of  the  lining  membrane  of  the  sac. 

The  sac  in  the  state  of  relaxation  has  lost  its  natural  contractility  of  tex- 
ture. Even  that  part  of  the  orbicularis  palpebrarum  which  covers  the  sac, 
and  to  which  the  duty  of  emptying  it  partly  belongs  when  it  becomes  filled 
with  fluid,  having  suffered  from  long-continued  extension,  is  incapable  of 
contracting  with  a  sufficient  degree  of  force,  and  is  somewhat  in  the  state  of 
the  muscles  of  the  abdomen  after  the  removal  of  the  water  of  an  ascites.  The 
patient  is  consequently  obliged  to  do  with  his  finger,  what  ought  to  be  done 
spontaneously  by  the  parts  themselves.  He  is  obliged  to  evacuate  the  sac  by 
pressure  frequently  in  the  course  of  the  day,  and  it  is  fortunate  if  he  begins 
and  continues  the  practice  of  evacuating  it  by  the  natural  route  through  the 
nasal  duct,  and  not  through  the  lachrymal  canals. 

The  general  cause  of  relaxation  is  over-distension  of  the  sac  by  puriform 
mucus,  dm'ing  neglected  dacryocystitis.  Sometimes,  as  has  been  already 
stated,  blennorrhoea  still  continues,  or  has  recurred.  Most  frequently  the 
blennorrhffia  has  disappeared,  and  left  relaxation  behind  it,  along  with  an 
excessive  secretion  of  healthy  mucus.  In  this  case  we  are  called  upon  to 
limit  this  secretion,  and  to  restore  to  the  anterior  side  of  the  sac,  the  orbicu- 
laris, and  the  integuments,  their  natural  cohesion  and  elasticity,  in  order  that 
the  important  function  of  evacuating  the  contents  of  the  sac  through  the  nasal 
duct  may  be  resumed. 

Prognosis. — We  ought  to  forewarn  the  patient  that  the  cure  will  be  tedious, 
and  require  much  attention  upon  his  part. 

Treatment. — This  consists  in  the  use  of  two  distinct  means,  each  of  which, 
as  may  be  seen  by  the  testimony  of  Pellier  and  others,  is,  when  used  alone, 
apt  to  fail.^ 

The  first  is  the  compression  of  the  sac  ;  and  here  let  it  be  observed,  that 
the  present  is  the  only  case  in  which  compression  of  the  sac  is  useful.  In 
any  other  disease  of  that  part,  this  practice  would  produce  injurious  eff'ects. 
The  compression  must  be  carefully  applied,  constantly  continued,  afid  gradu- 
ally increased.  Machines  have  been  invented  for  this  purpose,  but  they  never 
fulfil,  with  precision,  all  these  conditions.  We  cannot  by  such  an  instrument 
as  Sharp's  or  Petit's  compressorium,  the  first  invention  of  which  we  owe  to 
Hieronymus  Fabricius,  keep  up  a  regular  and  an  increasing  pressure  ;  the 
compressing  surface  upon  the  least  occasion,  especially  during  the  night,  is 
disarranged ;  and  the  patient  is  hindered  from  pursuing  his  business  by  the 
presence  of  such  an  apparatus.  Graduated  compresses,  then,  are  to  be  pre- 
ferred. Garengeot  recommends  the  surgeon  to  chew  a  piece  of  brown  paper, 
and  lay  it  on  next  the  skin.  It  will  compress  the  sac,  he  says,  exactly,  and 
as  it  dries,  so  mould  itself  to  the  figure  of  the  part,  that  the  compression  shall 
always  be  the  same.^  Over  the  compresses  a  firm  leather  pad  of  a  proper 
form  is  to  be  placed ;  and  the  whole  is  to  be  supported  by  a  narrow  roller 
passing  round  the  head.  In  this  manner,  the  pressure  affects  exactly  the 
part  which  ought  to  be  acted  upon ;  it  can  be  daily  increased  ;  the  pad  can- 
not, even  when  the  patient  is  very  restless,  be  shoved  aside ;  nor  need  such 
an  apparatus  prevent  him  from  following  his  ordinary  employment,  even  out 
of  doors. 

The  second  part  of  the  treatment  consists  in  the  application  of  some  astrin- 
gent fluid,  both  to  the  external  surface  of  the  tumor,  and  to  the  internal  sur- 
face of  the  relaxed  sac.  A  great  variety  of  astringents  might  be  mentioned 
as  proper  for  this  purpose ;  such  as  solution  of  alum,  infusion  of  oak  bark, 


298  MUCOCELE   OF   THE  LACHRYMAL   SAC. 

&c.  The  graduated  compresses  are  to  be  moistened  twice  or  thrice  daily 
with  the  astringent  fluid  which  may  be  selected.  A  small  quantity  also  of 
the  same,  or  of  some  similar  fluid,  is  to  be  dropped  into  the  lacus  lachry- 
marum,  and  left  to  be  absorbed  by  the  puncta. 

I  have  known  these  means  fail  after  the  most  careful  trial.  A  medical  gen- 
tleman, who  came  under  my  care  with  relaxation  of  the  lachrymal  sac,  found 
pressure  hurtful  rather  than  useful.  He  derived  considerable  benefit  from 
oak-bark  decoction,  dropped  into  the  lacus  lachrymarura,  and  used  as  a  lotion. 
The  disease  arose  without  blennorrhoea,  merely  from  the  tears  and  mucus  accu- 
mulating in  the  sac.  Blennorrhoea  afterwards  supervened.  If  the  patient 
went  to  bed  with  the  sac  distended,  he  found  it  empty  in  the  morning.  The 
use  of  a  style  afforded  this  patient  the  most  relief.  In  another  case,  a  fistu- 
lous opening,  left  after  the  removal  of  a  style,  afforded  to  the  patient  the 
means  of  emptying  the  sac,  once  or  twice  a  day,  of  a  large  quantity  of  healthy 
mucus.  In  such  a  case  as  this,  the  sac  might  with  propriety  be  exposed  by 
an  incision  of  the  integuments,  and  a  portion  of  it  removed  with  the  scissors, 
an  operation  sometimes  had  recourse  to  in  mucocele. 


'  Archives    Generales   de  Mcdecine;    Tome  Chirurgie  des  Yeux;   Tome  ii.  p.  270;   Paris, 

XX.  p.  578;  Paris,  1829.  1790. 

*  Pott,  Observations  on  the  Fistula  Lachry-  '  Traite  des  Operations  de  Chirurgie,  Tome 

malis;   Works,  Vol.  i.  p.  252;   London,  1808:  iii.  p.  78;   Paris,  1731. 
Pellier  de  Quengsy,  Cours  d'Operations  sur  la 


SECTION  VII. — MUCOCELE  OP  THE  LACHRYMAL  SAC. 

gyn. — Hydrops  sacci  lachrymalis.  Beer.     Varix  sacci  lachrymalis,  Schmidt. 

Fig.  Ammon,  ThI.  II.   Tab.  VIII.  Fig.  18. 

Symptoms. — This  disease  presents  in  its  commencement  the  oblong  shape 
of  the  sac,  the  tumor  which  it  forms  slowly  increases,  and  I  have  seen  it 
reach  the  size  of  a  pigeon's  egg  without  bursting.  In  some  cases  the  tumor 
appears  double,  being  partially  divided  by  a  depression  in  its  middle.  The 
integuments  covering  the  tumor,  ultimately  assume  a  livid  color.  A  muco- 
cele is  often  so  hard  that  it  scarcely  yields  to  the  pressure  of  the  finger.  In 
other  cases,  it  is  soft  and  elastic.  But  whether  hard  or  soft  to  the  touch,  no 
degree  of  pressure  is  capable  of  evacuating,  either  through  the  puncta  or  into 
the  nostril,  the  mucus  which  in  this  disease  is  pent  up  within  the  sac.  A 
mucocele  may  reach  a  very  considerable  size,  and  continue  of  the  same  mag- 
nitude, and  without  pain,  for  many  years  ;  the  eye  watery,  the  nostril  dry, 
and  considerable  deformity  resulting  from  the  bulk  and  appearance  of  the 
tumor.  It  is  not  until  the  overfilling  of  the  sac  has  reached  its  highest  pos- 
sible degree,  and  the  mucocele  threatens  to  burst,  that  the  disease  is  attended 
with  a  painful  feeling  of  tension.  The  patient  at  this  period  cannot  more 
than  half  open  his  eyelids,  on  account  of  the  size  of  the  tumor.  The  lower 
lid  especially  is  put  on  the  stretch,  and  projected  towards  the  nose.  The  sac 
is  also  very  considerably  extended  within  the  orbit. 

On  examining  a  mucocele,  we  distinguish  an  indistinct,  and  in  many  cases, 
no  fluctuation.  This  depends  upon  the  state  of  the  contained  mucus,  which  may 
be  either  quite  fluid,  or  may  have  acquired  a  gluey  consistence.  In  the  former 
case,  an  indistinct  fluctuation  is  felt,  the  tumor  is  still  a  little  elastic,  and  does 
not  exceed  the  size  of  a  horse-bean.  In  the  latter  case,  the  color  of  the 
integuments  is  livid,  like  that  of  a  varicose  vein,  the  mucocele  feels  hard  like 
a  pebble,  and  presents  not  the  slightest  degree  of  fluctuation,  while  the  tumor 
is  already  so  large  as  to  rise  over  the  caruncula  lachrymalis. 


RELAXATION  OF  THE  PUNCTA  LACHRYMALIA.  299 

The  frequent  livid  color  of  the  integuments  in  mucocele,  has  led  some 
authors  to  describe  this  disease  under  the  name  of  varix  of  the  lachrymal  sac ; 
while  the  hardness  and  size  of  the  tumor,  added  to  its  color,  have  sometimes 
led  to  the  extirpation  of  the  sac  affected  with  mucocele,  under  the  idea  that 
it  was  a  carcinomatous  tumor. 

Causes. — Mucocele  is  the  consequence  of  an  obstructed  state  of  the  lachry- 
mal canals  and  nasal  duct.  In  some  instances,  the  cause  is  a  congenital  con- 
traction of  the  lower  extremity  of  the  nasal  duct,  occasionally  combined  with 
an  unnatural  course  into  the  nostril.  Under  such  circumstances,  the  secre- 
tion of  mucus  from  the  internal  surface  of  the  sac  goes  on ;  but  as  it  can 
neither  be  diluted  by  the  tears,  discharged  into  the  nose,  nor  completely 
reabsorbed  by  the  membrane  which  secretes  it,  it  accumulates,  and  forms  the 
tumor  in  question. 

Treatment. — The  lancet  is  to  be  pushed  into  the  most  prominent  part  of 
the  tumor.  The  wound  may  sometimes  require  to  be  enlarged  upwards  and 
downwards  in  the  direction  of  the  length  of  the  sac,  both  that  its  contents 
may  be  evacuated,  and  that  we  may  be  able  to  proceed  in  the  remaining  steps 
of  the  treatment ;  but  in  general  a  simple  puncture  with  the  lancet  is  suf- 
ficient. In  performing  this  operation,  as  well  as  in  other  operations  on  the 
sac,  we  should  always  avoid  dividing  the  tendon  of  the  orbicularis  palpebra- 
rum. Yet  the  inconvenience  arising  from  cutting  that  tendon  across,  is  less 
than  might  have  been  anticipated ;  for  after  the  wound  has  healed,  the  eye- 
lids retain  their  natural  position,  and  the  muscle  performs  its  functions  as 
before.  This  is  to  be  attributed  partly  to  the  ligamentous  layer  which  lies 
beneath  the  muscle  and  supports  the  eyelids,  and  partly,  as  Mr.  Sharp  re- 
marked,* to  the  firm  cicatrice  which  is  left  when  the  cure  is  completed.  In 
dividing  the  tendon,  however,  there  is  a  danger  of  cutting  across  the  canali- 
culi,  which  would  probably  produce  incurable  stillicidium. 

If  the  mucus  be  liquid,  or  if  the  sac  be  filled,  as  is  sometimes  the  case,  with 
thick  fetid  pus,  a  little  of  it  issues  as  soon  as  the  incision  is  completed.  The 
remainder  is  to  be  cleared  out,  by  means  of  a  small  syringe  introduced  by 
the  wound,  through  which  a  quantity  of  water  is  to  be  repeatedly  injected. 
If  the  mucus  has  become  inspissated,  it  is  to  be  extracted  by  the  repeated  in- 
troduction of  a  small  pair  of  forceps  ;  after  which,  the  sac  is  to  be  completely 
washed  out. 

A  common  dressing-probe  may  now  be  passed  through  the  sac,  in  the  direc- 
tion of  the  nasal  duct ;  or  this  exploration  may  be  dispensed  with  for  the 
present,  and  a  small  quantity  of  soft  lint  may  be  placed  within  the  lips  of  the 
wound,  and  covered  with  a  piece  of  court-plaster.  Next  day,  the  lachrymal 
canals  and  nasal  duct  are  to  be  examined,  and  the  causes  of  the  mucocele 
being  ascertained,  the  proper  treatment  is  to  be  commenced. 

In  cases  of  very  large  mucocele,  it  may  be  proper  to  lay  bare  the  sac  in  the 
first  instance,  and  excise  a  portion  of  it  with  the  scissors. 


'  Treatise  of  the  Operations  of  Surgery,  p.  181;  London,  1758. 


SECTION  Vin. — RELAXATION  OP  THE  PUNCTA  LACHRYMALIA  AND  CANALICULI. 

We  meet  with  cases  in  which  the  puncta  and  canaliculi  are  in  a  state  of 
relaxation,  attended  with  atony  of  the  orbicularis,  and  probably  of  the  tensor 
tarsi ;  the  consequence  of  which  is  stillicidium  lachrymarum ;  a  symptom 
uniformly  depending  on  some  defect  in  the  absorption  and  conveyance  of  the 
tears  from  the  eye  into  the  nose,  and  therefore  to  be  carefully  distinguished 
from  the  superabundant  lachrymal  secretion  styled  epiphora. 


300  EVERSION   OF   THE  PUNCTA  LACHRYMALIA. 

Symptoms. — While  the  puncta  stand  widely  open,  the  canaliculi  are  dilated, 
and  appear  to  have  lost  their  natural  contractility  of  texture,  and  absorbing 
power,  the  consequence  of  which  is,  that  a  tear  constantly  gathers  on  the 
edge  of  the  lower  eyelid,  at  the  inner  canthus,  rendering  vision  indistinct,  and 
requiring  the  constant  use  of  the  handkerchief.  The  quantity  of  tears  which 
roll  over  the  cheek  is  not  considerable ;  they  fall  in  single  drops,  at  intervals, 
and  only  from  the  nasal  angle  of  the  eye.  The  nostril  belonging  to  the 
affected  side  is  dry,  as  little  or  none  of  the  fluids  collected  in  the  lacus  lachry- 
marum  is  conveyed  into  the  sac,  there  to  mix  with  the  mucus  secreted  by  its 
lining  membrane,  and  thence  to  be  discharged  into  the  nose.  There  is  no 
tumor,  nor  blennorrhoea,  of  the  sac.  On  injecting  a  little  water  with  Anel's 
syringe,  it  flows  out  by  the  nose  or  down  into  the  throat,  showing  that  the 
lachrymal  sac  and  nasal  duct  are  in  a  healthy  state.  There  is,  in  fact,  no 
obstruction  anywhere,  only  a  want  of  action. 

Causes. — The  causes  of  this  atonic  stillicidium  are  various.  Erysipelatous 
inflammation  of  the  eyelids,  and  long-continued  puro-mucous  ophthalmia,  are 
apt  to  give  rise  to  this  state  of  the  parts ;  as  are  the  ophthalmice  caused  by 
smallpox  and  measles.  Another  cause  of  a  different  sort  is  the  injudicious 
use  of  Anel's  probes  and  syringe  in  the  ti'eatment  of  chronic  dacryocystitis. 
Schmidt  mentions  two  cases  which  fell  under  his  observation,  in  which  the 
papillae  lachrymales  were  absolutely  split,  in  consequence  of  the  repeated  in- 
troduction of  these  instruments. 

Treatment. — A  solution  of  borax  in  peppermint  water,  with  a  small  quantity 
of  camphorated  spirits,  or  of  tincture  of  opium;  a  solution  of  the  sulphate  of 
iron ;  or  a  pretty  strong  solution  of  the  lapis  divinus,  with  the  same  addition 
of  spirit  or  of  tincture,  may  be  used.  One  of  these,  with  a  hair  pencil,  is  to 
be  applied  to  the  relaxed  puncta,  and  afterwards  dropped  iutothe  nasal  angle 
of  the  eye,  several  times  a  day,  the  patient  lying  on  his  back  for  some  minutes 
after  the  application.  The  tincture  of  nux  vomica,  applied  in  the  same  way, 
appears  to  be  useful. 


SECTION  IX. — EVEESION  OP  THE  PUNCTA  LACHRYMALIA. 

To  stillicidium  lachrymarura,  arising  from  displacement  outwards  of  the 
puncta,  especially  of  the  lower  one,  so  that  the  tears  no  longer  reach  the  ori- 
fice, attention  has  been  particularly  directed  by  Mr.  Bowman.^ 

The  displacement  of  the  puncta  from  ectropium  has  already  (p.  221)  been 
noticed.  It  is  only  a  slighter  degree  of  this  same  displacement  which  Mr. 
Bowman  has  minutely  described,  and  for  which  he  has  proposed  a  peculiar 
mode  of  treatment.  In  the  cases  in  question,  the  lid  is  either  in  natural  con- 
tact with  the  globe,  or  only  slightly  recedes  from  it  in  certain  positions,  as 
when  the  eye  is  turned  upwards.  The  natural  prominence  on  which  the  punc- 
tum  is  placed  is,  however,  wanting,  and  instead  of  it,  there  is  a  flattened  or 
rounded  cutaneous  surface,  on  which  the  orifice  may  be  discerned  at  a  little 
distance  from  the  mucous  surface  of  the  lid,  dry  and  contracted,  being  in  fact 
never  touched  by  the  tears. 

Two  causes  of  this  displacement  of  the  punctum  are  noticed  by  Mr.  Bow- 
man ;  the  one,  a  slight  chronic  inflammation  of  that  part  of  the  conjunctiva 
lying  near  the  punctum,  producing  thickening  and  consequent  eversiou;  the 
other,  a  chronic  cutaneous  affection  of  the  lower  lid,  by  which  a  general  but 
moderate  contraction  of  it  is  produced,  and  the  punctum  is  drawn  outwards. 

As  a  consequence  of  its  displacement  and  exposure,  the  mucous  surface  on 
the  inner  side  of  the  punctum  has  lost  its  natural  character,  and  has  become 


OBSTRUCTION   OP   THE   CANALICULI.  301 

cuticular,  so  that  the  tears  are  prevented  from  coming  up  to  it,  and  do  not 
wet  it,  but  collect  in  a  drop  at  the  caruncle,  and  roll  over  on  the  cheek. 

For  the  relief  of  such  cases,  Mr.  Bowman  has  been  led  to  propose  the  slit- 
ting up  of  the  lachrymal  canal,  from  the  punctum  towards  the  caruncle,  for 
a  length  sufficient  to  carry  the  absorbing  orifice  inwards  to  that  part  of  the 
conjunctival  surface  where  the  tears  collect.  He  finds  that  the  part  of  the 
canal  which  is  slit  up,  extending  to  perhaps  ^  inch,  is  converted  into  a  groove, 
the  edges  of  which,  after  a  little  time,  show  no  disposition  to  reunite,  while 
the  tears  find  their  way  from  this  groove  along  the  remaining  part  of  the  canal 
into  the  sac,  to  the  complete  removal  of  the  stillicidium. 

The  operation  is  performed  on  a  probe,  introduced  by  the  punctum,  and 
for  some  days  the  tendency  to  reunite  must  be  prevented,  by  breaking 
through  any  adhesions  which  may  form  in  the  divided  part  of  the  canal.  No 
visible  deformity  results  from  the  operation.  It  is  adapted  not  only  for  the 
cases  described,  but  also  for  those  in  which  ectropium  having  been  cured  by 
the  means  formerly  mentioned,  stillicidium  still  remains,  the  punctum  con- 
tinuing a  little  displaced,  or  surrounded  by  tumid  tissue,  and  irreparably 
altered  in  structure. 


'  Medico-Chirurgical  Transactions,  Vol.  xxxiv.  p.  337;  London,  1851. 


SECTION  X. — OBSTRUCTION  OF  THE  PUNCTA  LACHRYMALIA  AND  CANALICULI, 

The  puncta  are  sometimes  congenitally  absent.  This  may  or  may  not  be 
attended  by  defect  of  the  lachrymal  canals. 

Cases  occur  in  which  the  puncta  are  obliterated  from  burns,  and  from  inflam- 
mation or  ulceration.  In  a  case  of  this  kind,  occurring  after  smallpox,  the 
corresponding  canal  was  dilated  to  the  size  of  a  pea,  a  muddy  fluid  escaping' 
from  it  when  I  punctured  it.  Such  causes  as  have  now  been  mentioned,  as 
well  as  mechanical  injuries,  may  obliterate  portions,  more  or  less  extensive,  of 
the  canaliculi. 

In  other  cases,  the  puncta  are  contracted,  but  are  still  patent,  and  being 
dilated  with  the  point  of  a  middle-sized  pin,  Anel's  probe  will  pass  through 
them  without  difficulty.  This  state  is  attended  with  stillicidium,  sometimes 
with  paleness  of  the  semilunar  fold  and  caruncle,  and  occasionally  a  dry, 
almost  horny  state  of  the  latter ;  a  complication  which  is  very  unfavorable. 
The  stillicidium  is  always  less  when  the  patient  remains  within  doors.  It  is 
more  troublesome  during  cold  wet  weather.  Lotions  and  salves  are  pre- 
scribed in  vain ;  nor  does  the  frequent  passing  of  Anel's  probe  afford  relief. 
Fomenting  the  eyes  with  warm  water,  and  the  use  of  goggles,  moderate  the 
complaint. 

A  frequent  cause  of  the  obstruction  of  the  canals  is  tumefaction  of  their 
lining  membrane,  continuing  after  all  the  other  symptoms  of  acute  or  chronic 
dacryocystitis  have  disappeared. 

If  the  sac  has  been  laid  open  by  an  incision,  or  if  a  fistula  of  the  sac  has 
formed,  neither  the  artificial  opening  nor  the  fistula  is  to  be  healed  up,  till 
we  be  assured  of  the  healthy  state  of  the  lachrymal  canals.  The  state  of  the 
canals  is  also  to  be  ascertained  on  the  day  following  the  opening  of  a  mu- 
cocele. 

It  is  our  object  to  ascertain,  not  merely  whether  the  lachrymal  canals  be 
obstructed,  but  also  the  cause  of  their  obstruction.  This  may  depend  upon 
the  presence  of  inspissated  mucus,  tumefaction  of  their  lining  membrane, 
stricture,  or  absolute  obliteration  in  a  part  or  throughout  the  whole  of  their 
extent. 


302  OBSTRUCTION   OF   THE   CANALICULI. 

For  tlie  examination  of  the  canals  we  make  use  of  AnePs  probe,  which  is 
to  be  introduced  in  the  manner  described  at  p.  287.  If,  upon  continuing  to 
press  the  probe  onwards,  it  enters  the  sac,  so  that  we  come  to  touch  the  nasal 
side  of  that  cavity  with  the  point  of  the  instrument,  we  are  assured  that  there 
is  no  obliteration  of  the  canals.  If  an  obliteration  exists,  a  state  of  the  canals 
which  we  may  partly  suspect  beforehand  from  the  contracted  appearance  of 
the  papillte  and  puncta,  we  find  an  unconquerable  obstacle  to  the  passage  of 
the  probe,  and  ascertain  at  once  the  extent  and  situation  of  the  obliteration. 
In  some  cases,  the  obstruction  is  close  to  the  sac,  so  that  if  the  probe  is 
pressed  on,  the  outer  wall  of  the  sac,  with  the  skin  over  it,  is  moved  towards 
the  nose,  and  we  feel  an  elastic  resistance.  If  there  is  no  such  stoppage,  so 
that  the  probe  enters  the  sac  and  comes  into  contact  with  its  inner  wall,  the 
skin  over  it  is  not  moved.  Mr.  Bowman  suggests,'  that  as  the  distance  be- 
tween the  punctum  and  the  inner  wall  of  the  sac  when  the  canal  is  stretched 
by  drawing  the  lid  outwards,  is  just  ^  inch,  a  probe  covered  with  gold  for 
that  length  would  assist  in  determining  whether  the  sac  has  actually  been 
entered. 

If  the  presence  of  mucus  in  the  canals  is  the  sole  cause  of  the  obstruction, 
the  conveyance  of  the  tears  will  be  immediately  restored  by  carrying  the 
probe  onwards  into  the  sac.  When  there  is  tumefaction  of  the  mucous  mem- 
brane, the  conveyance  of  the  tears  is  not  restored  by  merely  sounding  the 
canals;  for  as  soon  as  the  probe  is  withdrawn,  the  contraction  of  their  calibre 
returns.  Such  tumefaction,  indeed,  depends  in  every  case  upon  inflammation, 
and  consequently  will  subside  only  as  this  disappears. 

When  one  or  both  of  the  canals  ai'e  contracted  or  obliterated  through  a 
small  part  of  their  extent,  for  instance,  less  than  the  length  of  a  line,  we 
ought  to  endeavor  to  force  the  probe,  but  not  violently,  through  the  stricture 
or  obliteration,  into  the  sac.  If  it  passes,  the  edges  of  the  eyelids  ought  to 
be  kept  moist,  for  some  days  after,  with  a  thin  and  mild  ointment,  and  the 
probe  passed  daily  along  the  canal  into  the  sac. 

When  a  complete  obliteration  of  the  canal,  whatever  be  its  origin,  does  not 
extend  beyond  a  line  or  two  from  the  punctum,  Jungken's^  operation  may  be 
tried.  The  lid  being  drawn  outwards  and  away  from  the  eyeball,  with  scissors 
he  removes  a  stripe  of  the  edge  of  the  lid,  including  the  obliterated  portion 
of  the  canal.  After  the  bleeding  has  ceased,  he  introduces  a  bristle,  after- 
wards a  fine  catgut,  and  lastly  a  fine  piece  of  leaden  wire,  retaining  this  last 
till  cicatrization  takes  place,  which  is  in  the  space  of  seven  or  eight  weeks. 
The  new  punctum,  although  nearer  the  inner  commissure,  conveys  the  tears 
perfectly  into  the  sac.  In  this  way,  Jungken  operated  successfully  on  a 
young  man  who,  in  consequence  of  a  burn,  had  a  closed  canal,  with  union 
between  the  commissure,  the  caruncle,  and  the  semilunar  fold. 

It  seems  not  unlikely  that  in  Jiiugken's  operation  the  canaliculus  may  have 
been  cut  obliquely ;  a  circumstance  much  in  favor  of  success ;  for,  as  Mr. 
Bowman  has  observed,^  were  the  division  transverse,  a  slight  contraction  in 
the  circular  direction  would  close  the  canal,  whereas  when  it  is  longitudinal 
or  oblique,  a  corresponding  amount  of  contraction  of  the  divided  wall  would 
not  close,  or  even  much  contract,  the  entrance  to  the  canal. 

Mr.  Bowman  does  not  interfere  with  the  obliterated  portion  of  the  canal ; 
but,  in  those  cases  in  which  the  obstruction  is  sufficiently  far  from  the  sac  to 
allow  of  the  canal  being  slit  up  in  the  interval,  he  proposes  in  one  or  the 
other  of  the  following  methods  to  restore  the  course  of  the  tears :  the  one  is, 
by  cutting  transversely  across  the  canal,  close  to  the  obstruction,  on  the  side 
towards  the  sac,  and  then  slitting  up  the  canal  and  the  conjunctiva  on  a  probe 
introduced  at  the  wound ;  the  other  method  is,  supposing  no  orifice  can  be 
found  after  this  transverse  section,  to  open  the  sac  below  the  tendon  of  the 


OBSTRUCTION   OF   THE   NASAL   DUCT.  303 

orbicularis,  run  a  probe  from  the  sac  into  the  canal  as  far  as  the  obstruction, 
and  then  slit  up  the  canal  on  the  probe,  through  the  conjunctiva,  and  near 
the  caruncle.  To  execute  the  second  method,  the  surgeon  must  previously 
take  pains  to  acquaint  himself  w^ith  the  anatomy  of  the  parts.  In  the  dead 
subject,  Mr.  B.  had  found  it  easy  to  pass  the  probe  from  the  sac  into  the 
canaliculus. 

When  the  canals  are  completely  obliterated,  it  has  been  proposed  to  make 
new  puncta  and  canals,  by  carrying  a  thread,  or  making  an  incision,  into 
the  sac  ;  but  such  artificial  passages  close  as  soon  as  the  seton  or  the  bougie 
ceases  to  be  inserted. 

In  such  cases,  it  has  been  recommended  to  lay  the  sac  completely  open, 
apply  caustic  to  its  lining  membrane  so  as  to  excite  a  degree  of  inflamma- 
tion, and  then,  by  compression,  endeavor  to  secure  the  obliteration  of  its 
cavity,  or  to  dress  it  for  some  time  with  strong  red  precipitate  ointment,  and 
gradually  allow  it  to  contract  and  close.  These  means  are  for  the  purpose 
of  preventing  abscesses  of  the  sac,  or  the  formation  of  mucocele. 

To  free  the  patient  from  the  stillicidium  lachrymarum  otherwise  attendant 
on  obliteration  of  the  canaliculi,  the  lachrymal  gland  may  be  extirpated,  as 
was  done  by  Mr.  Dixon  in  an  interesting  case  of  injured  eye,  in  which  he 
had  occasion  also  to  form  an  artificial  pupil.*  Unless  the  glandules  congre- 
gatae,  however,  are  also  removed,  tears  will  still  continue  to  be  secreted. 
Bernard  first  proposed  extirpating  the  lachrymal  gland,  in  cases  of  fistula  of 
the  sac  and  chronic  lachrymation,  which  might  seem  otherwise  incurable.^ 


'    Medico-Chirurgical     Transactions ;     Vol.  ^  Op.  cit.  p.  343. 

ssxiv.  p.  346 ;  London,  1853.  ■*  Lancet,  June  25,  1853,  p.  577. 

^  Die  Lehre  von  den  Augenkrankheiten,  p.  ^  Annales    d'Oculistique,    Tome   x.   p.    193, 

628  5  Berlin,  1832.  Bruxelles,  1843. 


SECTION  XI. — OBSTRUCTION  OF  THE  NASAL  DUCT. 

In  suspected  cases  of  strictured  nasal  duct,  when  there  is  no  opening  into 
the  sac,  Mejan,^  Cabanis,^  and  others  attempted  dilatation  by  means  of  a 
mesh,  drawn  up  through  the  duct,  and  into  the  sac,  by  means  of  a  thread, 
previously  introduced  into  the  nostril  from  the  upper  punctum  ;  while  Anel,^ 
Travel's,*  Jacob, ^  and  others,  have  recommended  that  probes  and  other 
means  for  removing  the  stricture  should  be  passed  down  from  the  puncta, 
through  the  sac,  and  into  the  duct.  Both  these  modes  of  practice  have  been 
found  to  be  painful,  dangerous,  and  ineffectual.  They  not  merely  fail  in  the 
object  intended,  but  are  apt  to  end  in  incurable  atony  of  the  puncta,  by 
causing  them  to  split,  or  to  ulcerate,  and  are  therefore  generally  abandoned. 
I  would  recommend  those  who  feel  inclined  to  try  dilatation  of  the  nasal 
duct  through  the  puncta,  to  read  Dr.  Jacob's  account  of  the  matter.  I 
think  the  difficulties  and  objections  stated  by  a  professed  admirer  of  the 
practice  will  be  sufficient  to  convince  them  of  the  futility  and  danger  of  this 
mode  of  treatment,  even  though  attempted  with  bristles  from  the  tail  of  a 
hippopotamus. 

An  examination  of  the  nasal  duct,  equally  as  of  the  canaliculi,  is  to  be 
instituted  before  healing  up  any  artificial  opening  or  fistula  of  the  sac  ;  also, 
on  the  day  after  a  mucocele  has  been  laid  open. 

The  best  instrument  for  examining  the  nasal  duct  is  a  silver  probe  about 
2V  inch  thick,  and  not  bulbous.  This  is  to  be  introduced  horizontally  by 
the  opening  which  has  been  made  through  the  skin  into  the  sac,  till  it 
touches  the  nasal  side  of  that  cavity  ;  it  should  then  be  raised  into  a  vertical 


304  OBSTRUCTION   OP   THE   NASAL   DUCT. 

position,  and  its  point  directed  downwards  and  a  little  backwards.  Turning 
the  probe  upon  its  axis,  we  pass  it  from  the  sac  into  the  duct ;  and  as  we 
continue  to  press  it  gently  downwards,  the  instrument,  if  the  duct  is  per- 
vious, slides  into  the  nose.  If  its  point  meet  with  some  obstruction,  we 
must  not  immediately  conclude  that  there  is  an  obliteration  of  the  duct.  We 
must  press  down  the  probe  a  little  more  strongly,  yet  without  violence ; 
turning  it  round  between  the  fingers,  and  giving  it  different  directions.  The 
natural  course  of  the  duct  is  not  straight,  but  somewhat  curved,  the  con- 
vexity of  the  curve  being  directed  forwards,  and  the  concavity  backwards. 
Should  the  straight  probe,  therefore,  not  pass  easily,  it  should  be  withdrawn 
and  slightly  bent,  to  correspond  to  the  curvature  of  the  duct.  By  these 
means,  the  obstacle  may  frequently  be  overcome,  and  the  probe  suddenly 
descend. 

If  the  obstacle  remain  as  before,  and  feel  extremely  firm,  still  this  is  not 
sufficient  ground  for  us  to  conclude  that  there  is  a  real  obliteration  ;  because 
there  are  many  other  causes,  particularly  diseased  states  of  the  mucous  mem- 
brane, from  which  the  difficulty  we  encounter  may  proceed.  The  membrane 
may  be  tumefied,  its  mucous  crypto  enlarged  and  indurated,  and  thereby  the 
calibre  of  the  duct  more  or  less  diminished,  yet  these  obstacles  may  be  capa- 
ble of  yielding,  so  that  by  considerable  pressure  we  may  succeed  in  passing 
the  probe  into  the  nose.  In  other  cases,  the  tumefaction  and  induration  of 
the  mucous  membrane  may  yield  so  little  as  to  render  it  impossible  to  reach 
the  nose  with  a  probe  of  the  ordinary  size,  and  it  requires  great  patience  to 
pass  a  small  silver  probe  through  the  duct. 

If  we  succeed,  though  it  may  not  be  without  considerable  difficulty  and 
after  many  trials  repeated  during  several  days,  in  bringing  a  probe  into  the 
nose,  which  we  can  easily  recognize  by  the  hitting  of  the  end  of  the  instru- 
ment against  the  floor  of  the  nostril,  as  well  as  from  the  sensation  experi- 
enced by  the  patient,  we  remain  convinced  that  it  is  yet  possible  to  restore 
the  whole  excretory  apparatus  of  the  tears  to  the  exercise  of  its  function. 

Though  the  nasal  duct  does  not  exceed  f  inch  in  length,  there  are  three 
points  in  its  course  at  which  stricture  is  particularly  apt  to  occur.  One  of 
these  is  exactly  where  the  sac  ends  and  the  duct  begins.  The  calibre  of  the 
duct  is  frequently  narrowed  there  by  a  circular  fold,  the  thickening  of  which 
will  cause  obstruction.  Janin^  details  the  appearances  upon  dissection  of  a 
stricture  in  this  situation,  and  describes  the  mucous  membrane  of  the  duct  as 
presenting  a  plaited  appearance  like  the  sleeve  of  a  shirt  at  the  wrist.  A 
second  fold  of  the  same  kind  occurs''  in  the  middle  of  the  duct,  in  many  sub- 
jects, though  not  in  all ;  and  hence  this  part  becomes  from  a  similar  cause 
the  frequent  seat  of  stricture.  The  third,  and  most  frequent  situation  of 
stricture,  is  at  the  termination  of  the  duct  in  the  nostril. 

In  order  to  treat  of  the  restoration  of  the  nasal  duct  with  precision,  I  sliall 
consider  three  different  cases.  The  first  is  when  we  have  already  passed  a 
probe  through  the  duct.  The  second  is  when  we  do  not  at  first  succeed  in 
passing  a  probe,  but  in  which  it  is  yet  possible  to  pass  it.  The  third  case  is 
when  it  is  impossible  to  pass  any  probe  through  the  duct. 

First  case. — If  we  have  succeeded  with  the  silver  probe,  we  ought  imme- 
diately to  introduce  a  style  of  the  same  size,  and  about  1^  inch  long  into  the 
duct.  We  now  proceed  progressively  to  restore  the  duct  to  its  natural  calibre. 
This  may  be  done  by  a  series  of  silver  styles,  or  of  catgut,  gum-elastic,  or 
wax  bougies,  introduced  from  the  sac  ;  by  a  long  piece  of  catgut,  entered  by 
the  sac  and  drawn  out  by  the  nostril ;  or  by  a  seton,  or  mesh  of  silk  threads, 
drawn  up  from  the  nostril. 

If  we  prefer  the  mesh,  we  introduce,  by  the  opening  into  the  sac  and  down 
the  duct,  a  bit  of  fine  catgut,  having  a  strong  doubled  silk  thread  fastened  to 


OBSTRUCTION   OF  THE   NASAL  DUCT.  305 

its  upper  extremity.  Tlie  catgut  is  to  be  pushed  well  down  into  the  nostril. 
In  the  course  of  a  day  or  two,  sometimes  in  a  few  hours,  the  lower  end  of  the 
catgut,  having  become  soft,  may  be  forced  out  of  the  nostril  by  blowiug  the 
air  through  it,  with  the  opposite  nostril  shut.  The  catgut  is  then  to  be  drawn 
out,  followed  by  the  doubled  silk  thread,  the  catgut  is  to  be  removed,  and 
into  the  loop  of  the  silk  thread  a  mesh  is  to  be  placed,  formed  by  another 
thread,  doubled  several  times  upon  itself,  and  long  enough  to  hang  out  of 
the  nostril.  The  upper  end  of  the  first  thread,  where  it  projects  through  the 
opening  into  the  sac,  is  now  to  be  laid  hold  of,  and  drawn  slowly  upwards, 
till  the  mesh  is  introduced  into  the  nasal  duct.  The  first  thread  must  now  be 
coiled  up,  the  coil  laid  upon  the  side  of  the  nose,  and  covered  with  a  bit  of 
court-plaster,  while  the  lower  end  of  the  mesh  is  to  be  turned  round  and  fixed 
in  the  same  manner  to  the  ala  nasi.  After  a  few  days,  having  loosened  the 
upper  end  of  the  first  thread,  and  the  lower  end  of  the  mesh,  from  these 
attachments,  we  lay  hold  of  the  latter  and  pull  it  downwards,  till  it  is  fairly 
out  of  the  nostril,  and  the  looped  lower  extremity  of  the  first  thread  again 
brought  into  view.  The  mesh  is  now  to  be  withdrawn,  and  a  thicker  one 
being  introduced  into  the  loop  of  the  thread,  is  to  be  drawn  up  into  the  nasal 
duct;  and  in  this  way  a  succession  of  meshes  is  to  be  employed,  till  the  neces- 
sary dilatation  is  accomplished.  One  advantage  of  this  method  is,  that  the 
mesh,  being  introduced  into  the  duct  from  its  lower  orifice,  the  opening  into 
the  sac  is  allowed  to  contract  to  a  small  size. 

For  dilating  the  nasal  duct,  Beer,  after  Richter,  employed  the  common 
catguts  of  the  violin.  Beginning  with  the  string  E,  having  softened  its  point 
between  the  teeth,  made  seven  or  eight  inches  of  it  perfectly  straight,  and 
dipped  it  in  a  little  oil,  he  introduced  it  into  the  sac,  and  thence  into  the 
duct.  He  pushed  it  down  slowly,  till  five  or  six  inches  of  it  had  descended, 
in  order  that  its  inferior  extremity  might  be  drawn  forth  from  the  nostril 
without  difficulty,  a  part  of  the  operation  which  was  left  to  the  patient.  The 
superior  part  of  the  catgut  was  coiled  up,  inclosed  in  a  piece  of  linen,  and 
fastened  under  the  hair  of  the  forehead.  Into  the  opening  of  the  sac  a  little 
lint  was  laid,  and  over  that  a  piece  of  court-plaster  was  applied. 

The  patient  was  directed  to  try,  after  two  or  three  hours,  to  bring  the 
inferior  end  of  the  catgut  out  of  the  nose,  by  shutting  his  mouth  and  the 
opposite  nostril,  and  driving  the  air  through  the  nostril  into  which  the  catgut 
had  descended.  When  he  felt  it  advance,  he  drew  it  out  of  the  nostril,  turned 
up  its  extremity  to  the  side  of  the  nose,  and  fixed  it  there  by  a  slip  of  court- 
plaster. 

On  the  following  day,  the  lint  was  removed  from  the  opening  of  the  sac, 
and  a  quantity  of  one  of  the  collyria,  which  will  be  afterwards  enumerated, 
was  injected  by  the  side  of  the  catgut,  as  well  to  wash  away  any  mucus  accu- 
mulated in  the  sac,  as  to  act  upon  the  mucous  membrane.  The  superior  end 
of  the  catgut  was  now  loosened  from  the  forehead,  a  sufiicient  fresh  portion 
undone  from  the  coil,  and  being  besmeared  with  one  of  the  substances  which 
I  shall  mention,  drawn  into  the  duct  by  the  patient  taking  hold  of  the  extre- 
mity which  hung  from  the  nose.  The  portion  of  catgut  which  had  been  used 
during  the  preceding  day,  was  now  cut  off,  and  the  new  end  turned  up  to  the 
side  of  the  nose,  and  there  fastened  as  before.  The  same  injection  was  now 
repeated,  the  lint  and  plaster  applied  to  the  opening  of  the  sac,  and  the  coil 
of  catgut  bound  up. 

In  this  manner  Beer  proceeded,  day  after  day,  till  the  catgut  E  was  com- 
pletely used.  Before  passing  a  new  catgut,  the  point  of  a  syringe  was  intro- 
duced through  the  sac  into  the  duct,  and  a  quantity  of  tepid  water  colored 
with  vinous  tincture  of  opium,  injected ;  care  being  taken  to  observe  whether 
any  part  of  the  fluid  was  discharged  by  the  nostril. 
20 


306  OBSTRUCTION   OF   THE   NASAL   DUCT, 

The  string  A  was  now  passed  as  E  had  formerly  been,  and  its  use  con- 
tinued exactly  in  the  same  manner.  When  it  was  finished,  the  injection  of  a 
colored  fluid  was  repeated,  in  order  to  ascertain  what  progress  had  been  made 
in  restoring  the  natural  diameter  of  the  duct. 

The  string  D  followed.  After  its  use,  the  injection  was  almost  constantly 
found  no  longer  to  drop  merely,  but  to  flow  freely  from  the  nostril.  Were 
this  not  the  case  after  the  employment  of  one  D,  this  catgut  was  repeated  till 
the  injection  was  discharged  from  the  nose  in  a  full  sti'eam.  Then,  and  not 
till  then,  the  treatment  was  brought  to  a  close. 

If  the  mucous  membrane  of  the  duct,  when  the  use  of  the  catguts  was  com- 
menced, was  merely  somewhat  tumefied,  and  opposed  no  great  obstacle  to 
the  probe,  the  portion  of  catgut  daily  introduced  was  moistened  with  the 
vinous  tincture  of  opium,  and  a  quantity  of  the  solutio  lapidis  divini  made 
lukewarm  was  injected  by  the  sac.  (See  Formula.)  The  lint,  too,  with  which 
the  wound  of  the  sac  was  dressed,  was  dipped  in  the  vinous  tincture  of  opium. 
If  the  tumefaction  of  the  mucous  membrane  was  firm,  so  that  the  silver 
probe  could  not  be  brought  into  the  nose  without  much  opposition,  the  cat- 
gut was  besmeared  with  citrine  ointment,  at  first  very  much  diluted,  but  gra- 
dually increased  in  strength.  The  same  ointment  was  applied  to  the  wound. 
For  an  injection  in  the  same  case,  a  solution  of  corrosive  sublimate  was 
employed,  together  with  some  vinous  tincture  of  opium.  If  the  cryptse  of  the 
mucous  membrane  were  indurated  and  enlarged,  so  that  the  probe  was  felt 
passing  successively  over  a  number  of  little  knots,  a  weak  ointment  of  red 
precipitate  was  employed  for  besmearing  the  catgut,  and  the  patient  was 
directed,  daily,  before  the  catgut  was  drawn,  to  rub  in  a  small  quantity  of 
camphorated  mercurial  ointment  around  the  opening  of  the  sac. 

Similar  applications  may  be  used,  if  we  prefer  bougies,  or  silver  styles,  for 
restoring  the  nasal  duct  to  its  natural  calibre.  Dr.  Parrish  recommends 
bougies  made  by  dipping  a  piece  of  fine  linen  into  melted  white  wax,  suddenly 
withdrawing  it  and  allowing  it  to  cool,  then  cutting  it  into  portions,  and  roll- 
ing them  tightly  into  the  form  of  small  cylinders.  Such  a  bougie  may  be 
cut  or  bent  with  ease,  and  be  made  smaller  by  unwrapping,  without  the 
necessity  of  having  a  number  of  sizes  already  prepared.^  Whatever  instru- 
ment we  select,  its  employment  must  be  continued  for  several  months,  and 
the  wished-for  restoration  eff"ected  very  gradually;  knowing  that  if  we  remove 
the  stricture  or  obstruction  suddenly,  it  will  almost  to  a  certainty  return. 

When  we  consider  ourselves  warranted  to  discontinue  the  dilating  instru- 
ment, we  may  try  the  experiment  of  dropping  a  deeply  colored  fluid  into  the 
lacus  lachrymarum,  observing  whether  it  appears  at  the  opening  into  the  sac; 
for  the  little  valvular  fold  which  in  many  subjects  covers  the  opening  of  the 
canals  into  the  sac,^is  apt  to  become  closed  from  the  long-continued  pressure 
of  a  foreign  substance.  Should  the  valve  be  shut,  it  must  be  forced  open  by 
the  Anelian  probe  passed  through  the  canals. 

The  wound  of  the  sac  is  now  to  be  dressed,  once  a  day,  with  plain  lint. 
The  colored  fluid  is  to  be  daily  injected.  If  for  fourteen  days  successively  it 
flows  in  a  full  stream  from  the  nose,  we  proceed  to  close  the  wound.  We 
make  its  edges  somewhat  raw  with  the  lancet,  and  then  bring  them  together 
with  adhesive  plaster. 

Second  case. — If  the  silver  probe  sticks  fast  in  the  duct,  we  may  leave  it 
there  till  next  day,  fastening  it  to  the  forehead  by  a  proper  bandage,  closing 
the  opening  of  the  sac  with  a  little  lint,  and  applying  over  the  lint  a  piece  of 
court-plaster.  For  a  week  we  ought  not  to  despair  of  overcoming  the  ob- 
struction, not  by  main  force,  but  by  gentle  and  daily  repeated  endeavors  to 
get  the  probe  a  little  and  a  little  farther  through  the  duct,  turning  the  instru- 
ment on  its  axis  at  every  trial,  and  varying  the  direction  of  the  pressure. 


OBSTRUCTION   OF   THE   NASAL  DUCT.  30t 

If  we  succeed  in  this  manner,  we  continue  the  treatment  as  has  been  ex- 
plained under  the  first  case.  If  we  fail,  this  second  case  must  be  treated  as 
the  third. 

Third  case. — If  the  nasal  duct  be  in  part  obliterated,  recourse  must  be  had 
to  perforation,  by  means  of  a  small  triangular  or  trocar-shaped  probe.  If  the 
extent  of  the  obliteration  be  inconsiderable,  this  perforation  may  be  performed 
with  a  confident  hope  of  success.  A  few  drops  of  blood  flow  from  the  nose 
on  the  perforation  being  effected.  The  probe  is  immediately  to  be  withdrawn, 
and  a  small  silver  style  introduced.  This  remains  for  a  day  or  two,  and  then 
the  very  gradual  dilatation  of  the  duct,  which  has  already  been  described,  is 
to  be  commenced. 

If  a  considerable  portion  of  the  duct,  or  even  its  whole  extent,  be  obliterated, 
the  same  operation  ought  to  be  attempted.  This  is  done  with  at  least  equal 
hopes  of  success  as  if  we  perforated  the  os  unguis.  It  is  true,  that  the  new 
passage  would  probably  close,  after  our  dilating  instruments  were  laid  aside. 
In  this  case,  then,  the  introduction  of  a  gold  tube  or  style  into  the  duct,  to 
be  left  for  life,  is  peculiarly  indicated.  The  surrounding  substance  will  con- 
tract upon  the  tube  or  style,  and  render  it  less  liable  to  be  displaced  than  a 
similar  instrument  passed  into  the  natural  calibre  of  the  duct. 

In  strictured  or  partially  obliterated  nasal  duct,  recourse  may  sometimes 
be  had,  with  advantage,  to  the  use  of  a  small  bougie,  armed  with  caustic.  A 
probe  with  a  dimple  in  its  point,  into  which  a  speck  of  lunar  caustic,  or  potassa 
fusa,  is  to  be  placed,  will  answer  the  purpose.  This  may  be  applied  from 
time  to  time,  exactly  as  we  employ  the  same  means  in  stricture  of  the  urethra, 
introducing  the  bougie  from  the  sac  down  into  contact  with  the  strictured  or 
obliterated  part  of  the  duct,  keeping  it  there  for  a  minute  or  two,  and  after 
withdrawing  it,  injecting  the  duct  with  tepid  water.  In  both  Germany  and 
France,  this  plan  has  been  employed  with  success.*" 

All  other  plans  failing,  there  still  remains  the  perforation  of  the  os  unguis. 
The  only  reason  why  such  an  operation  should  not  be  totally  abandoned  is, 
that  if  no  passage  is  obtained  from  the  sac  into  the  nostril,  the  patient  will 
be  exposed  to  perpetual  attacks  of  inflammation  in  the  sac,  which  will  give 
rise  to  much  distress,  and  to  the  formation  of  fistulse.  In  such  a  case  I  have 
seen  attempts  made  to  obliterate  the  sac,  by  laying  it  completely  open,  and 
dressing  it  with  escharotics.  It  is  much  more  difficult  to  obliterate  the  sac  in 
this  case,  than  in  that  which  I  have  described  at  page  302.  Indeed,  oblitera- 
tion will  not  be  obtained,  unless  we  manage  permanently  to  close  the  aper- 
tures of  the  lachrymal  canals  into  the  sac.  If  these  remain  patent,  the  tears 
flowing  through  them  will  gradually  redilate  the  sac.  Under  such  circum- 
stances, Bernard's  plan  of  extii'pating  the  lachrymal  gland  might  be  adopted; 
or  the  canaliculi  might  be  cut  across,  after  which  the  apertures  next  the  sac 
will  close,  so  that  the  tears  will  not  reach  the  sac. 

Besides  the  presence  of  foreign  substances  in  the  nostril,  which  sometimes 
become  the  nuclei  of  calcareous  concretions,"  and  the  pressure  caused  by 
polypus  nasi,  there  is  another  cause  of  obstructed  nasal  duct,  of  a  formidable 
nature,  which  I  must  notice  before  leaving  this  subject ;  namely,  exostosis  of 
the  osseous  passage  through  which  the  duct  descends.  "  I  have  found,"  says 
Mr.  Travers,  "the  canal  completely  obliterated  by  ossific  inflammation  at  its 
upper  orifice  in  skulls.'"^ 


«  Memoires  de  rAcademie  Royale  de  Chirur-  '  Synopsis  of  the  Diseases  of  the  Eye,  p.  .372 ; 

gie  ;  Tome,  v.  p.  Ill ;  12iuo  ;  Paris,  1787.  London,  1820. 

^  Ibid.  »  Dublin   Hospital  Reports;  Vol.  6,  p.  381; 

»  Tniite  de  la  Nouvelle  Metliodede  guerir  la  Dublin,  1830. 
FLstule  Lacrymale ;  Turin,  1713. 


308  CALCULI  IN  THE  EXCRETING  LACHRYMAL  PASSAGES. 

^  Memoireset  Observations  sur  rCEil,  p.  115;  '°  Harveng,  Archives   Generales  de  M^de- 

Lyon,  1772.  cine  ;  Tome  xviii.  p.  48  ;  Paris,  1828. 

^  Soemmerrin?,    Abbildungen    des   mensch-  »'  Kersten,DeDacryolithis,  sen potius  Rhino- 
lichen  Alices,  p. 32  ;  Frankfurt  am  Main,  ISOl.  lithis,  in    Radius,  Scriptores    Ophthalmologici 

'  Dublin  Journal  of  Medical  Science;  Vol.  Minores;  Yol.  iii.  p.  145;  Lipsite,  1830. 

xxxiv.  p.  516;  Dublin,  1844.  '2  Op.  cit.  p.  243.     See  case  of  Exostosis  of 

'  Rosenmiiller,    Partium    Externarum    Oculi  the  Os  Unguis,  operated  on  by  Dr.  Kritner.  m 

Ilumani  Descriptio;  ?  125;  Lipsife,  1810.  Grafe  und  Walther's  Journal;  Yol.  xii.  p.  156; 

Berlin,  1828. 


SECTION  XII. — DACRYOLITHS,  OR  LACHRYMAL   CALCULI,  IN  THE  EXCRETING 
LACHRYMAL  PASSAGES. 

We  have  already  spoken  (pages  141  and  255)  of  calculi  deposited  from 
the  tears,  and  lodged  in  the  lachrymal  ducts  and  in  the  sinuses  of  the  con- 
junctiva. 

The  lachrymal  canals  are  sometimes  obstructed  by  similar  depositions.  "  In 
more  than  one  instance,"  says  Mr.  Travers,  "  I  have  turned  out  a  consider- 
able quantity  of  calcareous  matter  wedged  in  those  ducts,  like  the  calculi  of 
the  salivary  ducts.  "^ 

In  such  cases,  the  canal  in  which  the  calculus  is  lodged,  is  much  dilated, 
and  gives  out  a  turbid  or  purulent  discharge.  A  tumor  forms,  which  projects 
both  towards  the  skin  and  towards  the  conjunctiva.  The  concretion  is  felt 
with  the  probe  passed  by  the  punctum,  and  is  to  be  removed  by  laying  open 
the  canal  through  the  conjunctiva,  avoiding  the  punctum.^ 

The  sac  is  also  the  occasional  seat  of  such  concretions ;  more  rarely,  the 
nasal  duct. 

Tuberville  tells  us  of  a  saddler's  daughter,  who  had  an  imposthume,  which 
broke  in  the  corner  of  one  of  her  eyes.  Out  of  it  there  came  about  thirty 
stones  as  big  as  pearls ;  after  which  she  had  a  fistula,  which  he  cured.* 

Dr.  Kjimer  relates  the  following  case : — 

Case  179. — A  woman  had  for  nine  months  been  aflFected  with  disease  of  the  excreting 
lachrymal  organs.  The  sac  was  swelled,  hard,  and  upon  the  most  prominent  part  of  the 
tumor,  which  was  red  and  painful,  there  was  a  small  ulcer  which  penetrated  into  the 
sac,  and  discharged  pus,  mixed  with  tears,  especially  on  pressure.  The  nasal  duct 
appeared  entirely  obliterated.  When,  in  order  to  re-establish  it,  Dr.  Krlmer  endeavored 
to  introduce  a  pointed  probe,  he  withdrew  on  its  extremity  a  concretion  of  the  size  of  a 
small  pea,  the  removal  of  which  left  the  canal  entirely  free,  and  the  fistula  was  promptly 
cured.  The  calculus  was  ash-gray,  covered  with  thick  mucus,  polished,  of  a  calcareous 
appearance,  and  insoluble  in  water,  alcohol,  and  weak  vinegar.  Dr.  Krlmer  thinks  that 
it  was  formed  in  the  lachrymal  sac,  by  inspissated  mucus.* 

It  is  remarkable,  as  Walther  has  observed,  that  these  depositions  do  not 
occur  in  cases  of  dacryocystitis,  even  when  the  nasal  duct  is  completely  ob- 
structed. 


'  Synopsis  of  the  Diseases  of  the  Eye,  p.  238;  '  Philosophical    Transactions,    No.  164;  or 

London,  1820.  Lowthorp's  Abridgment:  Yol.  iii.;  Pt.  i.  p.  40. 

*  See  case  by  Desmarres,  Annales  d'Oculis-  *  Grafe  und  Walther's  Journal  der  Cbirurgie 

tique  ;  Tome  vii.  p.  150;  Bruxelles,  1842.    Case  und  Augenheilkunde ;  Yol.  x.  p.  597  ;  Berlin, 

by  Syme,  Monthly  Journal  of  Medical  Science,  1827.    See  a  Case  in  Sandifort's  Observationes 

October,  1845,  p.  278.     Cases  by  Crichett  and  Anatomico-PathologiciE  ;  Lib.  iii.  p.  74;  Lug- 

Haynes  Walton,  Medical  Times  and  Gazette,  duni  Batavorum,  1779. 
October  22,  1853,  p.  423. 


SECTION  Xin. — ^POLYPUS  OF  THE  LACHRYMAL  SAC. 

Case  180. — A  woman,  aged  32,  of  delicate  constitution,  had  for  four  years  been  subject 
to  catarrh,  whenever  she  exposed  herself  to  cold.  After  some  time,  she  became  affected 
vwith  a  great  degree  of  dryness  of  the  eye,  followed  by  inflammation  extending  from  the 


DISEASES   OP   THE   ORBITAL   TISSUES.  309 

Schneiderian  membrane,  along  the  nasal  duct,  to  the  lachrymal  sac.  The  dacryocystitis 
being  neglected,  an  erysipelatous  inflammation  of  the  lower  lid  and  side  of  the  face  suc- 
ceeded, vrith  a  large  lachrymal  tumor,  which  did  not  suppurate.  The  tumefaction  of  the 
lid  and  face  went  off;  but  a  hard  swelling  remained  in  the  lachrymal  sac,  on  pressing 
which,  puriform  mucus  was  evacuated  by  the  nostril  and  by  the  puncta.  For  three  years, 
the  patient  suffered  from  relapses  of  the  dacryocystitis,  but  the  sac  never  suppurated. 
For  six  months,  the  sac  could  not,  as  formerly,  be  emptied  by  pressure,  and  the  patient 
now  felt  with  her  finger  a  round  hard  tumor,  distinct  from  the  rest  of  the  swelling.  When 
she  came  under  the  care  of  Professor  Walther,  this  tumor  equalled  in  size  a  small  filbert. 
It  was  round,  movable,  hard,  and  not  affected  by  compressing  the  sac.  He  suspected  it 
to  be  a  polypus. 

On  laying  open  the  sac,  a  large  quantity  of  puriform  mucus,  mixed  with  tears,  was 
discharged.  The  polypus  then  came  into  view,  it  was  laid  hold  of  with  a  pair  of  forceps, 
drawn  out,  and  its  pedicle  divided  with  the  scissors.  The  nasal  duct  was  found  to  be 
obstructed,  and  to  restore  it,  a  mesh  was  introduced,  by  means  of  which  the  patient  was 
perfectly  cured  in  three  months.' 


'■  Radius,    Scriptores    Ophthalmologici   Mi-     of  Lachrymal  Polypus,  by  Janin  :  Memoires  et 
nores;  VoL  ii.  p.  139;  Lipsiaj,  1828.    See  Case     Observations  sur  I'CEil,  p.  299  ;  Lyons,  1772. 


CHAPTER    VII. 


DISEASES  OF  THE  OCULAR  CAPSULE,  AND  OF  THE 
AREOLAR  AND  ADIPOSE  TISSUES  OF  THE  ORBIT. 


Texon^,  Dalrymple^,  Bonnet^,  and  O'Fen'all*  have  described  the  eyeball 
as  surrounded  by  a  capsule  of  condensed  areolar  tissue,  which  excludes  it  from 
contact  with  the  fat  of  the  orbit,  while  it  aflTords  passage  to  the  six  muscles 
of  the  eyeball  on  their  way  to  their  insertions.  It  would  be  difficult  to  re- 
concile the  differences  in  the  descriptions  of  the  ocular  capsule  given  by 
these  authors.  As  to  the  reality  of  such  a  structure,  there  can  be  no  doubt. 
It  is  easily  displayed,  in  the  dead  body,  by  the  method  pointed  out  by  Dr. 
O'Ferrall,  which  is  to  divide  each  eyelid  vertically  in  the  middle,  turn  the 
four  flaps  back,  divide  the  conjunctiva  all  around  at  its  angle  of  reflexion, 
and  then  with  a  probe  separate  the  areolar  tissue  which  slightly  connects  the 
eyeball  to  the  capsule  which  envelops  it.  Without  any  further  division  of 
parts,  the  six  muscles  are  seen  perforating  the  capsule,  to  reach  the  eyeball. 
In  this  mode  of  displaying  the  capsule,  it  is  brought  into  view  as  far  forward 
as  the  angle  of  reflexion  of  the  conjunctiva.  It  is  generally  acknowledged 
that  the  capsule  is  traceable  into  the  eyelids.  Without  denying  this,  it  is,  I 
think,  certain,  that  the  thin  cellular  web,  described  by  Mr.  Lucas^  under  the 
name  of  the  subconjunctival  fascia,  is  also  a  production  of  the  capsule,  so  that 
this  structure,  having  reached  the  angle  of  reflexion  of  the  conjunctiva,  may 
be  regarded  as  splitting  into  two  layers,  the  one  continued  on  to  the  tarsi, 
and  the  other  advancing  towards  the  cornea. 

It  would  evidently  be  important  to  distinguish  those  diseases  which  have 
their  seat  within  the  ocular  capsule,  from  those  situated  exteriorly  to  this 
structure.  This  Dr.  O'Ferrall  has  attempted  to  do.  He  conceives  that 
effusions  and  tumors  situated  within  the  capsule  will  project  the  conjunctiva 
round  the  cornea,  and  obliterate  the  fold  of  conjunctiva  between  the  eyeball 
and  the  eyelid,  while  the  same  diseases  situated  externally  to  the  capsule  will 
show  themselves  more  towards  the  margin  of  the  orbit,  and,  in  the  upper 
eyelid,  will  affect  that  portion  of  it  which  is  above  the  transverse  fold  caused 
by  the  action  of  the  levator.     If  a  tumor  be  situated  externally  to  the  cap- 


310  INJURIES   OP  THE   ORBITAL   AREOLAR   TISSUE. 

sule,  there  is  nothing  to  prevent  its  advancing  forwards  as  it  enlarges,  and 
thus  becoming  more  and  more  superficial ;  if  within  the  capsule,  and  bound 
down  by  it,  the  swelling  will  necessarily  appear  as  if  placed  on  the  surface 
of  the  eyeball  itself. 


'  Memoires  et  Observations  sur  rAnatomie,  '  Dublin   Medical    Press,    March    3,    1841, 

la  Pathologie,  et  la  Chirurgie,  et  principale-  p.  133. 

ment   sur   I'Drgane    de   I'CEil,   p.  193;   Paris,  '  Ibid.    March   10,    1841,    p.    158;    Dublin 

1816.  Journal  of  Medical  Science,  Vol.  six.  p.  336. 

^  Anatomy  of  the  Human  Eye,  p.  248;  Lon-  '  Practical  Treatise  on  the  Cure  of  Strabis- 

don,  1834.  mus,  p.  24;  London,  1840. 


SECTION  I. — ^INJURIES  OP   THE   ORBITAL  AREOLAR  TISSUE. 

Penetrating  wounds,  by  the  side  of  the  eyeball,  even  when  they  do  not 
appear  to  implicate  any  of  the  muscles  or  other  important  parts,  are  apt  to 
be  followed  by  severe  phlegmonous  inflammation,  and  even  loss  of  sight. 

Case  181. — Two  children  being  at  play,  one  of  them  shut  himself  up  in  a  room,  and 
excluded  the  other.  Piqued  at  this,  he  who  was  without,  took  a  stick  about  the  thick- 
ness of  a  writing  pen,  and  observing  that  he  who  was  within  the  room  looked  through  a 
small  hole  in  the  door,  drove  the  stick  with  such  violence  at  him,  that  he  buried  it  to  the 
depth  of  two  finger-breadths  between  the  globe  of  the  eye  and  the  nose.  The  stick  broke 
across ;  and  as  the  mother  did  not  know  what  had  happened,  a  day  or  two  passed  with- 
out anything  being  done,  till  swelling  and  inflammation  of  the  eye  and  neighboring  parts 
supervening,  medical  advice  was  called  in.  The  swelling  was  now  so  great  that  it  was 
with  difficulty  the  bit  of  stick  could  be  perceived,  and  it  required  great  force  to  extract  it 
with  pincers.  It  had  entered  so  much  the  more  easily,  as  it  was  very  slender  at  its  ex- 
tremity, and  it  was  now  swollen  by  remaining  so  long  in  the  orbit. 

The  extraction  being  accomplished,  the  patient  was  twice  bled,  and  soon  recovered. 
The  eyeball  seemed  to  have  suffered  neither  internally  nor  externally  ;  yet  it  had  entirely 
lost  the  power  of  vision.' 

Case  182. — A  soldier  was  wounded  by  a  bayonet,  which  penetrated  into  the  orbit  with- 
out injuring  the  eye.  The  symptoms  which  ensued  were  trifling,  until  the  patient  con- 
trived, three  days  afterwards,  to  absent  himself  for  24  hours,  and  get  drunk.  On  his 
return,  the  eyeball  was  protruded,  the  lid  could  not  be  raised  so  as  to  expose  the  eye, 
which  was  highly  inflamed ;  chemosis  had  taken  place,  vision  was  indistinct,  the  iris  dis- 
colored, the  pupil  contracted ;  the  pain  was  excruciating  both  in  the  eye,  which  felt  as 
if  too  large  for  the  orbit,  and  all  over  the  forehead  and  temple  of  that  side ;  flashes  of 
light  of  various  colors  darted  through  the  eye,  in  consequence  of  the  surrounding  pres- 
sure. The  swelling  increased,  delirium  came  on,  and  an  abscess  burst  in  the  upper  eye- 
lid on  the  fourth  day,  without  any  alleviation  of  the  symptoms.  The  patient  soon  after- 
wards became  comatose,  and  died,  probably  from  the  formation  of  matter  within  the 
cranium.     Before  death,  the  eye  had  been  lost  by  sloughing  of  the  cornea.* 

Foreign  bodies  penetrating  into  the  orbital  cellular  substance,  may  lodge 
there  for  a  great  length  of  time,  the  skin  or  the  conjunctiva  sometimes  heal- 
ing over  them,  while  in  other  cases,  the  wound  assumes  a  fungous  appear- 
ance, and  presents  a  sinuous  opening  communicating  with  the  place  occupied 
by  the  intruding  substance. 

Case  183. — A  gentleman's  horse,  in  hunting,  came  down  in  going  over  a  hedge,  and  the 
rider  fell  into  a  stubble-field.  Some  sharp-pointed  substance,  whether  a  piece  of  the 
hedge  or  a  straw,  he  could  not  tell,  entered  close  to  the  caruncula  lachrymalis,  between 
the  eye  and  the  orbit.  He  thought  he  himself  withdrew  the  whole  of  it  at  the  time. 
Leeches  were  applied  to  subdue  the  inflammation.  When  he  placed  himself,  three  months 
afterwards,  under  the  care  of  Dr.  Robertson,  of  Edinburgh,  this  gentleman  found  a 
number  of  small  fungous  granulations  close  to  the  caruncle,  which  the  different  practi- 
tioners, under  whose  care  he  had  previously  been,  attempted  to  destroy  by  caustics,  the 
knife,  &c.  There  was  also  some  discharge  of  purulent  matter.  On  feeling  minutely  the 
parts,  there  appeared  to  be  a  sort  of  fibrous  hardening,  of  the  nature  of  that  forming  the 
sides  of  a  fistulous  passage,  leading  backwards  to  the  posterior  part  of  the  orbit.  Be- 
lieving that  there  was  some  foreign  body  keeping  iip  the  discharge,  and  not  being  able 
by  the  probe  to  discover  any  passage,  Dr.  Robertson  made  an  incision  into  the  hardened 


INJURIES  OF   THE   ORBITAL  AREOLAR  TISSUE.  311 

part.     A  piece  of  straw  nearly  an  inch  long  was  tliscliarged,  afterwards  a  second  and  a 
third  portion,  when  the  patient  perfectly  recovered. 

A  foreign  substance,  such  as  a  bit  of  wood  or  a  piece  of  tobacco-pipe, 
driven  through  the  conjunctiva  and  lodging  in  the  orbit,  may  cause  a  large 
abscess,  which  will  point  either  through  the  conjunctiva  or  through  the  skin. 
The  opening  by  which  the  pus  is  discharged,  either  spontaneously  or  by  the 
lancet,  is  carefully  to  be  examined  with  the  probe,  so  that  any  foreign  body 
that  is  present  may  be  detected  and  removed.  The  patient  has  often  no 
suspicion  of  the  presence  of  any  foreign  body.^ 

The  danger  of  penetration  of  the  walls  of  the  orbit  can  scarcely  be  overlooked 
in  cases  of  this  sort ;  but  the  following  instance  shows  how  the  most  serious 
effects  may  be  produced,  although  the  walls  of  the  orbit  remain  completely  intact. 

Case  184. — Michael  Walsh,  an  Irish  lad,  15  years  old,  and  employed  as  a  bricklayer's 
laborer,  quarrelled  in  the  beginning  of  January,  1832,  with  one  of  his  countrymen,  whilst 
sitting  at  the  same  table,  in  a  public-house.  During  the  heat  of  the  argument,  his  oppo- 
nent, who  sat  opposite  to  him,  thrust  a  common  clay  tobacco-pipe  into  the  lad's  eye,  and 
made,  apparently,  a  very  deep  wound.  For  several  days,  nothing  was  thought  of  the 
event,  and  but  little,  if  any,  inconvenience  experienced  by  the  boy.  About  the  8th  or 
9th  day,  however,  his  appetite  was  perceived  to  fall  off;  he  became  languid  and  feverish, 
and  had  frequent  rigors,  followed  by  severe  pain  of  the  head,  especially  of  the  sinciput. 
He  applied  at  the  Westminster  Ophthalmic  Hospital,  and  a  portion  of  tobacco-pipe,  about 
two  inches  in  length,  was  extracted  from  the  orbit  by  Mr.  J.  R.  Alcock.  The  boy  was 
copiously  bled  and  purged,  but  his  sufferings  continued  to  increase ;  the  sight  of  the 
affected  eye  was  lost ;  he  became  delirious;  an  urgent  irritative  fever  succeeded;  audit 
was  iiiferred  that  suppuration  was  taking  place  within  the  cranium. 

In  this  state  the  lad  was  sent  to  the  Westminster  Hospital,  on  the  11th  of  January. 
He  was  sensible  only  at  short  intervals,  and  appeared  to  be  suffering  the  most  excru- 
ciating pain ;  he  was  continually  moaning  and  rolling  his  head  from  one  side  to  the  other, 
or  holding  it  fixed  in  a  state  of  apoplectic  insensibility.  His  pulse  was  140,  small,  irre- 
gular, feeble;  bowels  acting  imperfectly;  skin  of  variable  temperatui-e.  He  had  been 
bled  to  the  utmost  verge  of  prudence,  and  the  only  means  that  could  be  judiciously  era- 
ployed  were  merely  palliative.  His  respiration  became  hurried,  and  at  times  laborious 
and  stertorous,  presenting  nearly  an  apoplectic  character.  Blood  was  taken,  after  his 
admission,  from  the  temporal  artery,  but  no  improvement  was  observable.  The  affected 
eye  and  its  appendages  were  much  swollen,  but  the  wound  was  scarcely  perceptible.  He 
died  on  the  12th. 

Much  interest  was  felt  in  this  case,  for  it  was  imagined  the  pipe  must  have  broken  the 
orbitary  process,  and  penetrated  the  anterior  lobe  of  the  cerebrum.  On  raising  the 
calvaria,  the  membranes  were  found  a  little  more  injected  than  natural;  but  no  other 
morbid  appearance  was  discovered  in  the  whole  cerebral  mass,  save  a  little  opacity  of  the 
pia  mater  covering  the  pons  Varolii.  This  was  found  to  be  opposite  a  portion  of  dis- 
colored dura  mater,  extending  over  the  left  cavernous  sinus.  An  opening  was  made  into 
this  cavity,  and  a  piece  of  pipe,  an  inch  long,  was  discovered  thrust  between  the  nervus 
abducens  and  the  carotid  artery.  Extensive  disorganization  of  course  prevailed  through- 
out the  whole  sinus ;  and  the  existence  of  a  foreign  body  of  such  size,  in  such  a  centre  of 
nervous  sympathy,  was  considered  not  inadequate  to  account  for  the  severity  of  the 
symptoms.  No  extravasation,  however,  had  taken  place,  no  penetration  of  the  dura 
mater,  nor  any  fracture  of  the  orbitary  plate.  The  pipe  had  passed  itnder  the  roof  of 
the  orbit,  and  entered  the  cavernous  sinus,  by  the  spheno-orbitary  fissure.  The  carotid, 
though  contracted  a  little  in  diameter  at  its  point  of  contact  with  the  intruded  body,  was 
yet  sufficiently  pervious.'* 

M.  Baudens  relates^  two  cases  of  musket-balls  lodging  in  the  orbital  cellu- 
lar substance.  Extraction  of  one  of  the  balls  was  first  attempted  by  making 
an  incision  through  the  lower  eyelid;  but  this  plan  was  abandoned,  on  account 
of  the  mobility  of  the  ball.  By  pressing  back  the  eye,  drawing  forward  the 
lower  lid,  and  introducing  a  curette  behind  the  ball,  it  was  at  last  extracted. 
When  amaurosis  instantly  follows  a  penetrating  wound  of  the  orbit,  while 
the  eyeball  shows  no  appearance  of  having  been  injured,  there  is  reason  to 
suspect  that  the  optic  nerve  has  suffered.  Thus,  Dr.  Rognetta  mentions"  the 
case  of  a  shoemaker,  who  became  immediately  blind,  in  consequence  of  being 
struck  with  an  awl  at  the  external  orbital  angle.  He  supposes  the  oi)tic 
nerve  to  have  been  penetrated.     The  eyeball  preserved  its  natural  appearance. 


312  INFLAMMATION  OF  THE   ORBITAL  AREOLAR  TISSUE. 

'  Gendron,  Traite  des  Maladies   des  Yeux,  Seeker,  Medical  Gazette,  Vol.  xlv.  p.  606;  Lon- 

Tome  i.  p.  381:  Paris,  1770.  don,  1850. 

"Guthrie's  Lectures   on  the  Operative  Sur-  ■*  Lancet,  February  11,  1832,  p.  715. 

gery  of  the  Eye,  p.  146 ;  London,  1823.  '  Clinique  des  Plaies  d'Armes  ^  Feu,  p.  166  ; 

^  See  case  by  Cunier,  Annales  d'Oculistique,  Paris,  1836. 

Tome   vii.  p.  -4;    Bruxclles,    1842:    Case    by  ^  Cours   Public  d'Ophthalmologie ;  Lancette 

Frangaise,  3  Dec.  1836. 


SECTION  II. — EFFUSION  OF  BLOOD  INTO  THE  ORBITAL  AREOLAR  TISSUE. 

The  efifects  of  rupture  of  bloodvessels  within  the  orbit  may  be  more  or  less 
serious,  as  is  shown  in  the  two  following  cases : — 

Case  185. — A  man  received  a  kick  upon  the  cheek,  just  below  the  right  eye,  from  a 
maniac,  whom  he  was  endeavoring  to  secure.  The  immediate  consequence  was  double 
vision  in  a  vertical  direction,  every  object  at  which  the  patient  looked  appearing  double, 
but  the  one  image  above  the  other.  A  firm  swelling,  caused  by  extravasated  blood,  was 
felt  below  the  eye,  deep  in  the  orbit,  and  it  was  evident  that  the  organ  was  somewhat 
pushed  up,  and  out  of  its  natural  direction.  On  placing  a  finger  beneath  the  other  eye, 
and  pressing  into  the  orbit,  the  double  vision  was  immediately  corrected,  by  the  axis  of 
the  sound  eye  being  made  to  correspond  with  that  of  the  injured  one;  while  the  symptom 
returned  as  soon  as  the  finger  was  removed.  The  extravasated  blood  Avas  gradually 
absorbed,  and  the  patient,  after  a  few  weeks,  regained  correct  vision.' 

Case  186. — A  boy,  who  had  fallen  into  a  ship's  hold,  was  brought  to  the  London  Hos- 
pital, October  2,  1834,  with  concussion  of  the  brain,  violent  contusion  and  swelling  of  the 
right  side  of  the  head,  and  protrusion  of  the  right  eye,  which  was  fixed  and  motionless, 
the  pupil  dilated,  and  vision  lost. 

He  gradually  recovered  from  the  concussion  of  the  brain,  while  the  eye  gradually  be- 
came more  prominent.  The  protrusion  of  the  globe  immediately  after  the  accident, 
without  symptoms  of  cerebral  compression,  proved  that  it  arose  from  extravasation  of 
blood  within  the  orbit ;  and  the  further  continued  protrusion  rendered  it  probable  that 
the  aperture  in  the  vessel,  from  which  the  blood  escaped,  had  not  closed.  The  symptoms 
were  not  so  acute  as  to  indicate  suppuration.  As  the  globe  became  more  prominent,  the 
eye  could  be  distinctly  seen  to  be  propelled  forward  at  each  stroke  of  the  heart. 

Pressure  was  made  on  the  globe ;  but,  after  being  borne  for  two  days,  it  occasioned  so 
much  pain  that  it  was  abandoned.  On  Tuesday,  November  10,  just  after  the  eye  had 
been  examined,  a  profuse  arterial  hemorrhage  occurred  from  the  nose.  Jlr.  Scott  com- 
manded it  by  pressure  on  the  common  carotid,  and  immediately  secured  that  vessel.  The 
protrusion  of  the  eye  directly  receded  in  a  great  degree,  and  afterwards  greatly  diminished.* 


'  Delafield's  Notes  to  Travers'   Synopsis  of        *  Medico-Chirurgical  Transactions,  Vol.  xxii. 
the  Diseases  of  the  Eye,  p.  179;   New  York,     p.  134:  London,  1839. 
1825. 


SECTION  m. — PHLEGMONOUS  INFLAMMATION  OF  THE  ORBITAL  AREOLAR  TISSUE. 
Fig.  Dalrymple,  PI.  XIL  Fig.  3. 

It  has  already  (page  155)  been  stated,  that  erysipelatous  inflammation 
sometimes  spreads  from  the  eyelids  to  the  areolar  tissue  of  the  orbit,  and 
terminates  there  in  diffuse  abscess.  The  areolar  tissue  which  envelops  the 
muscles  and  nerves  of  the  orbit,  and  by  which  the  eyeball  is  supported,  is 
also  subject  to  aciite  phlegmonous  inflammation,  ending  in  suppuration,  and 
forming  one  of  the  most  severe  and  dangerous  affections  of  the  organ  of  vision. 

Symptoms. — During  the  first,  or  purely  inflammatory  stage,  pain  is  felt, 
deep  in  the  orbit,  rapidly  increasing  in  severity,  and  extending  to  the  forehead 
and  temple.  The  pain  is  of  neuralgic  character,  and  intermittent.  The  eye 
is  soon  observed  to  be  more  prominent  than  natural.  The  patient  feels  as  if 
it  were  constantly  pressed  upon,  or  as  if  the  orbit  had  become  too  small. 
The  pain  is  greatly  increased  by  touching  the  eye,  or  attempting  to  move  it. 
The  patient  is  distressed  by  the  sensation  of  flashes  of  fire  in  the  eye.  Vision 
begins  to  fail,  from  the  pressure  exercised  on  the  eyeball  by  the  inflamed  and 


INFLAMMATION   OF   THE   ORBITAL  AREOLAR   TISSUE.  313 

tumefied  parts  by  which  it  is  surroundecl,  from  the  iuflammation  spreading  to 
the  optic  nerve  and  its  envelop,  and  from  the  nerve  being  put  on  the  stretch 
by  the  projection  of  the  eyeball  forwards  from  the  orbit.  The  conjunctiva 
becomes  red  and  chemosed.  In  some  cases  the  pupil  is  contracted,  and  the 
eyeball  partakes  in  the  inflammation.  This,  however,  is  by  no  means  con- 
stantly the  case ;  matter  may  even  form  behind  the  eye,  and  yet  its  proper 
textures  remain  apparently  uninjured.  When  they  do  inflame,  the  iris  be- 
comes discolored  and  motionless.  The  secretion  of  tears  is  soon  checked, 
from  the  lachrymal  gland  taking  part  in  the  inflammation ;  but  till  then  there 
is  epiphora.  The  eyelids  are  red,  painful,  and  swollen,  as  if  affected  with 
erysipelas,  and  move  with  difficulty.  The  disease  is  apt  to  be  mistaken  for 
erysipelas  of  the  lids ;  and  nothing  effectual  being  attempted,  the  patient  may 
perish  from  deep-seated  orbital  abscess,  inducing  coma.  The  symptoms  of 
inflammatory  fever  attend  these  local  appearances.  The  pulse  is  hard,  full, 
and  frequent.  The  face  is  flushed.  The  patient  is  thirsty,  his  skin  hot,  he 
is  restless,  and  often  delirious,  especially  during  the  night.  The  inflammation 
may  extend  to  the  membranes  and  substance  of  the  brain,  and  then  we  have 
the  usual  symptoms  of  phrenitis. 

In  the  second  stage,  matter  having  formed  behind,  or  to  one  side  of  the 
eyeball,  this  is  still  more  protruded,  and  is  more  or  less  distorted.  It  is 
sometimes  so  much  thrust  out  as  to  project  beyond  the  eyelids,  pushing  them 
aside,  and  presenting  the  displacement  called  exophthalmos.  The  matter 
generally  presses  forwards  to  the  front  of  the  orbit,  and  fluctuates  behind  the 
conjunctiva,  or  between  the  edge  of  the  orbit  and  one  or  other  eyelid.  la 
some  cases,  there  are  several  points  of  fluctuation ;  one  perhaps  under  the 
conjunctiva,  and  another  behind  one  or  other  eyelid.  In  one  case,  which  I 
saw  at  the  Glasgow  Eye  Infirmary,  the  matter  burst  through  the  conjunctiva, 
by  the  upper  inner  side  of  the  eyeball,  and  appeared  as  if  coming  from  within  ^ 
the  sclerotica,  while  another  aperture  formed  through  the  upper  eyelid,  under 
the  middle  of  the  superciliary  ridge.  The  eye  was  saved.  If  there  is  only 
one  point  of  fluctuation,  it  is  reasonable  to  conclude  that  suppuration  has 
taken  place  only  on  one  side  of  the  eye.  The  eyeball,  in  this  case,  is  thrown 
forwards  in  an  oblique  direction.  Not  unfrequently  the  eyeball  falls  into  the 
state  of  exojMhahnia,  that  is,  it  is  not  only  protruded,  but  at  the  same  time 
destroyed  by  inflammation  and  suppuration.  The  photopsia  continues,  the 
delirium  increases,  the  pain  becomes  more  distinctly  pulsative,  and  is  of  ago- 
nizing severity.  Matter  is  seen  behind,  and  in  the  substance  of  the  cornea, 
which  after  a  time  bursts,  and  allows  the  humors  to  be  evacuated.  Vision 
is  totally  destroyed.  Even  when  the  eyeball  has  not  suffered  much  in  texture 
from  the  inflammation,  the  retina  is  left  in  a  state  of  insensibility.  In  some 
cases,  apoplectic  and  fatal  symptoms  occur  before  the  abscess  is  so  much  dis- 
tended as  to  point  externally.     Rigors  generally  attend  the  second  stage. 

If  this  disease  be  neglected  or  mistreated,  the  inflammation  may  spread 
not  only  to  the  eyeball,  but  (see  page  7*7)  to  the  periosteum  and  bones  of  the 
orbit,  or  the  matter  may  make  its  way  into  the  nostril,  the  maxillary  sinus,  or 
even  the  cavity  of  the  cranium. 

Although,  in  general,  inflammation  of  the  orbital  areolar  tissue  is  an  acute 
and  I'apid  disease,  it,  in  some  cases,  assumes  a  chronic  form,  so  that,  slowly, 
in  the  course  of  months  or  years,  and  sometimes  without  pain,  matter  accu- 
mulates within  the  orbit.  At  length  the  lids  become  swollen,  red,  and 
everted;  the  eyeball  protrudes;  fluctuation  is  felt;  the  abscess  bursts,  and 
leaves  a  sinus  which  is  apt  for  a  great  length  of  time  to  discharge  matter, 
even  where  there  is  no  affection  of  the  bones. 

From  the  indurated  and  adherent  state  of  the  areolar  tissue,  consequent  to 
orbital  abscess,  the  eyeball  may  remain  permanently  protruded  and  motionless. 


314  INFLAMMATION   OF   THE   ORBITAL   AREOLAR  TISSUE. 

In  this  case,  the  tears  run  over  the  cheek,  the  eyelids  cannot  close,  the  sur- 
face of  the  eye  becomes  inflamed  and  tender,  and  the  patient  continues  subject 
to  headache,  watchfulness,  fever,  and  great  anxiety.' 

Causes. — The  causes  of  inflammation  within  the  orbit  are  confessed  to  be, 
in  many  cases,  obscure.  Benedict  tells  us  that  this  disease  occurs  for  the 
most  part  in  plethoric  individuals,  after  sudden  changes  of  temperature,  and 
in  scrofulous  or  otherwise  disordered  constitutions.  Exposure  to  cold  is  often 
the  cause.  Foreign  bodies  thrust  with  violence  between  the  edge  of  the 
orbit  and  the  eyeoall,  and  even  slight  injuries,  occurring  in  peculiar  constitu- 
tions, or  under  particular  circumstances  of  the  system,  may  bring  on  inflam- 
mation of  the  orbital  areolar  tissue.  Thus,  Weller  instances  a  case  which 
occurred  in  a  healthy  young  woman,  who  happened,  while  in  the  state  of  men- 
struation, to  receive  a  slight  lacerated  wound  of  the  orbit.  The  fright  occa- 
sioned by  the  injury  brought  on  interruption  of  the  menses,- and  a  severe 
inflammation  of  the  whole  cavity  of  the  orbit  followed.  The  extirpation  of 
orbital  tumors  sometimes  gives  rise  to  severe  inflammation  ending  in  suppura- 
tion. I  have  seen  the  same  effects  follow  semi-extirpation  of  the  eyeball  for 
general  choroid  staphyloma. 

Treatment. — A  vigorous  antiphlogistic  treatment  must  be  had  recourse  to, 
in  the  first  instance.  Copious  and  repeated  bleedings  from  the  arm,  and  a 
liberal  application  of  leeches  round  the  orbit,  cold  lotions  to  the  head,  free 
purging,  abstinence,  rest,  and  darkness,  arc  evidently  indicated.  Even  when 
the  constitution  is  not  robust,  this  sort  of  treatment  must  be  followed,  to 
save  the  vision,  and,  it  may  be,  even  the  life  of  the  patient.  The  debility 
arising  from  the  use  of  active  antiphlogistic  means  of  cure  may  be  removed, 
while  a  temporizing  or  timid  plan  of  treatment  may  be  productive  of  the  most 
serious  mischief  If  the  conjunctiva  is  chemosed,  it  should  be  freely  scarified, 
or  pieces  of  it  cut  out,  which  will  procure  a  considerable  flow  of  blood. 
Benedict  recommends  sinapisms  to  the  neck,  friction  of  the  forehead  and 
temple  with  mercurial  ointment,  and  large  doses  of  calomel  internally. 

An  opening  through  the  conjunctiva,  or  through  the  eyelid,  for  the  evacu- 
ation of  the  matter  collected  within  the  orbit,  is  the  chief  point  of  treatment 
in  the  second  stage.  A  deep  and  free  incision  is  to  be  made  wherever  the 
fluctuation  is  discovered ;  and  even  when  there  is  no  distinct  fluctuation,  if 
other  symptoms  are  present  which  lead  us  to  conclude  that  in  all  prolmbility 
matter  has  formed,  it  is  safer  to  plunge  the  lancet  into  the  part  which  is 
swollen,  and  where  we  think  suppuration  is  likely  to  have  taken  place,  than 
to  allow  the  matter  to  accumulate,  the  bones  perhaps  to  suffer,  or  even  the 
brain  to  become  affected.  Of  course,  in  opening  the  abscess,  care  must  be 
taken  to  avoid  the  eyeball  and  other  important  parts.  The  incision  ought  to 
be  kept  open  with  a  dossil  of  lint,  and  a  poultice  is  afterwards  to  be  applied. 
The  eye  is  frequently  to  be  fomented  with  decoction  of  poppies,  or  aqueous 
solution  of  opium.  At  the  second  or  third  dressing,  after  the  abscess  has 
been  evacuated,  the  opening  into  the  orbit  may  be  cautiously  examined  with 
the  probe.  If  it  is  not  deep,  the  dossil  of  lint  is  gradually  to  be  diminished 
in  thickness,  and  pushed  less  into  the  orbit,  till  the  sinus  closes.  If,  on  the 
other  hand,  the  sinus,  or  sinuses  are  deep,  running  back  almost  to  the  bottom 
of  the  orbit,  a  mixture  of  eight  ounces  of  tepid  w^ater,  with  one  drachm  of 
aqua  potassae,  ought  daily  to  be  injected.  This  is  to  be  continued  till  the 
probe  is  found  not  to  pass  beyond  the  eyeball.  The  lint  may  be  introduced 
to  this  depth,  and  is  not  to  be  lessened  till  the  back  part  of  the  sinus  close. 
I  have  already  (Chapter  I.  Section  ii.)  explained  the  necessary  treatment  in 
cases  where  the  bones  of  the  orbit  are  found  to  be  affected. 

If  the  eyeball  has  suffered  much,  so  that  the  aqueous  chambers  are  dis- 
tended with  pus,  it  will  be  proper  to  open  the  cornea ;  but  if  only  a  small 


INFLAMMATION   OF   THE   ORBITAL   AREOLAR   TISSUE.  315 

quantity  of  matter  is  lodged  in  the  anterior  chamber,  or  between  the  lamellae 
of  the  cornea,  we  may  rely  on  this  being  absorbed,  if  the  general  inflamma- 
tion of  the  eye  and  orbit  is  subdued. 

If  the  vision  of  the  eye  is  completely  gone,  and  a  greenish  purulent  ap- 
pearance remains  behind  the  pupil,  the  lancet  should  be  plunged  through  the 
sclerotica.  Perhaps  only  a  little  thin  fluid  will  be  evacuated  ;  but  by  this 
means  the  tension  is  relieved,  the  eye  retreats,  and  the  life  of  the  patient  may 
be  saved. 

In  four  or  five  days  after  the  orbital  abscess  is  opened,  all  the  dangerous 
symptoms  have  in  general  subsided,  and  the  use  of  active  antiphlogistic 
remedies  may  be  laid  aside.  Easily  digested  food,  in  moderate  quantities, 
may  be  allowed,  and  if  the  patient  has  been  much  weakened  by  the  previous 
depletion,  some  such  tonic  may  be  given  as  is  not  apt  to  excite  the  vascular 
system. 

When  inflammation  within  the  orbit  assumes  a  chronic  form,  blisters  to 
the  temple  and  forehead  are  to  be  employed,  with  calomel  internally  till  sali- 
vation is  produced. 

Cases. — I  have  already  stated  (page  tT)  the  principal  circumstances  of  a 
case  related  by  Demours,  and  referred  to  another  by  Saint  Yves,  in  which 
this  disease  ended  in  extensive  caries  of  the  orbit. 

Mr.  Lawrence  has  related,  with  his  usual  clearness,  two  cases  which  fell 
under  his  care  in  an  early  stage  of  the  complaint.  "  Some  time  ago,"  says 
he,  "  I  saw  two  instances  of  this  affection,  in  which  the  local  and  general 
symptoms  were  characterized  by  a  degree  of  violence  which  I  have  hardly 
ever  witnessed  in  any  other  case." 

Cff.se  187. — A  man  between  20  and  30  years  of  age  came  to  Mr.  Lawrence,  accompa- 
nied by  his  wife,  who  said  he  had  suffered  such  agonizing  pain  for  the  three  or  four  pre- 
ceding nights,  that  she  was  afraid  he  would  have  gone  out  of  his  mind.  In  this  case, 
matter  was  presented  just  under  the  superciliary  ridge  ;  after  making  a  free  opening,  a 
large  quantity  was  discharged,  and  upon  putting  in  a  probe,  it  went  to  the  bottom  of  the 
orbit. 

Case  188. — In  a  child  between  three  and  four  years  old,  the  local  and  general  symp- 
toms were  equally  severe ;  the  matter  presented  between  the  lower  lid  and  the  globe,  but 
the  quantity  which  issued  on  making  an  opening,  was  not  very  considerable  in  this  case. 
In  both  instances  the  globe  of  the  eye  was  very  much  protruded,  but  not  actually  thi-ust 
out  between  the  eyelids,  and  after  the  matter  was  discharged  it  receded  to  its  natural 
situation.  In  the  child,  vision  was  restored ;  but  in  the  adult,  the  eye,  although  it  had 
not  been  inflamed,  remained  amaurotic. ^ 

Mr.  Ware  remarks  that  if  the  suppuration  be  slow,  and  the  matter  lie  con- 
siderably below  the  surface,  the  eye  will  be  protruded  before  any  fluctuation 
can  be  discovered,  and  the  existence  of  the  matter  will  only  be  learned  by 
paying  attention  to  the  accompanying  symptoms,  such  as  a  quick  pulse, 
white  tongue,  shiverings,  &c.  These  remarks  he  illustrates  by  the  following 
case  : —  , 

Case  189. — In  a  child,  six  yeai'S  old,  Mr.  "Ware  passed  a  lancet  on  the  side  of  the  eye 
next  the  nose,  a  little  below  the  commissure  of  the  eyelids,  at  least  an  inch  into  the  orbit, 
before  he  reached  the  matter.  On  withdrawing  the  instrument,  its  point  was  evidently 
marked  with  pus.  He  therefore  enlarged  the  aperture  with  a  blunt-pointed  bistoury, 
and  discharged  a  considerable  quantity  which  was  thick  and  putrid.  It  was  necessary  to 
preserve  the  opening  by  the  insertion  of  a  small  dossil  of  lint ;  on  the  removal  of  which, 
a  vent  was  given  daily  to  new  matter  for  a  fortnight.  Its  quantity  gradually  decreased, 
together  with  the  prominence  of  the  eye ;  and  at  length  it  wholly  ceased,  the  wound 
healed,  and  the  child  became  well.  The  motion  of  the  affected  eye,  however,  was  not 
quite  free  towards  the  nose  for  several  months  afterwards.' 

Case  190. — In  a  man,  whom  I  had  occasion  to  see  a  few  times,  the  disease  began  with 
pain,  apparently  neuralgic,  in  the  supra-orbital  region,  lasting  daily  from  8  till  10  A.  M. 
This  was  followed  by  double  vision,  and  the  eyeball  became  depressed.  There  was  no 
affection  of  the  conjunctiva,  but  the  upper  eyelid  was  distended.  These  symptoms  con- 
tinued from  December,  1840,  till  December,   1841.     A  poultice  was  applied,   and  an 


316  INFLAMMATION   OP  THE   ORBITAL  AREOLAR  TISSUE. 

abscess  burst  through  the  upper  eyelid,  close  to  the  edge  of  the  orbit.  The  opening 
healed,  and  the  eyelid  again  became  elevated.  Six  months  after  it  had  burst,  I  plunged 
a  lancet  into  it,  and  keeping  the  lips  of  the  wound  apart  with  a  probe,  discharged  a  large 
quantity  of  pus.     The  cavity  stretched  back,  above  the  eye,  to  the  depth  of  IJ  inch. 

Case  191. — Mrs.  H.,  aged  about  56,  came  under  the  care  of  Mr.  Espie,  surgeon,  at 
Falkirk,  on  the  IGth  April,  1836,  for  a  disease  in  the  right  orbit.  She  stated  that  about 
12  years  before,  she  received  a  severe  blow  over  the  right  eyebrow,  by  coming  suddenly 
in  contact  with  a  lamp-post.  After  the  lapse  of  four  years  from  the  date  of  the  injury, 
one  of  her  relations  observed  a  difference  in  the  appearance  of  her  eyes,  but  she  herself 
did  not  discover  anything  particular  about  them  for  another  period  of  four  years,  when 
she  observed  that  the  right  eyeball  protruded,  without  any  other  unpleasant  symptom. 

The  protrusion  gradually  increased,  and  was  attended  with  photopsia,  double  vision, 
dimness  of  sight,  and  much  feeling  of  tension.  She  complained  greatly  of  a  feeling  of 
traction  within  the  orbit. 

Mr.  Espie  found  the  right  eyeball  protruding  downwards  and  outwards.  It  appeared 
to  rest  on  the  orbitary  edge  of  the  malar  bone.  At  the  superior-internal  part  of  the  front 
of  the  orbit,  he  discovered  a  tumor,  slightly  elevated,  and  in  which  obscure  fluctuation 
could  be  detected.  The  patient  had  not  experienced  any  pain  in  the  seat  of  the  tumor. 
The  eyelids,  and  particularly  the  upper,  were  much  distended.  There  was  no  discolora- 
tion over  the  swelling.  The  patient  had  never  experienced  any  rigors  since  the  receipt 
of  the  injury.     Her  general  health  was  good. 

At  this  period,  I  saw  the  case,  and  advised  that  the  tumor  should  be  punctured,  on  the 
supposition  that  it  was  an  encysted  tumor. 

On  the  22d  April,  Mr.  Espie  punctured  the  tumor  at  its  most  prominent  part,  and  gave 
exit  to  a  large  quantity  of  pus,  first  flaky  and  then  healthy.  This  was  followed  by  imme- 
diate relief  to  the  feelings  of  tension  and  traction.  The  double  vision  and  other  symp- 
toms also  vanished.  The  eyeball  was  gently  returned,  to  a  certain  extent,  into  its  socket, 
and  a  tent  being  introduced  through  the  wound,  a  compress  and  roller  were  applied  over 
the  front  of  the  orbit,  so  as  to  support  the  eyeball. 

The  case  continued  under  treatment  for  about  six  months.  During  the  greater  part  of 
that  time,  on  introducing  a  director,  matter  continued  to  be  discharged  by  the  wound, 
and  it  was  necessary  repeatedly  to  dilate  the  opening.  On  one  occasion  of  enlarging  the 
wound,  from  its  becoming  fistulous,  the  eyeball  was  seized  with  an  involuntary  motion 
from  side  to  side,  which  lasted  fully  an  hour.  On  introducing  a  probe,  which  passed 
nearly  to  the  bottom  of  the  orbit,  no  carious  bone  could  be  detected.  The  eyeball  was 
ultimately  restored  to  nearly  its  natural  place  in  the  orbit,  and  the  vision  of  the  eye  was 
perfectly  preserved. 

Case  192. — Marshal  the  Count  Radetsky,  aged  70,  of  a  vigorous  constitution  but  liable, 
from  the  accidents  of  the  military  life,  to  rheumatic  and  catarrhal  complaints,  was  seized, 
in  consequence  of  exposure  to  alternations  of  heat  and  cold,  with  severe  pain  in  the  fore- 
head and  temples,  accompanied  by  inflammation  of  the  right  eye,  which  for  some  time 
had  been  affected  with  epiphora,  accompanied  by  partial  eversion  of  the  lower  eyelid. 
The  severe  pain  soon  subsided;  but  the  eyelids  continued  red,  and  the  conjunctiva 
swollen,  while  a  tumor  became  perceptible  to  sight  and  touch,  pushing  the  eyeball  from 
the  orbit.  When  Professor  Jitger  visited  the  patient  at  Milan,  he  found  a  tumor,  not 
only  filling  the  whole  orbit,  but  extending  greatly  beyond  it,  and  the  eye  so  much  pro- 
truded, and  the  lids  so  much  retracted,  that  could  they  have  closed,  they  would  have 
done  so  behind  the  globe.  The  tumor  on  which  the  eyeball  rested  was  painful  to  the 
touch,  hard  like  a  stone,  unequal,  and  bossulated.  The  lids  were  enormously  stretched 
in  every  direction,  swollen,  and  motionless;  their  external  color  dark  livid,  and  their 
surface  strewed  with  varicose  vessels.  The  lachrymal  gland  was  displaced  like  the  globe 
of  the  eye,  being  pushed  into  the  duplicature  of  the  upper  eyelid.  The  caruncle  and  sac 
were  also  greatly  enlarged,  hard,  and  painful  to  the  touch. 

Professor  Jiiger  seems  to  have  had  some  misgivings  as  to  the  nature  of  the  case,  whe- 
ther it  were  an  inflammation  in  the  orbit  which  might  end  in  abscess,  or  a  cancerous 
tumor  behind  the  eye.  He  seems,  however,  to  have  followed  the  opinion  of  two  other 
medical  practitioners  who  were  in  attendance  and  came  to  the  conclusion,  that  the  disease 
was  a  malignant  tumor.  Luckily  for  the  patient,  this  opinion  proved  erroneous ;  the  case 
was  nothing  more  than  an  abscess,  which,  having  burst  and  discharged  itself,  the  eye  got 
well.* 

Case  193.— In  a  case  occurring  at  the  Royal  London  Ophthalmic  Hospital,  under  the 
care  of  Mr.  Scott,  with  all  the  usual  symptoms  of  phlegmonous  inflammation  of  the  orbit, 
an  incision  was  made  through  the  swollen  conjunctiva,  deep  into  the  orbit;  a  sudden  and 
most  violent  gush  of  arterial  blood  instantly  followed  the  knife,  and  continued  to  issue, 
per  saltum,  to  such  a  degree,  as  to  lead  to  the  belief  that  an  aneurism  had  been  opened, 
and  the  surgeon  began  to  prepare  to  tie  the  carotid.     Pressure  and  cold,  however,  arrested 


INFLAMMATION   OF   THE   ORBITAL  AREOLAR  TISSUE.  317 

the  hemorrhage,  and,  in  a  few  days,  purulent  discharge  taking  place,  the  case  terminated 
as  one  of  ordinary  abscess  of  the  orbit.* 

Case  194. — An  unmarried  woman,  aged  25,  was  seized  with  acute  pain  over  the  left 
half  of  her  head,  under  which  she  continued  to  suffer  for  nearly  15  days  without  seeking 
medical  assistance.  At  length,  when  the  eye  began  to  turn  red  and  to  swell,  assistance 
was  called  in.  The  cheek  swelled  to  a  great  size,  and  presented  a  rose-red  color,  becom- 
ing white  on  pressure.  The  patient  was  affected  with  fever,  jactitation,  and  anxiety. 
On  account  of  the  swelling  and  inflammation,  the  eyelids  were  so  shut  up,  that  the  eye- 
ball could  not  be  uncovered.  After  some  days,  the  swelling  suppurated,  and  having  burst 
spontaneously  at  the  external  angle  of  the  eye,  a  great  quantity  of  fetid  pus  was  dis- 
charged. On  pressure,  pus  flowed  not  only  from  the  cavity  of  the  orbit,  but  from  the 
parts  surrounding  the  eye,  and  from  the  cheek.  The  swelling  of  the  eyelids  and  neigh- 
Ijoring  parts  soon  subsided,  so  that  the  eyeball  could  be  seen.  The  conjunctiva  was  very 
red,  and  much  chemosed ;  but  the  cornea  appeared  bright  and  clear.  The  pupil  was 
dilated,  and  the  vision  of  the  eye  was  lost. 

On  the  fourth  day  after  the  bursting  of  the  abscess,  the  patient  was  seized  with  a 
nervous  fit,  which  subsided  into  complete  loss  of  muscular  power  and  sensation,  with 
slow,  irregular,  and  stertorous  respiration,  and  a  small  intermitting  pulse,  soon  followed 
by  death. 

On  dissection,  it  was  found  that  the  whole  adipose  and  cellular  tissue  under  the  skin 
of  the  eyelids  and  cheeks,  even  down  to  the  lower  jaw,  was  destroyed,  and  that  in  place 
of  cellular  substance,  the  space  between  the  eyeball,  its  muscles,  and  the  bottom  of  the 
orbit,  was  filled  with  fetid  pus.  The  eyeball  and  its  contents  were  healthy,  and  the  cor- 
nea pellucid.  On  opening  the  cranium,  the  anterior  lobe  of  the  left  hemisphere  of  the 
cerebrum,  to  the  depth  of  the  lateral  ventricle,  was  found  to  be  in  a  great  measure  de- 
stroyed by  suppuration.  The  suppuration  surrounded  the  whole  optic  nerve,  and  com- 
municated with  the  cavity  of  the  orbit.  The  nerve  itself  had  not  suffered,  either  exter- 
nally, or  internally.^ 

Case  195. — J.  S.,  a  shoemaker,  aged  27,  robust,  but  of  irritable  temperament,  and 
given  to  drink,  had  one  of  the  upper  molar  teeth  on  the  left  side  extracted,  on  account  of 
severe  toothache.  This  was  followed  by  swelling  and  redness  of  the  left  side  of  the  face; 
and  soon  after  there  appeared,  in  the  site  of  the  extracted  tooth,  and  under  severe  pain, 
a  vesicle,  of  the  size  of  a  nut,  clear  like  water.  Ice-cold  water,  frequently  taken  into 
the  mouth,  gave  relief;  the  pain  subsided,  the  vesicle  disappeared,  and  the  swelling  of 
the  face  became  less.  Some  days  afterwards,  there  was  a  profuse  flow  of  tears  from  the 
left  eye,  which  soon  ceased,  and  was  followed  by  a  copious  watery  discharge  from  the  left 
nostril.  On  the  17th  April,  1830,  the  epiphora  was  abundant,  and  attended  by  photo- 
phobia and  by  pressing,  sometimes  lancinating,  pain  in  the  head.  Towards  evening,  the 
patient  was  seized  with  rigors,  followed  by  heat ;  the  photophobia  and  pain  of  the  head 
became  intolerable ;  the  left  half  of  the  face  and  the  eyelids  became  suddenly  much 
swollen,  the  swelling  was  tense,  the  eyeball  motionless,  and  sharp  burning  tears  ran  down 
the  cheeks.  The  patient  slept  none  that  night,  and  was  occasionally  troubled  with  pho- 
topsia. 

Early  on  the  18th,  he  complained  of  weakness,  with  alternate  feelings  of  heat  and  cold, 
and  great  thirst.  The  eyelids  and  left  cheek  were  more  swollen  and  tense ;  the  photopsia 
constant;  and  the  eye  deprived  of  vision.  Fomentations  and  other  means  were  tried; 
but  the  symptoms  increased  in  severity,  and  after  another  sleepless  night,  on  account  of 
the  severe  pulsative  hemicrania,  the  patient  applied  for  relief  on  the  19th,  at  the  Ophthal- 
mological  Clinic  in  Prague. 

The  symptoms  were  intense  fever,  with  frequent,  hard  pulse;  constipation  for  three 
days  ;  the  left  eyelids  enormously  swollen,  elastic,  dark  red,  and  extremely  painful ;  the 
eyeball  was  fixed,  but  could  not  be  exposed  to  view  on  account  of  the  tenseness  and 
swelling  of  the  eyelids ;  constant  photopsia ;  pulsating  pain,  almost  insufferable,  which 
concentrated  itself  chiefly  in  the  eyeball,  and  was  attended  by  a  feeling  of  the  eye  being 
too  big  for  the  socket;  the  eyeball  somewhat  protruded;  the  edges  of  the  eyelids  glued 
together  with  yellowish  tough  mucus. 

Professor  Fischer  bled  the  patient  to  the  extent  of  12  ounces,  and  put  on  12  leeches 
round  the  eye,  followed  by  a  cold  lotion,  frequently  renewed.  Internally,  a  decoction  of 
marshmallow  roots,  with  nitre  and  tartrate  of  potash,  was  given  in  doses  every  two  hours. 
The  patient  felt  much  relieved  by  the  bloodletting  and  leeching,  as  well  as  by  the  cold 
application.  In  the  evening,  he  seemed  generally  better,  and  had  one  stool.  The  eye 
was  in  the  same  state  as  formerly,  only  the  pain  was  less,  but  still  pulsative.  Twelve 
more  leeches  were  applied,  and  the  rest  of  the  treatment  continued.  This  night,  the 
patient  slept  some  hours. 

20th.  The  pain  in  the  eye  had  augmented,  although  the  swelling  was  more  confined  to 
the  eyelids,  and  less  tense.     The  eyelids  could  with  difBculty  be  separated  from  each 


31.8^  INFLAMMATION   OF   THE   ORBITAL   AREOLAR   TISSUE. 

N 

other  so  as  to  allow  the  chemosed  conjunctiva  to  be  seen  ;  the  cornea  appeared  natural, 
the  pupil  contracted  and  fixed.  In  the  evening,  the  pain  of  the  head  and  eye  increasing, 
15  leeches  were  applied. 

During  the  two  following  days  the  pain  was  less,  and  the  patient  had  more  rest  during 
the  nio-ht.  The  swelling  of  the  upper  eyelid  affected  more  its  inner  extremity,  without 
becoming  soft  or  fluctuating.     An  emollient  poultice  was  applied. 

23d.  Fluctuation  being  distinct  at  the  inner  angle  of  the  eye,  the  abscess  was  opened, 
and  a  large  quantity  of  fetid  greenish-yellow  matter  was  discharged.  The  swelling  fell 
at  the  inner  angle,  but  continued  unchanged  at  the  outer  angle  and  in  the  lower  eyelid. 
The  eyelids  could  now  be  separated  with  less  pain,  permitting  the  cornea  to  be  seen 
covered  with  puro-mucus,  the  conjunctiva  bulbi  swollen  and  fleshy,  and  folds  of  the  pal- 
pebral conjunctiva  protruding  at  the  outer  angle  from  between  the  eyelids. 

The  general  health  became  much  improved,  the  tongue  clean,  appetite  natural,  bowels 
rather  slow.  The  pain  in  the  left  side  of  the  head  was  sometimes  severe,  and  at  other 
times  seemed  entirely  gone.  The  patient  passed  the  nights  pretty  quietly;  he  slept,  and 
felt  refreshed.  His  mind  was  undisturbed.  The  swelling  of  the  eyelids  continued  to 
decrease;  the  flow  of  matter  was  copious,  and  purulent  shreds  required  often  to  be 
removed  from  the  opening. 

From  the  1st  till  the  7th  of  May,  the  patient  complained  only  of  a  frequent  and  irre- 
sistible desire  to  sleep.  The  swelling  of  the  lower  eyelid  continued;  the  eyeball  became 
movable ;  a  prolapsus  iridis  had  taken  place  through  the  cornea ;  the  patient  saw  none 
with  the  eye.  The  great  quantity  of  pus  which  flowed  from  the  abscess,  led  to  the  sus- 
picion that  there  was  a  collectiou  of  matter  deep  in  the  orbit.  The  patient  was  therefore 
advised  to  lie  on  the  left  side,  or  to  sit  with  his  head  bent  forwards,  to  aid  the  escape  of 
the  matter. 

8th.  Acid  eructations,  which  ceased  after  the  use  of  some  efi"ervescing  powders. 
9th.  Somnolence;  expression  of  countenance  changed;  he  complained  of  a  strong 
feeling  of  pressure  in  the  left  half  of  his  head ;  retching,  and  vomiting  of  a  slimy,  bilious 
fluid;  skin  moist;  pulse  slow,  soft,  and  full ;  swelling  fallen ;  discharge  diminished.  It 
appeared  probable  that  purulent  effusion  had  taken  place  Avithin  the  head.  Two  grains 
of  calomel,  with  half  a  grain  of  digitalis,  were  ordered  every  two  hours.  Four  hours 
after,  convulsions  of  the  right  upper  and  lower  extremities  supervened,  with  stertorous 
respii-ation  and  insensibility.  The  dose  of  the  powders  was  increased,  mercurial  oint- 
ment was  rubbed  upon  the  head,  sinapisms  were  applied  to  the  calves  of  the  legs  and 
soles  of  the  feet,  and  clysters  with  tartar  emetic  were  administered. 
Ou  the  10th,  the  patient  died  convulsive  and  apoplectic. 

On  dissection,  the  bloodvessels  of  the  dura  mater  were  found  to  be  much  distended,  and 
the  membrane  itself,  where  it  invested  the  anterior  lobe  of  the  left  hemisphere  of  the  brain, 
was  extensively  discolored,  being  turned  to  a  dirty  gray.  The  pia  mater,  especially  on 
the  left  side,  was  likewise  strongly  injected  with  blood.  The  left  anterior  lobe  of  the 
cei-ebrum  contained  in  its  interior  a  great  collection  of  pus,  communicating  with  the 
lateral  ventricle,  which  was  partially  filled  with  matter.  The  thalamus  of  the  left  side 
presented  a  grayish-brown  color,  and  soft  pappy  consistence ;  and  of  the  same  appear- 
ance was  the  inferior  surface  of  the  left  anterior  lobe.  The  substance  of  the  cerebellum 
was  softer  than  natural.  The  pons  Varolii  was  entirely  covered  with  matter,  and  its 
substance  soft.  The  fourth  ventricle  was  full  of  matter;  the  walls  of  the  aqueduct  of 
Sylvius  were  destroyed  by  suppuration;  the  corpora  striata  of  a  bluish-gray  color.  At 
the  basis  of  the  brain,  there  were  about  two  drachms  of  bloody  serum. 

The  sclerotica,  choroid,  lens,  and  vitreous  body  were  healthy.  Even  the  optic  nerve 
showed  no  remarkable  disease.  Of  the  muscles  of  the  eye,  only  the  rectus  superior  was 
involved  in  the  process  of  suppuration.  The  roof  of  the  orbit,  to  the  extent  of  an  inch  in 
diameter,  was  of  a  bluish-gray  color,  and  so  friable  that  the  least  pressure  broke  through 
it,  and  indeed  in  the  middle  of  this  space  the  bone  was  already  penetrated,  so  that  the 
cerebral  abscess  communicated  there  with  the  abscess  in  the  orbit.  The  floor  of  the 
orbit  was  also  of  a  bluish-gray  color,  and  drilled  through,  so  that  the  probe  passed  into 
the  antrum  and  to  the  back  part  of  the  soft  palate.  The  anti-um  was  full  of  matter, 
which  made  its  way  through  the  body  of  the  superior  maxillary  bone.'' 


'  Guthrie  on  the  Operative  Surgery  of  the  '  Dalrymple's  Pathology  of  the  Human  Eye, 

Eye.  p.  155;  London,  1823.  Explanation  of  Plate  xii.  ;  London,  1849. 

-  Lectures  in  the  Lancet;  Vol.  ix.  p.  500;  ^  Burserius, Institutiones  Medicina3 Practicae; 

London,  ]826.  Vol.  iii.  p.  9  :  Lipsia;,  1798. 

^  Observations  on  the  Treatment  of  the  Epi-  ''  Fischer,  Klinischer  Unterricht  in  der  Au- 

phora,  <te.,  p.  295  :  London,  1818.  genheilkunde,  p.  9;  Prag.  1832.     See  case  of 

*  Bulletin  de  I'Academie  Royale  de  M6decine  orbital  abscess,  with  caries  of  malar  bone  and 

de  Belgique;  Tome  ix.  No.  9.  protrusion  of  eyeball,  terminating  fatally,  by 


INFLAMMATION   OF   THE   OCULAR   CAPSULE.  319 

Walton.  Medical  Times,  November  14,  1S46,  p.  orbit,  communicating   with    frontal    sinus,    by 

127.      Case  of  abscess  in  orbit  and  brain,  by  AVarren,    American    Journal   of    the    Medical 

Walton,  Medical  Times  and  Gazette,  February  Sciences,  July,  1850,  p.  34. 
26,  1S53,  p.  217.     Case  of  encysted  abscess  in 


SECTION  IV. — INFLAMMATION  OF  THE  OCULAR  CAPSULE. 

For  our  knowledge  of  this  disease,  we  are  indebted  to  the  observations  of 
Dr.  O'Ferrall.*  He  considers  it,  as,  in  general,  a  rheumatic  affection.  The 
subjects  of  it  are  certainly  often  rheumatic,  and  are  sometimes  suffering  from 
pains  in  the  limbs,  when  their  eye  becomes  affected.  The  disease  may  have 
a  traumatic  origin. 

Symptoms. — The  symptoms  bear  a  general  resemblance  to  those  of  the 
disease  last  described.  The  patient  is  seized  with  pain  in  the  eye,  forehead, 
and  temple,  which  rapidly  increases  in  violence,  and  in  the  course  of  two  or 
three  days  becomes  insupportable.  It  is  liable  to  severe  exacerbations,  and 
is  compared  by  the  patient,  to  the  feeling  as  if  the  eye  was  being  dragged  out 
of  the  socket.  In  this  state  he  cannot  bear  the  finger  of  another  to  touch 
the  eye,  although  he  seems  to  derive  some  relief  from  keeping  the  palm  of  his 
own  hand  pressed  moderately  against  it.  The  pain  may  prevent  sleep  for 
several  nights  in  succession. 

The  eyeball  is  protruded  from  the  orbit,  sometimes  as  much  as  three 
quarters  of  an  inch,  so  that  it  is  uncovered.  The  power  of  moving  it  is  lost. 
The  conjunctiva  of  the  eyeball  is  protruded  all  round  the  cornea,  in  the  form 
of  chemosis,  but  is  not  red  or  vascular.  It  is  of  a  pale  amber  hue,  and  is 
manifestly  distended  by  serous  infiltration.  The  eyelids  become  much  swollen, 
they  are  cederaatous,  and  of  a  dusky  red  color,  from  the  distended  veins  with 
which  they  are  covered.  The  swelling  and  discoloration  of  the  upper  eyelid 
are  limited  above  by  a  well-defined  line,  with  about  half  an  inch  of  pale  skin 
between  it  and  the  margin  of  the  orbit.  This  is  a  particular  upon  which  Dr. 
O'Ferrall  insists  strongly,  as  marking  the  confinement  of  the  disease  within 
the  ocular  capsule,  leaving  the  extra-capsular  tissues  unaffected.  The  eyelids 
cannot  be  closed,  so  that  the  protruded  eyeball  is  uncovered.  In  the  midst 
of  tlie  swollen  conjunctiva  lies  the  cornea,  perfectly  transparent,  and  showing 
the  iris  in  a  state  of  health. 

The  patient  complains  of  frequent  flashes  of  light  in  the  eye,  but  vision  is 
not,  in  general,  impaired.  In  some  cases,  however,  the  pupil  is  much  dilated, 
and  vision  is  indistinct. 

The  eye  may  recover  from  the  state  now  described,  either  completely  or 
incompletely,  without  the  formation  or  evacuation  of  purulent  matter.  When 
the  recovery  is  incomplete,  the  eyeball  in  some  cases  remains  motionless, 
adhesioi^  having  taken  place,  between  the  sclerotica  and  the  ocular  capsule, 
while  the  thecse  of  the  muscles,  and  the  orifices  in  the  capsule  through  which 
they  pass,  have  become  consolidated  in  consequence  of  the  inflammation.  If 
purulent  matter  accumulates  to  a  certain  extent  within  the  capsule,  the  fold 
which  naturally  exists  between  the  eyeball  and  the  eyelids  is  obliterated,  the 
conjunctiva  then  appears  rounded  into  the  form  of  a  tumor,  and  if  not  opened 
artificially  the  abscess  may  burst  spontaneously. 

The  progress  of  this  disease  is  attended  by  considerable  fever,  the  pulse  is 
full  and  hard,  the  tongue  loaded,  and  the  renal  secretion  scanty. 

Diagnosis. — From  periostitis  of  the  orbit  this  disease  is  to  be  distinguished 
by  the  fact,  that  here  pressure  may  be  made  perpendicularly  against  the 
bones  of  the  orbit,  without  exciting  pain,  which  is  the  reverse  of  what  is 
observed  in  periostitis.    (See  p.  74)    From  phlegmonous  inflammation  of  the 


320  PROTRUSION   OF   THE   EYE   PROM   THE   ORBIT. 

orbital  areolar  tissue,  this  disease  maybe  distinguished  by  the  swelling  which 
attends  it,  showing  itself  in  the  tarsal,  not  in  the  orbital,  part  of  the  eyelids. 
These  two  diseases  may,  however,  be  conjoined.  Inflammation  of  the  ocular 
capsule  attends,  also,  some  of  the  varieties  of  ophthalmitis. 

Treatment. — 1.  Great  relief  is  obtained  from  venesection,  arteriotomy,  or 
numerous  leeches  to  the  temple  and  round  the  eye. 

2.  Antimonials  and  purgatives  are  useful. 

3.  Calomel  with  opium,  administered  till  constitutional  effects  are  produced, 
generally  overcomes  the  disease  by  the  third  or  fourth  day. 

4.  Iodide  of  potassium,  in  large  doses,  is  highly  recommended  by  Dr. 
O'Ferrall.  He  narrates  a  case  in  which  ten  grains  every  third  hour  of  the 
first  day,  and  fifteen  grains  every  third  hour  of  the  second  day,  appeared  to 
check  the  disease.  Diminished  doses  during  the  next  three  days  totally 
subdued  it. 

5.  Should  the  disease  proceed  to  suppuration,  the  ocular  capsule  will  remain 
to  be  opened  through  the  conjunctiva,  at  the  point  where  fluctuation  is  felt.^ 


'  Dublin  Journal  of  Medical  Science;  Vol.  xix.  p.  343;  Dublin,  1841. 


SECTION  V. — EXOPHTHAXMOS,   OR  PROTRUSION   OF   THE   EYE   FROM   THE   ORBIT. 

Fig.  Walton,  Fig.  105. 

Exophthalmos,  or  protrusion  of  the  eye  from  the  orbit,  is  a  symptom 
rather  than  a  disease  ;  but  as  it  is  often  the  only  symptom,  arising  from  some 
unknown  cause,  it  is  not  unfrequently  spoken  of  as  if  it  were  an  independent 
aff"ection.  If  the  eyeball  inflames  violently  in  the  protruded  state,  the  term 
exophtlialmia  is  substituted  for  exophthalmos. 

The  following  are  some  of  the  causes  of  exophthalmos:  1.  Periostosis 
and  exostosis  of  the  orbit.  2.  Fungus  of  the  dura  mater,  making  way  into 
the  orbit.  3.  Diseases  of  the  nasal  sinuses,  making  way  into  the  orbit. 
4.  Diseases  of  the  lachrymal  gland.  5.  Inflammation  of  the  orbital  areolar 
tissue,  or  of  the  ocular  capsule;  and  effusions  into  these  structures.  6.  Phleg- 
monous and  phlebitic  ophthalmitis.  7.  Orbital  tumors  and  aneurisms. 
8.  Fungus  haematodes  of  the  optic  nerve,  or  within  the  optic  sheath.  As  a 
probable  cause,  in  certain  cases,  may  be  added,  9.  A  varicose  state  of  the 
ophthalmic  veins. 

§  1.   Simple  ^Exophthalmos. 

Simple  exophthalmos,  with  the  movements  of  the  eyeball  unimpeded  and 
vision  good,  and  without  any  tangible  tumor,  growth,  or  fulness,  is  a  c^e 
which  occurs  not  unfrequently,  continues  perhaps  for  years  in  the  same  state, 
and  upon  which  no  distinct  diagnosis  can  be  given.  There  seems  reason  to 
believe  that  in  such  cases  the  cause  of  protrusion  is  without  the  ocular  cap- 
sule, else  the  eyeball  w^ould  be  impeded  in  its  movements,  if  not  absolutely 
fixed,  and  the  disease  is  not  within  the  optic  nerve,  else  vision  would  be 
abolished  ;  but  where  the  pressure  exists  which  displaces  the  eye,  whether 
above  or  below,  on  the  nasal  or  temporal  side  of  the  orbit,  or  behind  the 
eyeball,  or  out  of  the  orbit,  as  in  the  cranium  or  in  one  of  the  nasal  sinuses ; 
and  what  it  is,  whether  a  varicose  state  of  the  ophthalmic  veins,  or  an  effu- 
sion or  abscess  in  the  cellulo-adipose  tissue,  an  enlargement  of  the  lachrymal 
gland,  or  an  encysted  or  solid  tumor,  no  one  can  tell.  The  symptoms  are 
occasionally  somewhat  more  complicated ;  pain  is  sometimes  experienced ; 
in  other  cases  amaurosis  ;  or  both  of  these  together.     In  all  such  cases,  the 


PROTRUSION   OF   THE   EYE   FROM   THE   ORBIT.  321 

treatment  must,  till  a  cure  is  accomplished,  or  till  the  cause  becomes  tangi- 
ble by  protruding  between  the  eyeball  and  the  edge  of  the  orbit,  be  merely 
experimental. 

Cases  of  this  disease  occur  in  males  as  well  as  females.  The  subjects  of  it 
are  rai'ely  robust.  In  general,  one  eye  only  is  affected.  As  exciting  causes 
may  be  mentioned  fatigue,  anxiety,  and  exposure  to  cold.  I  was  consulted 
for  a  girl  of  eight  years  of  age,  with  exophthalmos  of  the  right  eye  produced 
by  chin-cough.  The  eye  was  movable,  and  vision  good.  Her  brother  had 
been  in  the  same  state,  but  in  him  the  eye  retreated  under  cold  applications. 
Another  instance  of  exophthalmos  which  I  saw,  was  first  observed  on  the 
day  following  a  violent  hysteric  fit.  In  this  case,  leeches  and  iodine  seemed 
to  produce  little  benefit. 

It  is  plain,  that  in  all  cases  of  exophthalmos,  the  recti  muscles  must  suffer 
a  degree  of  elongation.  That  a  want  of  their  natural  tonicity,  by  means  of 
which  the  eye  ought  to  be  retained  in  its  situation,  is  in  some  measure  the 
cause  of  the  displacement,  as  appears  to  have  been  supposed  by  Mr.  Dalrym- 
ple,^  is  not  improbable. 

There  is  a  peculiar  variety  of  exophthalmos,  in  which  the  eye  protrudes 
only  when  brought  into  a  depending  position,  receding  as  soon  as  the  head 
is  raised.  A  peculiar  protrusion  of  the  eye  is  mentioned,  as  a  result  of  palsy 
of  the  recti,  and  has  been  called  ophthalmoptosis.  Whether  the  eye  recedes 
into  the  orbit  in  this  affection,  I  am  not  aware.  In  the  following  case,  the 
only  one  of  the  kind  which  I  have  seen,  there  appeared  to  be  no  paralytic 
affection. 

Case  196. — The  patient  was  a  cooper  by  trade,  and  was  admitted  at  the  Glasgow  Eye 
Infirinarj',  for  catarrho-rheumatic  ophthalmia  aifecting  chieOy  the  right  eye.  After  he 
had  attended  for  a  few  days,  it  was  discovered  that  if  he  stooped  forwards,  although  only 
for  a  few  minutes,  he  felt  as  if  something  was  filling  or  pressing  above  his  right  eye, 
which  immediately  began  to  protrude.  On  raising  his  head,  the  protrusion  was  very 
striking.  In  this  state  he  saw  indistinctly  with  the  eye.  It  soon  began  to  retire,  and  in 
a  few  minutes  was  in  its  natural  place.  He  had  the  complete  power  of  moving  the  eye, 
when  in  its  natural  situation,  and  moved  it  considerably  even  while  it  was  displaced. 
The  iris  moved  naturally.  He  complained  of  considerable  pain  in  the  orbit,  which  was 
relieved  by  venesection,  and  the  use  of  mercurial  purges.  He  stated  that  the  protrusion 
of  the  eye  commenced  about  five  years  before  his  application  at  the  Eye  Infirmary,  after 
carrying  a  heavy  load  upon  his  back.  It  was  difficult  to  assign  any  satisfactory  explana- 
tion of  the  case.  The  most  likely  conjecture  seemed  to  be,  that  the  protrusion  depended 
on  a  varicose  state  of  the  ophthalmic  veins,  the  blood  flowing  back  through  tliese  vessels 
into  the  sinuses  of  the  dura  mater,  ivhen  the  head  was  elevated  or  thrown  back,  again  to 
gravitate  into  them,  in  their  relaxed  state,  when  the  head  was  bent  forward.  There  must 
also  have  been  a  defective  tonicity  of  the  muscles. 

In  simple  exophthalmos,  if  the  patient  is  at  all  able  to  bear  depletion,  and 
especially  if  there  is  pain  in  or  round  the  orbit,  leeches  should  be  applied 
abundantly  to  the  temple  and  side  of  the  nose ;  mercury  should  be  adminis- 
tered till  the  mouth  is  affected,  followed  by  iodide  of  potassium  ;  and  counter- 
irritation  to  the  temple  and  behind  the  ear  should  be  employed.  By  this 
plan  of  treatment,  I  have  repeatedly  seen  the  disease,  when  recent,  completely 
removed.^ 

By  several  authors  instances  are  recorded  of  exophthalmos,  in  which  neither 
sanguineous  effusion,  inflammation  of  the  orbital  areolar  tissue,  nor  any  cir- 
cumscribed orbital  tumor,  appears  to  have  existed.  In  some  of  the  cases,  the 
exophthalmos  yielded  to  the  use  of  remedies,  and  although  it  is  impossible  to 
determine  the  exact  nature  of  the  cause  to  which  the  protrusion  was  owing, 
the  facts  are  too  valuable  to  be,  on  this  account,  passed  over  without  notice. 
Saint- Yves  entitles  the  chapter  in  which  he  narrates  the  three  cases  which  I 
am  about  to  quote,  Des  Amas  d^ Humeurs  qui  se  font  derriere  le  Globe  deV  (Eil. 
Mr.  Ware''  speaks  of  similar  instances,  as  occasioned  by  a  morbid  accumula- 
21 


322  PROTRUSION   OF   THE   EYE   FROM   THE   ORBIT. 

tion  of  tlie  substance  on  which  the  eye  rests  in  the  orbit,  and  tells  us  that  the 
repeated  application  of  leeches  on  the  temple  and  forehead  has  been  of  great 
use  in  subduing  the  disease.  In  one  case  \Yhich  came  under  his  care,  the 
projection  was  speedily  diminished  by  opening  the  temporal  artery,  and  after 
the  bleeding  ceased,  converting  the  orifice  into  an  issue.  In  another  case,  a 
perfect  cure  was  accomplished  by  the  application  of  a  large  caustic  behind 
the  ear. 

Case  197. — In  the  first  case  related  by  Saint-Yves,  he  supposed  the  fatty  cellular  sub- 
stance behind  the  globe  of  the  eye,  as  well  as  the  lachrymal  gland,  to  have  been  tumefied 
by  the  efi"usion  of  a  viscid  liquid.  The  eyeball  Avas  protruded  at  least  three  lines.  Several 
surgeons  who  were  consulted  wished  to  extirpate  the  lachrymal  gland,  in  the  hope  that 
the  suppuration  of  the  wound  would  lead  to  the  replacement  of  the  eye,  and  dissipate  the 
swelling  within  the  orbit.  Saint- Yves  objected  to  this  proposal,  being  afraid  lest  the  dis- 
ease, which  appeared  to  him  of  a  scrofulous  nature,  might  degenerate  into  cancer.  He 
cured  it  perfectly  by  a  three  months'  course  of  tethiops  mineral. 

Case  198. — The  subject  of  Saint-Yves'  second  case  was  a  young  man,  who  came  to  Paris, 
with  the  globe  of  the  ej'c  inflamed,  and  extremely  protruded.  The  eyelids,  pressed  by  the 
globe  against  the  edge  of  the  orbit,  were  swollen,  and  the  upper  was  even  beginning  to  be 
livid,  as  if  ready  to  fall  into  a  state  of  gangrene.  The  patient  attributed  his  complaint  to 
a  coup  de  soleil,  which  had  been  followed  first  of  all  by  pain  deep  in  the  orbit,  and  then  by 
protrusion  of  the  eyeball.  Saint- Yves  concluded  from  the  symptoms,  that  either  there 
was  an  abscess  behind  the  eye,  or  that  the  fatty  cellular  membrane  of  the  orbit  was  tume- 
fied by  infiltration.  Had  he  been  certain  that  it  was  an  abscess,  he  would  have  pushed  a 
lancet  through  the  orbicularis  palpebrarum  to  the  bottom  of  the  orbit,  but  afraid  of  doing 
so  without  reason,  he  resolved  to  try  the  effect  of  a  sorbefacient  treatment.  He  ordered, 
therefore,  8  grains  of  calomel  at  night,  with  a  dose  of  senna,  manna,  and  jalap  next 
morning  ;  and  in  the  meantime  bled  the  patient  from  the  external  jugular  vein.  Finding 
that  the  first  dose  produced  some  good  effect,  he  continued  the  calomel  and  the  purgative 
mixture ;  and  in  a  few  days  had  the  satisfaction  of  finding  the  exophthalmos  completely 
removed. 

Ca.se  199. — Saint-Yves  relates  a  third  case,  in  which  the  symptoms  were  for  a  time 
alleviated  by  the  use  of  remedies  ;  but  at  length  the  pain  growing  insupportable,  and 
totally  preventing  sleep,  the  eye  at  the  same  time  becoming  disorganized,  he  removed  the 
contents  of  the  orbit.  Unfortunately,  he  neglects  to  give  any  account  of  their  appearance 
on  dissection,  although  he  speaks  confidently  of  the  cause  of  the  protrusion,  as  un  amas 
d'hiimeitrs  I'isqueuses.* 

Case  200. — Louis  quotes,  from  the  Medicina  Seplentrionalis  of  Bonetus.  the  case  of  a  girl, 
three  years  of  age,  whose  right  eye  was  almost  entirely  protruded  from  the  orbit.  Bonetus 
was  asked  whether  a  seton  in  the  neck  was  likely  to  be  useful.  He  observed  that  the 
child's  clothes  were  much  shorter  before  than  behind,  and  this  led  him  to  examine  the 
abdomen.  He  found  it  extremely  tumid,  tense,  and  hard.  The  child,  in  fact,  presented 
the  symptoms  of  tabes  infantum.  Bonetus  thought  that  nothing  could  be  done  directly 
for  the  exa,  but  that  the  obstructed  state  of  the  bowels  only  should  be  attended  to.  After 
being  purged,  she  was  put  on  the  use  of  tincture  of  rhubarb  for  a  month.  The  exoph- 
thalmos gradually  decreased  as  the  abdomen  fell ;  and  by  the  time  that  the  digestive  organs 
were  restored  to  health,  the  eyeball  had,  without  any  other  means  of  cure,  recovered  com- 
pletely its  natural  situation.* 

Case  201. — A  man,  aged  40,  experienced  for  four  or  five  days  a  racking  pain  in  the  right 
orbit,  temple,  and  side  of  the  head.  When  he  came  to  the  hospital,  these  symptoms  were 
getting  worse,  attended  with  high  fever,  but  no  derangement  of  the  intellectual  functions. 
Active  antiphlogistic  treatment  was  resorted  to  for  four  days,  without  alleviation  ;  at  the 
end  of  which  time,  and  in  the  course  of  one  night,  the  eyelids  became  enormously  tumid 
and  red,  which  state  extended  for  a  certain  distance  to  the  temple  and  cheek ;  the  eye 
was  extremely  protruded  downwards  and  outwards,  but  vision  not  impaired. 

It  was  thought  the  symptoms  might  be  owing  to  an  abscess  in  the  orbit.  An  incision 
was  accordingly  made  through  the  upper  eyelid,  but  though  first  a  scalpel,  and  then  a 
bistoury,  were  plunged  very  deep,  no  matter  issued.  A  poultice  was  ordered,  and  next 
day,  no  pus  having  appeared,  a  bistoury,  says  Mr.  Hamilton,  was  swept  nearly  right  round 
the  eye,  and  so  deep  as  almost  to  endanger  the  optic  nerve.  This  was  not  more  successful 
than  the  former  Operation  ;  every  symptom  became  aggravated,  and  on  the  fourth  day  the 
patient  became  stupid,  and  soon  expired.  His  intellect  and  vision  continued  unimpaired 
till  within  the  last  few  hours. 

A  post-mortem  examination  showed  the  swelling  of  the  orbit  to  depend  on  the  effusion 
of  serum,  no  matter  being  discovered ;  but  a  circumscribed  abscess  existed  in  the  right 
anterior  lobe  of  the  brain,  the  rest  of  the  brain  being  healthy. « 


PROTRUSION   OF  THE  EYE  FROM  THE   ORBIT.  323 

§  2.  Ancemic  Exophthalmos. 

In  this  Variety,  both  eyes  are  almost  always  affected.  They  look  as  if  they 
were  enlarged,  but  are  not  so  in  reality.  Women  are  more  frequently  the 
subjects  of  this  disease  than  men. 

Symptoms. — 1.  The  eyeballs  are  so  much  protruded,  that  the  eyelids  stand 
wide  open,  and  allow  a  considerable  portion  of  the  sclerotica  above  the  cornea 
to  be  seen.  This  gives  the  patient  a  staring,  wild  expression.  The  eyeballs 
feel  often  abnormally  firm  to  the  touch  of  the  observer.  There  is  no  visible 
disease  in  their  interior.  Their  motions  are  in  general  tolerably  free,  although 
the  patient  occasionally  complains  of  a  feeling  of  stiffness,  distension  and 
fulness  in  the  eyes,  and  of  a  difficulty  in  turning  them  completely  to  one  or 
other  side.  The  eyes  are  not  painful,  not  even  on  being  pressed.  In  general, 
any  redness  which  they  present,  consists  only  in  a  few  dilated  vessels  strewed 
over  their  surface.  The  conjunctiva  is  frequently  oedematous,  especially  to- 
wards the  periphery  of  the  eyeball.  The  eyelids  are  puffy,  and  the  lower  one 
is  sometimes  dark  and  discolored.  The  protrusion  of  the  eyes  is  sometimes 
so  great,  that  the  patient  cannot  close  them  completely,  or  even  at  all, 
without  first  pressing  them  back  with  the  palm  of  the  hand.  Yision  is  not 
materially  affected,  although  some  patients  complain  of  their  sight  failing 
them. 

2.  Anaemic  exophthalmos  is  generally  attended  by  enlargement  of  the  thy- 
roid gland,  and  these  two  symptoms  are  apt  to  make  their  appearance  to- 
gether. The  swelling  of  the  gland  is  generally  soft  and  uniform,  being  of  the 
nature  of  simple  hypertrophy,  but  sometimes  it  is  the  seat  of  various  adventi- 
tious structures.  The  exophthalmos  may  exist  without  the  bronchocele,  and 
vice  versa. 

3.  The  patient  presents  more  or  less  of  the  pale,  bloodless  complexion, 
characteristic  of  anaemia. 

4.  The  heart  is  affected  with  palpitation,  the  pulse  is  quick,  feeble,  and 
jerking,  and  the  patient  complains  of  dyspnoea,  faiutness,  pain  and  throbbing 
in  the  head,  vertigo,  and  tinnitus  aurium.  All  these  symptoms  are  increased 
on  exertion.  The  veins  of  the  neck  are  sometimes  remarkably  distended. 
The  heart  and  large  arteries  give  a  bellows-murmur,  especially  when  the  patient 
is  under  palpitation  from  excitement.  In  some  cases,  the  heart  is  dilated ;  but, 
in  general,  the  cardiac  symptoms  are  those  indicative  merely  of  exsanguinity. 

5.  The  patient  complains  of  dyspepsia,  debility,  and  nervousness. 

Exciting  causes. — 1.  Frequent  or  continued  loss  of  blood,  as  from  haemor- 
rhoids, menorrhagia,  or  epistaxis.  2.  Profuse  leucorrhcea,  chronic  diarrhoea, 
and  other  wasting  discharges.  3.  Frequent  child-bearing.  4.  Over-excite- 
ment, fatigue,  apprehension,  and  distress  of  mind. 

Dissection. — The  only  j^ost  mortem  examination  is  one  by  Sir  Henry  Marsh, 
in  which  the  heart,  especially  the  auricles,  was  found  extremely  dilated,  along 
with  the  veins  of  the  neck.  The  right  internal  jugular  vein  was  so  much 
dilated,  that,  when  emptied  by  puncture,  it  measured  an  inch  and  a  half 
across.^  It  can  scarcely  admit  of  doubt,  that,  when  anaemic  exophthalmos 
exists,  there  is  an  approach  to  the  state  so  accurately  described  by  Dr.  J.  S. 
Combe,*  in  a  case  of  anaemia,  in  which  the  eyes  were  not  affected.  A  defi- 
ciency of  red  blood,  then,  may  be  expected  on  dissection. 

Proximate  cause. — Impoverishment  of  the  blood,  so  that  it  is  deficient  in 
fibrin  and  in  red  corpuscles,  as  well  as  less  in  quantity  than  natural,  may  be 
regarded  as  the  general  proximate  cause.  The  want  of  a  healthy  and  suffi- 
cient circulation  through  the  brain  explains  many  of  the  symptoms.  The 
immediate  cause  of  the  protrusion  of  the  eye  is  unknown.  A  varicose  state 
of  the  ophthalmic  veins  may  possibly  be  the  cause.    This  conjecture  is  favored 


324  PROTRUSION   OF  THE  EYE   FROM   THE   ORBIT, 

by  the  state  of  the  veins  of  the  neck  in  the  case  dissected  by  Sir  H.  Marsh, 
and  by  the  fact  mentioned  by  Mr.  Walton,  of  a  patient  who  could  close  her 
eyes,  only  after  she  had  pressed  upon  them  for  some  minutes  with  the  palm 
of  her  hand.  A  serous  effusion  into  the  areolar  tissue  of  the  orbit,  which  is 
another  conjectural  cause  of  anosmic  exophthalmos,  could  scarcely  yield  to 
such  a  degree  of  pressure,  but  a  varicose  dilatation  of  the  veins  behind  the 
eyeball  might  readily  do  so.  The  motion  of  the  eyeballs  being  in  general  so 
little  affected,  it  does  not  appear  likely,  that  the  cause  is  an  effusion  into  the 
ocular  capsule.  Such  an  effusion,  however,  would  explain  the  apparent 
enlargement  of  the  eyes. 

Anaemic  exophthalmos  commonly  assumes  a  chronic  form,  but  in  some  cases 
it  occurs  so  suddenly,  and  runs  so  rapid  a  course,  that  it  may  be  regarded  as 
an  acute  disease. 

Case  202. — On  the  6th  April,  1850,  I  was  called  to  visit  in  consultation  a  lad  of  16, 
under  the  care  of  Dr.  James  Miller.  He  had  come  from  London  to  Glasgow  by  railway 
about  a  fortnight  before,  and  had  probably  been  exposed  to  cold  in  the  journey  immedi- 
ately after  which  he  was  seized  with  exophthalmos  of  both  eyes,  the  conjunctiva3  at  the 
same  time  becoming  oedematous  and  protruding  in  folds.  Under  the  apprehension  of  the 
case  being  one  of  phlegmonous  ophthalmitis,  Di\  M.  had  bled  him  copiously,  applied 
leeches  to  the  temples,  administered  antimony,  salivated  the  patient  gently,  applied  a 
blister  to  the  back  of  the  neck,  and  snipped  away  some  folds  of  the  conjunctiva,  so  as  to 
give  exit  to  the  serous  effusion. 

When  I  visited  the  patient,  he  was  confined  to  bed :  the  eyeballs  were  much  protruded ; 
the  pupils  large,  but  it  seemed  probable  that  they  were  naturally  so;  the  eyeballs  could 
easily  be  shoved  to  one  or  other  side  of  the  orbit,  and  were  not  fixed  as  in  phlegmonous 
ophthalmitis  ;  the  vision  was  good.  The  pulse  was  82,  full,  and  jerking.  On  laying  my 
hand  over  the  heart,  I  found  it  affected  with  palpitation.  On  opening  the  shirt,  the 
thyroid  gland  was  seen  to  be  enlarged,  and  was  painful  to  the  touch.  The  neck  was  much 
swollen,  all  round  to  the  nape.  The  swelling  seemed  of  the  nature  of  oedema.  The 
patient  was  by  times  slightly  delirious. 

This  young  lad  had  never  till  now  complained  of  palpitation.  He  had  been  observed 
to  be  pale  for  some  time.  He  had  been  much  given  to  violent  racing,  and  games  of 
strength. 

I  advised  rest,  without  any  further  depletion  or  mercury.  I  did  not  see  the  patient 
again.     He  died  in  a  few  days.     No  inspection  was  obtained. 

That  there  sometimes  exists  a  hereditary  predisposition  to  the  state  of  the 
blood  which  leads  to  anaemic  exophthalmos,  may  be  concluded  from  the  disease 
occurring  in  several  individuals  of  the  same  family. 

Case  203. — A  lady,  whom  I  saw  with  Ur.  Pagan,  had  exophthalmos  of  the  right  eye, 
accompanying  enlargement  of  the  thyroid  gland  and  of  the  uterus.  So  far  as  the  last- 
mentioned  affection  and  the  general  health  were  concerned,  much  benefit  had  been  de- 
rived from  chalybeates,  cod-liver  oil,  and  friction  with  iodine. 

This  lady's  sister  I  had  seen  some  years  before,  with  anaemic  exophthalmos  of  both  eyes. 
Naturally  of  a  nervous  and  languid  temperament,  her  health  had  not  been  robust  for 
many  years,  but  it  seemed  to  have  been  more  impaired  during  the  two  years  before  I  saw 
her,  and  since  her  last  confinement.  She  had  suffered  for  some  months  from  amenor- 
rhoea,  and  had  been  considerably  annoyed  by  dyspepsia  and  constipation.  During  the 
summer  before  she  consulted  me,  she  had  exposed  herself  to  much  fatigue,  while  in  the 
countrj-,  soon  after  which  she  observed  that  her  sight  began  to  fail,  and  her  eyes  became 
prominent.  She  also  had  an  evident  bronchocele.  These  symptoms  had  subsided,  to  a 
certain  extent,  after  a  slight  alterative  course,  followed  by  stomachic  and  purgative  medi- 
cines, and  the  internal  use  of  tincture  of  iodine,  while  the  throat  and  temjiles  were 
rubbed  with  an  ointment  containing  iodide  of  potassium.  Headaches,  however,  and  a 
tremulous  sensation  all  over  the  body,  supervening,  the  iodine  was  stopped. 

Treatment. — What  is  indicated  is  evidently  such  treatment  as  is  likely  to 
restore  due  assimilation  and  sanguification.  For  this  purpose,  the  patient 
should  adopt  a  nourishing  diet,  making  use  of  animal  food,  with  ale  or 
porter,  but  generally  without  wine.  All  agitation  and  fatigue  should  be 
avoided.  Passive,  or  gently  active,  exercise  out  of  doors,  and  change  of  air, 
are  to  be  recommended.     The  bowels  should  be  kept  in  a  regular  state  by 


PROTRUSION   OP   THE   ORBITAL   ADIPOSE    SUBSTANCE.  325 

proper  laxatives.  Extract  of  byoscyamus  has  been  found  useful  in  calming 
the  nervous  agitation.  The  eyes  should  be  bathed  frequently  with  cold  water. 
Stomachics,  such  as  calumba  and  cascarilla,  or  the  common  combination  of 
either  of  these  with  bicarbonate  of  soda,  rhubarb,  and  ginger,  are  of  much 
service.  The  principal  medicinal  means  of  cure,  however,  is  the  employ- 
ment of  chalybeates,  such  as  the  precipitated  carbonate,  the  sulphate,  the 
muriate,  the  citrate,  and  other  salts  of  iron.  These  are  to  be  given  in  large 
doses,  along  with  or  after  meals,  and  continued  uninterruptedly  for  months. 

Under  this  plan  of  cure,  the  eyes  have  been  found  to  retreat  into  the  orbits, 
the  lids  to  close  with  freedom,  the  thyroid  gland  to  return  to  its  natural  size, 
the  palpitations  to  cease,  the  strength  to  be  restored,  and  in  fact  a  perfect 
cure  to  be  attained.^ 

The  disease  resists  the  internal  uses  of  iodine  and  its  preparations.  They 
even  seem  to  be  hurtful,  disagreeing  with  the  stomach,  and  causing  such  un- 
pleasant sensations  throughout  the  frame,  as  oblige  them  to  be  discontinued. 
Mercurials  are  still  more  to  be  deprecated  than  the  preparations  of  iodine.'"' 


'  Lancet,  May  26.  1849;  p.  553.  Society  of  Edinburgh;    Vol.  i.  p.  194;  Edin- 

^  See    cases   by   Pilcher,    Lancet,    June    10,  burgh,  1824. 

1848:  p.  640:  Case  by  Browne,  Dublin   Quar-  '  The  use  of  a  chalybeate  water  for  cooking 

terly  .Journal  of  Medical  Science;  Vol.  xi.  p.  and   drinking    prevents    the    development    of 

232;  Dublin,  1851.  goitre.     See    Pascal,  London   and    Edinburgh 

"  Observations  on  the  treatment  of  the  Epi-  Monthly  Journal  of  Medical  Science,  Decem- 

phora,  &c..  p.  295:  London,  1818.  ber.  1842. 

■*  Nouveau  Traite  des  Maladies  des  Teux,  p.  '°  On    Anoemic  Exophthalmos  consult  Mac- 

141;  Paris,  1722.  donnell,  Dublin    Journal  of  Medical  Science; 

'  Memoires   de   I'Academie   Royale   de  Chi-  Vol.  xxvii.  p.  200;  Dublin,  1845:  Hill,  ibid.  p. 

rurgie;  Tome  xiii.  p.  350;  12mo;  Paris,  1774.  399:    Begbie,   Monthly    Journal    of     Medical 

°  Dublin  Journal  of  Medical  Science;  Vol.  Science,     February,     1849;    p.     495:      White 

ix.  p.  262:  Dublin,  1836.  Cooper,  Lancet,  May  26,  1849;  p.  551:    Syme, 

'  Dublin   Journal  of  Medical  Science;  Vol.  Monthly  Journal   of  Medical  Science,  Vol.  x. 

XX.  p.  472;  Dublin,  1842.  p.  488;  Edinburgh,  1850. 

"  Transactions    of    the    Medico-Chirurgical 


SECTION  \T;. — PROTRUSION  OF  THE  ORBITAL  ADIPOSE  SUBSTANCE. 

We  owe  our  knowledge  of  this  affection  to  Mr.  Bowman,  w^ho  relates  the 
following  case  : — 

Case  204. — A  boy,  aged  16,  applied  at  the  Ophthalmic  Hospital,  Moorfields,  on  account 
of  a  red  and  somewhat  pendulous  swelling  of  both  upper  eyelids,  which  made  his  friends 
and  himself  uneasy  by  its  unsightly  appearance,  though  he  had  experienced  no  pain. 
The  swelling  was  precisely  alike  on  the  two  sides.  It  was  almost  limited  to  the  outer 
half,  or  outer  two-thirds  of  the  lid,  extending  from  the  brow  to  within  a  sixteenth  of  an 
inch  of  the  tarsal  border.  It  was  quite  soft,  as  if  from  oedema  of  the  parts  subjacent  to 
the  skin.  The  feeling  was  that  of  redundant  and  loose  cellular  tissue  beneath  the  orbi- 
cularis, and  not  of  any  tumor.  Eversion  of  the  lid  showed  the  conjunctiva  and  subjacent 
tissue  to  be  perfectly  natural.  Pressure  behind  the  external  angular  process  detected  no 
tumor. 

Various  remedies  having  been  tried  without  effect,  Mr.  Bowman  determined  to  employ 
a  modification  of  the  operation  for  entropium,  and  to  remove,  not  merely  a  horizontal 
ellipse  of  integument  from  the  most  projecting  part  of  the  swelling,  but  also  a  corres- 
ponding portion  of  the  orbicularis,  and  of  the  fascia  below  it,  and  so  endeavor  to  con- 
solidate the  integuments  with  the  parts  beneath,  which  seemed  the  principal  seat  of  the 
disease. 

A  piece  of  the  integument  was  taken  up  with  the  entropium  forceps,  and  removed  with 
scissors  to  the  extent  of  two-thirds  of  the  horizontal  width  of  the  lid,  and  one-third  its 
vertical  depth.  The  orbicularis  thus  exposed  was  healthy,  and  was  removed  to  exactly 
the  same  extent.  A  dense  cellular  fascia  then  bulged  forward  in  the  gap,  which  being 
removed  in  its  turn,  a  mass  of  fat,  resembling  the  natural  fat  of  the  orbit,  and  about  as 
large  as  an  almond,  fell  forward  in  the  opening,  and  was  immediately  removed.     It  was 


326  TUMORS   IN   THE   ORBIT. 

not  tightly  embraced  by  any  capsule  of  the  areolar  tissue  which  surrounded  it,  but  was 
divided  into  pellets,  or  small  lobes,  which  moved  freely  over  one  another.  It  therefore 
had  not  the  appearance  of  a  fatty  tumor.  After  its  abstraction,  there  was  no  other  tissue 
projecting;  the  wound  was  therefore  closed  by  sutures  ;  and  in  four  days  Mr.  B.  had  the 
satisfaction  of  seeing  it  heal,  with  an  almost  complete  removal  of  the  deformity. 

The  same  operation  was  performed  first  on  the  left,  and  then  on  the  right  side,  and  with 
the  same  result.' 


'  London  Journal  of  Medicine,  November,  18i9;  p.  989. 

CHAPTER   VIII. 

INTRAORBITAL  TUMORS. 


SECTION  I. — SOLID  AND  ENCYSTED  TUMORS  IN  THE  ORBIT. 

Tumors  in  the  orbit  are  malignant  or  non-malignant,  and  the  latter  solid 
or  encysted.  On  the  determination  of  the  question,  to  which  of  these  two 
classes,  and  to  which  of  these  two  sub-classes,  a  tumor  belongs,  hinges  greatly 
the  prognosis  and  the  treatment. 

Malignant  tumors  grow  more  rapidly,  are  attended  with  more  pain,  are 
soft  in  some  parts  and  firm  in  others,  and  are  more  likely  to  involve  the  skin 
and  the  neighboring  textures,  than  the  non-malignant.  When  it  is  difficult 
to  form  a  diagnosis,  in  cases  where,  besides  displacement  of  the  eyeball,  there 
is  a  tumor  evident  to  the  touch,  it  is  recommended  to  make  an  exploratory 
puncture,  or  even  to  divide  the  integuments  covering  the  tumor,  and  endeavor 
to  ascertain  its  nature.  A  careful  inquiry  into  the  progress  of  the  case, 
with  the  exercise  of  the  necessary  degree  of  tact  in  examining,  ought,  in 
general,  to  preclude  recourse  to  a  practice  so  apt  to  prove  hurtful.  It  can- 
not be  denied,  however,  that  in  many  non-malignant  orbital  tumors,  the 
cachectic  condition  of  the  patient,  and  the  appearance  of  the  local  disease 
being  very  indicative  of  malignancy,  were  exploration  omitted,  the  patient 
might  be  left  unrelieved,  from  a  mistaken  notion  of  the  incurability  of  the 
case. 

Symptoms. — Whatever  be  the  nature  of  a  morbid  growth  within  the  orbit, 
it  necessarily  produces,  after  it  reaches  a  certain  size,  displacement,  protrusion, 
and  immobility  of  the  eye,  pressure  on  the  eyeball  and  its  nerves,  so  as  to 
cause  pain,  and  traction  of  the  nerve,  which,  added  to  the  pressure,  gives  rise 
to  amaurosis.  This  last  is  often  the  earliest  symptom  which  attracts  attention. 
A  great  degree  of  deformity  is  produced  by  the  unnatural  position  of  the  eye- 
ball in  such  cases,  even  when  it  is  not  at  all  affected  in  structure.  There  is 
intolerance  of  light,  the  tears  run  over  the  cheek,  the  pain  extends  from  the 
orbit  to  the  temple  and  rest  of  the  head,  and  at  length  the  eye  inflames,  bursts, 
and  is  disorganized. 

The  solid  non-malignant  tumors  of  the  orbit,  formerly  styled  sarcomatous, 
but  now  more  frequently  known  as  fibrous,  are  more  or  less  of  a  firm  con- 
sistence, and  often  very  hard.  They  are  less  frequent,  and  grow  more  slowly 
than  the  encysted  tumors,  but  seldom  reach  so  great  a  size.  They  are  circum- 
scribed, lobulated,  movable,  and  free  from  tenderness.  The  bounds  of  the 
tumor  can  be  distinctly  made  out,  and  the  skin  can  be  moved  over  it,  which 
circumstances  assist  in  distinguishing  it  from  any  malignant  growth.  On 
extirpation,  it  is  found  of  a  yellowish-white  color,  surrounded  by  a  covering 


TUMORS   IN   THE   ORBIT.  32t 

of  condensed  areolar  tissue,  with  a  few  bloodvessels  entering  it.  Its  struc- 
ture, microscopically  examined,  appears  identical  with  natural  fibrous  tissue, 
sometimes  mixed  with  spiculaj  of  bone.  The  contents  of  the  encysted  tumors 
are  very  various ;  sometimes  limpid  {hygroma)  like  white  of  Qg^,  in  other 
cases  a  thick  bloody  fluid  {hcematocysi),  in  others  a  substance  like  suet  {stea- 
toina),  pap  {atheroma),  or  honey  {meliceris).^  Under  the  microscope,  these 
contents  show  chiefly  epithelial  celjs,  with  oil-globules,  and  crystals  of  stearine. 
Sometimes  the  cyst  is  thin  and  serous,  in  other  cases  thick  and  fibrous.  Oc- 
casionally hairs,  and  sometimes  teeth,  are  found  growing  from  the  internal 
surface  of  the  cyst. 

No  part  of  the  orbit  is  exempt  from  becoming  the  seat  of  tumors.  They 
grow  near  the  front  of  the  cavity,  so  as  from  the  first  to  advance  before  the 
eyeball.  Sometimes  they  are  within  the  ocular  capsule.  Their  most  fre- 
quent situation  is  below  and  somewhat  behind  the  eye.  They  grow  above 
and  behind  it.  Less  frequently  are  they  found  by  the  nasal  or  temporal  side 
of  the  orbit.  In  some  cases,  they  lie  deep  in  the  orbit,  or  even  surround  the 
optic  nerve. 

Their  connections  are  very  different ;  sometimes  loose,  so  that  on  exposing 
the  tumor,  it  is  easily  separated  and  extracted,  while  in  other  cases  it  adheres 
firmly  to  the  muscles  and  nerves,  insinuates  itself  between  these  parts,  involves 
the  lachrymal  gland,  or  adheres  firmly  to  the  eyeball,  the  optic  nerve,  or  the 
walls  of  the  orbit. 

They  have  all  a  tendency  to  advance  out  of  the  cavity  of  the  orbit,  pushing 
on  between  its  walls  and  the  eyeball,  pressing  the  eyeball  forwards  and  to 
one  side,  projecting  the  eyelids  or  everting  them,  and  elevating  the  conjunc- 
tiva. When  considerably  advanced,  we  are  able  to  detect  a  degree  of  fluc- 
tuation in  many  of  the  encysted  tumors,  while  the  fibrous  feel  sometimes 
spongy,  often  solid  and  resisting.  The  encysted  are  often  so  soft,  that  on 
pressure  they  seem  to  retire  within  the  orbit,  appearing  again  as  soon  as  the 
pressure  is  removed.  They  are  always  more  elastic  to  the  touch  than  the 
fibrous  tumors. 

Encysted  tumors  in  the  orbit  are  sometimes  combined  with,  or  degenerate 
into,  malignant  disease.  A  remarkable  instance  of  this  I  met  with  in  a  pa- 
tient at  the  Glasgow  Eye  Infirmary,  22d  September,  1852.  He  came  from  a 
distance,  with  an  encysted  tumor,  which  had  repeatedly  been  tapped  by  his 
surgeon  at  home,  and  into  the  cavity  of  which  a  tent  had  been  at  one  time 
introduced.  I  proceeded  to  extirpate  it  as  a  common  encysted  tumor,  but, 
on  extracting  the  firm  fibrous  cyst  from  the  bottom  of  the  orbit,  I  found  it 
filled  with  encephaloid  deposit. 

In  some  cases,  a  great  degree  of  oedema  of  the  eyelids  comes  on,  and 
obscures  an  orbital  tumor  previously  distinctly  felt,  and  even  the  opposite 
lids  sometimes  swell  to  a  large  size,  as  well  as  those  covering  the  orbit  which 
contains  the  tumor.  Under  such  circumstances,  we  are  obliged  to  judge  a 
good  deal  from  the  previous  history  of  the  case,  and  the  displacement  of  the 
eyeball. 

It  is  a  fact  worthy  of  remark,  that  the  pressure  of  a  tumor  within  the  orbit 
will  sometimes  dilate  that  cavity,  or  induce  inflammation  and  caries  of  its 
walls,  the  eyeball  continuing  to  resist  the  effects  of  the  pressure.  In  this 
case  matter  is  apt  to  collect,  which,  bursting  through  one  of  the  eyelids, 
allows  the  probe  to  be  passed  into  contact  with  the  diseased  bone,  by  the 
side  of  the  tumor.  A  tumor  in  the  orbit,  if  altogether  left  to  itself,  may 
extend  to  a  very  great  size,  and  at  length  prove  the  occasion  of  the  patient's 
death  by  pressure  on  the  brain. 

In  cases  of  non-malignant  tumors  in  the  orbit,  there  is  generally  no  con- 
stitutional disturbance.     In  cases  of  abscess,  such  disturbance  attends  the 


328  TUMORS   IN   THE   ORBIT. 

comniencement  of  the  disease,  but  subsides  after  matter  is  formed.  In 
malignaut  cases,  there  is  pain  from  the  first,  which  continues  as  the  disease 
advances,  and  is  attended  by  signs  of  cancerous  cachexia. 

Causes. — Blows  on  the  edge  of  the  orbit,  and  exposure  to  cold,  are  the 
causes  most  frequently  referred  to,  in  cases  of  orbital  tumors  on  record. 

Encysted  tumors  of  the  orbit  have  been  described  as  hydatids  by  Schmidt, 
Weldon,  Delpech,  and  others.  Cysts  containing  hydatids  do  occur  occasion- 
ally in  the  orbit,  as  I  shall  have  occasion  to  state  in  the  chapter  on  Entozoa 
in  the  Organ  of  Vision ;  but  there  is  no  good  ground  for  believing  that  the 
tumors  referred  to  by  those  authors,  were  of  that  nature. 

Treatment. — Leeches  round  the  orbit,  counter-irritation,  and  sorbefacient 
remedies,  as  iodine,  both  internally  and  externally,  appear  to  be  of  little  or 
no  service  in  cases  of  orbital  tumors.  We  are  obliged,  therefore,  to  have 
recourse  either  to  the  palliative  cure  of  puncturing  encysted  tumors,  or  to 
partial  or  total  extirpation.  The  last  mentioned  is  the  only  means  which  we 
can  adopt  when  the  tumor  is  solid.  When  an  encysted  tumor  contains  a 
fluid,  puncturing  the  cyst  always  affords  temporary  relief,  and  in  some  in- 
stances has  been  followed  by  a  radical  cure.  To  procure  this  result,  injecting 
them  has  also  been  tried. 

1.  Puncture  of  encysted  tumors. — Encysted  tumors  in  different  parts  of  the 
body,  and  especially  in  superficial  situations,  are  apt  to  burst  in  consequence 
of  blows,  or  at  length  give  way  simply  from  distension,  and  dischai'ge  their 
contents.  The  cyst  remains  for  a  time,  and  operates  like  a  foreign  substance; 
inflammation  comes  on,  ending  in  suppuration,  and  the  cyst,  especially  if  it 
be  of  the  thin  serous  kind,  is  evacuated,  either  entire,  or  broken  down  into 
shreds  ;  after  which  the  cavity,  formerly  occupied  by  the  tumor,  contracts 
and  heals  up.  Upon  this  course,  sometimes  followed  by  nature,  is  founded 
the  practice  of  puncturing  encysted  tumors,  and  evacuating  their  contents. 
It  is  not  a  practice  to  be  much  commended.  It  is  tedious  and  uncertain ;  for 
the  cyst  may  not  come  away  for  weeks  or  months,  and  if  any  portion  of  it  is 
left  behind,  or,  as  is  often  the  case,  if  the  whole  of  it  is  left,  a  new  collection 
of  fluid  is  apt  to  take  place.  It  may  also  happen  in  the  orbit,  as  it  has  often 
happened  in  other  parts  of  the  body,  that  this  practice  of  puncturing  encysted 
tumors  produces  great  pain  and  irritation,  and  gives  rise  to  a  fungous  growth 
from  the  inside  of  the  cyst,  especially  if  its  walls  are  thick  and  fibrous.  The 
difficulty,  however,  on  the  one  hand,  of  completely  extirpating  encysted 
tumors  of  the  orbit,  and  on  the  other,  the  total  subsidence  of  the  swelling, 
and  the  return  of  the  eye  to  its  natural  situation,  after  the  contents  of  the 
cyst  are  evacuated,  have  occasionally  led  surgeons  to  content  themselves  with 
this  palliative  plan  of  treatment.  In  numerous  instances,  the  cure  has  luckily 
proved  radical,  by  a  discharge  of  the  cyst.  This  is  most  apt  to  follow  when 
the  contents  are  like  suet  or  pap,  not  when  the  tumor  is  hygromatous  or 
hfemato-cystic. 

On  puncturing  encysted  tumors  in  the  orbit,  an  oily  matter  is  not  unfre- 
quently  discharged,  very  like  pus ;  and  hence  tumors  of  this  sort  may  some- 
times have  been  mistaken  for  abscesses. 

The  following  is  an  instance  of  the  accidental  bursting  of  an  orbital  en- 
cysted tumor  : — 

Case  205. — A  lively  girl,  about  17  years  of  age,  had  a  small  opening  at  the  temporal 
edge  of  the  left  orbit,  close  to  the  tarsus  of  the  upper  eyelid.  Every  morning,  she  found 
the  neighborhood  of  this  opening  somewhat  swollen,  and  by  pressure  evacuated  through 
it  a  quantity  of  a  whitish,  pretty  consistent,  ropy  substance,  something  like  half-fluid 
tallow.  The  origin  of  her  complaint  was  her  suddenly  leaping  against  a  door,  believing 
it  to  be  open  when  it  was  shut,  and  which  she  struck  violently  with  the  left  side  of  her 
head.  The  part  immediately  became  swollen  and  livid.  Fomentations  and  poultices  were 
employed,  and  the  immediate  consequences  of  the  contusion  were  removed.     After  some 


TUMORS   IN   THE   ORBIT.  329 

time,  a  small  swelling  made  its  appearance  under  the  skin  of  the  part  ■which  had  been 
struck.  This  swelling  increased,  notwithstanding  the  use  of  embrocations  and  the  like, 
and  much  disfigured  the  girl's  countenance.  It  had  acquired  the  size  of  a  walnut,  and  a 
day  was  fixed  for  its  extirpation,  when  she  happened  by  accident  again  to  strike  her 
head  against  the  same  door  so  violently,  that  the  cuticle  was  stript  from  off  the  part,  and 
the  tumor  so  much  bruised  that  it  suppurated.  The  abscess  was  opened,  the  cyst  gave 
■way,  and  a  yellowish-white  substance,  like  honey,  was  discharged,  after  which,  the  wound 
contracted  to  the  small  opening,  which  existed  when  Dr.  Schwai-z,  the  narrator  of  the 
case,  saw  the  patient.  He  did  not  think  it  necessary  to  urge  her  to  have  the  cyst  removed 
by  operation,  as  the  inconvenience  of  emptying  it  from  time  to  time  was  but  trifling.^ 

In  the  two  following  cases,  the  puncturing  of  encysted  tumors  in  the  orbit, 
proved  a  radical  cure. 

Cane  20G. — Cure  by  puncture  and  suppuration.  A  shoemaker,  aged  45  years,  had  the 
left  eye  prominent,  and  almost  entirely  out  of  its  orbit.  This  exophthalmos  had  come  on 
gradually,  attended  with  pain,  but  without  inflammation.  The  eye  was  pushed  out  by  a 
hard  tumor,  which  appeared  to  be  situated  between  the  globe  and  the  inner  wall  of  the 
orbit.  Several  practitioners  of  Paris  were  of  opinion  that  the  tumor  was  cancerous. 
The  protruded  eye  was  not  enlarged,  but  was  deprived  of  sight  from  compression  and 
traction  of  the  optic  nerve.  Piicherand  proposed  to  the  patient  to  extirpate  this  suspected 
cai'cinoma,  although,  from  the  renitency  of  the  tumor,  he  had  his  doubts  concerning  its 
nature.  After  having  disunited  the  eyelids  at  their  outer  angle,  and  divided  the  con- 
junctiva, he  thought  proper,  before  going  on  with  the  operation,  to  assure  himself  of  the 
real  nature  of  the  disease  by  plunging  into  it  the  point  of  his  knife.  This  was  followed 
by  the  exit  of  2  or  3  ounces  of  a  fluid  similar  to  white  of  egg.  Being  now  certain  that 
the  exophthalmos  depended  on  an  encysted  tumor,  and  the  eye  having  already,  in  conse- 
quence of  the  contraction  of  the  cyst,  retired  partly  into  its  natural  place,  Richerand  re- 
nounced the  idea  of  extirpation,  and  contented  himself  with  applying  wet  compresses 
over  the  eye.  Considerable  inflammation  followed,  for  which  he  bled  the  patient.  The 
cyst  suppurated,  and  the  patient  was  cured  after  the  excision  of  some  excrescences  foi'med 
by  the  conjunctiva.' 

Case  207. — Cyst  discharged,  after  being  punctured.  A  woman  was  brought  to  Mr.  Wel- 
don,  with  one  of  her  eyes  considerablj'  protruded.  About  two  years  before,  she  felt  a 
fulness  of  the  eye,  and  a  stiffness  of  the  eyelids,  so  that  they  moved  with  difficulty.  As 
these  symptoms  increased,  she  became  sensible  of  a  feeling  of  pressure  and  uneasiness  in 
the  ball  of  the  eye,  ■which  gradually  became  painful,  especially  on  moving  it.  At  length 
the  eye  became  fixed,  and  the  pain  increased  to  such  a  degree  that  the  patient  was  at 
times  delirious.  When  Mr.  W.  saw  her,  the  eye  was  protruded  forwards,  and  rather 
upwards,  towards  the  inner  angle.  The  eyelids  were  open  and  immovable,  and  there 
"was  a  general  fulness  of  the  surrounding  integuments.  The  sight  had  been  lost  about 
12  months,  and  the  iris  was  motionless.  The  bloodvessels  of  the  eye  were  full  and 
turgid.  The  pain  she  described  as  being  intolerable,  and  almost  ■without  remission,  ex- 
tending at  times  over  the  whole  head,  but,  in  general,  pretty  much  confined  to  the  globe 
of  the  eye,  and  the  situation  of  the  optic  nerve.  It  was  attended  by  a  sense  of  pressure 
and  great  distension.  On  feeling  the  integuments  that  covered  the  orbit  beneath  the  eye, 
the  sensation  to  the  finger  resembled  that  produced  by  feeling  a  loose  fatty  substance, 
but  on  examining  the  part  more  attentively,  a  deep-seated  fluctuation  was  very  evident. 
The  parts  were  free  from  any  tenderness  or  pain  on  pressure.  With  a  cataract-knife, 
Mr.  W.  made  a  puncture  into  the  tumor,  from  the  middle  of  the  lower  edge  of  the  orbit, 
and  pressed  out  a  small  quantity  of  transparent  fluid.  He  then  extended  the  wound  for 
nearly  an  inch  towards  the  outer  canthus,  taking  care  to  keep  the  point  of  the  knife  suffi- 
ciently deep,  and  to  carry  it  forwards  at  the  same  time,  so  as  to  open  the  cyst  very  freely. 
About  two  tablespoonfuls  of  a  clear  transparent  fluid,  slightly  adhesive,  came  away.  This 
was  followed  by  instantaneous  ease,  while  the  eye  sunk  nearly  into  its  natural  place.  The 
lips  of  the  wound  were  kept  asunder,  and  in  five  or  six  days  the  cyst,  which  Mr.  W. 
fancies  to  have  been  a  hydatid,  appeared  in  view,  and  was  withdrawn.  This  coat,  as 
Mr.  W.  terms  it,  was  spherical,  rather  thicker  than  the  coats  of  hydatids  of  a  corre- 
sponding size  usually  are,  and  had  a  smooth  shining  surface.  The  discharge  gradually 
lessened,  and  the  wound  healed  without  further  trouble  in  the  course  of  three  weeks. 
The  pain  and  aff"ection  of  the  head  totally  ceased,  and  the  eye,  to  a  common  observer, 
appeared  as  the  other.     The  iris  remained  motionless,  and  the  sight  totally  lost.'' 

Case  208. — Death  after  the  operation  of  puncturing  a  cyst,  tvhich  teas  prolonged  through 
the  foramen  opticum  into  the  cavity  of  the  cranium.  Louis  Bonnet,  aged  20,  from  the  time 
he  was  eight  years  of  age  had  a  considerable  tumor  which  filled  the  left  orbit,  and  formed 
so  large  a  projection  between  the  eyelids  that  they  were  kept  separate  from  each  other 
to  the  extent  of  an  inch  and  a  half.     The  intermediate  space  was  covered  by  inflamed 


330  ENCYSTED   TUMORS   IN  THE   ORBIT. 

conjunctiva,  scarcely  any  trace  remained  of  the  cornea,  and  the  eye  was  atrophic.  The 
tumor,  which  distended  the  lids,  and  seemed  to  fill  the  orbit,  was  so  placed  between  the 
muscles  of  the  eye,  that  it  was  moved  by  their  contractions  as  the  eye  naturally  is.  The 
renitency  of  the  tumor  showed  it  to  be  encysted. 

The  patient  could  say  nothing  of  the  cause  of  his  disease.  He  recollected  that  in  the 
commencement  he  had  pretty  smart  pain,  for  a  month,  in  the  bottom  of  the  orbit,  followed 
by  gradual  protrusion  of  the  eyeball,  that  the  vision  became  weaker  and  weaker  as  the 
eye  protruded,  and  that  the  cornea  ulcerated  and  burst,  allowing  the  humors  to  escape. 

It  was  easy  to  see  that  the  cavity  of  the  orbit  had  undergone  an  extraordinary  degree 
of  dilatation,  so  much  so  as  to  change  the  form  of  the  forehead,  nose,  and  upper  jaw. 
The  opposite  orbit  seemed  natural,  the  sight  of  the  right  eye  perfect,  the  other  senses 
and  the  intellect  entire.  The  patient  had  no  headache,  and  perceived  no  difference  in 
the  power  of  the  two  sides  of  his  body.  He  suffered  most  from  frequent  conjunctival 
inflammation,  and  was  earnestly  desirous  of  a  cure. 

Delpech  plunged  a  straight  bistoury  through  the  middle  of  the  lower  lid,  the  point 
where  the  tumor  felt  most  renitent  and  fluctuating.  A  transparent,  yellowish  fluid  was 
immediately  ejected  with  great  force.  The  quantity,  also,  was  much  more  than  Delpech 
had  expected,  even  taking  into  account  the  enlarged  size  of  the  orbit.  On  passing  his 
finger  into  the  cavity  of  the  tumor  he  found,  as  he  had  anticipated,  that  the  cyst  was  of 
the  sero-mucous  kind,  and  that  it  presented  numerous  irregular  indurations ;  but  what 
was  his  astonishment  when  he  discovered  that  the  cavity  was  prolonged  into  that  of  the 
cranium,  through  the  foramen  opticum,  which  was  dilated  to  such  a  size  as  readily  to 
admit  his  forefinger!  Caddis  was  gently  passed  into  the  cavity  of  the  cyst,  and  the 
edges  of  the  wound  kept  separate  by  a  fold  of  linen  covered  with  cerate. 

The  patient  sufiered  but  little  during  the  first  two  days;  but  on  the  3d  day,  the  symp- 
toms announced  inflammation  of  the  brain  and  its  membranes.  Pain  extended  from  the 
wound  to  the  forehead  and  occiput;  the  features  of  the  patient  changed;  and  notwith- 
standing venesection,  emollient  fomentations  of  the  head,  and  other  remedies,  he  was 
very  restless  during  the  night,  and  somewhat  delirious.  Next  day  his  pulse  was  more 
frequent,  with  burning  heat  of  skin.  Twenty  leeches  were  applied  to  each  temple.  On 
the  5th  day  he  was  insensible,  and  died  in  the  evening. 

The  vessels  of  the  brain  were  highly  injected;  the  sub-arachnoid  cellular  tissue  infil- 
trated and  semi-opaque.  In  the  lateral  ventricles  there  were  about  3  ounces  of  milky 
serosity.  All  the  lower  surface  of  the  brain,  especially  towards  its  left  and  anterior  part, 
was  soft  and  of  a  slate  color. 

Opposite  the  internal  temporal  fossa  of  this  side,  and  close  to  the  sella  Turcica,  there 
was  such  an  adhesion  of  the  cerebral  substance,  that  it  was  necessary  to  cut  it  in  thin 
layers  to  separate  it,  and  to  discover  the  state  of  the  parts.  It  was  then  perceived  that 
the  softening  of  the  brain  in  almost  its  whole  left  anterior  lobe  had  advanced  to  the  state 
of  purulency.  A  prolongation  of  the  orbital  cyst  was  found  imbedded  in  the  inferior 
surface  of  the  same  lobe,  to  the  depth  of  nearly  3  inches,  having  pushed  aside  to  that 
extent  the  pia  mater  and  tunica  arachnoidea.  It  was  firmly  adhering  to  these  mem- 
branes. This  prolongation  presented,  like  the  rest  of  the  cyst,  bosses  and  considerable 
inequalities  of  thickness  in  its  parietes.  Its  structure  was  completely  the  same,  its  cavity 
contained  the  same  purulent  matter,  and  in  fact  it  was  separated  from  the  orbital  portion 
merely  by  a  sort  of  isthmus  formed  by  the  foramen  opticum.  This  foramen  presented  a 
diameter  of  about  two-thirds  of  an  inch,  a  change  which  it  had  evidently  undergone 
while  yet  in  a  soft  state.  The  left  optic  nerve  had  entirely  disappeared  in  consequence 
of  the  pressure  of  the  cyst. 

On  the  inferior  surface,  and  in  the  substance  of  the  right  anterior  lobe  of  the  cere- 
brum, was  another  sero-mucous  cyst,  similar  to  that  on  the  left  side,  except  that  its 
cavity  contained  only  pure  serosity,  and  that  it  lay  in  the  substance  of  the  brain  without 
pressing  aside  the  pia  mater  and  tunica  arachnoidea.  Its  size  was  equal  to  half  a  pigeon's 
egg  divided  longitudinally.  Round  this  cyst  the  brain  was  softened  and  of  a  slate  color, 
and  the  corresponding  point  of  the  meninges  had  suffered  slightly  from  inflammation.^ 

2.  Partial  extirpation  of  encysted  tumors. — On  account  of  the  difficulty  of 
removing  the  cyst  in  an  entire  state,  and  the  danger  of  injuring  important 
parts  when  the  disease  reaches  deep  into  the  orbit,  recourse  is  sometimes  had 
to  partial  extirpation  of  encysted  tumors  in  this  situation.  The  front  of  the 
tumor  being  exposed  in  the  usual  way,  the  cyst  is  laid  hold  of  with  a  double 
volsella,  and  as  much  of  it  excised  as  can  conveniently  be  brought  within  the 
grasp  of  the  scissors.  The  portion  of  the  cyst  which  is  left  inflames,  the  ex- 
ternal wound  heals  up  more  or  less  promptly,  and  in  some  cases  there  is  no 


ENCYSTED   TUMORS   IN   THE   ORBIT. 


331 


further  trouble  experienced;  but  more  frequently  the  wound  opens  repeatedly, 
till  the  cyst,  destroyed  by  suppuration,  is  discharged. 

Case  209. — Anterior  half  of  cyst  removed,  and  posterior  half  touched  with  caustic.  Donald 
Mackinnes,  aged  18  years,  was  admitted  into  the  Glasgow  Eye  Infirmary,  under  the  care 
of  Dr.  Monteath,  on  the  28th  of  September,  1827,  on  account  of  a  soft  tumor  which,  since 
infancy,  had  been  observed  to  project  from  the  right  orbit,  immediately  above  the  tendon 
of  the  orbicularis  palpebrarum.  Its  projecting  part  was  as  large  as  a  middle-sized  goose- 
berry, and  as  far  as  could  be  judged,  the  tumor  dipped  deep  into  the  orbit.  The  eyeball 
was  not  disiDlaced,  nor  did  the  patient  experience  any  pain,  but  he  was  anxious  to  have  the 
tumor  removed  on  account  of  the  deformity,  which  was  very  considerable.  The  integu- 
ments were  divided  and  dissected  back,  and  when  the  anterior  half  of  the  tumor  was  thus 
exposed,  it  was  laid  hold  of  and  excised.  The  cavity  of  the  posterior  half  could  now  be 
distinctly  seen,  dipping  nearly  an  inch  into  the  orbit,  close  to  its  nasal  wall.  It  was  evi- 
dent that  this  part  of  the  cyst  could  not  be  removed,  even  by  a  laborious  dissection.  The 
whole  cavity  was  therefore  rubbed  over  with  nitrate  of  silver,  and  then  stuffed  gently  with 
lint,  over  which  a  compress  and  bandage  were  applied.  Very  little  inflammation  succeeded 
the  operation.  The  cavity  contracted  from  day  to  day,  and  was  very  soon  completely  oblite- 
rated, leaving  no  deformity. 

The  following  case  will  illustrate  some  of  the  dangers  attendant  even  on 
the  simple  operation  of  partial  extirpation : — 

Case  210. —  Violent  inflammation  after  removal  of  anterior  half  of  cyst.  Agnes  Crawford, 
aged  14  years,  was  admitted  a  patient  at  the  Glasgow  Eye  Infirmary,  under  the  care  of  Dr. 
Monteath,  on  the  24th  October,  1827.    For 

six  years,  a  tumor  had  been  observed  to  pro-  Fig.  48. 

ject  from  the  right  orbit,  pushing  the  upper 
eyelid  before  it,  and  most  protuberant  about 
midway  between  the  tarsal  border  of  the 
eyelid  and  the  bony  edge  of  the  orbit.  The 
greatest  projection  of  the  tumor  was  at  the 
upper  and  inner  part  of  the  orbit,  so  that 
the  eye  was  forced  downwards  and  out- 
wards. (Fig.  48.)  The  part  of  the  tumor 
which  appeared  externally  was  as  large  as 
a  green  gage  plum,  and  from  the  very  great 
displacement  of  the  eyeball,  it  was  con- 
cluded that  the  portion  lying  within  the 
orbit  was  also  large  and  extended  deep. 
The  skin  covering  the  tumor  had  a  dirty 
livid  color.  On  partially  everting  the  eye- 
lids, the  inferior  part  of  the  tumor  was 
seen  bulging  through  the  conjunctiva.  The 
girl  suffered  no  pain.  The  vision  of  the 
eye  was  perfect,  and  the  tunics  free  from 
inflammation.  Though  the  eye  was  turned 
very  much  to  the  right  side,  she  had  no 
diplopia.  She  enjoyed  good  health.  She 
had  never  menstruated.     The  tumor  had 

been  repeatedly  punctured,  and  at  one  time  a  thread  had  been  drawn  through  it  and  worn 
for  some  time,  without  producing  either  good  or  bad  effects. 

On  the  28th  of  October,  after  low  diet  for  three  or  four  days,  and  two  doses  of  laxative 
medicine,  the  patient  was  laid  on  a  table,  and  an  incision,  nearly  two  inches  long,  made  in 
the  direction  of  the  fibres  of  the  orbicularis  palpebrarum.  The  integuments  were  dissected 
back  with  a  scalpel  and  a  blunt  silver  knife,  till  more  than  the  anterior  half  of  the  tumor 
was  exposed.  This  was  now  cut  away  with  the  scissors.  An  immense  discharge  of  fluid 
immediately  took  place  from  the  sac,  of  the  appearance  of  dark  blood.  This  was  followed 
by  very  considerable  hemorrhage  from  the  bottom  of  the  orbit.  Dr.  M.  thrust  his  finger 
to  the  bottom  of  the  orbit,  and  by  pressure  soon  stopped  the  violence  of  the  bleeding. 
Cold  water  was  next  injected  for  about  a  minute,  by  means  of  a  syringe,  deep  into  the 
orbit,  which  caused  the  bleeding  to  cease.  Examination  Avith  the  finger  clearly  demon- 
strated that  the  tumor  had  extended  to  the  very  bottom  of  the  orbit,  and  even  occupied 
there  much  space.  It  was  therefore  impossible  to  dissect  out  the  posterior  part  of  the 
cyst,  so  that  it  was  merely  stuffed  moderately  with  a  strip  of  lint.  Another  strip  was 
placed  between  the  lips  of  the  external  wound,  to  prevent  adhesion.  A  compress  was  laid 
over  all,  and  the  eyes  shaded.  Before  the  patient  had  left  the  operation  table,  the  eye- 
ball had  retreated  very  considerably  into  its  natural  position. 


332  ENCYSTED   TUMORS   IN   THE  ORBIT. 

Next  day  the  -whole  of  the  upper  eyelid  was  red  and  much  swollen.  The  patient  com- 
plained of  headache,  and  her  pulse  was  112.  Ten  leeches  were  ordered  round  the  orbit; 
after  which  an  emollient  poultice  was  applied,  and  she  had  a  dose  of  castor  oil.  On  the 
third  day  the  report  states  that  the  leeches  had  bled  freely ;  but  that  the  tumefaction 
having,  upon  the  whole,  increased,  as  well  as  the  headache  and  fever,  the  tent  was  with- 
drawn. She  had  suffered  much  during  the  night,  the  pain  being  pulsating  and  constant, 
both  in  the  eye  and  head.  In  the  mornini;  she  had  been  seized  with  vomiting.  The  pulse 
was  still  above  100.  The  tumefaction  was  now  so  much  increased  that  the  exophthalmos 
was  greater  than  before  the  operation.  The  eyeball  being  chemosed,  a  portion  of  the 
swollen  conjunctiva  was  snipped  off.  A  probe  was  passed  through  the  wound  to  the 
bottom  of  the  orbit,  but  no  retained  blood  nor  pus  was  discharged.  A  small  portion  of 
sloughy  matter,  apparently  part  of  the  cyst,  was  extracted  from  the  wound,  at  the  mouth 
of  which  it  presented.  Twelve  ounces  of  blood  were  taken  from  the  arm  at  noon,  and  six 
more  at  7  P.  M.  On  both  occasions  slie  became  faintish.  The  blood  was  buffy.  The 
pulse  fell  a  little,  became  softer,  and  she  felt  relieved.  The  poultice  was  continued,  and 
she  was  ordered  a  dose  of  Epsom  salts  in  divided  quantities,  which  operated  freely  in  the 
night,  and  disturbed  her  sleep.  She  had  much  less  pain  than  during  the  previous  night. 
Next  day,  the  fourth  after  the  operation,  the  pulse  was  about  90  and  soft,  the  tumefaction 
of  the  eyelids,  of  a  deep  red  color,  and  very  sensible  to  the  touch,  was  increased  to  the 
bulk  of  the  half  of  a  middle-sized  apple,  the  greater  part  of  the  swelling  being  formed  of 
the  upper  eyelid ;  the  chemosed  conjunctiva  projected  from  between  the  aperture  of  the 
lids ;  the  cornea  continued  transpai-ent,  and  vision  was,  as  yet,  good.  Her  thirst  had 
been  immoderate  for  the  last  three  days,  and  still  continued.  She  had  frequent  transient 
chills  through  the  course  of  the  day.  Upon  the  whole,  the  pain  of  the  eye  and  head  was 
less  than  on  the  preceding  day.  She  was  ordered  a  draught,  with  25  drops  of  laudanum, 
and  her  general  health  was  improving. 

For  two  days  the  tumefaction  of  the  lids  increased,  particularly  of  the  lower,  which 
became  so  broad  as  to  reach  as  low  as  the  opening  of  the  nostril.  The  swelling  was  indeed 
enormous,  and  the  whole  of  it  very  tender  to  the  touch.  The  cornea  could  with  difficulty 
be  seen,  being  overlapped  by  the  chemosed  conjunctiva.  So  far  as  it  could  be  seen  it  was 
transparent,  but  the  pupil  appeared  enlarged,  and  she  said  she  could  not  see. 

From  the  fourth  till  the  eighth  day  the  pulse  varied  from  75  to  90;  the  thirst  gradually 
ceased  ;  there  was  some  return  of  appetite ;  and  the  headache  and  pain  of  the  eye  declined, 
so  that  by  the  eighth  day  they  were  nearly  gone.  The  bowels  were  gently  purged  with 
Epsom  salts,  and  she  had  an  anodyne  each  night  with  much  benefit.  On  the  seventli  and 
eighth  days  the  wound  discharged  matter  pretty  freely.  Both  eyelids  had  by  this  time 
become  softer,  and  much  less  swollen.  On  the  eighth  day  it  was  observed  that  pus  had 
made  its  way  from  the  bottom  of  the  orbit,  through  two  apertures  in  the  conjunctiva, 
where  it  is  reflected  from  the  lower  eyelid  to  the  eyeball,  near  the  nasal  canthus.  For 
some  days  previously  to  this  the  poultice  had  been  discontinued,  and  the  eyelids  covered 
with  lint  smeared  with  simple  ointment.  The  draught  was  now  omitted.  On  the  28th  of 
January,  1828,  the  report  states  that  the  incision  had  been  completely  closed  for  some 
time,  and  that  the  eye  had  retired  more  into  its  proper  situation.  The  pupil,  however, 
continued  dilated,  and  there  was  no  return  of  vision.  The  patient  was  free  from  pain, 
and  her  general  health  was  improving. 

On  the  8th  of  February,  the  eye  was  still  more  in  its  natural  place,  and  its  power  of 
motion  increased,  but  no  renewal  of  vision.  The  patient  now  left  the  Infirmary  for  her 
home  in  the  country,  and  in  a  few  months  died  of  phthisis  pulmonalis. 

3.  Total  extirpation  of  encysted  tumors. — The  complete  extirpation  of  an 
orbital  encysted  tumor  is  an  operation  almost  always  attended  with  consider- 
able difficulty.  The  flow  of  blood,  the  danger  of  rupturing  the  cyst,  the 
instant  escape  of  its  contents  if  it  be  accidentally  torn  or  wounded,  the 
embarrassment  attending  the  removal  of  it  in  the  collapsed  state,  and  the 
great  depth  to  which  the  cyst  often  extends  within  the  orbit,  are  the  cir- 
cumstances which  have  led  to  the  practices  of  puncture  and  partial  extir- 
pation.    The  total  removal,  however,  of  the  cyst,  is  more  satisfactory. 

The  operation  of  extirpating  a  tumor,  situated  exterior  to  the  ocular 
capsule,  is  generally  performed  by  making  a  transverse  incision  through  the 
skin  of  one  or  other  eyelid,  parallel  to  the  fibres  of  the  orbicularis  palpebra- 
rum. This  incision  is  not  to  be  made  freely,  but  cautiously,  avoiding  the 
lachrymal  passages  at  the  inner  canthus,  and  taking  care  not  to  open  the 
cyst,  which  is  often  almost  immediately  under  the  skin.  The  cellular  sub- 
stance beneath  the  orbicularis  and  the  fibrous  layer  of  the  eyelids  being  next 


ENCYSTED   TUMORS   IN   THE   ORBIT.  333 

divided,  the  connections  of  the  cyst  are  to  be  separated.  This  is  best  effected 
by  means  of  a  pair  of  blunt  forceps  and  a  silver  knife  ;  with  the  former  laying 
hold  of  the  cyst,  and  with  the  latter  destroying  its  cellular  attachments.  This 
being  accomplished  as  completely  round  the  cyst  as  possible,  it  is  to  be 
dragged  forwards,  and  its  posterior  connections  divided  with  the  knife  or  the 
scissors.  The  finger  ought  now  to  be  introduced  into  the  cavity  left  by  the 
removal  of  the  tumor,  and  an  examination  made,  lest  any  indurated  attach- 
ments or  roots  of  the  cyst  have  been  left.  These  are  to  be  laid  hold  of,  and 
extirpated  w^ith  the  scissors.  It  is  the  general  practice  to  fill  the  cavity 
formerly  occupied  by  the  tumor  with  lint,  but  this  does  not  appear  to  be 
necessary.  We  may  leave  it  filled  with  the  blood  which  flows  from  the  parts 
which  we  have  divided.  Its  parietes  will  most  probably  inflame  and  sup- 
purate, and  then  gradually  contract ;  but  by  stuffing  it  with  lint,  the  inflam- 
mation which  follows  is  likely  to  be  more  severe  and  extensive,  so  that  the 
contents  of  the  orbit  may  suffer  severely,  the  eye  be  prevented  by  the  swelling 
and  the  matting  together  of  the  parts  from  retreating  into  its  natural  place, 
or  even  a  new  and  permanent  degree  of  protrusion  of  the  eye  be  produced. 
Orbital  tumors  are  generally  situated  exteriorly  to  the  ocular  capsule. 
They  lie  oftener  between  the  muscles  of  the  eye  and  the  periorbita,  than 
between  the  muscles  and  the  optic  nerve  or  eyeball.  When  they  protrude 
the  upper  eyelid,  they  generally  lie  between  the  levator  palpebras  and  the 
periorbita,  so  that  the  muscle  runs  little  or  no  risk  in  the  operation.  Dr. 
O'Ferrall  has  pointed  out,  however,  that  when  a  tumor  lies  within  the  ocular 
capsule,  the  eyelid  may  be  thrown  forward  in  such  a  manner  as  to  make  the 
practitioner  suppose  the  morbid  growth  to  lie  nearer  to  the  orbit  than  the 
eyeball,  and  very  little  covered  by  soft  parts.  Proceeding  to  extirpation 
through  the  integuments,  he  may  find  that  his  incisions  have  to  pass  through 
a  great  depth  of  parts,  to  remove  a  tumor  which  actually  lies  in  contact  with 
the  eyeball,  and  could  be  easily  reached  by  a  division  of  the  conjunctiva.^ 

The  following  case,  related  by  Saint-Yves,  appears  to  have  served  as  an 
encouraging  example  of  extirpation  of  an  orbital  tumor  to  several  of  his 
successors : — 

Case  211. — Encysted  tumor  with  three  cavities.  In  a  girl  of  12  years  of  age,  a  tumor 
was  situated  below  the  eyeball,  so  that  it  turned  the  pupil  upwards,  and  protruded  the 
lower  lid  for  more  than  half  an  inch.  It  extended  towards  the  cheek  for  the  breadth  of 
an  inch.  Saint- Yves  divided  the  skin  and  the  orbicularis  palpebrarum  by  a  semilunar 
incision,  extending  the  whole  length  of  the  tumor ;  he  then  laid  hold  of  it  with  a  hook, 
separated  it  from  its  attachments  with  a  bistoury,  and  removed  it.  With  the  scissors  he 
next  cut  away  its  root,  which  was  hard  and  coriaceous.  In  thirteen  days  the  wound  was 
healed.  The  eye  returned  to  its  place,  and  the  patient  saw  with  it  as  with  the  other. 
The  tumor  presented  three  cavities.  That  which  lay  next  the  skin  contained  a  purulent 
fluid  ;  the  second  was  filled  with  a  thicker  matter  partly  calcareous  ;  and  the  contents  of 
the  third  resembled  white  of  egg.'' 

Case  212. — Tumor  extirpated  through  the  conjunctiva,  after  disunion  of  the  eyelids.  A 
woman,  about  40  years  of  age,  was  admitted  a  patient  at  the  Surgical  Hospital  of  Gottin- 
gen,  with  her  left  eye  very  prominent,  and  at  the  same  time  pressed  upwards  and  inwards. 
The  lower  fold  of  the  conjunctiva  was  protruded  by  a  hard  swelling,  which  pressed  down 
the  lower  eyelid  and  surrounded  the  ej'eball  from  the  inner  canthus  to  the  outer,  and 
hence  to  the  upper  edge  of  the  oi'bit.  This  swelling  was  somewhat  movable,  and  could 
be  surrounded  by  the  fingers,  so  that  no  firm  adhesions  were  to  be  expected.  The  pro- 
truded eye  was  of  natural  appearance,  the  pupil  was  regular,  and  the  iris  expanded  and 
contracted,  but  there  was  no  vision. 

Professor  Langenbeck  began  the  operation  by  dividing  the  outer  commissure  of  the 
eyelids  and  the  conjunctiva.  After  both  eyelids  were  separated  from  the  swelling,  it  was 
seen  to  be  a  steatomatous  tumor,  connected  with  the  eyeball  and  its  muscles.  The 
separation  from  these  parts  was  accomplished  partly  with  the  cutting  edge  of  the  scalpel, 
partly  with  its  handle,  and  partly  with  the  finger.  The  large  opening  left  after  the 
extirpation  of  the  tumor  was  filled  with  charpie,  till  granulations  appeared.  The  eyeball 
gradually  retired  within  the  orbit,  and  the  power  of  vision  returned  so  completely  that 


334  ENCYSTED   TUMORS   IN   THE   ORBIT. 

the  pntient  could  distinguish    the   smallest  object    before    she  left   the  hospital.     The 
deformity  also  was  entirely  removed. ^ 

Case  213.  —  Cj/st  evacuated,  and  then  dissected  out.  A  laborious  countryman  was  attacked 
with  pain  and  dimness  of  sight  in  one  of  his  eyes.  These  symptoms  did  not  attract  any 
particular  attention  for  two  or  three  years,  when  he  became  quite  blind  of  the  eye,  the 
globe  being  at  the  same  time  greatly  protruded,  and  the  lower  lid  everted.  Many 
surgeons  who  were  consulted,  dissuaded  him  from  submitting  to  any  operation,  appre- 
hensive that  his  complaint,  if  not  already  cancerous,  was  likely  to  become  so  by  meddling 
with  it.  lie  was  therefore  urged  not  to  hazard  the  danger  of  any  operation,  seeing  that 
his  disease  did  not  render  life  intolerable,  but  might  be  supported  without  farther  incon- 
venience than  the  want  of  sight  in  the  eye,  and  its  unseemliness  from  being  so  far  thrust 
out  of  its  socket.  He  was  recommended,  however,  to  consult  Mr.  Ingram,  a  surgeon  in 
London,  who,  on  carefully  examining  the  case,  imagined  that  he  felt,  on  pressure,  a 
resisting  fluid  under  the  eye,  and  formed  the  opinion  that  this  fluid  was  contained  in  a 
cyst,  detached  from  the  lachrj'mal  gland.  He  therefore  gave  encouragement  to  attempt 
the  man's  relief.  jMr.  Bromfield  approved  of  this  proposal,  and,  with  Mr.  Ingram's 
assistance,  performed  the  following  operation  : — 

He  pressed  upwai-ds  the  distorted  lower  lid,  till  it  was  brought  as  near  as  possible 
to  its  natural  position.  While  it  was  thus  held  tight,  Mr.  B.  cut  through  the  integuments 
into  the  lower  part  of  the  orbit  under  the  conjunctiva,  till  an  aperture  was  made  sufiicient 
to  permit  the  introduction  of  the  finger,  so  as  to  direct  a  sharp-pointed  scalpel,  with 
which  he  perforated  the  tumor.  Immediately  a  thin  pellucid  liquor  was  discharged,  not 
far  short  in  quantity  of  a  small  wine-glassful.  Here  Mr.  B.  paused,  to  give  the  patient 
a  little  water  to  cleanse  his  mouth  from  the  blood,  and  observed  that  his  business  was 
not  more  than  half  done,  until  he  should  extract  the  cyst  which  had  contained  the  water. 
He  therefore  introduced  two  small  hooked  instruments  to  catch  hold  of  it,  and  took  it 
completely  out.  The  wound  was  filled  with  lint,  and  dry  dressings,  and  these  were 
secured  by  a  proper  bandage. 

Within  less  than  twenty-four  hours,  the  patient's  head  and  neck  were  swollen  to  a  pro- 
digious size.  Treated  as  a  common  superficial  wound,  in  less  than  a  month  the  whole  was 
healed,  and  the  man  sent  home  perfectly  satisfied.  Mr.  I.  was  all  along,  even  before  the 
operation,  confident  that  the  over-stretched  muscles  of  the  eye  would,  in  time,  recover 
their  natural  power,  that  the  globe  of  the  eye  itself  would  consequently  be  included  within 
its  socket,  without  leaving  any  outward  blemish,  and  that  even  the  sight  would,  to  a  cer- 
tain degree,  return.  Dr.  Brocklesby,  who  relates  the  case,  owns  that  he  gave  not  much 
credit  to  all  this,  till  five  months  after  the  man  Avent  home,  when,  being  in  the  country, 
he  sent  for  him  to  satisfy  his  curiosity.  \Vhen  he  saw  him,  he  scarce  knew  him  again ; 
for  his  eyelid  had  fully  recovered  its  natural  position  and  functions.  About  a  month 
before  Dr.  B.  saw  him,  the  eye  began  to  be  sensible  of  the  difi"ercnce  between  darkness 
and  bright  sunshine,  and  ever  since  that  period  its  power  of  perception  had  become 
gradually  strengthened. ^ 

Case  214. — Double  cyst  extending  to  bottom  of  orbit,  and  containing  a  tooth.  Thomas 
Heard,  a  healthy-looking  lad  of  17,  was  admitted  as  an  in-patient  of  the  Exeter  Eye  In- 
firmary, under  the  care  of  Mr.  Barnes,  on  account  of  a  tumor  which  completely  obstructed 
the  sight  of  his  left  eye.  The  tumor  was  situated  beneath  the  eye,  occupying  a  very  con- 
siderable portion  of  the  orbit;  the  eye  in  consequence  was  pushed  into  the  upper  part  of 
that  cavity,  so  as  to  be  almost  wholly  hidden  behind  the  upper  lid.  On  tracing  it  back- 
wards, the  tumor  appeared  to  extend  to  a  very  considerable  depth,  while  it  projected  so 
much  in  front  as  to  constitute  a  striking  deformity.  Anteriorly  it  was  round  in  form.  A 
superficial  groove,  running  obliquely  across  its  upper  surface,  formed  a  slight  line  of 
division  between  the  more  prominent  and  movable  part  of  the  swelling,  and  that  more 
immediately  under  the  eyeball.  The  ciliary  edge  of  the  lower  tarsus,  with  a  few  scattered 
hairs  in  it,  crossed  the  front  of  the  tumor  rather  above  its  middle;  the  conjunctiva,  drawn 
forwards  from  the  eyeball,  greatly  stretched,  but  apparently  not  much  altered  in  struc- 
ture, investing  it  above  ;  and  a  thin  skin  of  a  deep  red,  loaded  with  purple  vessels,  cover- 
ing it  below;  but  neither  of  them  closely  adherent  to  it.  The  portion  of  the  tumor  in 
front  was  soft,  and  could  be  moulded  into  dififerent  shapes  by  the  fingers;  the  posterior 
division  felt  more  elastic.  By  an  effort,  the  patient  could  raise  the  upper  eyelid  a  little, 
but  not  high  enough  to  discover  even  the  lower  edge  of  the  cornea.  By  lifting  it  up  with 
the  finger,  a  portion  of  the  pupil  might  be  exposed,  and  he  could  then  distinguish  objects 
partially.  The  eye  was  apparently  perfect,  but  he  had  scarcely  any  power  of  moving  it. 
The  swelling  was  at  first  observed  in  early  infancy,  and  was  at  that  time  not  much  larger 
than  a  pea.  It  increased  slowly,  until  about  four  or  five  years  before  his  admission  into 
the  infirmary,  when  it  began  evidently  to  enlarge,  and  for  some  time  grew  rapidly. 
More  recently,  it  had  not  advanced  much.     It  caused  no  pain,  but,  as  it  was  a  great  de- 


SOLID   TUMORS  IN  THE   ORBIT.  335 

formity,  was  still  enlarging,  and  by  its  presence  rendered  the  eye  useless,  it  was  thought 
advisable  to  remove  it. 

lu  the  operation,  a  division  was  made  of  the  inferior  oblique  muscle  of  the  eye,  which 
appeared  stretched  across  the  front  of  the  tumor,  having  been  pushed  before  it,  in  its 
progress  from  the  deeper  parts  of  the  orbit.  The  sac  adhered  firmly  to  the  outer  angle 
and  part  of  the  lower  edge  of  the  orbit;  in  most  other  points  it  was  but  loosely  connected 
with  the  surrounding  parts.  It  was  found  to  extend  almost  to  the  bottom  of  the  orbit, 
and  to  occupy  more  of  it  than  did  the  eye  itself.  As  it  was  impossible  to  proceed  in  the 
dissection  far  within  that  cavity,  without  greatly  endangering  the  eye,  on  account  of  the 
very  narrow  space  between  it  and  the  posterior  division  of  the  swelling,  the  contents 
of  the  latter  were  partially  evacuated,  to  obtain  room,  and  the  sac  cautiously  separated 
from  its  deeper  attachments.  Towards  the  posterior  point,  on  the  inner  side,  and  more 
than  an  inch  from  the  edge  of  the  orbit,  the  sac  felt  as  if  it  embraced  a  sharp  bony  process, 
arising  from  about  the  line  of  junction  between  the  ethmoid  and  superior  maxillary  bones. 
Unwilling  to  proceed  at  hazard,  the  operator  cut  otF  the  cyst  close  up  to  this  projection, 
that  its  nature  and  connections  might  be  examined  before  an  attempt  was  made  to  remove 
it.  It  appeared  to  be  formed  of  bone  terminating  in  a  sharp  point,  and  projecting  nearly 
in  a  perpendicular  direction  into  the  cavity  of  the  orbit.  It  was  slightly  movable,  as  if 
attached  to  the  periosteum  only ;  and  was  removed  without  much  difficulty,  together  with 
the  remains  of  the  sac  which  adhered  to  it.  On  examination  it  Avas  found  to  be  a  tooth, 
resembling  in  form  and  size  the  supernumerary  teeth  sometimes  found  in  the  palate.  The 
part  which  projected  into  the  sac  was  conical,  and  covered  by  smooth,  shining,  white 
enamel ;  the  sac  firmly  adhered  round  a  contracted  portion  at  the  base  of  the  cone,  re- 
sembling the  neck  of  a  tooth;  and  without  the  sac  there  was  the  appearance  of  a  root, 
truncated  obliquely,  with  a  passage  in  the  centre,  evidently  containing  bloodvessels.  It 
was  by  this  part  that  it  was  connected  with  the  floor  of  the  orbit.  The  patient  had  a 
complete  natural  set  of  teeth,  though  many  of  them  were  disposed  irregularly. 

The  extirpated  tumor  was  found  to  be  made  up  of  two  cysts,  separable  by  dissection, 
at  the  groove  already  mentioned,  to  some  depth  all  round,  but  indissolubly  united  in  the 
centre.  That  in  front  allowed  the  color  of  its  contents  to  be  distinguished  through  it. 
The  posterior  sac  was  thicker  and  more  vascular.  The  interior  surface  of  that  in  front 
was  rough,  with  here  and  there  a  chalky  matter  adhering  to  it.  It  contained  a  compact 
lardaceous  yellow  substance.  The  inner  surface  of  the  posterior  sac  was  smooth,  except- 
ing a  part  near  the  tooth,  where  it  had  much  the  appearance  of  coarse  skin  with  many 
pores  in  it.  The  contents  were  partly  a  whey-colored  fluid,  and  partly  a  yellow  curdy 
substance.  The  eye  did  not  in  the  least  drop  on  the  removal  of  the  tumor;  and  the  large 
cavity  wliich  this  had  occupied  was  filled  with  pieces  of  soft  sponge,  dipped  in  oil.  On 
removing  the  last  piece  of  sponge,  on  the  seventh  day  after  the  operation,  the  cavity  was 
found  to  be  everywhere  covered  by  healthy  granulations.  The  opening  contracted  rapidly, 
and  the  eye  sunk  fast,  so  that  within  a  fortnight  it  was  nearly  on  a  level  with  the  other. 
The  patient  was  discharged  in  the  beginning  of  January,  with  the  wound  perfectly  healed. 
The  lower  lid  did  not,  at  that  time,  cover  so  much  of  the  eyeball  as  it  does  naturally; 
and  in  onp  spot  the  ciliary  edge  was  a  little  inverted.  He  had  the  power  of  moving  it 
slightly,  but  he  could  not  raise  it  high  enough  to  bring  it  into  accurate  apposition  with 
the  upper.  There  was  a  considerable  hollow  above  the  eyeball ;  and  the  eye  was  not  quite 
in  a  line  with  the  other,  but  rather  above  it.  He  could  not  move  it  at  all  downwards, 
nor  freely  in  any  direction.  With  the  exception  of  this  inconvenience,  he  enjoyed  with 
it  perfect  vision. '" 

Case  215. — Encysted  tumor  in  the  orbit,  complicated  with  symblepharon.  The  eye  of  a  man, 
29  years  of  age,  was  pressed  inwards  and  downwards  by  a  tumor  which  occupied  the 
upper  and  outer  side  of  the  orbit.  The  tumor  fluctuated,  and  was  very  prominent.  In 
consequence  of  previous  inflammation,  the  cornea  was  opaque,  and  the  eyelids  were  united 
to  the  eyeball.  Professor  Langenbeck  divided  the  upper  lid,  over  the  tumor,  which,  as 
soon  as  it  was  laid  bare,  presented  the  appearance  of  a  shining  transparent  cyst.  He 
removed  it  perfectly  entire.  It  was  about  the  size  of  a  pigeon's  egg,  and  filled  with  fluid. 
The  edges  of  the  wound  were  brought  together,  and,  after  it  was  healed,  the  morbid 
union  of  the  lids  to  the  ball  of  the  eye  was  divided,  so  that  the  eye  was  restored  to  its 
natural  place  and  power  of  motion." 

4.  Extirpation  of  solid  tumors. — The  extirpation  of  a  solid  tumor  in  the 
orbit  may  occasionally  be  effected  by  dividing  merely  the  skin  or  the  conjunc- 
tiva, according  to  the  situation  of  the  swelling,  laying  hold  of  the  tumor 
with  a  hook  or  double  volsella,  or  passing  a  ligature  through  it,  so  as  to  drag 
it  forwards,  and  dissecting  it  out  with  a  small  scalpel.  In  other  cases  it  is 
necessary,  in  order  to  effect  the  extirpation  of  the  tumor  with  ease,  first  to 


336  SOLID   TUMORS   IN   THE   ORBIT. 

disunite  the  eyelids  by  an  incision,  carried  from  their  outer  angle  towards 
the  temple.  The  conjunctiva  covering  the  tumor  is  thus  completely  exposed, 
and  all  the  remaining  steps  of  the  operation  effected  with  less  difficulty. 
When  the  tumor  lies  close  to  the  bones  of  the  orbit,  and  is  perhaps  adherent 
to  the  periorbita,  the  extirpation  is  more  readily  effected  by  cutting  through 
the  eyelid  in  a  direction  parallel  to  the  fibres  of  the  orbicularis  palpebrarum, 
and  along  the  edge  of  the  orbit,  leaving  the  conjunctiva  untouched.  A  per- 
pendicular division  of  the  lid  covering  the  tumor  has  sometimes  been  had 
recourse  to,  but  ought  rather  to  be  avoided.  The  tumor  is  to  be  extirpated, 
if  possible,  without  injuring  the  parts  in  its  neighborhood,  or  to  which  it 
adheres.  They  are  to  be  separated  from  it  by  cautious  touches  with  the 
point  of  the  scalpel,  with  a  silver  knife,  which  serves  to  tear  rather  than  cut, 
or  with  the  finger-nail.  But  if  the  adhesions  be  inseparable,  the  parts  to 
which  the  tumor  adheres  must  be  sacrificed.  Even  the  eyeball  will  sometimes 
require  to  be  removed.  No  portion  of  the  tumor  ought  to  be  left,  else  the 
disease  will  be  apt  to  be  reproduced.  After  the  tumor  is  extirpated,  the 
displaced  eyeball  sometimes  returns  immediately  to  its  natural  situation,  and 
recovers  its  power  of  motion ;  but  in  general  this  is  effected  not  at  once,  but 
slowly,  in  the  course  of  several  weeks,  or  even  months,  and  may  sometimes 
be  assisted  by  the  application  of  a  compress  and  bandage. ^'^  The  removal 
of  the  pressure  caused  by  the  tumor  is  in  some  cases  followed,  more  or  less 
immediately,  by  restoration  of  the  sight  of  the  eye;  while,  on  the  other  hand, 
I  have  known  the  swelling  and  inflammation,  subsequent  to  extirpation  of  an 
orbital  tumor,  produce  for  a  time  a  greater  degree  of  displacement  than  had 
previously  existed,  and  a  total  loss  of  vision,  in  an  eye  with  which,  although 
much  displaced,  the  patient  had  continued  to  see  till  the  operation.  The 
severe  inflammation  which  sometimes  follows  the  extirpation  of  an  orbital 
tumor  may  even  extend  to  the  brain  or  its  membranes,  and  prove  fatal." 

Case  216. — Fibrous  tumor  in  orbit,  extirpated  at  tivice.  John  Searle,  aged  28,  was  admit- 
ted into  the  Royal  Ophthalmic  Hospital,  Moorfields,  London,  under  the  care  of  Mr. 
Critchett,  August  25th,  1852.  In  the  lower  half  of  the  right  orbit  was  a  large,  ill-defined 
solid  tumor,  by  which  the  eye  was  considerably  protruded,  and  forced  upwards  and  out- 
wards. The  upper  lid  was  distended  and  tense,  while  the  lower  was  everted,  and  its 
conjunctiva  exposed.  The  eye  was  so  much  displaced  that  he  could  look  only  upwards ; 
he  had,  however,  perfect  vision  in  that  direction.  The  protrusion  of  the  eye  had  first 
been  noticed  fifteen  months  previously,  and  the  growth  of  the  tumor  had  not  been  attended 
with  more  pain  than  was  accounted  for  by  its  pressure  on  the  surrounding  parts.  As  far 
as  he  knew,  he  had  never  received  any  injury  on  the  part.  His  general  health  had  not  at 
all  degenerated,  he  thought,  since  it  began  to  grow.  It  was  decided,  at  a  consultation, 
to  make  an  exploratory  incision  into  the  tumor,  and  to  attempt  its  removal  or  not,  as 
might  then  appear  desirable. 

As  the  patient  believed  himself  quite  able  to  bear  the  pain  of  the  operation,  chloroform 
was  not  administered.  Mr.  Critchett  first  divided  freely  the  everted  conjunctiva  of  the 
lower  lid,  and,  dissecting  it  off,  brought  into  view  a  firm,  whitish  growth.  When  this  had 
been,  with  care,  separated  from  the  surrounding  parts,  and  several  large  portions  of  it 
removed,  it  was  found  to  extend  very  deeply  into  the  orbit,  being  apparently  attached  to 
the  sheath  of  the  optic  nerve.  Considerable  hemorrhage  took  place  during  the  dissection, 
and  the  pain  was  so  great  that  the  patient  became  unmanageable.  It  was  deemed,  there- 
fore, best  to  desist,  and  the  cavity  having  been  stopped  with  lint,  the  patient  was  sent  to 
bed. 

The  portiou  of  the  growth  which  had  been  removed  was  firm,  rough,  and  of  a  pale  gray 
color;  exhibiting,  when  torn,  the  appearance  of  radiating  bands  of  parallel  fibres.  Under 
the  microscope,  it  seemed  made  up  of  white  fibrous  tissue,  with  many  elongated  cells. 
Scarcely  any  constitutional  disturbance  followed  the  operation;  the  lower  lid,  and  the 
parts  in  the  lower  half  of  the  orbit,  however,  became  very  much  swollen;  and,  from  the 
latter,  a  large  slough  separated.  When  the  hollow  left  by  the  separation  of  the  slough 
was  nearly  filled  up,  the  man  became  an  out-patient;  and  the  tumor  having  soon  after- 
wards increased  to  nearly  its  former  size,  he  was  transferred  to  the  London  Hospital, 
with  a  view  to  a  second  operation. 

The  lower  lid  was  now  everted  as  before,  and  exposed  a  florid  and  much  thickened 


SOLID   TUMORS  IN  THE   ORBIT.  33T 

conjunctiva.  The  tumor,  although  it  had  increased  rather  rapidly,  showed  no  tendency 
to  ulcei-ate  or  bleed.  It  had  latterly,  by  pressing  on  the  globe,  produced  very  much  pain, 
and  the  man  vras  extremely  anxious  that  some  operation  should  again  be  attempted.  Mr. 
Critchett,  having  apprised  him  that,  from  the  deep  attachments  of  the  growth,  the  in- 
tegrity of  the  eye  would  be  much  endangered  in  the  dissection  necessary  for  its  removal, 
consented  to  make  another  trial.  The  patient  having  been  placed  under  the  full  influence 
of  chloroform,  the  thickened  conjunctiva  was  dissected  from  the  whole  fi'ont  of  the  tumor. 
Mr.  C.  then  carefully  divided,  without  injury  to  the  globe,  the  adhesions  between  the 
tumor  and  the  surrounding  parts ;  having  freed  it  to  a  considerable  extent,  he  next  seized 
it  with  toothed  forceps,  and  made  pretty  firm  traction,  endeavoring,  at  the  same  time, 
with  a  pair  of  blunt-pointed,  curved  scissors,  to  separate  its  posterior  attachments.  A 
mass,  of  the  size  of  a  large  walnut,  was  removed,  which,  as  it  was  surrounded  in  most 
parts  by  a  distinct  fibrous  envelop,  probably  included  the  whole  of  the  growth.  It  pre- 
sented much  the  same  appearances  as  the  portion  formerly  extirpated,  save  that,  while 
not  quite  so  firm  in  its  general  texture,  it  contained  in  its  substance  numerous  particles 
of  bone.  There  were  also  a  very  few  small,  smooth-walled  cysts.  No  spots  of  ecchy- 
mosis  existed;  it  yielded  no  juice,  and  was  with  difficulty  disintegrated  by  pressure. 

The  operation  was  followed  by  a  pretty  acute  suppuration  of  the  cellular  tissue  of  the 
orbit,  which,  during  the  last  fortnight,  occasioned  considerable  swelling;  accompanied, 
however,  with  very  little  constitutional  disturbance,  and  no  inflammation  of  the  eye  itself. 
At  the  end  of  that  time,  the  tumefaction  began  to  subside,  and  the  eye  gradually  receded. 
About  the  end  of  September,  the  eye  had  resumed  its  natural  place,  or  was,  if  anything, 
a  little  more  sunk  than  the  other.  Vision  was  perfect;  but,  owing  to  the  injury  which 
the  inferior  rectus  had  sustained,  the  eye  was  directed  a  little  upwards.  He  could  roll  it 
with  ease  in  very  direction  excepting  downwards. 

A  second  microscopic  inspection  of  the  growth,  made  after  the  last  operation,  coincided 
in  its  results  with  the  former  one.  There  could  be  little  hesitation,  therefore,  in  assigning 
it  to  the  class  of  fibrous  tumors,  of  which  it  was  one  of  the  loose-textured,  cyst-containing 
variety,  which  had,  as  is  not  unusual,  undergone  interstitial  calcification  in  many  parts.'* 

Case  217. — Tumor  extirpated  through  a  perpendicular  incision  of  the  upper  eyelid — Disease 
returns.  Dr.  Monteath  shortly  states  the  case  of  a  young  girl,  who  had  a  tumor  on  the 
upper  and  outer  side  of  the  orbit.  In  order  to  get  at  it,  he  was  obliged  to  cut  through 
the  whole  perpendicular  length  of  the  upper  eyelid,  and  dissect  back  the  two  flaps.  The 
tumor  was  nearly  the  size  of  a  plum,  and  reached  as  far  back  as  the  eyeball.  It  was 
slightly  encysted,  perfectly  organized,  and  of  anomalous  texture.  The  healing  of  the 
wound  was  rapid,  and  contrary  to  expectation,  the  eyelid  reunited  perfectly,  and  regained 
very  nearly  its  natural  power  and  extent  of  motion.  The  eyeball  did  so  also,  and  the 
vision  was  perfect.  The  patient  went  to  England  some  months  after,  and  Dr.  M.  was  con- 
cerned to  learn  that  the  tumor  had  begun  to  grow  again. '^ 

Case  218. — Tumor  returns  from  not  being  completely  extirpated — Operation  rendered  difficult 
bg  patient's  resistance.  Mr.  Wardrop  relates,  that  a  young  woman,  of  a  robust  form,  had 
a  tumor  on  the  orbital  plate  of  the  left  frontal  bone,  the  base  of  which  adhered  firmly  to 
the  bone,  whilst  the  exterior  portion  was  attached  to  the  integuments,  in  which  there  was 
a  small  sinus  leading  into  the  interior  of  the  tumor.  The  diseased  mass  did  not  exceed 
the  bulk  of  an  almond,  but  it  was  attended  with  great  pain,  and  even  cautiously  touching 
the  orifice  of  the  sinus  with  a  probe  excited  violent  irritation.  A  tumor  had  been  ex- 
tirpated from  the  seat  of  this  swelling  some  months  previously,  a  portion  of  which,  adher- 
ing to  the  bone,  being  left  behind,  gave  origin  to  this  new  growth.  Though  she  had  come 
from  a  distance,  determined  to  get  the  disease  removed  by  an  operation,  if  it  was  con- 
sidered advisable,  yet  when  the  scalpel  touched  the  integuments,  she  made  a  violent 
resistance.  A  second  attempt  was  made,  she  being  previously  secured  on  a  table  with 
numerous  assistants;  but  such  was  the  force  and  exertion  she  made  to  extricate  herself, 
whenever  the  operation  was  about  to  be  begun,  that  every  hope  of  success  was  abandoned. 
It  now  occurred  to  Mr.  W.  as  the  only  resource  (the  antesthetic  use  of  ether  or  chloroform 
not  being  at  that  time  known),  that  if  she  would  allow  herself  to  be  bled  to  a  state  of 
deliquium,  the  tumor  might  be  extirpated  while  she  remained  insensible.  After  a  few 
days,  she  submitted  to  this  measure.  A  large  vein  was  freely  opened  while  she  sat  in  the 
erect  posture,  in  a  very  warm  room,  in  which  thei-e  were  seven  people,  with  the  doors  and 
windows  kept  shut  to  hasten  her  fainting.  No  less  than  50  ounces  of  blood  were  drawn 
before  she  fainted,  and  then  a  complete  state  of  syncope  came  on,  which  lasted  a  sufficient 
time  to  allow  the  tumor  to  be  removed.  The  operation  was  accomplished  with  great 
facility;  and  in  order  to  promote  an  exfoliation  of  the  diseased  portion  of  bone,  its  sur- 
face was  rubbed  over  with  kali  purum.  When  the  fainting  went  ofi",  she  would  not  believe 
that  the  operation  had  been  performed,  until  she  had  examined  her  face  in  the  glass.  She 
suffered  little  from  the  effects  of  the  operation ;  and  though  she  remained  pale  and  feeble 
22 


338  TUMORS   IN   THE   ORBIT, 

for  a  few  days  from  the  profuse  bleeding,  yet  in  a  -week  she  was  better  than  most  patients 
are  who  have  undergone  so  severe  an  operation.'^ 

Case  219. — Tumor  encircling  optic  nerve — Eyeball  extirpated.  A  young  adult  woman 
consulted  Dr.  Monteath  on  account  of  an  orbital  disease  of  two  years'  standing,  which 
had  produced  hideous  exophthalmos.  It  was  found  impracticable  to  extirpate  the  tumor 
without  also  removing  the  eyeball,  which  was  accordingly  done.  The  tumor  exceeded 
the  size  of  the  eyeball,  lay  directly  behind  it,  and  so  completely  encircled  the  optic  nerve, 
that  the  latter  was  diminished  one-half  in  thickness  by  the  pressure.  Vision  had  been 
rapidly  declining  previously  to  the  operation.  The  tumor  was  exceedingly  hard,  of  ano- 
malous texture,  and  surrounded  by  a  layer  of  condensed  cellular  substance.  The  anterior 
surface  of  the  tumor  touched  and  pressed  upon  the  posterior  surface  of  the  eyeball,  but 
had  no  connection  with  it  except  through  the  medium  of  the  optic  nerve  and  cellular  sub- 
stance.    Twenty  months  after  the  operation,  the  patient  continued  well.''' 

Case  220. — Death  from  erysipelas  after  extirpation  of  an  orbital  tumor.  Sir  George  Bal- 
lingall,  in  a  clinical  lecture  delivered  to  the  students  of  the  Royal  Infirmary  of  Edinburgh, 
in  March,  1828,  and  afterwards  printed  for  their  use,  states  that,  on  the  12th  of  Novem- 
ber, 1827,  James  Mcintosh  was  admitted  with  a  soft  movable  tumor  impacted  between 
the  roof  of  the  orbit  and  globe  of  the  right  eye.  The  superior  eyelid  was  protruded  out- 
wards and  considerably  inflamed,  as  well  as  the  conjunctiva  covering  the  surface  of  the 
tumor ;  the  ball  of  the  eye  was  depressed  by  the  swelling  towards  the  check.  The  struc- 
ture of  the  eye  appeared  perfectly  sound,  and  the  vision  unimpaired,  except  in  so  far  as 
it  was  partially  obstructed  by  the  projection  of  the  tumor,  which  obliged  the  patient  to 
throw  back  his  head,  and  to  elevate  his  face,  in  attempting  to  see  objects  placed  before 
him.  He  knew  of  no  accident  to  which  this  complaint  could  be  attributed,  assigning  its 
origin  to  exposure  to  cold  in  the  month  of  January  preceding.  In  July,  he  had  been  in 
the  Infirmary,  at  which  time  the  tumor  occupied  the  site  of  the  lachrymal  gland,  and  was 
not  above  a  fourth  of  the  size  it  had  attained  in  November.  He  was  urged  to  have  it  re- 
moved, but  would  not  consent,  although  told  that  he  would,  in  all  probability,  return 
with  it  at  a  future  period,  when  the  operation  would  be  more  difiScult.  This  accordingly 
happened;  and  in  November  he  was  solicitous  for  its  removal. 

The  operation  was  begun  by  dividing  the  superior  palpebra  upwards  and  outwards 
from  the  external  canthus.  After  dissecting  the  eyelid  from  the  surface  of  the  swelling, 
the  tumor  was,  with  much  diflSculty,  separated  from  the  contiguous  parts ;  a  pedicle  or 
neck,  by  which  it  was  found  adherent  to  the  very  bottom  of  the  orbit,  was  then  cut  across 
with  a  pair  of  probe-pointed  scissors,  and  some  small  portions  of  it  afterwards  removed. 

The  operation  was  followed,  in  the  first  instance,  by  a  very  moderate  degree  of  swell- 
ing and  inflammation — much  less,  indeed,  than  was  to  be  anticipated.  For  nearly  a  week 
the  case  had  a  favorable  aspect,  but,  at  the  end  of  this  time,  the  forehead  and  upper  part 
of  the  face  became  involved  in  erysipelatous  inflammation,  which  extended  over  the  whole 
head,  accompanied  with  delirium,  the  pulse  rising  as  high  as  150.  It  was  observed,  soon 
after  the  operation,  that  the  patient's  breath  was  imbued  with  the  mercurial  fetor,  which 
be  attributed  to  some  medicines  taken  before  his  admission.  The  urgent  symptoms  were 
somewhat  alleviated  by  bleeding,  both  general  and  topical,  the  internal  exhibition  of  anti- 
monials  and  saline  purgatives,  the  application  of  a  blister  to  the  nape  of  the  neck,  and 
the  use  of  an  anodyne  fomentation  to  the  inflamed  parts.  On  the  22d,  he  had  sunk  so 
low,  that  he  was  not  expected  to  live  through  the  night;  his  pulse  120,  his  breathing 
laborious,  and  his  extremities  cold,  with  low  muttering  typhoid  delirium.  From  this 
state  he  again  rallied  under  the  use  of  brandy  and  water,  beef  tea,  and  the  application  of 
a  second  blister  to  the  nape  of  the  neck.  A  copious  discharge  of  unhealthy  matter  had 
for  some  days  been  going  on  from  the  afi'ected  eye,  the  cornea  of  which  now  ulcerated, 
and  on  the  morning  of  the  27th,  the  crystalline  lens  was  discharged  through  the  opening. 
His  delirium  continued,  with  occasional  intermissions,  during  which  he  asked  for  and 
devoured  food  with  a  ravenous  appetite.  His  pulse  continued  frequent  and  weak,  his 
breath  fetid  and  offensive,  and  his  general  appearance  resembling  that  of  a  patient  in  the 
advanced  stages  of  typhus.  The  cuticle  separated  in  crusts  from  those  parts  of  the  head 
and  face  in  which  the  inflammation  had  been  seated ;  rigors  and  diarrhoea  latterly  super- 
vened, and  he  expired  on  the  evening  of  the  28th. 

Permission  could  not  be  obtained  to  examine  the  body;  but  a  hasty  examination  was 
made  of  the  head  and  parts  concerned  in  the  operation.  A  portion  of  the  principal  tumor 
was  found  still  adherent  to  the  sheath  of  the  optic  nerve,  and  several  small  melanotic 
tubercles  imbedded  in  the  fatty  matter  surrounding  the  muscles  of  the  eye.  Some  serous 
effusion  had  taken  place  both  on  the  surface  and  into  the  ventricles  of  the  brain.  Sir 
George  remarks,  that  if  he  had  been  fully  aware  of  the  nature  of  the  disease,  and  of  the 
deep  attachment  of  the  tumor,  he  should  have  proceeded  at  once  to  extirpate  the  whole 
.contents  of  the  orbit ;  but  having  succeeded  in  removing  the  bulk  of  the  tumor  with 
safety  to  the  eyeball,  he  felt  reluctant  to  change  the  plan  of  the  operation.     The  inflam- 


OSSEOUS   TUMORS   IN    THE   ORBIT.  339 

mation  immediately  succeeding  to  the  removal  of  the  tumor,  was  much  less  than  was  to 
have  been  expected  from  so  severe  an  operation ;  but  when  the  symptoms  of  erysipelas 
supervened,  it  was  obvious  that  the  case  became  one  of  a  very  perplexing  and  hazardous 
description.  The  patient's  system,  surcharged  with  mercury,  precluded  the  employment 
of  mercurial  purgatives,  so  often  beneficial  in  erysipelatous  inflammation,  and  it  had  been 
remarked  that,  even  when  in  the  hospital  in  July,  he  had  something  of  that  sallow 
cachectic  look  often  attendant  upon  internal  organic  disease,  and  which  rendered  him,  in 
Sir  George's  estimation,  an  unfit  subject  for  profuse  evacuations  of  blood.'^ 


'  On    Encysted    Tumors,    consult   Walther,  Ophthalmologie;    Vol.    ii.  p.    40;    Hannover 

Grafe   und    Walther's    Journal    der    Chirurgie  1819. 

und  Augenheilkunde;  Vol.  iv.  p.  386  ,:  Berlin,  '*  See  case  by  Hope,  in  which  after  fextir- 

1822:  Lawrence,  Medico-Chirurgical  Transac-  pation  of  an  orbital  tumor,  the  eyeball  was  re- 

tions;  Vol.  xvii.  p.  43;  London,  1832.  stored  to  its  place  by  the  pressure  of  a  steel 

'^  Griife  und  Walther's  Journal  der  Chirurgie  bandage;  Philosophical   Transactions  for  1744 

und  Augenheilkunde;  Vol.  vii.  p.  235;  Berlin,  and  1745,  Vol.  xliii.  p.  194;  London,  1748. 

1825.  '^  See  case  by  Robertson,  in  which  purulent 

^  Nosograpbie  Chirurgicale ;  Tome  ii.  p.  119;  effusion  on  the  surface  of  the  brain  took  place 

Paris,  1813.  after  extirpation  of  the  eyeball,  along  with  an 

'  Cases  and  Observations  in  Surgery,  p.  104;  orbital  tumor  ;  Northern  Journal  of  Medicine, 

London,  1806.  December,  1844. 

'  Delpech,  Chirurgie    Clinique  de  Montpel-  "  Medical  Times  and  Gazette,  November  6, 

lier;  Tome  ii.  p.  505;  Paris,  1828.  1852,  p.  465. 

^  Dublin  Journal  of  Medical  Science,  Vol.  "  Translation   of  Weller's  Manuel;  Vol.  i. 

xix.  p.  352;  Dublin,  1841.  p.  195;  Glasgow,  1821. 

■■  Nouveau  Traite  des   Maladies    des  Yeu.x,  "  Medico-Chirurgical  Transactions  ;  Vol.  x. 

p.  147;  Paris,  1722.  p.  275;  London,  1819. 

*  Neue  Bibliothek   fiir    die    Chirurgie   und  ''  Op.  cit.,  Vol.  i.  p.  196. 

Ophthalmologie;    Vol.   ii.   p.    238;    Hanover,  ''  On    Orbital   Tumors,  see   Acrel's  Chirur- 

1819.  gische  Vorfiille,  iibersetzt  von  Murray  ;  Vol.  i. 

"  Medical  Observations  and  Inquiries;  Vol.  p.   88;  Gbttingen,  1777;  Hedenus,   Grafe  und 

iv.  p.  371 ;  London,  1772.  Walther's  Journal  der  Chirurgie  und  Augen- 

'°  Medico-Chirurgical  Transactions;  Vol.  iv.  heilkunde;  Vol.  ix.  p.  267:  Berlin,  1826;  Del- 

p.  316;  London,  1813.  pech,  Op.  cit.,  pp.  92,  99. 

"  Neue   Bibliothek  fUr   die   Chirurgie   und 


SECTION  II. — OSSEOUS  TUMORS  IN  THE  ORBIT. 

Mr.  Lucas  has  related  the  following  case  of  bony  tumor,  arising  after  an 
injury,  and  successfully  extracted  from  the  orbit : — 

Case  221. — The  patient  was  a  farmer's  daughter,  28  years  of  age.  On  the  25th  of 
February,  1809,  she  received  a  blow  from  a  cow's  horn  on  the  upper  and  inner  angle  of 
the  left  orbit,  nearly  on  the  transverse  suture.  As  the  pain  soon  subsided,  it  was  con- 
sidered merely  a  slight  contusion,  and  little  attention  was  paid  to  it.  About  the  begin- 
ning of  March,  there  was  discovered  on  the  spot  where  the  blow  had  been  received,  a  small 
hai-d  tumor,  which  gradually  increased,  with  very  little  pain  and  no  interruption  to  her 
general  state  of  health,  so  that  she  continued  her  usual  laborious  employments  about  her 
father's  house.  On  the  1st  of  October,  she  consulted  Mr.  L.,  who  found,  covered  by  the 
upper  eyelid,  a  very  hard  tumor,  of  an  oval  form,  and  rather  flat,  somewhat  more  than 
an  inch  in  its  perpendicular  diameter,  and  extending  horizontally  about  an  inch  and  a 
half  in  length,  from  the  inner  angle  of  the  orbit  towards  the  eyeball,  which  was  dis- 
placed. The  tumor  seemed  to  occupy  the  greater  part  of  the  orbit,  and  had  forced  the 
eye  forwards  and  outwards,  so  that  it  hung  pendulous  and  loose,  and  apparently  entirely 
beyond  the  exterior  edge  of  the  outer  angle  of  the  orbit.  Mr.  L.  concluded  that  the  optic 
nerve  and  muscles  must  have  been  elongated  nearly  an  inch.  She  could  still  discover 
objects  with  the  eye,  although  its  sight  was  much  impaired.  She  complained  of  little  pain, 
even  when  the  tumor  was  pressed  or  handled  pretty  freely. 

Mr.  Lucas  resolved  to  ascertain  the  nature  of  the  tumor,  which,  although  hard,  appeared 
somewhat  loose.  With  this  view  he  made  a  horizontal  incision  through  the  upper  eyelid, 
about  an  inch  in  length,  along  the  greater  diameter  of  the  tumor.  On  separating  and 
raising  the  edges  of  the  wound,  the  tumor  was  discovered  to  be  a  solid  piece  of  bone, 
covered  only  by  the  common  integuments,  and  a  thin  membrane  somewhat  resembling 
periosteum,  to  which  the  tumor  was  but  slightly  attached.  No  part  of  the  bones  of  the 
orbit  was  denuded ;  and  although  the  manner  of  the  adhesion  of  the  tumor  to  the  sur- 
rounding parts  could  not  be  asce'rtained,  it  remained  firm  and  immovable,  notwithstanding 


340  SCIRRHUS  IN  THE   ORBIT. 

considerable  efforts  to  loosen  it  and  bring  it  away.  The  wound  made  by  the  incision  did 
not  heal  up,  but  continued  nearly  of  its  original  size,  discharging  a  small  quantity  of  thin 
matter.  The  bone  continued  to  increase  in  size,  and  the  eye  was  still  more  pushed  out 
of  its  natural  position,  although  some  degree  of  sight  still  remained.  The  patient  con- 
tinued in  perfect  health.  At  length,  towards  the  end  of  September,  1803,  the  bone 
becoming  carious  and  evidently  loose,  and  pushing  somewhat  forwards,  Mr.  L.  endeavored 
to  extract  it,  by  making,  with  a  small  scalpel,  an  incision  around  the  edges  of  the  former 
wound,  and  then  taking  firm  hold  of  it  with  a  pair  of  strong  forceps.  The  first  attempt 
failed ;  but  a  second,  made  several  days  afterwards,  succeeded.  Mr.  L.  extracted,  with- 
out  much  exertion  or  difiiculty,  a  piece  of  bone,  of  an  oblong  shape,  weighing  1  ounce 
and  2  drachms,  Ih  inch  in  length,  and  2|  inches  in  circumference,  hard,  solid,  and  pretty 
smooth.  The  extraction  of  the  bone  was  followed  by  no  hcemorrhagy ;  a  few  drops  of 
blood  only  were  discharged  from  the  edges  of  the  wound.  The  cavity  from  which  it 
was  extracted  was  found  to  be  lined  with  a  strong  membrane,  quite  smooth  on  the 
upper  and  inner  sides,  but  somewhat  uneven  on  the  side  next  the  ball  of  the  eye. 
No  perforation  or  communication  with  any  of  the  surrounding  parts  could  be  discovered 
in  it ;  when  examined  both  with  a  probe  and  the  finger,  little  irritation  or  pain  was 
produced,  and  the  tumor  had  evidently  no  connection  or  adhesion  with  any  bone  adjoin- 
ing to  it. 

In  March,  1805,  when  Mr.  L.  published  his  account  of  the  case,  the  wound  was  still 
open,  and  the  cavity  still  extended  in  a  straight  direction  backwards  to  the  depth  of  two 
inches.  A  little  lint,  covered  by  a  bit  of  silk,  hid  the  deformity.  Every  time  the  dressing 
was  removed,  the  inside  of  the  cavity  was  found  to  be  covered  with  a  slight  exudation. 
The  eyeball  had,  in  a  great  measure,  recovered  its  natural  situation,  and  the  sight  of  the 
eye  had  been  completely  restored. 

The  bone  extracted  in  this  case  was  particularly  examined  and  analyzed  by  Dr.  Duncan, 
junior,  who  published  two  figures  illustrating  its  external  appearance  and  internal  struc- 
ture. Its  shape  he  represents  as  extremely  irregular,  but  somewhat  resembling  a  wedge 
cut  out  of  a  sphere.  The  convex  back  of  the  wedge,  which  was  turned  towards  the  middle 
line  as  it  lay  in  the  orbit,  although  extremely  irregular  and  studded  with  processes,  was 
in  general  smooth  and  polished.  The  sides  were  concave,  and  much  less  uneven,  but  in 
no  part  had  a  smooth  or  polished  surface.  They  resembled  those  points  of  bone  to  which 
cartilage,  ligament,  or  membrane  is  firmly  attached,  being  covered  with  small  pits  or  de- 
pressions, and  rough,  as  if  corroded  by  the  action  of  a  caustic  fluid.  In  no  part,  after 
the  most  careful  examination,  did  it  show  any  appearance  of  fracture,  and  therefore  (con- 
cludes Dr.  D.)  could  not  have  been  an  exostosis.  Its  color  was  yellowish-white  ;  its  saw- 
dust snow  white.  It  was  extremely  hard.  When  cut,  its  internal  structure  was  found 
to  be  nearly  uniform,  somewhat  like  that  of  ivory,  being  very  slightly  marked  with  the 
appearance  of  radii,  extending  from  the  middle  of  the  edge  to  the  convex  back  of  the  wedge. 
It  admitted  of  being  polished  like  ivory.  In  specific  gravity  and  chemical  composition,  it 
scarcely  differed  from  a  piece  of  adult  os  femoris.' 

Case  222. — At  the  Glasgow  Eye  Infirmary,  July  -5,  1844,  Dr.  A.  Anderson  extirpated  an 
osseous  tumor  from  behind  the  lower  eyelid.  It  always  sank  back  out  of  reach  of  feeling 
through  the  eyelid,  till  the  upper  eyelid  was  pressed  back  into  the  orbit.  It  then  became 
prominent.  It  was  smooth  externally,  about  ^■*,  inch  in  diameter,  and  presented,  on  being 
divided,  layers  of  cartilage  and  bone. 


'  Edinburgh  Medical  and  Surgical  Journal;  Vol.  i.  pp.  405,  407  ;  Edinburgh,  1805. 


CHAPTER    IX, 


MALIGNANT  DISEASES  OF  THE  AREOLAR  AND  FIBROUS 
TISSUES  OF  THE  ORBIT. 


SECTION  I. — SCIRRHUS  IN  THE  ORBIT. 


The  areolar  and  fibrous  tissues  of  the  orbit  are  liable  to  become  the  seat 
of  scirrhus,  encephaloid  cancer,  and  melanosis.  Liable  as  those  tissues  are  to 
,the  many  and  various  morbid  afifections  already  considered,  the  fact  of  their 


SCIRRHUS   IN   THE   ORBIT.  341 

being  also  occasionally  involved  in  malignant  growths,  so  multiform  as  those 
now  mentioned,  adds  greatly  to  the  difficulty  of  accurate  diagnosis  in  diseases 
of  the  orbit. 

In  general,  only  one  kind  of  malignant  disease  occurs  in  the  orbit  at  once ; 
but  in  some  cases,  they  are  complicated,  either  one  with  another,  or  with 
encysted  tumors.  Encephaloid  tumor  is  deposited  in  some  instances  on  a 
scirrhous  base ;  and  not  unfrequently  melanosis  is  combined  with  encephaloid 
tumor. 

A  remarkable  circumstance  is,  that  in  some  cases  not  only  the  areolar  and 
fibrous  tissues  are  affected,  but  also  the  muscles,  and  the  lachrymal  gland ; 
while  the  eyeball  mei'ely  shrinks  from  compression,  its  textures  remaining 
totally  free  from  the  malignant  degeneration. 

The  areolar  tissue  near  the  front  of  the  orbit  sometimes  becomes  hard, 
tuberculated,  and  scirrhous.  Behind  the  eyeball,  it  has  been  found  in  the 
same  morbid  condition.  The  whole  of  the  areolar  and  fibrous  tissues 
between  the  walls  of  the  orbit  and  the  eyeball  may  become  infiltrated  with 
scirrhous  deposition,  compressing  the  eyeball,  and  protruding  it  from  the 
orbit. 

Case  TIZ. — A  piece  of  limestone  struck  the  outer  edge  of  the  orbit,  producing  a  lacerated 
wound  of  no  great  extent,  and  which  readily  healed.  Some  time  after,  a  small  hard 
swelling  formed  at  the  site  of  the  injury,  was  extirpated,  and  was  found  to  contain  a 
minute  fragment  of  limestone.  After  some  months,  another  small  tumor  made  its  ap- 
pearance in  the  same  spot,  and  in  connection  with  it  another,  attached  so  firmly  to  the 
edge  of  the  orbit  that  it  was  taken  for  an  exostosis.  In  a  few  weeks,  a  third  circum- 
scribed swelling  was  discovered  running  along  the  lower  edge  of  the  orbit,  more  movable 
than  that  last  mentioned,  but  as  firm  to  the  touch  as  a  piece  of  cartilage.  The  patient 
was  under  the  care  of  Mr.  Samuel  Clarke,  whom  I  assisted  at  the  removal  of  the  tumors. 
The  two  which  felt  so  like  exostoses,  lay  partly  within  the  orbit,  and  adhered  firmly  to  its 
periosteum.  On  making  a  section  of  them,  they  presented  the  white  striated  texture  of 
scirrhus.  The  extirpation  was  accomplished  after  a  semilunar  incision,  running  parallel 
to  the  outer  and  lower  edge  of  the  orbit,  and  every  particle  of  indurated  substance  was 
carefully  removed.  More  than  a  year  after  the  operation,  there  was  no  return  of  the 
disease. 

Case  224. — William  CuUen,  aged  44,  was  admitted  a  patient  at  the  Glasgow  Eye  In- 
firmary, 31st  July,  1835,  on  account  of  catarrho-scrofulous  inflammation  of  his  left  eye, 
a  large  portion  of  the  cornea  being  rough  and  opaque.  He  continued  to  attend  till  the 
15th  November,  the  eye  having  improved  by  the  use  of  leeches  to  the  temple,  a  blister 
behind  the  ear,  Plummer's  pill,  the  collyriuiu  hydrargyri,  and  red  precipitate  salve,  but 
the  cornea  still  continuing  nebulous. 

On  the  29th  July,  1841,  six  years  after  his  former  attendance,  he  returned  with  the  left 
orbit  filled  with  a  large  hard  tumor,  protruding  the  eyeball  and  eyelids,  and  adhering 
apparently  all  round  to  the  periorbita.  The  lids  were  much  extended  both  vertically  and 
horizontally,  covered  with  varicose  vessels  externally,  and  so  much  pressed  upon  by  the 
tumor,  that  scarcely  any  of  their  inner  surface  could  be  exposed.  The  conjunctiva, 
especially  towards  the  inner  canthus,  was  swollen  and  lobulated ;  the  cornea,  scarcely 
visible;  and  the  bulb  of  the  eye,  apparently  in  a  great  measure  disorganized.  The  tumor, 
which  filled  the  orbit,  was  judged  to  be  an  enlargement  of  the  eyeball;  but  this  the  event 
showed  to  be  a  fallacy.  The  seemingly  enlarged  eyeball  was  excessively  hard,  and  pro- 
jected fully  \  inch  out  of  the  orbit.  Its  surface  was  very  irregular,  and  its  motion  very 
limited.  Vision  was  almost  completely  extinct,  yet,  even  with  the  lids  closed,  the  patient 
could  discern  light  and  shade  with  the  eye.  The  lower  lid,  towards  its  inner  extremity, 
appeared  to  be  carcinomatous,  and  under  the  internal  angular  process  a  portion  of  the 
tumor  was  still  harder  than  the  rest,  and  more  firmly  adherent  to  the  periorbita.  The 
patient  stated  that  the  tumor  had  commenced,  several  years  before,  between  the  eye  and 
the  nose,  with  a  growth  on  the  white  of  the  eye,  and  that  the  eyeball,  previously  to  the 
tumor  appearing,  had  shrunk  in  size.  He  did  not,  in  general,  seem  to  sufi"er  much  pain, 
but  stated  that  frequently  he  felt  a  suppurative  pain  in  the  eyeball.  Pulse  72.  General 
health  good. 

2d  August.  The  external  commissure  of  the  left  lids  being  divided,  a  curved  needle 
armed  with  a  strong  thread,  was  passed  through  the  eyeball.  The  lids  were  then  dis- 
sected from  the  eyeball,  and  the  upper  lid  being  divided  vertically  near  the  union  of  its 
inner  third  with  its  two  outer  thirds,  the  tumor,  including  the  eyeball,  was  detached  and 


342  FUNGUS   H^MATODES   IN   THE   ORBIT. 

extracted.  Its  connection  with  the  periorbita  appeared  to  be  entirely  by  firm  carcino- 
matous substance.  In  endeavoring  to  dissect  away  what  remained  attached  to  the  walls  of 
the  orbit,  the  ophthalmic  artery  bled  very  freely,  and  the  patient  became  faint.  The  eye- 
lids, in  almost  their  whole  extent,  were  affected  with  the  carcinomatous  degenei'ation,  and 
were  removed.  The  orbit  was  stuffed  with  dry  lint,  and  firmly  covered  with  a  compress 
and  roller. 

On  examination  of  the  diseased  structure,  the  sclerotica  and  parts  within  it  were  found 
to  be  sound,  the  lens  transparent,  and  the  retina  entire,  but  the  eyeball  reduced  to  about 
two-thirds  of  its  normal  size  by  the  pressure  which  had  been  exercised  upon  it  by  the 
diseased  parts.  The  areolar  tissue  of  the  orbit  and  the  conjunctiva  were  converted  into 
a  substance  of  a  gristly  consistence,  with  white  bands  running  through  it,  and  the  muscles 
were  much  indurated,  and  immovably  fixed  in  the  cancerous  mass. 

The  remains  of  the  eyelids  soon  began  to  contract,  and  the  patient  was  dismissed  on 
the  7th  September.' 

'See  a  similar  case  by  Roux,  Reveu  Medicale;  Tome  iv.  p.  398;  Paris,  1832. 


SECTION  II. — FUNGUS  HiEMATODES  IN  THE  ORBIT. 

Mr.  Travers  tells  us  that  the  adipose  tissue  behind  the  eye  is  the  frequent 
seat  of  fungus  haematodes,  or,  as  he  terms  it,  medullary  cancer.  "  An  ex- 
traordinary globular  tumor,"  says  he,  "is  formed  around  the  ball,  of  which 
the  perished  cornea  forms  the  centre.  It  projects,  stretching  and  so  separat- 
ing the  lids,  that  they  gird  tightly  the  base  of  the  enormous  swelling.  I  have 
seen  children  subjects  of  this  affection.  The  growth  is  sometimes  confined 
to  the  upper  or  frontal  aspect  of  the  orbit.  The  upper  lid  is  then  prolonged 
and  stretched  over  the  globe  so  tightly  that  it  is  difficult,  if  practicable,  to 
obtain  a  view  of  the  latter.  The  medullary  matter  is  of  a  granular  or  ricy 
consistence,  and  pervades  and  destroys  the  muscles,  periosteum,  and  finally 
the  bony  vault  of  the  orbit.  I  have  seen  its  extirpation  boldly  performed  ; 
but  its  reappearance  has  been  almost  immediate,  and  its  progress  quick  to 
destruction."^ 

Fungus  haematodes  has  been  met  with,  affecting  the  substance  of  the  optic 
nerve,  while  the  eyeball  remained  sound, ^  and,  in  other  cases,  it  has  been 
seated  within  the  sheath,  which  the  optic  nerve  derives  from  the  dura  mater, 
the  nerve  itself  not  being  affected.*  Such  a  growth,  in  an  advanced  stage, 
will  not  only  fill  the  back  part  of  the  orbit,  but  project  by  the  side  of  the 
protruded  eye,  giving  rise  to  the  appearances  described  by  Mr.  Travers. 

Exactly  as  the  areolar  and  fibrous  tissues  of  the  orbit  are  sometimes  in- 
filtrated by  scirrhous  deposition,  so  are  they  in  other  cases  by  encephaloid. 
The  following  instance  of  this  is  recorded  by  Dr.  Robertson : — 

Cast  225. — In  Mrs.  Walker,  aged  G2,  the  left  ej'e  had  been  in  a  weak  state  since  child- 
hood, and  had  been  the  subject  of  repeated  attacks  of  inflammation,  which  had  always 
yielded  to  the  usual  remedies.  After  the  last  attack  of  inflammation,  and  about  three 
years  before  having  the  contents  of  the  orbit  removed,  a  fleshy  elevated  ring  formed 
round  the  cornea,  and  remained  stationary  for  about  a  year  and  a  half;  it  then  began 
slowly  to  enlarge,  and  continued  to  do  so  in  spite  of  leeches,  blisters,  mercurials,  and 
every  kind  of  lotion.  The  swelling  appeared  to  have  proceeded  from  the  margin  of  the 
cornea  backwards,  gradually  projecting  the  eye  from  the  socket.  For  two  years  she  had 
suffered  from  severe  lancinating  pains  passing  from  the  eye  to  the  temple  and  occiput. 
The  transparency  of  the  cornea  and  the  functions  of  the  retina  remained  unimpaired 
until  about  three  months  before  the  operation,  when  vision  failed,  the  cornea  becoming 
opaque,  probably  in  consequence  of  the  inflammation  caused  by  the  constant  exposure  of 
the  eye  to  the  air  and  light,  the  lids  being  no  longer  capable  of  closing  over  the  eyeball. 
Her  health  and  strength  had  been  failing  under  constant  pain  and  want  of  sleep.  After 
excision  of  the  contents  of  the  orbit,  she  made  a  rapid  recovery.  She  died  from  general 
decay,  without  any  marked  disease,  twelve  years  after  the  performance  of  the  operation. 

On  making  a  transverse  section  of  the  eyeball  after  excision,  its  membranes  and  their 


MELANOSIS  IN  THE   ORBIT.  343 

contents  were  found  perfectly  healthy.     Exterior  to  the  sclerotic,  and  under  the  con- 
junctiva, the  eye  was  surrounded  by  a  dense  mass  of  medullary  sarcoma.* 

The  periorbita  is  sometimes  the  structure  whence  encephaloid  cancer  takes 
its  rise  ;  and  in  this  case  the  bones  are  apt  to  suffer.  Occasionally  the  tumor 
which  fills  the  orbit  originates  from  one  or  other  of  the  neighboring  cavities; 
and  this  may  not  be  detected  till  an  attempt  is  made  at  extirpation. 


'  MecUco-Chirurgical  Transactions;  Vol.  xv.  formation  of  such  a  tumor  the  nerve  must  have 

p.  238.     London,  1829.  undergone  an  extraordinary  degree  of  elonga- 

°  Wishart,  Edinburgh  Medical  and  Surgical  tion,  within  a  very  limited  portion  of  its  normal 

Journal;    Vol.   xi.  p.  274;    Edinburgh,   1833.  extent. 

Schott  states  (Controverse  iiber  die  Nerven  des  '  Panizza,    Annotazioni    Anatomico-Chirur- 

Nabelstrangs  ;     Advertisement     at    the    end;  giche   sul  Fungo  MidoUare    dell'   Occhio,    pp. 

Frankfurt  am  Main,  1836),  that  he   extirpated  106,  107;  Tav.  iii.  fig.  1;  Pavia,  1821. 

the    eye    in   a  case  where  fungus    hamatodes  ^  Northern  Journal  of  Medicine,  December, 

formed  a  tumor  as  big  as  a  hen's  egg  in  tho  1844,  pi.  vi.,  fig.  14,  and  pL  vii.,  fig.  15.     See 

optic  nerve,  from  the  foramen  opticum  to  within  case   by  Velpeau,   Annales    d'Oculistique,    ler 

an  inch  of  the  eyeball.    He  removed  the  whole  vol.    supplementaire,    p.    16;    Bruxelles,  1842. 

contents  of  the  orbit  in  1829,  and  the  patient  Case  by  Maisonneuve;  Ibid.,  p.  19.     Case  by 

continued   well    in   1836.     As  the  optic   nerve  Jacob  ;    Dublin  Medical  Press,  December  25, 

from  the  foramen  opticum  to  the  sclerotica  raea-  1850,  p.  402. 
Eures  only  IJ  inch  in  length,  to  permit  of  the 


SECTION  III. — MELANOSIS  IN  THE  ORBIT. 

Case  226. — A  fatal  case  of  melanosis  of  the  liver  is  recorded'  by  Chomel,  in  which  the 
cellular  membrane  of  the  orbit  was  affected  with  the  same  disease.  The  right  eye  was 
inflamed,  and  projected  remarkably  from  the  orbit.  An  abscess  occupied  the  lower  third 
of  the  cornea,  and  the  patient  saw  very  obscurely  with  this  eye,  behind  which  there  was 
found,  on  dissection,  a  round  melanotic  mass,  about  an  inch  in  diameter.  It  seemed  to 
be  formed  at  the  expense  of  the  cellular  membrane  at  the  bottom  of  the  orbit,  and  had 
displaced  the  optic  nerve,  without  altering  its  texture. 

Case  227. — A  farmer,  aged  51,  had  complained,  twenty-five  years  before,  of  loss  of 
vision,  and  slight  projection  of  the  eyeball,  which  symptoms  yielded  to  the  use  of  iodine. 
Since  that  time,  the  eyeball  had  been  very  prominent  at  two  other  periods,  but  was  again 
replaced  by  the  same  remedies.  It  had  now  protruded  from  the  orbit  for  two  years,  and 
notwithstanding  every  effort  to  reduce  the  tumor,  the  eye  was  continuing  to  advance. 
When  the  contents  of  the  orbit  were  removed  by  M.  J.  B.  Fife,  the  eye  was  projected 
beyond  the  lids  by  an  elastic  fungoid  tumor,  which,  covered  by  the  thickened  and  con- 
gested conjunctiva,  encircled  the  eyeball  in  such  a  manner  that  the  cornea  was  alone 
visible.  Until  within  a  few  months  preceding  the  operation,  no  pain  attended  the  pro- 
gress of  the  disease. 

The  whole  of  the  contents  of  the  orbit  were  removed  without  difficulty.  The  hemor- 
rhage was  very  profuse,  but  quickly  ceased  on  plugging  the  cavity.  The  tumor  entirely 
fiUed  the  orbit,  and  on  being  cut  open  was  found  as  black  as  coal ;  it  was  encrusted  with 
a  covering  of  cellular  tissue,  which  also  ran  into  the  intei-ior  of  it,  separating  the  whole 
into  lobules ;  in  structure  it  was  soft,  and  consisted  of  a  cellular  tissue,  infiltrated  with 
pigment,  which  was  readily  washed  out  of  the  tissue  when  incised.  The  pigment  under 
the  microscope  exhibited  innumerable  dark-brown  organic  granules,  existing  singly,  or 
aggregated  together  in  compound  granular  cells  of  great  variety  of  size  and  form,  together 
with  numerous  oil  globules,  with  faint  outlines,  containing  in  their  interior  small  shining 
granules,  and  occasionally  other  smaller  cells  of  similar  appearance  to  themselves;  also 
cells  of  varying  size,  with  thick  dark-brown  walls,  only  very  slightly  transparent,  and 
containing  in  the  cell-walls  numerous  dark  granules,  and  occasionally  nuclei.  These 
latter  cells  appeared  as  if  they  were  the  colorless  cells  transformed  by  growth  and  the 
acquisition  of  pigment  into  the  peculiar  cell  of  melanosis. 

Three  months  after  the  operation,  the  patient  reported  himself  as  being  quite  well.* 

With  respect  to  the  propriety  of  operating  in  cases  of  malignant  diseases 
affecting  the  areolar  and  fibrous  tissues  of  the  orbit,  notwithstanding  the  suc- 
cess which  has  in  a  few  instances  attended  the  removal  of  the  diseased  parts, 
the  practice  is  in  general  not  to  be  commended.  It  is  in  adults  only,  and 
even  in  them  very  rarely,  that  the  extirpation  of  malignant  growths  from  the 


344  ANEURISM  OP  THE  OPHTHALMIC  ARTERY, 

orbit  has  been  attended  with  permanent  recovery.  A  case  of  apparent  suc- 
cess in  a  child  affected  with  medullary  cancer  in  the  orbit,  in  whom  extirpa- 
tion was  performed  by  Mr.  Lloyd,  was  published  in  the  Medical  Times  and 
Gazette,  JSTovember  6,  1852;  but  in  the  same  periodical  for  July  16,  1853, 
it  is  stated  that  the  disease  returned,  even  before  the  child  left  the  hospital. 
Within  a  month  of  the  time  when  she  returned  home  she  was  seized  with  head 
symptoms,  and  died,  a  large  mass  of  soft  cancer  being  found  in  the  brain. 


'  Nouveau  Journal  de  Medecine;  Tome  iii.  cal  Times  and  Gazette,  September  4,  1852;  p. 

p.  41  ;  Paris,  1818.  248.     Case  by  "Wordsworth,  in  which  operation 

"^  Medical  Gazette;  Vol.  xlvii.  p.  .344;  Lon-  was  abandoned,  after  exploratory  incision,  and 

don,  1851.  microscopic  examination  of  a  small  portion  of 

See  case  by  Lightfoot,  of  melanotic  tumor  of  the  tumor;  Ibid.,  May  21,  1853,  p.  525. 
the  orbit,  unconnected  with  the  eyeball ;  Medi- 


CHAPTER    X. 
INTRAORBITAL  ANEURISMS. 


SECTION  I. — ANEURISM  OF  THE  OPHTHALMIC  ARTERY. 

LiEa;  the  internal  carotid  by  the  side  of  the  sella  Turcica,  the  anterior 
cerebral,  and  other  arteries  within  the  cranium,  the  ophthalmic  artery  within 
the  orbit  is  subject  to  true  aneurism. 

Case  228. — Mr.  Guthrie'  saw  a  case,  in  which  both  ophthalmic  arteries  were  dilated, 
and  which  terminated  fatally.  The  symptoms  were  similar  to  those  of  aneurism  by  anas- 
tomosis, but  no  tumor  could  be  perceived.  The  eye  was  protruded  until  it  seemed  to  be 
exterior  to  the  orbit,  but  vision  was  scarcely  affected.  A  hissing  noise  in  the  head  could 
be  distinctly  heard,  and  was  attributed  to  aneurism.  On  the  death  of  the  patient,  an 
aneurism  of  the  ophthalmic  artery  was  discovered  on  each  side,  of  about  the  size  of  a 
large  nut.  The  ophthalmic  vein  was  greatly  enlarged,  and  obstructed  near  where  it 
passes  through  the  sphenoid  fissure,  in  consequence  of  a  great  increase  of  size  which  the 
four  recti  muscles  had  attained,  accompanied  by  an  almost  cartilaginous  hardness.  This 
state  of  the  muscles  had  been  as  much  concerned  in  the  protrusion  of  the  eye  as  the 
enlargement  of  the  vessels.  The  disease  existing  on  both  sides  prevented  Mr.  Guthrie 
from  proposing  any  operation  on  the  carotid,  to  which,  indeed,  he  thinks,  the  patient 
would  not  have  submitted. 

Case  229. — Mr.  Busk  records  a  case  of  aneurismal  tumor  in  the  orbit,  which  he  regards 
as  having  been  a  true  aneurism  of  the  ophthalmic  artery,  or  of  some  one  of  its  branches. 
In  consequence  of  a  severe  blow  on  the  right  side  of  the  head,  from  the  gaff  of  the  vessel 
to  which  he  belonged,  a  seaman,  aged  20,  became  affected  with  insensibility,  which  con- 
tinued till  next  day,  hemorrhage  from  the  right  ear,  deafness  on  that  side,  palsy  and 
numbness  of  the  left  side  of  the  face,  and  palsy  of  the  muscles  of  the  left  eye.  In  con- 
sequence of  the  palsy  of  the  orbicularis,  the  left  eye  inflamed,  an  onyx  formed,  and  the 
'lower  half  of  the  cornea  became  opaque.  More  than  six  months  had  elapsed  from  the 
time  of  the  accident,  when  Mr.  B.  detected  a  distinct  pulsation  of  the  globe,  and  on  more 
close  examination,  a  firm  pulsating  tumor  in  the  upper  and  inner  part  of  the  left  orbit, 
immediately  within  the  superciliary  ridge.  It  measured  about  \  inch  in  its  long  diameter, 
appeared  to  be  situated  between  the  levator  of  the  eyelid  and  the  bone,  and  was  not 
visible  externally.  When  the  eyelid  was  raised,  it  caused  some  projection  of  the  conjunc- 
tiva. Its  pulsation  was  accompanied  by  a  distinct  thrill,  which  could  also  be  felt  on 
pressing  the  parts  in  its  immediate  neighborhood.  Through  a  small  ivory  stethoscope  it 
gave  a  loud  whizzing  sound,  which  could  be  heard  also  on  applying  the  instrument  over 
the  inner  canthus  of  the  right  eye,  and  on  the  left  side  of  the  frontal  bone,  as  high  as  the 
roots  of  the  hair,  and  nearly  as  far  back  as  the  ear.  The  eye  felt  hot  and  uneasy ;  but, 
otherwise,  the  patient  had  no  pain,  and  complained  principally  of  noises  in  the  head. 

As  pressing  on  the  left  common  carotid  stopped  the  pulsation  in  the  tumor  and  eye, 
as  well  as  the  sounds  heard  through  the  stethoscope,  and  the  tinnitus  aurium,  it  was  clear 


ANEURISM  or  THE  OPHTHALMIC  ARTERY.  345 

they  depended  on  a  common  cause,  and,  probably,  on  an  aneurism  of  gome  vessels  within, 
or  close  upon,  the  orbit.  Mr.  B.,  therefore,  tied  the  common  carotid;  two  days  after 
which,  no  remains  of  the  tumor  could  be  felt,  all  pulsation  was  gone  from  the  orbit,  no 
sound  could  be  heard  by  means  of  the  stethoscope,  and  the  internal  noises  were  removed. 
The  eye  became  less  vascular,  and  not  so  prominent.  The  cure  of  the  aneurism  was  in 
fact  complete. 

Mr.  B.  is  inclined  to  think  that  not  only  this  case,  but  also  the  cases  (see  next  section) 
operated  on  by  Mr.  Travers  and  Mr.  Dalrymple,  were  instances  not  of  aneurism  by  anas- 
tomosis, but  of  true  aneurism.  He  grounds  this  opinion  on  the  following  particulars: 
1.  The  sudden  accession  of  the  disease,  attended  with  pain.  2.  Its  rapid  increase.  3. 
The  powerful  pulsation  in  the  tumors,  when  recent  and  small.  4.  The  strong  aneurismal 
whizzing  sound,  which,  in  his  case,  was  heard  over  so  extended  a  space.^ 

With  regard  to  these  arguments,  it  may  be  remarked  that  both  strong 
pulsation  and  distinct  arterial  susurrus  attend  aneurism  by  anastomosis. 
Rapid  increase  of  the  symptoms  might  attend  both  true  and  anastomotic 
aneurism.  The  suddenness  of  the  attack  is  the  fact  most  indicative  of  true 
aneurism  in  the  cases  in  question. 

The  following  case  has  been  published  as  one  of  true  aneurism  within  the 
cavity  of  the  cranium.  The  part  which  the  eye  took  in  the  disease  will  vin- 
dicate my  introducing  it  here. 

Case  230.— In  1836,  the  patient  had  become  subject,  at  irregular  periods,  to  pain  over 
the  right  eye,  which  gradually  increased,  both  in  frequency  of  occurrence,  and  in  attendant 
suffering.  Before  the  expiration  of  the  second  year,  the  eye  was  considerably  protruded 
from  the  orbit.  In  1839,  the  right  temple,  as  well  as  the  eye,  was  morbidly  prominent, 
and  about  this  time  the  pain  became  so  excruciating  as  to  occasion  delirium,  one  attack  of 
which  was  protracted  to  fifteen  days.  Occasional  severe  pain  was  at  this  period  experienced 
also  in  the  left  side  of  the  face  and  temple.  During  the  winter  of  1838-9,  for  a  number 
of  weeks,  the  patient's  suffering  was  incessant,  but  was,  finally,  much  lessened  after  a 
copious  spontaneous  discharge,  from  the  nostrils,  of  a  yellow  fluid.  Increased  sufl"ering, 
ever  after,  succeeded  to  any  interruption  of  this  nasal  discharge.  His  right  eye  became 
entirely  useless  in  regard  to  distant  objects,  and  in  his  right  ear  he  was  perfectly  deaf. 

To  the  examiner,  the  first  object  which  at  this  period  attracted  attention,  was  the  pro- 
truded eye,  which  was  about  \  inch  in  advance  of  the  other.  The  inferior  and  external 
portion  of  the  os  frontis,  including  the  orbital  plate  and  the  external  half  of  the  super- 
ciliary ridge,  along  with  corresponding  portions  of  the  parietal,  temporal,  and  sphenoid, 
separated  from  the  bodies  of  these  bones,  were  involved  in  one  common  enlargement  of 
the  temple  and  side  of  the  head.  The  whole  of  the  enlarged  mass  communicated  to  the 
touch  the  thrill,  characteristic  of  aneurism,  while  the  eyeball,  viewed  laterally,  presented 
an  alternate  protrusion  and  recession,  corresponding  to  the  action  of  the  heart. 

Much  of  the  suifering  of  the  patient  was  allayed  by  the  treatment  preparatory  to  opera- 
tion, consisting  in  the  use  of  plainly  dressed,  easily  digested  food,  in  moderate  quantities, 
with  such  evacuants  as  were  necessary  to  place  the  digestive  organs  in  a  favorable  state ; 
and  in  the  month  of  January  a  ligature  was  applied  to  the  common  carotid  artery,  by 
Professor  Dudley,  of  Lexington.  The  eS'ect  of  the  ligature  was  immediately  sensible  in 
the  eye,  and  all  the  right  side  of  the  head  and  face.  The  eye  gave  no  more  evidence  of 
pulsation,  the  circulation  in  the  integuments  immediately  became  languid,  and  the  tense- 
ness of  the  whole  parts  involved  in  the  enlargement  was  greatly  lessened,  while  the 
patient  expressed  himself  as  being  suddenly  relieved  of  all  noise  and  motion  in  the  head. 

The  rapid  subsidence  of  the  tumid  state  of  all  the  parts  involved,  by  the  end  of  the 
first  week  after  the  operation,  rendered  manifest  the  changes  they  had  undergone.  Iso- 
lated spiculse  could  then  be  distinctly  traced,  beginning  about  the  centre  of  the  super- 
ciliary ridge,  and  invading  portions  of  the  parietal  and  temporal  bones ;  while  the^  little 
finger  could  be  pressed  into  a  vacuity,  at  the  outer  angle  of  the  eye,  corresponding  to 
the  transverse  suture.  By  the  twentieth  day  from  the  operation,  the  lines  of  separation 
between  the  bones  had  become  obscure,  the  spiculse  were  indistinct,  and  the  whole 
enlargement  was  rapidly  on  the  decline.  The  eye,  now  restored  almost  to  its  natural 
position  in  the  orbit,  had  recovered  its  usefulness  for  distant  objects,  and  the  ear,  which 
had  been  deaf,  was  now  as  acute  as  the  other.  Six  months  after  the  operation,  the 
patient  was  in  the  enjoyment  of  good  health,  and  engaged  in  the  labors  of  a  blacksmith.^ 


'  Lectures  on  the  Operative  Surgery  of  the        '  American  Journal  of  the  Medical  Sciences, 
Eye,  p.  158  ;  London,  1823.  January,  1843,  p.  173. 

^  Medico-Chirurgical  Transactions;  Vol.  sxii. 
p.  124;  London,  1839. 


346  ANEURISM  BY   ANASTOMOSIS  IN  THE   ORBIT. 


SECTION  II. — ANEURISM  BY  ANASTOMOSIS  IN  THE  ORBIT. 

The  disease  so  well  described  by  Mr.  John  Bell  under  the  name  of  aneurism 
from  anastomosis,  does  not  appear  in  every  instance  to  arise  from  an  original 
malformation,  such  as  we  observe  in  ntevus  maternus;  but  may  begin  in  ap- 
parently healthy  adults,  from  sudden  and  sometimes  hidden  causes.  Neither 
is  it  confined  to  the  skin  or  subcutaneous  areolar  tissue,  but  affects  indis- 
criminately all  parts  of  the  body,  and  brings  on  complicated  morbid  pheno- 
mena even  among  the  viscera.  Numerous  cases  are  now  recorded,  in  which 
aneurism  by  anastomosis  has  arisen  within  the  orbit,  characterized  by  pain  in 
the  eye  and  head,  a  peculiar  sensation  compared  to  a  snap  or  crack,  followed 
by  a  whizzing  noise  in  the  head,  blindness,  protrusion,  and  pulsation  of  the 
eye,  and  pulsatory  or  aneurismal  swellings  between  the  eye  and  the  orbit. 
The  instances  which  have  occurred  of  this  disease  in  the  orloit  have  been  too 
few  to  permit  us  to  describe  from  actual  observation  its  ultimate  effects  and 
termination ;  but  reasoning  from  the  history  of  aneurisms  by  anastomosis  in 
other  parts  of  the  body,  we  cannot  doubt  that  the  progress  of  the  disease 
would  be  equally  rapid  in  this  situation,  the  bleedings,  if  the  complaint  were 
neglected,  alarming  and  dangerous,  and  the  issue  fatal.  It  is  probable  that 
orbital  aneurism  by  anastomosis  will,  like  the  same  disease  in  other  parts  of 
the  body,  be  sometimes  passive  or  venous,  and  in  other  cases  active  or  arterial. 
It  seems  to  be  more  frequently  the  latter. 

I  have  already  quoted  (p.  191)  from  Mr.  Abernethy  a  case  of  nsevus  ma- 
ternus of  the  upper  eyelid,  in  which  the  disease  extended  also  into  the  orbit, 
and  of  which  a  cure  was  effected  by  the  simple  abstraction  of  heat,  by  means 
of  folded  linen,  wet  with  a  saturated  solution  of  alum  in  rose  water,  and  kept 
constantly  applied  over  the  tumor.  This  mode  of  treatment,  however,  and 
also  that  of  pressure  on  the  aneurism,  are  evidently  inapplicable  when  this  dis- 
ease is  situated  deep  within  the  orbit.  To  puncture  an  aneurism  by  anasto- 
mosis, and  trust  to  the  obliteration  of  the  tumor  by  the  pressure  of  the 
extravasated  blood,  a  practice  which  in  external  ntevi  has  succeeded,  and 
which  seems  actually  in  one  case  of  orbital  aneurism  by  anastomosis  to  have 
been  followed  by  a  cure,*  would  also  be  altogether  unwarrantable.  Neither 
can  incision  be  had  recourse  to  in  such  a  case,  unless  we  resolve  at  once  to 
remove  the  whole  contents  of  the  orbit ;  and  even  were  the  patient  ready  to 
submit  to  this  operation,  could  we  with  safety  attempt  it,  knowing,  as  we  do 
from  the  recorded  histories  of  many  aneurisms  by  anastomosis,  the  innumer- 
able sources  from  which  such  tumors  are  supplied  with  blood,  the  great 
dilatation  which  the  neighboring  bloodvessels  commonly  present,  and  the 
difficulty  which  has  often  been  experienced  in  arresting  the  hemorrhage  at- 
tendant on  attempts  to  extirpate  tumors  of  this  nature  ?  Dr.  Rognetta  tells'' 
us  he  had  twice  seen  Dupuytren  extirpate  the  eye  on  account  of  aneurism  by 
anastomosis  in  the  orbit;  but  we  cannot  ground  any  conclusion  on  so  vague 
a  report. 

The  only  other  mode  of  treatment  likely  to  impede  the  progress  of  an 
anastomotic  aneurism  within  the  orbit,  is  to  diminish  the  quantity  of  blood 
and  the  force  of  the  circulation  through  the  tumor,  by  applying  a  ligature  to 
the  common  carotid  artery.  It  is  probable,  that  the  ultimate  effect  is  not  to 
obliterate  the  enlarged  vessels,  but  that  they  remain  pervious,  only  recovering 
their  natural  calibre.  We  owe  the  first  proof  of  the  efficacy  of  this  plan,  not 
only  in  preventing  the  increase,  but  even  in  effecting  the  cure  of  this  disease, 
to  Mr.  Travers.  His  example  has  been  followed  by  Mr.  Dalrymple,  of  Nor- 
wich, who  has  published  a  second  highly  interesting  example  of  the  efficacy 
of  the  operation  j  while,  still  more  recently,  Mr.  Wardrop  has  demonstrated 


ANEURISM  BY   ANASTOMOSIS  IN   THE   ORBIT.  341 

(see  p.  199)  that  similar  good  effects  maybe  expected  from  tying  the  carotid, 
in  cases  of  extensive  nsevus  occupying  the  external  parts  of  the  face.  The 
cases  by  Mr.  Travers  and  Mr.  Dalrymple  are  valuable,  not  only  as  proofs  of 
the  efficacy  of  the  mode  of  treatment,  but  as  illustrations  of  the  origin,  pro- 
gress, and  effects  of  the  disease.  I  shall,  therefore,  quote  them,  almost  with- 
out abridgment.  At  the  same  time,  there  is  a  suggestion  made  by  Mr.  Hodg- 
son,'' which  is  worthy  of  notice,  namely,  that  in  similar  cases  it  would  be 
advisable  to  aid  the  process  of  cure,  after  the  operation,  by  depletion  and 
abstinence.  In  Mr.  Travers'  patient,  the  diminution  of  the  tumor  was  very 
remarkable  after  violent  discharges  of  blood  from  the  uterus.  A  very  spare 
diet,  and  the  avoidance  of  all  violent  exercise,  in  conjunction  with  repeated 
bloodletting,  have  of  themselves  been  sufficient  to  cure  carotid  aneurism.* 
The  observance  of  a  similar  regimen  must  be  highly  proper,  after  the  appli- 
cation of  a  ligature  to  the  carotid,  in  any  case  of  aneurism  by  anastomosis. 

Case  231. — Frances  StofFell,  aged  34,  a  healthy  active  woman,  the  mother  of  five  chil- 
dren, on  the  evening  of  the  28th  of  December,  1804,  being  some  months  advanced  in 
pregnancy,  felt  a  sudden  snap  on  the  left  side  of  her  forehead,  attended  vrith  pain,  and 
followed  by  a  copious  effusion  of  a  limpid  fluid  into  the  cellular  substance  of  the  eyelids 
on  the  same  side.  For  some  days  preceding,  she  had  complained  of  a  severe  pain  in  the 
head,  which  was  now  increased  to  so  great  a  degree,  that  for  the  space  of  a  week  she  was 
unable  to  raise  it  from  the  pillow.  The  oedematous  swelling  surrounding  the  orbit  was 
reduced  by  punctures;  an  issue  was  set  in  the  temple  for  a  smart  attack  of  ophthalmia 
which  supervened,  and  leeches  and  cold  washes  were  applied.  She  now  first  perceived  a 
protrusion  of  the  globe  of  the  eye,  with  dimness  of  sight,  and  the  appearance  of  a  cir- 
cumscribed tumor,  elastic  to  the  touch,  and  as  large  as  a  hazelnut,  upon  the  infra-orbi- 
tary  ridge.  Another  softer  and  more  difl'used  swelling  arose  at  the  same  time  above  the 
tendon  of  the  oi-bicu'laris  palpebrarum.  The  lower  tumor  communicated  both  to  the  sight 
and  the  touch,  the  pulse  of  the  larger  arteries ;  the  upper  gave  the  sensation  of  a  strong 
vibratory  thrill.  The  swellings  grew  slowly,  and  the  skin  between  the  eyes,  as  well  as 
that  of  the  lower  eyelid,  became  puffed  and  thickened.  The  globe  of  the  eye  was  gra- 
dually forced  upwards  and  outwards,  and  its  motions  considerably  impeded.  She  had  a 
constant  noise  in  her  head,  which,  to  her  sensation,  exactly  resembled  the  blowing  of  a 
pair  of  bellows.  The  pulsatory  motion  of  the  tumors  was  much  increased  by  agitation  of 
mind,  or  strong  exercise  of  body,  but  the  most  distressing  of  her  symptoms  was  a  cold 
obtuse  pain  in  the  crown  of  the  head,  occasionally  shooting  across  the  forehead  and  tem- 
ples. She  was  compelled  to  rest  the  left  side  of  her  head  on  her  hand  when  in  the  recum- 
bent posture,  and  found  the  beating  and  noise  to  increase  sensibly  when  her  head  was  low 
and  unsupported. 

Such  was  the  substance  of  the  patient's  report,  when  Mr.  Travers  was  requested  to  see 
her.  He  found  the  skin  in  the  region  of  the  orbits  morbidly  thick  and  wrinkled,  the  eye- 
brow of  the  diseased  side  pushed  two  or  three  lines  above  the  level  of  the  opposite  one, 
and  the  hollow  of  the  orbit  lost  from  the  elevation  of  the  globe  of  the  eye.  The  upper 
half  of  the  inner  canthus  was  filled  by  the  thrilling  tumor,  which  afforded  a  loose  woolly 
sensation  to  the  touch,  was  very  compressible,  and,  when  firmly  pressed,  was  felt  slightly 
to  pulsate.  The  veins  of  the  upper  lid  and  on  the  sides  of  the  nose  were  varicose,  and 
the  skin  was  much  pursed  over  the  lachrymal  sac.  The  lower  tumor,  which  projected 
above  the  infra- orbitary  foramen,  was  of  a  conical  shape,  firm,  but  elastic  to  the  touch. 
It  could  be  emptied,  or  pressed  back  into  the  orbit,  but  the  pulsation  then  became  violent; 
and  from  the  increased  pressure  of  the  globe  upon  the  roof  and  side  of  the  orbit,  the 
pain  was  insupportable.  Careful  compression  of  the  temporal,  angular,  and  maxillary 
arteries,  produced  no  effect  on  the  aneurism.  Upon  applying  the  thumb  to  the  trunk  of 
the  common  carotid,  Mr.  T.  found  the  pulsation  to  cease  altogether,  and  the  whiz  of  the 
little  swelling  to  be  rendered  so  exceedingly  faint,  that  it  was  difficult  to  determine  whe- 
ther it  continued  or  not.  The  recent  increase  of  pufiBness  in  the  skin  over  the  root  of  the 
nose,  and  below  the  inner  angle  of  the  opposite  eye,  had  given  alarm  to  the  patient  and 
her  friends,  who  feared,  not  without  some  appearance  of  reason,  a  similar  affection  of  the 
right  orbit. 

Mr.  Travers  felt  persuaded  that  the  disease  could  be  no  other  than  aneurism  by  anas- 
tomosis. It  bore  so  strong  a  resemblance  in  its  principal  features  to  several  of  Mr.  John 
Bell's  cases,  and  in  particular  to  thatcommunicated*  by  Mr.  Freer,  of  Birmingham,  whose 
patient,  refusing  assistance,  expired  of  hemorrhage,  that  Mr.  T.  considered  the  sensible 
growth  of  the  disease  an  argument  of  sufficient  force  to  justify  any  rational  attempt  to 
repress  it.     From  the  character  of  similar  cases,  and  the  idea  which  he  had  formed  of 


348  ANEURISM  BY  ANASTOMOSIS  IN   THE   ORBIT. 

this,  it  was  to  be  expected  that  although  it  had  been  slow  in  its  formation,  it  would  be 
rapid  in  its  increase ;  and,  unlike  the  aneurism  of  trunks,  would  resist  control  as  it 
acquired  size.  He  first  tried  pressure,  but,  although  moderate,  it  could  be  borne  only 
for  a  limited  time,  by  reason  of  the  pain  attending  the  exasperated  action  of  the  arte- 
ries. Cold  applications  had  been  already  made  use  of  without  advantage,  but  indeed 
the  duration  and  aspect  of  the  disease  made  this  remedy  appear  trifling.  Excision, 
the  only  method,  of  which,  in  similar  cases,  experience  had  confirmed  the  success,  was 
clearly  impracticable  without  extirpation  of  the  eye ;  and  from  the  great  displacement 
of  the  globe,  and  the  obvious  origin  of  the  disease  within  the  orbit,  Mr.  T.  considered 
the  result  of  such  an  operation  to  be  most  precarious.  Satisfied  of  the  increase  of 
the  disease,  knowing  from  the  happy  precedent  of  Sir  Astley  Cooper's  first  case  of 
carotid  aneurism,  the  perfect  practicability,  and,  under  favorable  circumstances,  the 
moderate  risk  of  placing  a  ligature  on  the  carotid  artery,  and  particularly  reflecting 
that  the  obstruction  of  such  a  channel,  must,  at  all  events,  be  followed  by  a  sensible 
and  permanent  diminution  of  the  impulse  of  blood  destined  to  the  disease,  Mr.  T.  tied 
the  carotid  on  the  23d  of  May,  1809. 

After  exposing  the  artery,  a  curved  eyed  probe,  carrying  a  stout  round  ligature,  was 
passed  beneath  it,  and  upon  compressing  the  vessel  with  the  finger,  as  it  lay  over  the 
probe,  the  pulsation  of  the  lower  tumor  immediately  ceased.  The  probe  being  cut 
away,  the  ligatures  were  drawn  apart  from  each  other,  and  tied.  Before  she  quitted 
the  table,  the  patient  observed  that  the  pain  was  benumbed,  and  that  the  noise  in  her 
head  had  entirely  ceased.  The  small  tumor  over  the  angle  of  the  eye  was  still  thrilling, 
but  very  obscurely.  The  ligatures  came  away  on  the  21st  and  22d  days.  Few  symp- 
toms of  general  irritation  followed.  By  the  5th  day,  the  pulse,  which  had  risen  to  130, 
fell  to  84 ;  her  headache  had  subsided ;  and  she  felt  comfortable  in  every  respect. 

The  following  are  the  principal  changes  which  succeeded  the  operation.  In  the  even- 
ing of  the  same  day,  the  lower  tumor  had  already  acquired  the  thrilling  motion  of  the 
upper.  On  the  8d  day,  the  tingling  or  thrilling  sensation  was  experienced  in  both  tumors, 
upon  light  contact  of  the  finger;  if  firmly  compressed,  a  pulse  was  perceived  in  the 
lower.  On  the  5th  day,  the  tumors  were  very  considerably  diminished,  the  eye  less 
prominent;  the  globe  of  the  eye  communicated  a  slight  pulsation;  her  sight  was  short, 
and  objects  appeared  to  her  larger  than  natural,  and  misty.  On  the  21st  day,  she  found 
no  inconvenience  from  sitting  up,  and  working  all  day,  and  was  astonished  to  find  that 
she  could  read  small  print,  and  do  fine  work  with  her  right  or  sound  eye,  which  she  had 
been  unable  to  do  for  years.  By  the  end  of  the  5th  week,  she  could  perform  all  the 
duties  of  her  situation  as  well  as  before  the  operation,  and  expressed  herself  well  satisfied 
with  the  obvious  diminution  of  the  tumor,  the  decrease  of  the  pulsation,  and  the  total 
freedom  she  enjoyed  from  pain,  which  had  distracted  her  for  years.  Four  months  after 
the  operation,  the  tumors  were  evidently  smaller,  and  their  motion  materially  diminished ; 
the  eye  was  less  projecting;  the  cold  dull  pain,  formerly  uninterrupted,  was  now  but 
rarely  felt;  the  artery  of  the  left  side  was  distinguished  beating  very  feebly  below  the 
angle  of  the  jaw,  while  the  carotid  of  the  opposite  side  contracted  with  more  than  ordi- 
nary force. 

On  the  28th  of  October,  she  miscarried  at  the  period  of  about  10  weeks  after  concep- 
tion. The  hemorrhage  was  so  considerable  as  to  induce  syncope,  and  left  her  in  a  state 
of  extreme  debility.  Next  morning,  the  upper  tumor  was  flattened,  and  the  pulsation 
had  altogether  ceased.  On  the  30th,  she  felt  pain  in  the  afiFected  side  of  the  head,  and 
was  feverish.  In  the  course  of  a  few  hours,  the  cellular  substance  of  the  orbit  was  filled 
with  serous  fluid,  precisely  as  at  the  commencement  of  the  disease.  The  pain  was  re- 
lieved, and  the  oedematous  swelling,  and  heat  of  the  surface,  were  reduced  by  a  cold 
lotion.  In  November,  the  pain  in  her  head  had  entirely  subsided,  but,  owing  to  her  ex- 
treme debility  from  loss  of  blood,  she  was  subject  to  occasional  palpitation  of  the  heart, 
and  giddiness.  The  upper  tumor,  and  the  folds  of  the  integuments  between  the  eyebrows, 
had  totally  disappeared.  The  eye  projected  less;  the  lower  tumor  was  inelastic,  and  had 
no  preternatural  pulsation.  In  May,  1811,  a  knob,  of  the  size  of  a  large  pea,  over  the 
inner  angle  of  the  eye,  was  the  only  vestige  that  remained  of  the  disease.^ 

Nearly  five  years  after  the  operation,  Mr.  Hodgson  had  an  opportunity  of  examining 
the  patient.  She  was  then  in  perfect  health,  and  the  cure  of  the  aneurism  so  complete, 
that  it  was  impossible  to  discover  that  disease  had  existed  in  the  orbit.'' 

Case  232.— On  the  24th  of  November,  1812,  Dinah  Field,  aged  44  years,  of  a  delicate 
and  sickly  habit  of  body,  came  to  Mr.  Dalrymple,  of  Norwich,  with  a  complaint  in  the 
left  eye.  She  said  that,  about  five  months  before,  being  then  pregnant  of  her  sixth  child, 
she  was  seized  in  the  middle  of  the  night  with  an  intense  pain  in  the  left  eyeball,  accom- 
panied by  a  whizzing  noise  in  the  head,  which  grievously  distressed  her.  The  attack  was 
instantaneously  sudden.  Hearing  a  noise,  as  of  the  cracking  of  a  whip,  and  feeling  at 
the  same  moment  an  extraordinary  kind  of  pain  in  the  globe  of  the  left  eye,  she  awoke 


ANEURISM   BY  ANASTOMOSIS  IN   THE   ORBIT,  349 

in  great  alarm,  and  leaped  out  of  bed.  About  10  or  12  hours  afterwards,  the  eye  became 
inflamed,  and  the  eyelids  so  much  swelled,  as  to  project  considerably  beyond  the  level  of 
the  upper  and  lower  orbitary  ridge.  She  also  felt  acute  pain  over  the  whole  of  the  left 
side  of  the  head;  while  in  the  left  eyebrow,  and  at  the  bottom  of  the  orbit,  her  anguish 
was  scarcely  to  be  borne.  In  the  succeeding  night,  the  extreme  violence  of  the  pain 
abated,  but  the  swelling  of  the  eyelid  seemed  rather  to  increase ;  and  she  thought  she 
felt  as  if  the  globe  of  the  eye  was  forcibly  drawn  up  towards  her  forehead. 

No  particular  alteration  took  place  in  the  next  seven  weeks,  at  the  end  of  which  time 
she  was  delivered.  During  her  labor,  which  was  said  to  be  very  severe,  there  was  pro- 
jected between  the  eyelids  a  bright  red  tumor  of  an  oblong  form,  which,  for  seven  or 
eight  days,  gradually  enlarged,  until  it  occupied,  in  a  vertical  direction,  almost  the  whole 
space  between  the  superciliary  ridge  and  the  lower  edge  of  the  ala  nasi,  reaching  hori- 
zontally from  the  external  angle  of  the  left  eye,  across  the  root  of  the  nose,  to  nearly  the 
internal  canthus  of  the  right  eye.  In  the  course  of  her  confinement,  this  tumor  was 
punctured,  in  several  places,  by  a  surgeon  who  then  attended  her.  It  bled  freely,  be- 
came smaller,  and  assumed  a  strikingly  darker  color.  A  week  afterwards,  it  was  again 
punctured,  and  with  similar  results;  and  although  the  operation  was  repeated  four  other 
times,  the  latter  incisions  afforded  no  relief  About  two  months  previously  to  the  appear- 
ance of  this  swelling,  the  patient  lost  all  power  over  the  levator  muscle  of  the  upper  eye- 
lid ;  but  if  the  swelling  was  depressed,  and  the  lid  raised,  she  could  see  as  well  as  ever. 
She  soon,  however,  became  totally  blind  on  this  side. 

Three  or  four  months  after  Mr.  D.  first  saw  her,  he  found  that  her  general  health  had 
sensibly  declined,  and  that  the  local  affection,  now  marked  by  very  decided  characters, 
was  distinctly  aneurismal.  She  had  constant  and  acute  pain,  referred  chiefly  to  the 
bottom  of  the  orbit;  but  her  severest  suS'ering  was  occasioned  by  the  increasing  noise  in 
her  head,  which  she  compared  to  the  rippling  of  water,  and  which  became  absolutely  in- 
supportable, when,  by  any  accident,  her  head  fell  below  a  certain  level.  The  left  eyeball 
was  immovable,  and  either  enlarged,  or  thrust  with  so  much  force  against  the  upper  eye- 
lid, as  to  cause  this  part  to  project  in  a  convex  form,  considerably  beyond  the  superciliary 
and  infra-orbitary  ridges.  The  eyebrow,  also,  of  the  afi"ected  side,  rose  somewhat  above 
the  level  of  the  other.  The  external  surface  of  the  tumid  eyelid  was,  for  the  most  part, 
soft  and  elastic  to  the  touch,  but  its  cuticle  was  remarkably  coarse,  as  was,  indeed,  the 
texture  of  the  skiu  generally  in  the  vicinity  of  the  orbit.  Deep-seated  within  the  integu- 
ments of  the  eyelid,  a  little  towards  the  inner  canthus,  there  was  a  cluster  of  small 
tumors,  of  a  firm  and  dense  structure,  causing  great  pain  when  compressed,  and  commu- 
nicating to  the  finger  a  pulsatory  thrill.  Interposed  between  this  cluster  and  the  lower 
edge  of  the  eyebrow,  precisely  in  the  course  of  the  frontal  branch  of  the  ophthalmic 
artery,  there  was  a  hard  tubercular  substance,  which  rose  somewhat  higher  above  the 
general  surface  of  the  eyelid,  and  pulsated  still  more  distinctly  than  the  smaller  swellings. 
The  texture  of  this  substance  was  particularly  hard  and  compact,  and  the  slightest  pres- 
sure upon  it  occasioned  intolerable  pain.  The  lower  eyelid  was  everted,  and  formed  a 
bright  and  red  convex  tumor,  following  in  its  outline  the  direction  of  the  inferior  edge  of 
the  orbit,  and  reaching  from  the  external  commissure  of  the  eyelids  to  a  little  way  be- 
yond the  tendon  of  the  orbicularis.  At  its  upper  part  it  was  covered  by  an  overlapping 
of  the  upper  eyelid,  which  was  paralytic,  and  entirely  concealed  the  globe  of  the  eye.  The 
most  depending  part  of  this  tumor  reached  to  within  a  line  of  the  infra-orbitary  foramen. 
Like  the  tumors  at  the  upper  part  of  the  orbit,  this  swelling  communicated  to  the  touch 
an  aneurismal  thrill.  Its  pulsation  became  evident  to  the  sight  whenever  the  force  of 
the  circulation  was  increased.  In  addition  to  these  appearances,  immediately  above  the 
nasal  third  of  the  superciliary  ridge,  the  integuments  were  gently  elevated  into  a  soft  ill- 
defined  tumor,  occupying  very  exactly  the  situation  of  certain  branches  of  the  frontal 
artery,  and  pulsating  simultaneously  with  the  artery  at  the  wrist.  A  similar  elevation 
of  the  skin  was  perceptible  at  the  root  of  the  nose,  giving  a  faint  tremulous  motion  to  a 
finger  placed  upon  it. 

When  the  globe  of  the  eye  was  uncovered,  it  appeared  at  first  to  be  enlarged,  but  a 
closer  inspection  showed  it  to  be  forcibly  thrust  forwards,  in  a  direction  somewhat  out- 
wards and  upwards.  A  multitude  of  enlarged  vessels  could  be  traced  from  the  surface 
of  the  lower  tumor  to  that  portion  of  the  conjunctiva  which  covers  the  sclerotica.  The 
cornea  retained  its  natural  lustre  and  transparency,  but  there  was  a  total  loss  of  power 
in  the  iris,  and  the  pupil,  much  dilated,  was  slightly  irregular.  Behind  the  lens,  a  fawn- 
colored  appearance  was  observed,  similar  to  that  I'epresented  in  the  second  plate  of  Mr. 
Saunders's  posthumous  work.  The  cutaneous  veins  were  very  full  of  blood,  and  gave  to 
the  skin  of  the  left  side  of  the  face  the  complexion  of  a  person  strangled.  When  strong 
pressure  was  made  upon  the  common  carotid  artery,  the  tremulous  motions  of  the  tumor, 
situated  at  the  lower  part  of  the  orbit,  ceased  entirely,  but  the  pulsations  of  the  upper 


350  ANEURISM   BY   ANASTOMOSIS   IN   THE   ORBIT. 

swellings  continued  in  some  degree.     The  force  of  the  stroke  was,  indeed,  much  weakened, 
but  no  pressure  which  the  patient  was  able  to  bear,  could  entirely  suppress  it. 

At  noon,  on  the  7th  of  April,  1813,  Mr.  D.  tied  the  common  trunk  of  the  left  carotid 
artery.  The  effects  of  the  operation  were  immediate  and  decisive.  As  soon  as  the  liga- 
tures were  tied,  the  pulsatory  motions  of  the  tumors  on  the  forehead  and  cheek  entirely 
ceased ;  but  a  slight  thrilling  was  still  perceptible  in  the  tumid  upper  eyelid.  The  red 
swelling  of  the  lower  eyelid  became  paler,  and  its  surface  shrivelled.  A  few  minutes 
after  the  patient  was  placed  in  bed,  she  was  quite  free  from  pain,  and  the  noise  by  which 
she  had  been  so  long  tormented  having  also  ceased,  she  declared  that  her  head  no  longer 
felt  like  her  old  head.  At  5  P.  M.  there  was  no  pulsation  in  any  of  the  tumors.  Kext 
day  the  upper  eyelid,  for  the  first  time  during  several  months,  was  movable.  The  day 
after,  the  tumor  over  the  inner  part  of  the  eyebrow  was  entirely  gone ;  the  swelling  of 
the  upper  eyelid  was  much  smaller,  its  texture  much  softer,  and  it  was  less  painful  when 
compressed ;  the  globe  of  the  eye  also  had  considerably  retired  within  its  orbit.  By  the 
15th  of  April,  great  changes  had  taken  place  in  the  tumors;  the  globe  of  the  eye  had 
completely  retired  within  its  oi'bit,  the  general  prominence  of  the  upper  eyelid  had  sunk 
proportionably,  and  not  the  slightest  pulsatory  or  thrilling  motion  was  perceptible  in  any 
of  the  diseased  parts.  By  the  17th  of  INIay,  the  tumors  had  all  disappeared,  and  the 
patient's  general  health  seemed  re-established ;  yet  the  wound  was  not  entirely  closed, 
although  the  ligatures  had  come  away,  the  upper  on  the  18th  of  April,  and  the  lower  ou 
the  4  th  of  May. 

On  the  evening  of  the  3d  of  July,  Mr.  D.  was  called  in  great  haste,  in  consequence  of  a 
bleeding  which  had  taken  place  at  the  lower  part  of  the  wound.  The  hemorrhage  had 
ceased  before  he  could  reach  the  house.  The  color  of  the  blood  was  florid,  and  the  quan- 
tity lost,  10  or  12  ounces.  A  similar  discharge  took  place  on  the  evening  of  the  9th  of  July, 
but,  like  the  former,  ceased  spontaneously,  and  happily  proved  the  last  of  a  series  of 
incidents,  not  unlikely  to  disappoint  the  hopes  which  the  earlier  circumstances  of  the 
case  had  inspired.  From  this  period  the  course  of  events  was  prosperous ;  and  on  the 
19th  of  July,  which,  reckoning  from  the  morning  of  the  operation,  comprises  a  period  of 
103  days,  the  wound  was  firmly  healed,  and  the  patient's  recovery  secured.  After  a 
lapse  of  nearly  two  years,  her  cure  appeared  complete,  with  the  exception  of  her  sight, 
which  seemed  irrecoverably  lost.  AVith  respect  to  the  state  of  the  local  circulation,  there 
was  no  pulsation  to  be  felt  in  any  of  the  branches  of  the  left  temporal  and  facial  arte- 
ries ;  but,  as  in  the  case  treated  by  ]\Ir.  Travers,  the  carotid  might  be  distinguished 
beating  very  feebly  below  the  angle  of  the  jaw,  while  a  very  brisk  action  of  the  collateral 
branches  lying  near  the  surface,  was  visible  in  the  vicinity  and  along  the  course  of  the 
cicatrice.^ 

In  addition  to  the  above  cases  of  anastomotic  aneurism  in  the  orbit,  several 
others  have  occurred,  the  narrations  of  which  I  must  content  myself  with 
presenting  to  the  reader  in  a  condensed  form. 

Case  233. — A  gentleman,  aged  60,  of  a  lively  imagination,  and  greatly  given  to  read- 
ing, who  had  sutfered  from  bronchitis,  became  suddenly  affected  with  exophthalmos  of 
the  right  eye.  'When  he  consulted  M.  Jobert,  the  eye  was  projected  straight  forwards 
from  the  orbit,  its  motions  were  much  impeded,  and  it  was  red,  and  intolerant  of  light ; 
the  eyelids  could  not  cover  the  eyeball,  there  was  constant  lachrymation,  and  vision  was 
nearly  lost.  On  touching  the  parts,  a  tumor  was  detected,  which  had  destroyed  the 
superciliary  arch  to  the  extent  of  nearly  -|  inch.  In  the  course  of  some  months,  the 
tumor  rapidly  increased,  and  projecting  through  the  notch  it  had  formed,  it  mounted  over 
the  frontal  bone,  towards  the  frontal  protuberance.  The  diagnosis  now  became  more 
distinct.  That  the  disease  was  an  aneurismal  tumor  was  evident,  from  the  pulsations 
with  which  it  was  affected,  synchronous  with  those  of  the  heart,  the  manifest  movement 
of  expansion  which  it  showed,  and  the  sort  of  susurrus  which  is  remarked  in  varicose 
aneurisms. 

No  amelioration  having  been  obtained  from  the  employment  of  refrigerants  and  astrin- 
gents, acupuncture  having  caused  only  an  increase  in  the  tumor,  which  had  now  attained 
the  size  of  a  small  hen's  egg,  and  such  being  the  violence  of  the  inflammation,  and  the 
degree  of  sensibility  of  the  lids,  that  they  could  not  move  without  insufferable  pain,  M. 
Jobert  determined  to  tie  the  common  carotid  artery.  Before  doing  so,  to  assure  himself 
positively  of  the  nature  of  the  tumor,  he  plunged  into  it  a  very  small  trocar.  Through 
the  canula  there  came  a  continuous  stream  of  arterial  blood. 

As  soon  as  the  artery  was  tied,  the  pulsation  and  the  dreadful  pain  ceased.  On  the 
third  day  after,  the  eye  could  be  moved  in  every  direction,  without  uneasiness.  By  and 
by,  it  retreated  into  the  orbit,  and  no  trace  could  be  distinguished  of  the  tumor,  except 
the  loss  of  bony  substance  caused  by  its  pulsations.  When  the  patient  coughed,  the  skin 
covering  the  deficient  part  of  the  bone  was  observed  to  be  slightly  raised,  and  immediately 


ANEURISM  BY  ANASTOMOSIS  IN   THE   ORBIT, 


351 


to  fall  down  again.  This  looked  as  if  a  communication  had  been  formed,  in  the  course  of 
the  disease,  with  the  frontal  sinus.  The  arteries  of  the  right  side  of  the  face  scarcely 
presented  the  slightest  pulsation ;  but  on  the  left  side,  the  arteries  had  acquired  an 
evident  degree  of  abnormal  development.  The  left  eye  had  also  assumed  a  more  than 
ordinary  vivacity. 9 

Case  234. — A  man,  aged  30,  having  received,  in  January,  1839,  a  blow  on  the  neck 
with  a  wooden  plank,  was,  some  weeks  afterwards,  attacked  with  pain  in  the  right  side 
of  the  head,  and  pulsation  in  the  right  orbit.  Gradually  the  right  eye  seemed  to  enlarge, 
and  its  vision  became  confused.  In  July,  when  the  patient  came  into  the  Charile,  at 
Paris,  there  was  evident  exophthalmos ;  the  cornea  and  humors  were  transparent ;  but 
the  sight  was  much  impaired ;  bosses  of  a  somewhat  livid  hue,  were  distinguished  through 
the  skin  of  the  upper  eyelid,  beneath  the  superciliary  arch,  and  were  the  seat  of  pulsa- 
sations,  which  could  be  seen  and  felt ;  by  auscultation,  a  very  distinct  bruit  de  forge  was 
beard  in  them  ;  they  subsided  under  pressure.  The  left  orbit  presented  similar  bosses 
and  pulsations,  but  without  exophthalmos  or  impaired  vision. 

The  right  common  carotid  was  tied,  and  the  symptoms  of  an  erectile  tumor  immediately 
disappeared  almost  completely ;  but  at  the  end  of  six  weeks  a  degree  of  blowing  sound 
could  again  be  heard  in  the  right  orbit,  and  in  three  months  there  was  a  complete  relapse. 

A  very  remarkable  circumstance  in  this  case  was,  that  from  first  to  last,  compression 
of  the  right  carotid  caused  the  bruit  and  pulsation  of  the  left  orbit  to  cease,  while  that  of 
the  left  carotid  completely  stopped  the  movement  of  the  tumor  in  the  right  orbit,  although 
its  pulsations  yielded  only  partially  to  the  compression  of  the  right  carotid.  It  seems  to 
have  puzzled  M.  Velpeau,  under  whose  care  the  patient  had  been,  to  explain  how  the 
compression  of  the  right  carotid  could  affect  both  the  tumors  at  the  same  time,  and  that 
of  the  left  orbit  in  a  manner  more  decided  than  that  of  the  right.'" 

Case  235. — A  remarkably  fine  girl,  two  months  old,  was  brought  to  Mr.  Walton,  at  the 
Central  London  Ophthalmic  Hospital,  in  1851,  with  a  slight  prominence  of  the  right  eye, 

Fig.  49. 


[From  Walton.] 

discovered  within  a  month  after  birth.  There  was  no  indication  of  any  partidular  dis- 
ease, and,  after  a  few  visits,  the  infant  was  not  again  brought  till  she  was  four  months 
old.  At  that  time,  the  eye  was  prominent,  the  lids  swollen,  the  cheek  piifiFy,  and  the  con- 
junctiva thickly  set  with  large  bright-red  vessels.  Pressure  on  the  eyeball  lessened  the 
protrusion  for  a  few  seconds,  while  crying  rendered  the  eye  more  vascular,  and  caused 
great  temporary  protrusion.  In  a  fortnight,  there  was  increase  of  all  the  symptoms. 
Although  Mr.  Walton  could  not  satisfy  himself  that  there  was  any  pulsation,  several  other 
surgeons  declared  they  felt  it;  and  the  stethoscope,  applied  over  the  eye,  detected  an 
arterial  souffle,  not  heard  at  the  other  orbit.     All  agreed  that  there  was  an  aneurism  by 


352  INJURIES   OF   THE   MUSCLES   OF   THE   EYEBALL. 

anastomosis.  A  cold  lotion  had  been  constantly  applied  for  three  weeks  without  effect. 
It  was  not  considered  prudent  to  apply  pressure,  from  the  pain  which  it  seemed  to  pro- 
duce. 

When  the  child  was  four  months  and  three  weeks  old,  Mr.  Walton  tied  the  common 
carotid.  Dr.  Snow  administering  chloroform.  The  incision  over  the  course  of  the  artery 
was  If  inch  long.  The  undeveloped  state  of  the  muscles  of  the  neck,  and  the  adhesion 
of  their  surfaces  peculiar  to  infancy,  rendered  the  use  of  the  knife  necessary  for  their 
separation.  The  ligature  was  passed,  but  not  tied  till  the  effect  of  the  chloroform  had 
subsided.  This  was  observed  as  a  precautionary  measure,  but  there  was  not  the  slightest 
perceptible  effect  on  the  brain  when  the  circulation  was  checked. 

From  the  fourth  day  after  the  operation,  pressure  was  applied  by  means  of  pads, 
retained  by  an  elastic  bandage  round  the  head.  The  protrusion  of  the  eyeball  gradually 
diminished,  and  by  the  fifth  day,  the  child  could  easily  close  the  lids  when  asleep,  which 
she  could  not  do  prior  to  the  operation.  A  year  afterwards,  the  eye  had  returned  nearly 
to  its  natural  position,  only  the  slightest  prominence  remaining,  and  all  the  movements 
perfect.  The  little  patient's  health  was  excellent,  there  not  having  been  the  least  ill 
result  from  the  operation." 

'  See  case  by  Schmidt,  Ammon's  Zeitschrift  *  Medico-ChirurgicalTransactious;  Vol.  ii.p. 

fiir  die  Opbthalmologie;  Vol.  i.  p.  26.3;  Dres-  1;  London,  1813. 

den,  1831.  '  Op.  cit.  p.  446. 

*  Revue  Medicale;  Tome  iv.  p.  400 ;  Paris,  *  Medico-Chirurgical  Transactions;  Vol.  vi. 

1832.  p.  Ill:  London,  1815. 

^  Treatise  on  the  Diseases  of  Arteries  and  '  Memoires  de  rAcademie  Royalo  de  Mede- 

Veins,  p.  446:  London,  1815.  cine;  Tome  ix.  p.  57;  Paris,  1841. 

■"  Miimoires  de  TAcademie   Royale  des  Sci-  '"  Translation  of  this  work  into  French,  p. 

ences  pour  1765;  Tome  xx.xvii.  p.  758;  Am-  xx. ;  Paris,  1844. 

sterdnm,  1771.  "  Walton's  Operative  Ophthalmic  Surgery, 

'  Bell's    Principles  of  Surgery;    Vol.  iv.  p.  p.  258;  London,  1853. 
262;  Edinburgh,  1808. 


CHAPTER   XL 
DISEASES  OF  THE  MUSCLES  OF  THE  EYEBALL. 


SECTION  I. — INJURIES  OF  THE  MUSCLES  OF  THE  EYEBALL. 

Injuries  of  the  muscles  of  the  eyeball  are  extremely  rare.  In  many  cases 
of  penetrating  wound,  the  looseness  of  the  orbital  areolar  tissue  saves  both 
the  eyeball  and  its  muscles.  The  recti  are  farther  protected  by  their  position 
behind  the  eyeball,  while  the  branches  of  the  third  nerve,  and  the  sixth  nerve, 
by  which  they  are  supplied  with  nervous  energy,  enter  their  substance  on 
their  central  surface,  so  as  to  be  placed  as  much  out  of  the  way  of  injury  as 
possible.  Still  it  must  occasionally  happen  (in  such  wounds,  for  example,  as 
have  been  described  in  the  1st  Section  of  Chapter  I.)  that  the  muscles  shall 
sustain  more  or  less  extensive  injury  :  and  the  consequence  will  be  a  certain 
degree  of  impediment  in  the  motions  of  the  eyeball. 

The  swelling  and  inflammation  which  almost  immediately  ensue,  on  pene- 
trating wounds  of  the  orbit,  added  to  the  depth  of  the  injured  parts,  will  in 
general  render  it  impossible  to  determine  the  amount,  or  perhaps  even  the 
reality,  of  injury  done  in  such  cases  to  the  muscles.  Nor  is  this  of  much 
consequence  in  a  practical  point  of  view ;  rest,  soothing  applications,  and 
antiphlogistic  means,  making  up  the  treatment  in  all  such  cases. 

Beer  relates*  the  case  of  a  medical  student,  in  whom  the  abductor  oculi 
appears  to  have  been  torn  by  a  tobacco-pipe,  thrust  into  the  orbit. 

Case  236. — I  saw  a  man  at  the  Glasgow  Eye  Infirmary,  who,  by  falling  on  the  edge  of 
an  iron  pan,  had  divided  the  upper  eyelid  and  the  rectus  internus.     The  eyeball  waa 


DIPLOPIA.  353 

prominent  and  turned  up,  so  that  the  pupil  lay  behind  the  edge  of  the  upper  lid.  He 
could  not  turn  the  pupil  towards  the  nose.  There  was  a  partial  symblepharon  between 
the  upper  lid  and  the  eyeball,  which  I  divided,  after  which  the  motions  of  the  eye  gradu- 
ally improved. 

'  Lehre  von  den  Augenkraukheiten,  Vol.  i.  p.  146, •  Wien,  1813. 


SECTION  n. — WANT  OF  CORRESPONDENCE  IN  THE  ACTION  OF  THE  MUSCLES  OF 

THE  EYEBALLS. 

§  1.  Dijilopia. 
From  h-rrT^oo;,  double,  and  o^t;,  vision. 

In  strabismus,  tliongli  there  is  no  palsy,  there  is  an  evident  want  of  cor- 
respondence in  the  actions  of  the  muscles  of  the  eyeballs,  and  at  the  com- 
menceraent  of  the  complaint,  there  is  double  vision  ;  but  it  would  appear 
that  double  vision  occasionally  occurs  also  with  a  degree  of  distortion  of  the 
eyes,  and  impediment  in  their  motion,  so  very  slight,  as  scarcely  to  be  ob- 
servable. The  double  vision  to  which  I  now  refer  is  binocular,  and  takes 
its  origin,  at  least  in  some  cases,  from  over-exertion  of  the  eyes,  or  it  may  be 
of  one  eye  to  the  exclusion  of  the  other.  It  is  necessary  to  be  aware  of  the 
existence  of  cases  of  this  kind,  whether  we  attribute  them  to  a  loss  of  excit- 
ability, to  spasm,  or  to  any  other  condition  of  the  muscular  iibres  produced 
by  fatigue,  lest  we  should  confound  them  with  those  in  which  want  of  corre- 
spondence in  the  action  of  the  muscles  of  the  eyeball,  and  consequent  double 
vision,  are  owing  to  paralysis. 

Sir  Everard  Home,  who  first  pointed  out  the  practical  importance  of  this 
distinction,  has  related  two  cases  as  illustrative  of  the  symptoms  and  treat- 
ment of  the  diplopia  in  question.  The  cases  are  interesting  in  several 
respects,  although  it  must  be  confessed  that  there  is  no  very  conclusive  evi- 
dence to  prove  that  the  symptoms  were  dependent  merely  on  an  affection  of 
the  muscles,  and  not  on  the  state  of  the  encephalon. 

Case  237. — A  lieutenant-colonel  of  engineers,  who  was  in  perfect  health,  shooting 
moor-game  upon  his  estate  in  Scotland,  was  very  much  surprised,  towards  the  evening  of 
a  fatiguing  day's  sport,  to  find  all  at  once  that  everything  appeared  double;  his  gun,  his 
horse,  and  the  road,  were  all  double.  The  appearance  distressed  him  exceedingly,  and 
he  became  alarmed  lest  he  should  not  find  his  way  home ;  in  this,  however,  he  succeeded, 
by  giving  the  reins  to  his  horse.  After  a  night's  rest,  the  double  vision  was  much  less ; 
and  in  two  or  three  days  he  went  again  to  the  moors,  when  his  complaint  returned  in  a 
more  violent  degree.  He  went  to  Edinburgh  for  the  benefit  of  medical  advice.  The 
disease  was  referred  to  the  eye  itself,  and  treated  accordingly ;  the  head  was  shaved, 
blistered,  and  bled  with  leeches.  He  was  put  under  a  course  of  mercury,  and  kept  upon 
a  very  spare  diet.  This  plan  was  found  to  aggravate  the  symptoms  ;  he,  therefore,  after 
giving  it  a  sufficient  trial,  returned  home  in  despair,  and  shut  himself  up  in  his  own  house. 
He  gradually  left  off  all  medicine,  and  lived  as  usual.  His  sight  was  dui-ing  the  whole 
time  perfectly  clear,  and  near  objects  appeared  single;  but  at  three  yards,  they  became 
double,  and  by  increasing  the  distance,  the  two  images  separated  further  from  each  other. 
When  he  looked  at  an  object,  it  was  perceived  by  a  by-stander  that  the  two  eyes  were  not 
equally  directed  to  it.  The  complaint  was  most  violent  in  the  morning,  and  became 
better  after  dinner,  when  he  had  drunk  a  few  glasses  of  wine.  It  continued  for  nearly  a 
twelvemonth,  and  gradually  went  oif. 

Case  238. — A  house-painter,  who  had  worked  a  good  deal  in  white  lead,  was  admitted 
a  patient  into  St.  George's  Hospital,  on  account  of  a  fever  attended  with  violent  head- 
ache. Upon  recovering  from  the  fever,  he  was  very  much  distressed  at  seeing  everything 
double ;  and  as  the  fever  was  entirely  gone,  he  was  put  under  Sir  Everard's  care  for  this 
affection  of  his  eyes.  Upon  inquiring  into  his  complaints.  Sir  E.  found  them  to  corre- 
spond exactly  with  those  of  the  former  case,  and  therefore  treated  them  as  arising  entirely 
from  an  affection  of  the  muscles.  He  bound  up  one  eye,  and  left  the  other  open.  The 
23 


1 


354  PALSY  OF  THE  MUSCLES   OF   THE  EYEBALL. 

patient  now  saw  objects  single,  and  very  distinctly,  but  looking  at  them  gave  him  pain  in 
the  eye,  and  brought  on  headache.  This  led  Sir  E.  to  believe  that  he  had  erroneously 
tied  up  the  sound  eye ;  the  bandage  was  therefore  removed  to  the  other,  and  that  which 
had  been  bound  up  was  left  open.  He  now  saw  objects  without  pain  or  the  smallest  un- 
easiness. He  was  thus  kept  with  one  eye  confined  for  a  week,  after  which  the  bandage 
was  laid  aside ;  the  disease  proved  to  be  entirely  gone,  nor  did  it  return  in  the  smallest 
degree  while  he  remained  in  the  hospital.  Rest  alone  had  been  sufficient  to  allow  the 
muscles  to  recover  their  strength,  and  thus  to  produce  a  cure. 

Sir  Everard  concludes  by  obsei'ving  that  when  muscles  are  strained  or 
over-fatigued,  the  first  object  of  attention  is  to  put  them  in  an  easy  state,  and 
confine  them  from  motion,  and  that  this  practice  is  no  less  applicable  to  the 
muscles  of  the  eye  than  to  those  of  other  parts.*  Dr.  Young*  remarks  on 
this,  that  when  one  eye  is  diseased,  it  is  by  no  means  sufficient  to  cover  this 
eye  only,  in  order  to  give  rest  to  its  muscles,  since  these  muscles  unavoidably 
follow  the  motions  of  the  sound  eye. 

§  2.     Monoblepsis. 

From  juo'vo?,  single,  and  B'Ki-i'H;,  view. 

Case  239. — I  was  some  time  ago  consulted  by  a  gentleman,  who,  after  spending  a  whole 
night  in  writing,  was  affected  in  the  following  manner:  With  either  eye  singly  he  saw 
quite  well,  but,  owing  to  double  vision,  he  could  not  use  both  eyes  together,  a  symptom 
termed  monoblepsis.  Whenever  he  looked  downwards  with  both  eyes  be  lost  sight  entirely 
of  the  objects  before  him,  although  he  saw  well  enough  when  he  looked  upwards.  He 
complained  of  vertigo,  but  had  no  headache.  The  symptoms  slowly  subsided  after  rest, 
bloodletting,  blistering,  purgatives,  and  mercury.  They  did  not  recur,  although  after 
some  time  this  patient  had  serious  symptoms  of  disease  within  the  head. 

The  following  appears  to  be  another  case  of  the  same  sort: — 
Case  240. — John  Frost,  carrier,  aged  48,  of  stout  make,  and  rather  plethoric  habit,  on 
his  return  from  Exeter  market,  was  seized  with  such  a  dimness  of  sight  that  he  could  not 
discern  any  object  at  the  distance  of  a  few  yards,  and  was  unable  to  keep  on  the  road 
without  holding  by  the  end  of  his  cart,  though  it  Avas  only  about  3  o'clock  P.  M.,  and  the 
day  quite  fine  and  clear.  Before  reaching  his  home,  however,  be  found  that  on  closing 
or  covering  either  eye,  he  could  see  sufficiently  well  with  the  other.  Mr.  Reed  was  called 
in  next  morning,  and  found  that  the  patient  could  scarcely  perceive  even  the  lines  of  a 
book  when  both  eyes  were  open,  but  that,  on  closing  either  of  them,  he  could  read  dis- 
tinctly every  word.  These  symptoms  were  accompanied  with  considerable  pain  in  the 
forehead,  and  a  full,  quick,  and  rather  hard  pulse. 

Mr.  Reed  took  blood  from  his  arm,  purged  him  with  calomel  and  colocynth  pills,  and 
applied  a  blister  to  the  back  of  his  neck,  but  without  producing  any  alteration  on  his 
sight.  The  pain  of  the  head  was  gone ;  but  he  was  still  under  the  necessity  of  wearing 
a  bandage  over  one  eye,  without  which  he  could  not  see  even  to  walk.  Errhines,  and  a 
little  sulphuric  ether  applied  to  the  eyes,  always  afforded  him  temporary  relief.  There 
was  not  the  slightest  iri^gularity  in  the  appearance  or  motions  of  the  pupils,  the  humors 
appeared  perfectly  transparent,  and  no  traces  of  inflammation  could  be  perceived.3 

Should  diplopia  or  monoblepsis  not  yield  to  rest  and  other  remedies,  pal- 
liation might  be  obtained  by  using  prismatic  lenses,  such  as  have  lately  been 
recommended  for  strabismus.  By  shifting  the  place  of  the  image  on  one  or 
on  both  retinae,  objects  might  thereby  be  made  to  appear  single. 


1  Philosophical  Transactions  for  1797;  Part        '^Introduction  to  Medical  Literature,  p.  99; 
I,  p.  7,  London,  1823. 

'  Lancet  for  1831-2;  Vol.  i.  p.  167. 


SECTION  in. — PALSY  OF  THE  MUSCLES  OF  THE  EYEBALL. 
Syn. — Ophthalmoplegia. 

I  have  already  had  occasion  to  refer  (page  215)  to  the  frequency  of  para- 
lytic affections  of  the  muscles  supplied  by  the  third  nerve  or  motor  oculi. 


PALSY   OP  THE   MUSCLES  OF  THE  EYEBALL.  355 

We  often  have  an  opportunity  of  observing  palsy  of  the  rectus  superior, 
inferior,  and  internus,  accompanied  by  a  similar  affection  of  the  levator  pal- 
pebrse  superioris,  while  the  rectus  externus  retains  its  power,  and  turns  the 
eyeball  towards  the  temple.  If  with  the  finger  we  lift  the  upper  lid  in  such 
a  case,  and  tell  the  patient  to  look  to  the  ground,  we  see  that  he  attempts  to 
do  so,  but  is  utterly  unable  to  accomplish  his  intention.  If  we  tell  him  to 
look  upwards  or  inwards,  he  fails  in  both ;  and  even  when  he  endeavors  to 
look  straight  forwards,  the  eye  is  scarcely,  if  at  all,  turned  from  its  direction 
towards  the  temple.  This  state  of  immovable  distortion  is  styled  luscitas. 
We  observe  also  that  the  pupil  is  dilated,  and  does  not  contract  Avhen  exposed 
to  bright  light;  for  the  iris,  which  receives  its  stimulus  for  motion  from  the 
third  nerve,  is  involved  in  the  paralytic  affection. 

In  some  cases  it  happens  that,  after  the  paralytic  state  of  the  muscles  sup- 
plied by  the  third  nerve  has  continued  for  some  time,  the  abductor  also 
becomes  palsied,  so  that  the  eye  looks  no  longer  towards  the  temple,  but 
directly  forwards,  and  can  be  turned  in  no  other  direction  by  any  voluntary 
effort  of  the  patient.  We  may  conclude,  in  such  circumstances,  that  the  dis- 
ease which  originally  caused  pressure  on  the  third  nerve  only,  has  extended 
so  as  to  affect  the  sixth  also. 

When  all  motion  of  the  eye  is  lost,  from  the  palsied  state  of  the  recti,  the 
eyeball  is  apt  to  project  unnaturally  from  the  orbit,  a  state  which,  as  I  formerly 
mentioned,  is  called  ophthaJmoptosis,  and  of  which  Sir  Charles  Bell  records* 
an  instance,  combined  with  anaesthesia  of  the  parts  supplied  by  the  fifth  pair. 

We  meet,  in  some  instances,  with  palsy  of  the  abductor  only,  so  that  the 
eye  is  turned  inwards,  and  cannot  be  moved  towards  the  temple.  In  a  case 
of  this  sort,  which  I  saw  at  the  Glasgow  Eye  Infirmary,  and  which  seemed  of 
an  apoplectic  nature,  the  patient  was  affected  with  circumorbital  pain,  vertigo, 
and  double  vision.  Dr.  Yelloly  has  recorded*^  a  case  of  palsy  of  the  left 
abductor,  arising  from  the  pressure  of  a  tumor,  lying  on  the  pons  Varolii, 
and  extending  to  the  left  corpus  pyramidale.  The  affection  of  the  eye  was 
attended  with  palsy  of  the  right  side  of  the  body.  The  pupil  retained  its 
sensibility  to  light.  A  tumor  in  the  fourth  ventricle  has  also  been  known  to 
produce  palsy  of  the  abductor.^ 

When  the  motions  produced  by  the  levator  palpebras,  the  rectus  internus, 
superior,  and  inferior  oculi,  are  partially  or  totally  impeded,  the  movement 
inwards  and  upwards  of  the  eyeball,  which  takes  place  when  we  wink,  or  close 
the  eyes  in  sleep,  and  which  is  attributable  to  the  action  of  the  obliquus  in- 
ferior, is  evidently  performed  with  difficulty,  or  is  altogether  lost.  The  eyeball 
is  also  observed  to  roll  abnormally  on  its  antero-posterior  axis,  an  effect  of 
the  action  of  the  superior  oblique,  uncontrolled  by  that  of  the  inferior. 

We  find,  in  most  cases  of  palsy  of  the  muscles  of  the  eyeball,  that  the  fifth 
nerve  and  the  portio  dura  continue  to  exercise  their  functions.  The  retina 
also  generally  retains  its  sentient  power ;  but  when  the  third  is  the  nerve 
affected,  vision  is  somewhat  indistinct,  owing  to  the  dilated  and  fixed  state  of 
the  pupil.  In  some  cases  there  is  complete  amaurosis,  with  much  pain  in  the 
head. 

Headache,  vertigo,  and  double-vision  generally  attend  attacks  of  palsy  of 
the  muscles  of  the  eyeball.    The  stomach  and  bowels  are  also  often  deranged. 

Diplopia  is  often  the  chief,  sometimes  the  only  symptom  of  which  the  pa- 
tient complains.  By  passing  the  finger  from  side  to  side,  and  upwards  and 
downwards,  before  the  patient,  and  desiring  him  to  follow  it  with  his  eyes 
without  moving  his  head,  we  detect  which  eye  and  which  muscle  is  affected, 
even  when  the  loss  of  power  is  very  slight.  In  general,  it  is  the  adductor 
or  abductor  of  one  or  other  eye,  that  is  defective,  so  that  the  organ  cannot 
be  completely  inverted  or  everted.     Diplopia  is  experienced,  in  general,  when 


356  PALSY   OF  THE   MUSCLES   OP  THE   EYEBALL. 

the  patient  endeavors  to  look  straight  before  him,  and  always  when  he  tries 
to  looli  in  the  direction  opposite  to  the  deviation  of  the  affected  eye.  If  the 
levator  oculi,  for  instance,  is  palsied,  diplopia  occurs  whenever  the  patient 
attempts  to  look  upwards ;  and  if  we  desire  him  to  look  steadily  at  some 
object  placed  directly  before  him,  we  observe  the  lower  edge  of  the  cornea  of 
the  affected  eye  to  sink  behind  the  lower  eyelid. 

In  cases  of  palsy  of  the  fourth  nerve,  or  of  the  branch  of  the  third  going 
to  the  obliquus  inferior,  the  rotatory  motions  of  the  eye  will  be  interfered 
with,  as  may  perhaps  be  detected  by  laying  hold  of  the  patient's  head,  and 
bending  it  from  shoulder  to  shoulder. 

Causes. — As  has  been  already  (page  215)  mentioned,  palsy  of  the  muscles 
of  the  eye  sometimes  arises  from  exposure  to  cold,  wliile  in  other  cases  it  is 
owing  to  vascular  congestion,  sudden  effusion,  morbid'  growths,  or  slow  dis- 
organization within  the  cranium.  These  latter  cases  are  sometimes  conse- 
quent to  blows  or  falls  on  the  head.  Palsy  of  the  muscles  of  the  eye  is  not 
unfrequently  syphilitic.  It  is  then  attended,  in  general,  by  neuralgia  of  the 
fifth  nerve,  and  by  secondary  syphilitic  symptoms.  In  such  cases,  I  have 
witnessed  the  remarkable  combination  of  anajsthesia  with  neuralgia. 

In  some  cerebral  cases,  the  symptoms  come  on  slowly  and  insidiously ;  in 
others  suddenly,  and  to  a  great  degree.  At  the  commencement,  as  happens 
in  other  palsies,  the  symptoms  sometimes  come  and  go  repeatedly. 

Besides  tumors  pressing  on  the  third  and  sixth  pairs,  effusions  of  coagulated 
lymph,  surrounding  the  affected  nerve,  have  been  seen  on  dissection.* 

Case  241. — A  clergj-man,  officiating  at  a  marriage,  was  detained  for  several  hours,  in 
an  over-heated  room,  seated  between  an  open  door  and  window,  with  his  loft  side  to  tlie 
door.  Next  morning,  on  awaking,  he  was  surprised  to  find  tliat  he  could  not  open  his  left 
eye.  The  eyeball  was  everted,  and  could  neither  be  inverted,  elevated,  nor  depressed. 
The  pupil  was  widely  dilated  and  fixed.  The  vision  of  the  left  eye  singly  was  good ;  but, 
if  both  eyes  were  opened,  double  vision  and  vertigo  immediately  occurred. 

Case  242. — I  saw  a  gentleman,  along  with  Dr.  King,  in  whom,  from  palsy  of  the  abduc- 
tors, both  eyes  were  inverted.  This  symptom  had  been  preceded,  six  years  before,  by 
weakness  of  the  lower  extremities,  and  pain  in  the  vertex.  There  was  reason  to  think 
that  his  complaints  wei'e  the  consequence  of  a  fall  from  a  cart,  on  the  back  of  his  head, 
when  a  boy. 

On  dissection,  the  dura  mater  in  the  vicinity  of  the  longitudinal  sinus  was  found  much 
thickened,  strongly  fibred,  and  presenting  osseous  spiculte  on  both  its  surfaces.  Between 
its  inner  surface  and  the  tunica  arachnoidea  covering  the  brain,  there  was  much  Pacchio- 
nian matter.  Where  it  covered  the  basilar  fossa,  the  dura  mater  presented  an  atheromatous 
growth  on  both  its  surfaces,  whereby  it  was  greatly  thickened.  This  degeneration  reached 
as  far  down  as  the  processus  dentatus  The  pituitary  gland  and  cavernous  sinuses  ap- 
peared natural.  The  central  parts  of  the  brain  were  softened,  especially  the  septum 
lucidum,  and  the  surface  of  the  corpora  striata  and  thalami. 

Treatment. — I  have  little  to  add  to  what  has  been  said  under  this  head  at 
page  216.  The  same  morbific  causes  being  in  operation,  they  must  be  com- 
bated by  the  same  remedies.  In  rheumatic  and  sudden  cerebral  cases,  we  are 
often  successful  by  means  of  depletion,^  counter-irritation,  and  the  use  of 
sorliefacients  ;  syphilitic  cases  yield  to  the  steady  employment  of  mercury  and 
iodide  of  potassium  ;  while  in  the  slow  cerebral  cases  we  are  too  often  but 
mere  spectators  of  the  loss  of  one  function  after  another,  till  death  closes  the 
scene.  The  neuralgia,  which  is  often  an  attendant  on  palsy  of  the  muscles  of 
the  eye,  is  greatly  relieved  by  small  doses,  taken  internally,  of  tincture  of  aconite. 

Electricity  and  galvanism  are  of  great  service.  In  a  case,  arising  from  a 
fall  from  a  horse,  related  by  Dr.  E.  Gr'afe,'^  electro-puncture  seemed  useful. 
Magendie  notices  a  case  in  his  lectures,"  in  which  a  single  application  of 
electro-puncture  produced  a  cure. 

'  Nervous  System  of  the  Human  Body;  Ap-  '  Medico-Chirurgical  Transactions;  Vol.  i.  p. 
pendix,  p.  cv. ;  London,  1809.  181;  London,  1809. 


STRABISMUS.  35T 

'  Ibid.;  p.  216.  '  See  case  in  -wbich  palsy  of  the  third  nerve 

*  Bell,  Op.  cit.,  pp.  xxxii,  liii.     See  case  of  preceded    by    severe    pain    in    the    head,    was 

Agnes  Robertson,  in  whom  palsy  of  both  nerves  treated  ineffectually  by  anti-neuralgic  remedies, 

of  the  third  pair  arose  from  a  fungous  tumor  of  but  cured  by  bleeding ;  Billing's  First  Princi- 

the  dura  mater;  Medical  Gazette,  Vol.  xxii.  p.  pies  of  Medicine,  p.  219;  London,  1838. 

781,  London,  1838.     See  case  by  Struthers,  of  ''  Grafe  und  Walther's  Journal  der  Chirurgio 

palsy  of  motor  oculi,  the  nerve  being  found,  on  und  Augenlienkunde ;  Vol.  xii.  p.  336;  Berlin, 

dissection,    small,    and    of   a    yellowish-brown  1828. 

color;    Monthly  Journal  of  Medical  Science,  '  Lancette  Franjaise,  6  Fev.  1836. 
July  1853,  p.  1. 


SECTION  IV. — STRABISMUS,  OR  MOVABLE  DISTORTION  OF  THE  EYEBALL. 
Erom  a-rpE^iw,  /  tur7i.     Sijn. —  Strabismus  activus. 
Fig.  DiefiFenbach,  Tab.  I.  Boyer,  PL  I.  II. 

I.  Symptoms. — Sti'abismus  is  that  disease,  in  which,  although  the  patient 
means  to  look  at  the  same  object  with  both  eyes,  one  of  them,  moving  invol- 
untarily, and  independently  of  the  motions  of  the  other,  turns  away  from  its 
natural  direction.  If  the  sound,  or  better  eye,  be  now  closed,  the  one  which 
squinted  assumes  generally  the  proper  position,  and  so  long  as  it  is  used  alone, 
can  be  turned  at  the  will  of  the  patient  in  any  direction  he  pleases.  The 
instant,  however,  that  the  sound,  or  better  eye,  is  again  opened,  the  one 
affected  with  strabismus  revolves  inwards  or  outwards,  and  there  it  remains, 
not  harmonizing  in  the  movements  of  its  fellow,  or  if  it  does  move  along  with 
the  sound  eye,  yet  never  so  as  to  permit  the  two  axes  to  be  pointed  at  the 
same  object.  Hence  the  patient  sees  double,  especially  in  the  commencement 
of  the  disease ;  but  after  a  time,  the  double  vision  wears  off,  the  impression 
on  the  squinting  eye  being  neglected. 

The  eye  is  much  more  frequently  distorted  inwards  than  outwards,  the 
adductor  seeming  to  overpower  the  abductor.  When  the  eye  turns  inwards, 
the  disease  is  termed  strabismus  convergens ;  when  it  turns  outwards,  diverg- 
ens.  We  also  meet  with  strabismus  upwards  or  downwards,  or  in  any  inter- 
mediate direction.  In  some  individuals,  we  find  the  eyes  squint  alternately, 
or  both  together.  In  one  case  only  have  I  seen  strabismus  directly  upwards. 
The  disease  was  congenital ;  and  although  the  eye  seemed  natural  when  viewed 
by  itself,  it  was  considerably  less  than  the  other,  and  greatly  deficient  in  sen- 
tient power.  In  a  person  recovering  from  amaurosis  of  the  right  eye,  stra- 
bismus upwards  and  outwards  came  on  in  the  left  eye,  without  double  vision 
or  confusion  of  sight. 

The  vision  of  an  eye  that  squints  is  almost  always  imperfect ;  and,  of  course, 
those  who  squint  with  both  eyes  see  indistinctly  and  confusedly.  Those  who 
squint  inwards  with  both  are  generally  very  short-sighted,  or  incompletely 
amaurotic. 

II.  Proximate  cause. — It  is  a  common  opinion  that  the  most  frequent 
cause  of  strabismus  is  weak-sightedness,  imperfect  vision  from  short-sighted- 
ness, or  some  congenital  defect  of  the  retina.  The  distorted  eye,  in  almost 
every  case,  is  very  considerably  inferior  in  power  of  sensation  to  the  other. 
I  use  the  words  very  considerably ,  because  we  meet  with  many  individuals 
who  have  the  eyes  slightly  unecpial  who  do  not  squint ;  and  with  others  who 
have  labored  from  birth  under  complete,  or  almost  complete,  amaurosis  of 
one  eye,  and  yet  are  quite  free  from  strabismus.  Buffon  considered  the  in- 
equality which  produced  strabismus  as  averaging  3-8ths.  The  impression, 
then,  on  the  one  eye,  being  considerably  less  perfect  than  that  on  the  other, 
is  very  liable  to  be  neglected  altogether,  and  the  defective  eye,  instead  of 
being  fixed  on  the  object  before  it,  is  left  to  wander  from  the  true  axis  of 
vision.     There  seems  even  to  be  an  instinctive  attempt,  in  some  cases,  still 


358  STRABISMUS. 

farther  to  distort  the  weak  eye,  and  to  turn  it  so  far  inward,  and  under  the 
upper  lid,  that  no  impression  can  be  received  upon  it,  but  that  the  sound  eye 
only  shall  become  the  instrument  of  sensation. 

That,  in  general,  convergent  strabismus  depends  on  no  change  in  the 
structure  of  the  adductor,  and  divergent  strabismus  on  no  change  of  the  ab- 
ductor, is  shown  by  the  motions  which  the  squinting  eye  performs  along  with 
its  fellow,  and  still  more  strikingly  by  keeping  the  squinting  eye  open,  and 
closing  the  other;  for  when  this  is  done,  we  observe  the  squinting  eye  to  as- 
sume a  natural  position,  and  move  from  side  to  side,  always  with  considera- 
ble freedom,  and  often  in  a  perfectly  natural  manner.  The  same  experiment 
also  disproves  the  notion,  that  in  strabismus  there  is  a  paralytic  state  of 
the  muscles,  belonging  to  the  side  from  which  the  eye  is  distorted;  and 
equally  sets  aside,  at  least  in  all  ordinary  cases  of  the  disease,  the  hypothesis 
that  the  most  sensitive  part  of  the  retina  of  a  squinting  eye  is  not,  as  in  the 
retina  of  a  sound  eye,  the  vertex,  but  some  other  part,  in  order  to  see  with 
which,  the  patient  distorts  the  eye  till  that  part  receives  the  image ;  for  we 
find,  in  general,  that  the  instant  the  opposite  eye  is  shut,  the  squinting 
eye,  under  the  guidance  of  its  abductor  and  adductor,  points  its  pupil,  and 
consequently  the  vertex  of  its  retina,  towards  the  object.  An  exception  to 
this  rule  is,  when  a  speck  of  the  cornea  partially  covers  the  pupil.  If  there 
is  no  such  speck,  and  yet,  on  shutting  the  good  eye,  the  squinting  one  is  not 
turned  directly  towards  objects,  but  remains  distorted,  then,  but  not  till  then, 
there  will  be  reason  to  suspect  that  the  vertex  of  the  retina  of  that  eye  is 
less  sensitive  than  some  part  to  the  side  of  the  vertex.  The  cause  of  ordi- 
nary strabismus,  then,  must  lie  deeper  than  the  muscles  of  the  eye,  and 
deeper  even  than  the  retina ;  namely,  in  the  brain  and  nerves,  the  organs 
which  govern  the  associated  actions  of  the  muscles  of  both  eyes.  It  is, 
therefore,  not  to  be  wondered  at,  that  when  the  thought  first  occurred  to  tiie 
minds  of  medical  men,^  that  the  division  of  the  adductor  might  perhaps 
prove  useful  in  convergent  strabismus,  the  plan  of  thus  remedying  a  disor- 
dered exercise  of  a  nervous  function,  by  dividing  one  of  the  muscles,  which,  in 
consequence  of  that  disorder,  acted  abnormally,  should  have  been  conceived 
with  distrust,  and  allowed  to  fall  aside. 

III.  Pathological  anatomy. — Dissection  has  thrown  but  little  light  on  the 
cause  of  strabismus.  In  dissecting  the  muscles  of  a  squinting  eye,  there  is, 
in  general,  nothing  unnatural  observed  in  them  or  their  attachments. - 

A  young  man  under  the  care  of  M.  Guersent,  squinted,  and  had  a  speck 
on  the  cornea  of  the  squinting  eye,  when  he  was  seized  with  typhus  fever,  of 
which  he  died.  Dr.  Cavarra'  dissected  the  muscles  of  his  eye  with  great 
care,  their  vessels  and  their  nerves,  but  found  no  appearance  of  disease  about 
any  of  them.  The  brain  seemed  healthy,  except  only  that  the  lateral-external 
part  of  the  cms  cerebelli,  on  the  same  side  as  the  strabismus,  presented  a 
loss  of  substance  for  some  lines,  exposing  the  medullary  substance.* 

In  a  case  of  convergent  strabismus  dissected  by  Mr.  Partridge,  the  ex- 
ternal rectus  was  elongated,  and  much  attenuated  ;  the  internal  was  short, 
bulky,  and  had  a  much  thickened  tendon.  Except  in  the  levator  palpebr*, 
the  muscular  fibrils  appeared,  under  the  microscope,  to  be  made  up  of  pure 
granular  matter,  inclosed  in  the  usual  sarcolemmar  sheaths  ;  only  here  and 
there  a  few  striped  fibres  were  observable,  and  in  the  external  rectus  they 
were  scarcely  to  be  detected.  The  sixth  nerve,  just  after  its  entrance  into 
the  orbit,  had  a  light  gray  semi-transparent  look,  and  in  its  trunk  was  an 
oval  enlargement,  about  the  size  of  a  pin's  head,  quite  firm  to  the  touch.^ 

IV.  Varieties  of  strabismus. — The  muscles  and  motor  nerves  of  the  eyes 
being  perfectly  free  from  disease,  and  the  person  looking  straight  before  him 
towards  some  distant  object,  the  pupil  of  each  eye  is  placed  nearly  midway 


STRABISMUS.  359 

between  the  nasal  and  temporal  sides  of  the  orbit,  and  the  axes  of  the  eye 
are  accounted  parallel,  although  they  are  not  strictly  so.  The  distance  be- 
tween the  pupils,  or  between  the  inner  margins  of  the  cornese,  being  mea- 
sured, if  the  person  now  turns  his  eyes  to  either  side,  and  towards  objects 
placed  at  the  same  distance  as  the  object  which  he  looked  at  directly,  the  one 
eye,  by  the  action  of  its  abductor,  becomes  everted,  and  the  other,  by  the 
action  of  its  adductor,  becomes  inverted  ;  but  the  pupils  maintain  the  same 
relative  distance  as  at  first,  and  the  axes  of  the  eyes  continue  parallel. 

Mutual  parallelism,  then,  is  the  normal  condition  of  the  eyes  when  directed 
to  distant  objects,  and  as  this  condition  continues  even  when  one  eye  is  blind, 
it  must  be  independent  of  vision,  and  arise  from  the  constitution  of  the  motor 
nerves. 

In  strabismus,  when  the  person  looks,  with  both  eyes  open,  at  a  distant 
object  placed  straight  before  him,  one  of  his  pupils  is  placed  in  its  normal 
situation,  but  the  other  is  turned  towards  the  nose  or  towards  the  temple. 
When  one  or  other  of  the  pupils  is  thus  distorted,  the  axes  of  the  eyes  are 
no  longer  parallel,  but,  if  continued,  would  meet  and  cross  each  other,  before 
the  eyes  in  the  convergent  variety,  and  heliind  them  in  the  divergent.  This  is 
the  case,  whether  the  person  looks  forward  or  to  either  side ;  for  if  we  measure 
the  distance  between  the  inner  margins  of  the  corneae  whilst  the  patient  is  , 
looking  at  a  remote  object  straight  before  him,  we  find  it  less  in  convergent, 
and  greater  in  divergent  strabismus  than  it  ought  to  be  ;  and  let  the  eyes  be 
turned  as  they  may,  the  same  faulty  distance  continues,  and  the  same  want  of 
parallelism  consequently  continues  also. 

There  is,  then,  in  strabismus  a  new  and  abnormal  association  of  the  eyes; 
a  mutual  convergence  in  one  variety,  and  a  mutual  divergence  in  the  other. 
Like  parallelism,  this  new  association  is  shared  by  both  eyes  ;  like  it,  is  un- 
affected by  the  state  of  vision ;  and  like  it,  continues,  whatever  be  the  direction 
of  the  object  looked  at.  The  one  eye  may  be  straight  or  central,  as  when  the 
patient  looks  at  an  object  directly  before  him,  while  the  other  eye  is  inverted 
or  everted :  the  one  eye  may  be  everted,  and  the  other  inverted,  as  in  looking 
to  a  side ;  by  moving  the  object  to  the  temporal  side  of  the  distorted  eye  in 
convergent  strabismus,  or  to  its  nasal  side  in  divergent  strabismus,  both  eyes 
will  become  equally  inverted  in  the  one  case,  and  equally  everted  in  the  other ; 
yet  the  faulty  distance  between  the  pupils  will  continue  as  before,  and  con- 
sequently, the  want  of  parallelism,  and  the  mutual  convergence  or  divergence, 
as  the  case  may  be,  will  be  unchanged. 

In  treating  of  strabismus,  we  require  to  distinguish  inversion  and  eversion 
from  tnutual  convergence  and  mutual  divergence.  In  many  cases,  both  of  con- 
vei'gent  and  divergent  strabismus,  we  observe  that  when  the  patient  looks 
fully  to  one  side,  the  one  eye  is  inverted,  and  the  other  everted.  Want  of 
parallelism  in  the  axis  of  the  eyes,  and  not  mere  inversion  or  eversion,  is  the 
essential  characteristic  of  strabismus  f  and  the  whole  object  of  the  treatment 
in  this  disease  is,  not  so  much  to  remove  the  mere  inversion  or  eversion  of 
the  eyes,  still  less  to  destroy  their  power  of  inversion  or  eversion,  as  to  restore 
them  to  parallelism  in  all  their  movements. 

When  parallelism  is  lost,  it  will  always  be  observed,  as  Mr.  Elliof  of  Car- 
lisle has  pointed  out,  that  on  desiring  the  patient  to  look  straight  before  him, 
one  eye  is  directed  in  the  natural  way,  straight  upon  the  object,  while  the 
other  is  inverted  or  everted,  according  to  the  kind  of  strabismus.  The  po- 
sition of  the  one  eye  is  regulated  by  the  object  looked  at,  and  is  subservient 
to  its  exercise  of  vision ;  the  position  of  the  other  is  regulated  by  the  asso- 
ciation of  motion  between  the  eyes,  and  does  not  depend  on  vision  any  more 
than  does  the  position  of  a  blind  eye  in  a  person  whose  eyes  are  parallel.  If 
the  eyes  in  any  case  of  strabismus  are  unequal  in  visual  power,  the  more  clear- 
sighted is  always  used  by  the  patient,  in  preference  to  the  other,  when  both 


360  STRABISMUS. 

eyes  are  open.  The  worse  eye  is  distorted,  because,  if  used  at  all,  it  would 
supplant  the  better  eye.  The  patient  has  no  power  to  substitute  the  vision 
of  the  worse  eye  for  that  of  the  better,  when  both  eyes  are  open  and  neither 
is  shaded;  and,  therefore,  under  such  circumstances,  the  former  is  always 
distorted.  If  the  eyes  are  equal  in  visual  power,  they  will  be  distorted  alter- 
nately, though  the  mutual  convergence  or  divergence,  or,  in  other  words,  the 
faulty  distance  between  the  cornese,  will  always  be  the  same.  In  strabismus 
characterized  by  mutual  convergence,  then,  when  the  patient  looks  forward, 
one  eye  must  be  inverted ;  and  in  strabismus  characterized  by  mutual  diverg- 
ence, one  eye  must  be  everted,  as  both  eyes  cannot  be  directed  straight 
upon  an  object  unless  their  axes  are  parallel.  The  relative  powers  of  vision 
decide  as  to  which  organ  will  be  employed,  while  the  other  must  obey  the 
abnormal  association  of  motion. 

[It  is  often  a  matter  of  some  difficulty,  in  a  case  of  slight  strabismus,  to 
determine  which  eye  is  at  fault.  To  settle  this  important  point.  Dr.  J.  D. 
Macdonald  had  recourse  to  a  very  ingenious  experiment,  which  he  has  detailed 
in  the  Medical  Times  for  Sept.  1,  1849,  p.  176.  He  says,  that  when  a  stra- 
tum of  dust  is  laid  upon  the  surface  of  a  mirror,  each  particle  and  its  reflection 
so  lie,  one  with  respect  to  the  other,  that  a  line  drawn  through  them  both 
will  be,  in  every  case,  as  the  radius  of  a  circle,  whose  centre  is  in  the  pupil 
of  one  of  the  observer's  eyes  as  seen  in  the  glass,  so  that  an  appearance  of 
rays  is  thus  produced,  seeming  to  emanate  from  that  point. 

Now,  "  if  the  right  eye  be  illuminated  by  a  candle  while  the  left  remains  in 
shadow,  the  experimenter  will  perceive,  by  looking  into  a  mirror  prepared  as 

Fig.  50. 


'''''.  "V"' V/'''. '///;'  I'iWv  \^ 


above,  that  the  irradiation  proceeds  from  the  pupil  of  the  shaded  eye  ;  and 
this  without  reference  to  its  position.  Placing  the  light  on  the  opposite 
side  (the  left),  the  physical  circumstances  are  altered,  and  the  appearance  is 
just  the  reverse  of  the  former  case."     (Fig.  51.) 

"  But  should  two  candles  be  employed,  one  on  either  side  of  the  observer's 
head,  the  lines  formed  by  the  dust  particles,  and  their  reflections,  will  either 
seem  to  irradiate  from  l3oth  eyes,  as  centres,  or  to  spread  from  each  side 
mutually  across  the  opposite  eye."     (Fig.  52.) 

"  In  explanation  of  these  facts,"  Dr.  Macdonald  observes,  "that  when  any 
circumstance  incapacitates  either  eye  from  discharging  its  function  perfectly 
(as  the  light  in  the  first  and  second  experiments  cited),  the  unafi"ected  organ 
appears  to  have  dominion,  and  this  is  manifested  by  the  radiation  of  the  par- 
ticles seeming  to  take  place  from  its  pupil  in  the  mirror,  and  overpowering 
those  of  the  other  ej^e.  In  consequence  of  the  sympathy  existing  between 
the  optic  nerve  and  iris,  when  a  strong  light  falls  upon  the  latter,  the  pupil 


STRABISMUS, 


361 


diminislies  in  size,  so  as  to  regulate  the  amount  of  light  impinging  on  the 
nerve  according   to  its  sensibility.     When  one  eye  is  thus  influenced,  its 

Fig.  51. 


/       /       '    /    ,      '    \     \     N      ^     -     V    ^v   ~~.       -- 

'     /  /  ;    I  \    \    \        ^,    .    -^   "■ 

powers  are  lessened  considerably,  for,  while  it  is  directed  to  the  image  in  the 
glass,  the  iris  cannot  admit  a  sufficient  amount  of  light  to  impinge  upon  the 


retina  from  that  quarter,  having  a  much  stronger  stimulus  in  active  operation 
to  contend  with  from  another.  This  state  of  things  is  quite  reversed  in  a 
shaded  eye,  because  the  iris  is  free  from  the  action  of  a  powerful  light,  and 
has  only  to  discharge  its  office  in  allowing  the  ingress  of  as  many  rays  from 
the  dust  particles  or  their  reflections  as  the  delicacy  of  the  optic  nerve  can 
bear,  which  fully  accounts  for  the  strength  of  the  impression  overpowering 
that  of  the  weakened  eye." 

"When  two  candles  are  employed,  as  in  the  third  experiment,  both  eyes 
are  equally  influenced,  receiving  a  similar  distribution  of  light,  and  are,  con- 
sequently, alike  fitted  (cseteris  paribus)  for  the  performance  of  their  respective 
functions,  so  that  the  lines  necessarily  appear  to  irradiate  from  both  eyes." 

"  Now,  the  practical  application  of  the  experiments  alluded  to  (if  properly 
conducted)  is  this,  that  the  least  inequality  of  the  powers  of  one  eye,  when 
contrasted  with  those  of  the  other,  is  instantly  discovered;"  for,  "  a  very  close 
relationship  exists  between  the  co-ordination  of  the  muscular  movements  of 
the  eyeballs,  and  the  function  of  adaptation  to  distance,  and  also  an  intimate 
connection  between  this  latter  and  the  condition  of  the  retina.  Thus,  if  the 
retina  of  one  ej^e  be  in  any  state  of  debility,  the  adaptive  changes  do  not 
take  place  equally  in  both  eyes,  and,  as  a  necessary  result,  the  co-ordination  of 
the  muscular  actions  which  so  wonderfully  effects  the  consentaneous  move- 
ments of  the  eyeballs  is  disarranged,  and  strabismus  (or  squinting)  is,  under 
such  circumstances,  satisfactorily  accounted  for." — H.] 


362  STRABISMUS. 

Authors  speak  of  single  and  double  strabismus.  To  constitute  a  case  of 
single  strabismus,  the  distortion,  whether  convergent  or  divergent,  should 
always  appear  in  the  same  eye,  and  not  affect  the  good  eye,  even  on  shading 
it  with  the  hand  while  the  squinting  eye  is  directed  straight  towards  objects. 
Such  a  case  rarely,  if  ever,  occurs,  unless  after  operation. 

It  is  a  common  notion  that  there  is  a  double  convergent  strabismus,  in 
which  both  eyes  are  inverted  at  the  same  moment,  and  a  double  divergent 
strabismus,  in  which  both  are  simultaneously  everted.  A  patient,  in  a  fit  of 
musing,  or  regarding  things  carelessly,  or  employing  his  eyes  with  rapid  al- 
ternation, may  seem  to  squint  with  both  eyes ;  but  the  moment  that  his  atten- 
tion is  directed  to  a  particular  object  at  a  considerable  distance,  the  one  eye 
becomes  straight,  and  the  other  remains  distorted.  Only  when  the  object  is 
very  near  are  both  eyes  inverted  together,  in  convergent  strabismus.  Both 
eyes  might  also  be  inverted,  were  the  vertices  of  both  retina?  insensible,  or  if 
there  happened  to  be  insensibility  of  the  vertex  of  the  retina  of  the  better- 
sighted  eye,  with  mutual  convergence. 

Not  unfrequently  we  meet  with  cases  in  which,  both  eyes  being  uncovered, 
the  distortion  seizes  sometimes  the  one  eye,  and  at  other  times  the  other,  the 
patient  using  only  one  eye  at  a  time.  Such  cases  are  designated  by  the  name 
of  alternating  strabismus.  The  patient  possesses  the  power  of  directing  the 
eyes  alternately  upon  the  object  looked  at,  when  both  eyes  are  open,  and 
neither  is  shaded.  Parallelism  is  equally  wanting  in  these  cases  as  in  the 
others ;  the  eyes  are  still  mutually  convergent  or  mutually  divergent,  accord- 
ing to  the  direction  of  the  distortion. 

The  most  common  cases  of  strabismus  are,  with  both  eyes  open,  no7i-alter- 
nating;  although  the  distortion  can  be  made  to  alternate,  by  shading  the 
clear-sighted  eye  and  calling  the  opposite  one  into  action.  Whether  the  dis- 
ease is  convergent  or  divergent,  when  both  eyes  are  open  the  same  eye  is 
always  used  for  the  purposes  of  vision,  and  the  distortion  always  appears  in 
the  other ;  and  hence,  one  eye  only  seems  to  be  affected,  although  both  are 
involved.  With  both  eyes  open,  and  neither  of  them  shaded,  the  patient  is 
able  to  direct  only  one  eye,  and  always  the  same  one,  towards  the  object. 

We  are  able  readily  to  detect  non-alternating,  as  well  as  alternating  stra- 
bismus, by  desiring  the  patient  to  look  steadily,  with  either  of  his  eyes,  at 
any  object  straight  before  him,  while  with  our  hand  we  hide  the  object  from 
his  other  eye,  but  keep  the  hand  sufficiently  raised  towards  the  temple  to 
allow  us  to  watch  the  movements  of  the  eye  which  is  thus  shaded.  Whether 
the  strabismus  is  alternating  or  non-alternating,  the  shaded  eye  is  distorted.^ 
If,  in  such  a  case,  we  close  both  eyes,  and  then  suddenly  raise  the  upper  eyelid 
of  either  while  the  other  remains  closed,  the  one  which  is  opened  is  seen  to 
be  distorted.  If  both  eyes  are  suddenly  opened,  the  pupil  of  the  w^^rse  eye 
is  discovered  to  be  more  distorted  than  that  of  the  better  eye.^ 

If,  on  trying  these  experiments,  the  eye  which  is  shaded,  or  either  of  them 
on  being  opened  suddenly,  showed  no  obliquity,  we  would  pronounce  that 
eye  to  be  sound,  and  assure  the  patient  that  the  distortion  of  its  fellow  might 
be  cured  without  operation,  simply  by  exercising  the  squinting  eye,  with  the 
other  bandaged. 

If  the  shading  of  either  eye  makes  the  other  straight,  and  throws  the  one 
which  is  shaded  into  distortion,  the  case  is  plainly  one  in  which  both  eyes  are 
implicated.  On  again  exposing  both  eyes,  the  distortion  settles  as  before, 
in  the  eye  whose  vision  is  the  more  defective,  which  should  therefore  be  sub- 
jected to  a  division  of  its  adductor  or  abductor,  according  as  the  case  is  con- 
vergent or  divergent.  Out  of  a  hundred  cases  of  strabismus,  five  probably 
are  divergent,  and  the  rest  convergent.  Distortion  directly  upwards  or 
downwards  is  very  rare.     Not  unfrequently,  in  convergent  strabismus,  the 


STRABISMUS.  363 

eye  is  turned  upwards  and  inwards,  or  downwards  and  inwards ;  which  might 
lead  us  to  suppose  that,  besides  the  adductor,  the  inner  fibres  of  the  levator 
or  depressor  would  require  to  be  divided.  Experience  shows,  however,  that 
dividing  the  adductor  is  generally  sufficient. 

V.  Degrees  of  distortion  and  impeded  mobility  of  the  eyes. — We  meet 
with  cases  in  which  the  distortion  is  slight ;  others,  in  which,  though  greater, 
it  is  still  moderate,  none  of  the  cornea  being  covered  ;  while  in  a  third  set 
the  cornea  is  almost  hidden  from  view,  so  that  the  distortion  is  extreme. 
Similar  gradations  occur  in  respect  to  the  mobility  of  the  distorted  eye,  when 
the  opposite  eye  is  closed  ;  for  in  some  cases  the  power  of  turning  the  eye  is 
perfect ;  in  others,  the  eye  can  be  brought  to  the  central  position,  but  no 
farther ;  while,  in  a  third  set,  the  eye  cannot  reach  the  central  position,  and 
presents  but  a  very  limited  power  of  motion. 

The  degree  of  mobility,  much  more  than  that  of  distortion,  affects  the 
prognosis ;  for  a  great  degree  of  distortion,  if  the  mobility  is  free,  may  often 
be  remedied  by  a  simple  and  easy  operation,  while  a  case  in  which  the  motion 
is  much  impeded,  although  the  faulty  direction  is  trifling,  generally  requires 
more  trouble  to  free  it  from  its  distorted  state,  and  is  less  apt  to  be  perfectly 
cured.  The  power  of  abduction  being  free,  in  convergent  strabismus,  indi- 
cates that  the  inversion  is  principally  caused  by  the  adductor,  and  is  not  much 
owing  to  the  action  of  the  levator  and  depressor. 

Mr.  Elliot's  observations  show,  that,  whether  the  strabismus  is  alternating 
or  non-alternating,  if  the  distortion  is  slight,  an  operation  on  one  eye  will 
generally  be  sufficient  to  restore  parallelism  ;  but  that  if  it  is  great,  both 
eyes  will  often  require  to  be  operated  on. 

In  alternating  cases,  if  the  distortion  is  moderate,  and  the  power  of  invert- 
ing and  everting  each  eye  singly  is  free,  the  division  of  the  adductor  or  the  ab- 
ductor of  one  of  them,  according  as  the  strabismus  is  convergent  or  divergent, 
is,  in  general,  sufficient.  If  the  distortion  is  extreme,  and  the  movements 
imperfect,  the  operation  will  require  to  be  performed  on  both  eyes. 

With  respect  to  the  prognosis  in  cases  where  there  is  no  alternation,  but 
where  the  same  eye  always  squints,  and  the  other  is  straight,  as  the  patient 
looks  directly  before  him,  with  both  eyes  open,  the  following  facts  are  esta- 
blished : — 

If  the  bad  eye  is  but  slightly  distorted,  and  its  power  of  motion,  when  the 
better  eye  is  closed,  is  free,  the  cure  which  is  obtained  by  dividing  the  ad- 
ductor or  the  abductor  of  the  bad  eye,  according  as  the  case  is  convergent 
or  divergent,  is  so  nearly  perfect,  that  it  is  unnecessary  to  operate  on  the 
better  eye.  But  where  the  distortion  is  greater,  and  the  power  of  motion  is 
less,  either  the  restoration  of  the  bad  eye  to  its  natural  position  is  prevented 
after  the  operation,  or  the  distortion  shifts  to  the  better  eye,  in  consequence 
of  the  abnormal  association  of  the  nerves  of  the  two  sides.  This  association 
is  broken,  and  parallelism  restored,  by  operating  on  both  eyes. 

After  the  first  eye  is  cut,  Mr.  Elliot,  by  the  following  simple  rule,  deter- 
mines whether  the  second  requires  to  be  operated  on  or  not :  If  any  distor- 
tion be  apparent  in  either  eye,  on  looking  straight  forward  immediately  after 
the  first  operation,  the  second  eye  should  be  cut. 

Care  must  of  course  be  taken,  not  to  mistake  luscitas  for  strabismus  ;  lest 
we  fall  into  the  error  of  dividing  the  adductor  or  abductor  for  a  distortion 
caused  by  palsy  of  the  antagonist  muscle. 

yi.  Remote  and  exciting  causes. — Strabismus  is  connected  with  many  re- 
mote or  exciting  causes. 

1.  Although  rarely  congenital,  squinting  is  hereditary  ;  not  unfrequently 
three  or  four  children  in  a  family  taking  it  from  the  father  or  mother.  Dr. 
Parry  states,^"  that  if  the  father  or  mother  of  a  family  squints,  the  majority 


364  STRABISMUS. 

of  the  children  have  the  same  defect.  He  asserts,  however,  that  this  does 
not  commonly  ai'ise  from  hereditary  defect ;  for  that  if  taken  while  infants 
from  their  parents,  they  do  not  acquire  the  habit.  They  squint,  he  thinks, 
merely  from  imitation.  This  may  fairly  be  doubted.  I  think  it  more  proba- 
ble that,  in  such  instances,  if  one  eye  is  not  imperfect  in  sentient  power,  one 
of  the  muscular  nerves  defective,  or  one  of  the  recti  weak,  from  birth,  there 
exists  at  least  a  predisposition  to  the  disease  in  the  organization  of  some 
portion  of  the  optic  apparatus.  It  is  a  familiar  observation,  that  children 
first  show  a  disposition  to  squint  at  nearly  the  same  age  as  the  parents  or 
the  uncle  or  aunt,  had  done,  and  this  several  years  after  birth.  This  happens 
as  Dr.  John  Clarke  mentions,"  without  any  symptoms  of  oppressed  brain 
having  occurred. 

2.  Strabismus  is  supposed  to  take  its  origin,  in  many  cases,  from  improper 
education  of  the  eyes  in  young  children.  Their  eyes  must  be  trained  to  regu- 
lar and  harmonious  movement,  by  exposing  them  equally  to  the  light,  and 
presenting  to  their  view  objects  likely  to  fix  their  attention,  neither  too  near 
nor  at  too  great  a  distance,  and  much  less  in  any  unnatural  direction.  The 
bad  custom  of  laying  a  child  in  such  a  position  in  its  cradle  that  it  sees  the 
light,  or  any  other  remarkable  object,  chiefly  with  one,  and  always  the 
same  eye,  may  give  rise  to  a  continued  action  of  certain  muscles,  and  cor- 
responding inaction  of  their  antagonists.  Holding  the  child's  toy  near  its 
eyes,  or  amusing  it  by  suddenly  presenting  some  favorite  object  close  to  its 
face,  may  excite  squinting.  Strabismus  divergens  is  attributed  to  the  im- 
proper practice  of  exciting  a  child  to  look  at  the  same  time,  at  two  objects  of 
which  it  is  fond,  but  which  are  distant  from  one  another. 

3.  Children  occasionally  become  squinters  from  the  trick  of  looking  at  the 
point  of  their  nose,  or  if  there  be  any  wart  or  spot  upon  it,  by  attempting 
frequently  to  inspect  this  deformity.  They  thus  distort  the  eyes,  and  fall 
into  the  habit  of  doing  so  unconsciously. 

4.  Imitation  has  been  accused  as  a  cause  of  squintiug.^^  The  child  is  sup- 
posed to  catch  the  disease  from  its  nurse. 

5.  Squinting  frequently  follows  injuries,  inflammation  and  other  affections, 
which  render  the  natural  movements  of  the  eye  painful.  Ophthalmia  tarsi, 
or  even  a  stye,  has  been  observed  to  produce  squinting  in  this  way.  Ulcer 
of  the  cornea,  followed  by  a  speck,  is  a  frequent  cause.  We  are  in  the  habit 
of  attributing  the  squint  to  the  speck ;  but  I  believe  the  ulcer  to  be  generally 
the  true  cause.  A  child  finds,  that  by  a  particular  effort  of  the  muscles,  he 
can  so  turn  the  eye  as  to  ease  the  pain  attending  the  friction  of  the  ulcer  in 
the  natural  movements  of  the  organ.  This  effort  is  attended  by  a  squint, 
and  by  frequently  repeating  this  effort,  or  almost  constantly  employing  it  for 
a  time,  a  habitual  strabismus  is  formed,  which  is  often  not  detected  till  the 
ulcer  is  healed. 

6.  It  is  not  at  all  unlikely,  however,  that  a  speck  on  the  cornea  may  cause 
squinting.  By  turning  the  eye  out  of  the  natural  axis  of  vision,  the  patient 
is  able  to  see  better  past  the  speck.  He  is  very  apt  so  to  turn  the  eye  with 
the  speck,  if  it  happens  to  be  the  better  eye  of  the  two.  In  this  way  strabis- 
mus is  not  an  unfrequent  consequence  of  scrofulous  ophthalmia. 

7.  Darwin  was  of  opinion  that  the  most  general  cause  of  squinting  in 
children  was  the  custom  of  covering  a  weak  eye,  which  had  become  diseased 
by  an  accidental  cause,  before  the  habit  of  observing  objects  with  both  eyes 
was  perfectly  established.  In  all  cases  of  ophthalmia  both  eyes  should  be 
shaded,  and  a  single  shade  never  permitted. 

8.  Strabismus  is  sometimes  attributed  to  a  spasmodic  affection  of  one  of 
the  recti,  and  this  is  supposed  to  arise  from  various  causes ;  as,  terror  from  a 
puncture  of  the  eye,  &c.     I  was  consulted  by  the  friends  of  a  little  boy,  who 


STRABISMUS.  365 

became  affected  witli  strabismus  immediately  after  squirting  the  oily  juice 
of  a  piece  of  orange  skin  into  liis  eye,  whicli  produced  a  great  degree  of  pain. 

9.  Painful  affections  of  the  mind  sometimes  give  rise  to  squinting.  A  fit 
of  passion  is  a  common  cause  of  squinting  in  children.  It  probably  acts  by 
inducing  a  degree  of  apoplexy.  Both  eyes  are  often  affected,  but  the  one 
more  than  the  other.  A  child  has  been  known  to  squint  for  months  after  a 
violent  fit  of  crying.  A  little  boy  awoke  in  the  middle  of  the  night  on  board 
a  steam-boat ;  he  was  greatly  alarmed,  and  soon  after  was  observed  to  squint. 
In  another  boy,  this  affection  appeared  in  consequence  of  forcibly  bathing 
him  in  the  sea,  which  was  persevered  in  for  some  time,  notwithstanding  violent 
screams,  and  other  expressions  of  terror. 

10.  Strabismus  is  induced  by  various  diseases  of  the  brain,  as  irritation 
from  costiveness,  worms,  teething  and  the  like  ;  inflammation,  ramollissement, 
apoplexy,  epilepsy,  hydrocephalus,  scrofulous  tubercles,  &c. 

Sometimes  squinting  is  the  earliest  sign  of  hydrocephalus.  In  this  case, 
it  is  speedily  followed  by  convulsions. 

Scrofulous  tubercles  in  the  brain  often  give  rise  to  squinting  as  their  first 
symptom.  On  careful  examination,  other  signs  of  cerebral  disease  will  be 
discovered ;  such  as  dropping  of  one  or  both  upper  eyelids,  heaviness  of  the 
head,  the  head  drawn  back  or  to  one  side ;  partial  loss  of  power  in  the  limbs, 
difficulty  in  swallowing,  difficulty  in  evacuating  the  fajces  or  urine,  which  are 
sometimes  retained  for  days,  and  similar  symptoms.  By  and  by,  the  patient 
is,  perhaps,  aflected  with  inability  to  close  one  or  both  eyes,  one  cheek  is 
more  flushed  than  the  other,  a  peculiar  stiffness  is  observed  in  the  limbs  for- 
merly in  a  state  approaching  to  palsy,  there  is  difficult  breathing,  and  convul- 
sions set  in,  followed  by  coma  and  death.  On  dissection,  tubercles  are  found 
in  the  cerebellum,  or  in  the  neighborhood  of  the  pons  Yarolii,  which  have 
pressed  upon  the  nerves,  and  induced  an  accumulation  of  water  in  the  ven- 
tricles. 

In  a  valuable  analysis  of  200  cases  of  strabismus.  Dr.  Radcliffe  HalP* 
enumerates  the  following  causes  as  those  assigned  by  the  patients  themselves 
or  their  parents,  without  vouching  for  the  correctness  of  the  testimony, 
except  where  physical  conditions  yet  remained  to  substantiate  the  opinions 
given  : — 

1.  Convulsions  during  infancy,  in  9  cases  ;  falls  on  the  head,  in  Y  ;  severe 
concussion  of  the  brain,  in  1 ;  difficult  dentition,  in  3  ;  hooping-cough,  in  2  ; 
intestinal  worms,  in  3  ;  epilepsy,  in  2 ;  a  severe  thrashing,  in  1 ;  excessive 
fright,  in  1. 

2.  Ophthalmia  which  had  left  no  opacities,  in  14  ;  opacity  of  the  cornea, 
iu  5  ;  opacity  said  to  have  existed  formerly,  in  1 ;  wound  of  the  cornea,  by  a 
stocking  needle,  in  2;  by  a  fork,  in  1 ;  by  a  thorn,  in  2  ;  blow  on  the  eye,  in 
5 ;  burn  of  the  eye  from  a  piece  of  metal  flying  into  it,  in  1 ;  a  habit  of  look- 
ing at  the  sun,  in  2  ;  crush  from  a  cart-wheel  going  over  the  orbit,  in  2  ; 
amaurosis,  in  2 ;  imperfect  cataract,  in  3  ;  exposure  during  infancy  to  the 
light  and  heat  of  a  blazing  fire,  in  3. 

3.  Imitation  of  a  squinting  person,  in  39  ;  watching  the  motions  of  a  shut- 
tle, in  1  ;  voluntarily  trying  to  squint,  in  1  ;  a  habit  of  looking  at  a  scar  on 
the  eyebrow,  in  1 ;  at  a  scar  on  the  nose,  in  2  ;  at  a  scar  on  the  cheek,  in  2  ; 
at  a  small  encysted  tumor  at  the  inner  canthus,  in  1 ;  at  a  small  nosvus  in  the 
same  situation,  in  1 ;  at  a  mole  on  the  nose,  in  1 ;  a  habit  of  sucking  the 
thumb,  and  looking  steadfastly  at  it,  at  the  same  time,  in  1 ;  holding  the 
head  sideways  whilst  knitting,  in  3. 

4.  Measles,  4  ;  smallpox,  in  G. 

5.  Severe  burns  of  the  abdomen,  in  2. 


366  STRABISMUS. 

In  four  instances,  Dr.  Hall  was  assured  that  the  strabismus  was  congenital. 
In  the  remaining  cases  of  the  200,  no  causes  were  assigned. 

It  appears  probable,  that  in  the  first  and  fifth  classes,  an  equal  communi- 
cation of  nervous  energy  to  the  muscles  of  the  eye,  in  consequence  of  disease 
in  the  brain  or  its  vessels,  is  the  origin  of  the  distortion.  In  the  second  and 
fourth  classes,  the  distortion  is  probably  at  first  an  effort  to  free  the  eye  from 
pain,  or  the  results  of  such  disuse  of  the  eye  and  of  its  natural  movements, 
as  must  often  arise  from  wearing  a  shade  over  one  eye.  In  the  third  class, 
strabismus  arises  from  habit. 

In  the  early  stage  of  every  strabismus,  double  vision  must  exist.  An  effort 
to  get  free  from  the  confusion,  attending  diplopia,  probably  increases  the  dis- 
tortion. As  the  disease  becomes  confirmed,  the  vertex  of  the  retina  of  the 
squinting  eye,  being  no  longer  turned  towards  objects,  and  therefore  receiving 
only  the  light  which  falls  upon  it  obliquely,  seems  to  lose  a  great  share  of  its 
sensibility,  merely  from  disuse. 

In  all  the  five  classes,  strabismus,  having  once  become  habitual,  so  that 
one  of  the  muscles  of  the  eye  is  almost  always  in  a  state  of  active  contrac- 
tion, while  its  antagonist  is  left  in  a  state  of  relaxation,  the  former  not  only 
obtains  an  increase  of  power  at  the  expense  of  the  latter,  but  there  is  reason 
to  think  that  interstitial  changes  sometimes  take  place,  by  which  the  active 
muscle  becomes  hypertrophied,  and  the  inactive  one  wasted.  The  process  by 
which  such  a  condition  of  the  parts  can  be  brought  about  must  be  slow,  and 
can  occur  only  where  the  strabismus  has  continued  for  years,  with  little  or  no 
intermission.  Were  such  a  state  of  the  muscles  known  to  exist  in  any 
case,  it  would  lead  to  an  unfavorable  prognosis  in  regard  to  the  result  of  the 
operation. 

yil.  Treatment  tvithout  surgical  operation. — 1.  As  strabismus  often 
arises  in  children  from  abdominal  irritation,  communicated  perhaps  through 
the  great  sympathetic,  to  the  orbital  nerves,  we  ought  in  recent  cases  to  try 
the  effect  of  an  active  purge  or  two,  and  then  follow  this  up  by  mild  aperients, 
and  a  carefully  regulated  diet.  Squinting  children  are  generally  weakly  and 
often  scrofulous,  so  that  a  course  of  tonic  medicine  might  be  useful. 

2.  Strabismus  is  frequently  observed  in  children  to  be  connected  with  a 
careless  employment  of  the  eyes,  which  is  instantly  corrected  by  exciting 
their  attention.  In  this  case,  Buffon's  advice  may  be  of  advantage  :  Make 
the  child  look  often  in  the  glass ;  he  Avill  see  the  squint,  and  correct  it.  This 
is  a  useful  means  of  cure,  when  volition  is  sufficient,  as  it  sometimes  is,  to 
prevent  the  squint.  In  other  cases,  the  squint  is  never  observed,  except 
when  the  child  is  in  bad  temper.     The  occasions  of  this  are  to  be  avoided. 

3.  When  only  one  eye  squints,  and  when  the  defect  in  the  sight  of  that 
eye  is  not  very  great,  much  may  be  done,  by  strengthening  its  muscles,  to 
cure  the  strabismus.  The  strengthening  of  the  muscles  is  effected  chiefly  by 
excluding  the  light  from  the  sound  eye,  and  thus  obliging  the  patient  to 
exercise  naturally  the  eye  which  squints.  The  light  is  best  excluded  by 
means  of  a  small  concave  shade,  covered  with  black  silk,  fitting  exactly 
round  the  orbit,  allowing  free  motion  of  the  eye  and  eyelids,  and  fixed  by  a 
ribbon  tied  about  the  head.  Whenever  the  sound  eye  is  blindfolded,  the 
weak  eye  recovers  its  natural  position  in  the  orbit,  and  its  natural  motions. 
The  patient  finds  that  the  sight  gradually  improves  by  use  ;  and  though  the 
strabismus  does  return,  on  again  exposing  the  sound  eye,  especially  after 
sleep,  from  the  muscles  having  been  inactive,  yet  it  is  not  to  the  same  extent, 
and  day  after  day  becomes  less,  if  the  plan  of  cure  is  continued. 

The  patient  need  not  keep  the  sound  eye  covered  during  the  whole  day. 
At  first  the  shade  may  be  worn  for  half  an  hour  or  an  hour  at  a  time,  and 
then  for  longer  periods.     During  the  blindfolding  of  the  sound  eye,  the  weak 


STRABISMUS.  36t 

one  is  to  be  exercised  both  on  distant  and  near  objects,  but  especially  on  the 
former.  If  the  patient  be  a  child,  he  must  be  encouraged  to  exercise  the 
weak  eye  in  playing  at  ball  or  shuttlecock,  viewing  extensive  prospects  in 
the  country,  reading  books  printed  in  a  large  type,  looking  at  prints,  &c. 
Many  authorities  might  be  produced  in  favor  of  the  efficacy  of  this  mode  of 
cure.  Professor  Roux  cured  himself  in  this  way  of  a  squint,  which  he  had 
had  for  thirty-five  years.'*  Beer'^  tells  us,  that  by  binding  up  the  sound  eye 
every  day  even  for  a  couple  of  hours  only,  he  had  in  most  cases  been 
successful. 

It  is  worthy  of  remark,  however,  that  this  plan  of  curing  strabismus  is 
often  attended  by  a  diminished  power  both  of  motion  and  of  vision  in  the 
sound  eye  ;  and  that  it  has  sometimes  happened,  that  the  squinting  eye  being 
cured  by  perseverance  in  this  method,  the  sound  eye  has  become  distorted. 
If  both  eyes  squint  from  the  first,  they  must  be  blindfolded  alternately,  each 
for  several  days  at  a  time. 

Exercise  of  the  squinting  eye  is  promoted  by  the  use  of  goggles  of  vari- 
ous sorts.  The  best  which  I  have  seen,  were  obligingly  sent  me  by  Mr. 
Bullmore,  of  Truro.  They  are  formed  of  two  short  oval  tubes,  which  are 
sewed,  as  usual,  into  a  piece  of  leather,  and  this  tied  round  the  head.  The 
front  of  the  tube  which  is  applied  before  the  good  eye,  is  furnished  with  a 
central  aperture  of  about  a  line  in  diameter.  Into  the  front  of  the  tube,  ap- 
plied before  the  squinting  eye,  is  inserted  a  slide,  capable  of  being  so  moved 
that  the  aperture  in  it  is  brought  nearer  and  nearer,  from  time  to  time,  to  the 
central  position,  as  the  squinting  eye  improves  in  its  power  of  direction.  The 
slide  can  be  reversed,  so  as  to  adapt  the  goggles  either  to  a  convergent  or  to 
a  divergent  squint.^" 

Another  method  of  exercising  the  weak  eye  is  that  recommended  by 
Jurin.*''  Having  placed  the  patient  before  us,  we  bid  him  close  the  good 
eye,  and  look  at  us  with  the  one  which  squints.  When  w^e  find  the  axis  of 
this  eye  fixed  directly  upon  us,  we  bid  him  endeavor  to  keep  it  in  that  situa- 
tion, and  open  his  good  eye.  Immediately  the  squinting  eye  turns  away  from 
us  towards  the  nose,  and  the  axis  of  the  other  is  pointed  at  us.  But  with 
patience  and  repeated  trials,  he  will  by  degrees  be  able  to  keep  the  squinting 
eye  fixed  upon  us,  for  some  little  time  at  least  after  the  other  is  opened. 
When  we  have  brought  him  to  continue  the  axes  of  both  eyes  fixed  upon  us, 
as  we  stand  directly  before  him,  it  will  be  time  to  change  his  position,  and  to 
set  him  first  a  little  to  one  side  of  ns  and  then  to  the  other,  and  so  to  prac- 
tise the  same  thing.  When,  in  all  these  situations,  he  can  perfectly  and 
readily  turn  the  axes  of  both  eyes  towards  us,  the  cure  is  effected.  An  adult 
may  practise  all  this  in  a  mirror,  without  any  director,  though  not  so  easily 
as  with  one. 

4.  As  there  is  an  inequality  in  the  sensations  of  the  sound  and  of  the 
weak  eye,  it  has  been  suggested  that  we  should  endeavor  to  put  them  more 
upon  a  par,  and  that  this  of  itself  would  tend  to  correct  the  distortion. 
Bufifon  recommended,  therefore,  that  the  patient  should  wear  a  pair  of  spec- 
tacles with  a  plane  glass  opposite  to  the  bad  eye,  and  a  convex  glass  opposite 
to  the  good  eye.  In  this  way  the  vision  of  the  good  eye  would  be  rendered 
less  distinct,  and  consequently  it  would  be  less  in  a  state  to  act  independently 
of  the  other. '^  As  the  weak  eye  is  often  short-sighted,  the  same  advantage 
might  perhaps  be  derived  from  placing  a  plane  glass  before  the  good  eye, 
and  a  concave  glass  before  the  distorted  one. 

5.  Dr.  Kurke  has  recently  recommended  a  prismatic  lens  to  be  placed 
before  the  squinting  eye,  with  its  basis  or  thicker  edge  on  that  side  towards 
which  the  eye  should  be  directed.  By  means  of  the  prismatic  lens,  the  image 
on  the  retina  of  the  squinting  eye  is  shifted  so  as  to  produce  diplopia,  to 


368  STRABISMUS. 

avoid  which  the  patient  is  led  to  bring  the  relaxed  muscle  into  play,  and  by 
persevering  in  the  effort  thns  to  free  himself  of  the  diplopia,  the  strabismus, 
in  slight  cases,  is  ultimately  cured. ^^ 

6.  Dr.  Cavarra  recommends  electricity.  He  uses  electro-puncture  of  the 
supra-orbitary  and  infra-orbitary  nerves.  With  platina  needles  the  two 
branches  are  penetrated  where  they  come  out  on  the  face,  and  then  the  ends 
of  the  needles  are  connected  for  an  instant  with  the  poles  of  a  Galvanic  pile. 
This  being  repeated  six  or  seven  times,  the  needles  are  withdrawn.  This 
operation  is  repeated  twice  or  thrice  a  week.  It  is  most  successful  in  chil- 
dren, and  is  stated  by  Dr.  C.  to  be  neither  painful  nor  dangerous. ^^ 

T.  The  treatment  of  strabismus  will,  of  course,  be  varied,  according  as  the 
cause  is  more  or  less  intimately  connected  with  the  muscles  of  the  eyeball.  A 
mere  bad  habit  in  the  use  of  these  muscles  will  probably  be  completely  over- 
come by  exercising  the  weak  eye,  according  to  the  methods  already  described, 
and  thereby  strengthening  the  patient's  volition  over  its  motions.  In  cases 
of  speck  of  the  cornea,  myopia,  partial  amaurosis,  disease  within  the  cranium, 
nervous  irritation  communicated  from  distant  organs,  means  suited  to  these 
different  causes  must  be  adopted.  In  some  cases,  a  certain  degree  of  success, 
obtained  by  one  plan,  must  be  followed  up  by  another  of  a  different  kind. 
Thus  Pellier  relates^*  the  case  of  a  girl  whose  squint  was  occasioned  by  a 
speck  on  the  cornea  consequent  to  smallpox.  By  the  use  of  stimulating 
drops,  he  removed  the  speck,  but  the  strabismus  remained  the  same.  He 
then  began  a  careful  system  of  exercise,  with  the  sound  eye  covered,  and  by 
this  means  effected  a  cure. 

8.  In  cases  of  strabismus  convergens,  affecting  both  eyes,  it  is  recom- 
mended that  a  pair  of  blinders,  projecting  in  front  of  the  temples,  should  be 
tried  during  at  least  a  portion  of  every  day,  with  the  view  of  attracting  the 
eyes  outwards ;  and  that  when  the  blinders  are  laid  aside,  a  broad  green 
shade  should  be  worn.  In  most  cases  of  squinting,  a  shade  for  both  eyes  is 
useful,  or  the  employment  of  glasses  of  a  pretty  deep  neutral  tint. 

Darwin-  employed  a  different  plan,  and  with  considerable  success,  in  the 
following  case,  which  appears  to  have  partaken  of  the  nature  of  this  strabis- 
mus:— 

Case  243. — The  patient  was  a  child  five  years  of  age,  exceedingly  tractable  and  sen- 
sible. He  viewed  every  object  which  was  presented  to  him  with  but  one  eye  at  a  time. 
If  the  object  was  presented  on  his  right  side,  he  viewed  it  with  his  left  eye,  and  vice  versa. 
He  turned  the  pupil  of  that  ej-e  which  was  on  the  same  side  with  the  object,  in  such  a 
direction  that  the  image  of  the  object  might  fall  on  that  part  of  the  bottom  of  the  eye 
where  the  optic  nerve  enters  it.  When  an  object  was  held  directly  before  him,  he  turned 
his  head  a  little  to  one  side,  and  observed  it  with  but  one  eye,  viz:  with  that  most  dis- 
tant from  the  object,  turning  away  the  other  in  the  manner  above  described;  and  when 
he  became  tired  with  observing  it  with  that  eye,  he  turned  his  head  the  contrary  way,  and 
observed  it  with  the  other  eye  alone,  with  equal  facility ;  but  never  turned  the  axes  of 
both  eyes  on  it  at  the  same  time.  He  saw  and  named  letters,  with  equal  ease  and  at 
equal  distances,  with  the  one  eye  as  with  the  other.  There  was  no  perceptible  difference 
in  the  diameters  of  the  irides,  nor  in  their  contractility  after  having  covered  his  eyes 
from  the  light. 

From  these  circumstances,  Darwin  was  led  at  first  to  conclude  that  there  was  no  defect 
in  cither  eye  ;^  but  that  the  disease  was  simply  a  depraved  habit  of  moving  the  eyes, 
probably  occasioned  by  the  form  of  a  cap  or  headdress,  which  might  have  been  too  pro- 
minent on  the  sides  of  his  face,  like  bluifs  used  on  coach-horses,  and  might,  in  early 
infancy,  have  made  it  more  convenient  for  the  child  to  view  objects  placed  obliquely  with 
the  opposite  eye,  till  bj'  habit  the  adductores  were  become  stronger,  and  more  ready  for 
motion  than  their  antagonists. 

Darwin  recommended  a  paper  gnomon  to  be  made,  and  fixed  to  a  cap.  "When  this  arti- 
ficial nose  was  placed  over  his  real  nose,  so  as  to  project  an  inch  between  his  eyes,  the 
child,  rather  than  turn  his  head  so  far  to  look  at  oblique  objects,  immediately  began  to 
view  them  with  that  eye  which  was  next  to  them.  This  plan  of  cure  was  not  persisted 
in;  so  that,  six  years  after,  Darwin  found  all  the  circumstances  of  this  child's  mode  of 


STRABISMUS.  369 

vision  exactly  as  they  had  been,  except  that  they  seemed  established  by  longer  habit,  so 
that  he  could  not  bend  the  axes  of  both  his  eyes,  on  the  same  object,  not  even  for  a  mo- 
ment. 

By  Darwin's  advice,  a  gnomon  of  thin  brass  was  made  to  stand  over  his  nose,  with  a 
half  circle  of  the  same  metal  to  go  round  his  temples.  These  were  covered  with  black 
silk,  and  by  means  of  a  buckle  behind  his  head,  and  a  cross-piece  over  the  vertex,  this 
gnomon  was  worn  without  inconvenience,  and  projected  before  his  nose  about  two  inches 
and  a  half.  By  the  intervention  of  this  instrument,  he  soon  found  it  more  convenient  to 
view  oblique  objects  with  the  eye  next  to  them,  instead  of  the  eye  opposite  to  them. 
After  his  habit  was  weakened  by  a  week's  use  of  the  gnomon,  two  bits  of  wood,  about 
the  size  of  a  goose-quill,  blackened  all  but  a  quarter  of  an  inch  at  their  summits,  were 
frequently  presented  for  him  to  look  at,  one  being  held  on  one  side  of  the  extremity  of 
the  gnomon,  and  the  other  on  the  other  side.  As  he  viewed  these,  they  were  gradually 
brought  forward  beyond  the  gnomon,  and  then  one  was  concealed  behind  the  other.  By 
this  means,  in  another  week,  he  could  bend  both  his  eyes  on  the  same  object  for  half  a 
minute  together.  By  the  practice  of  this  exercise,  before  a  glass,  almost  every  hour  in 
the  day,  he  became  in  another  week  able  to  read,  for  a  minute  together,  with  his  eyes  both 
directed  on  the  same  objects.  By  perseverance  in  the  use  of  the  artificial  nose,  he  ac- 
quired more  and  more  the  voluntary  power  of  directing  both  eyes  to  the  same  object, 
particularly  if  the  object  was  not  more  than  four  or  five  feet  from  him,  so  that  Darwin 
anticipated  a  complete  cure. 

9.  In  strabismus  divergens,  aflfecting  both  eyes,  alternate  blindfolding  of 
the  eyes  is  as  likely  to  be  useful  as  in  the  strabismus  convergens.  It  has  also 
been  advised  to  apply  a  piece  of  black  plaster  on  the  point  of  the  nose,  which 
may  attract  the  patient's  view,  and  correct  the  divergence. 

Weller  recommends'^*  a  short  funnel,  made  of  pasteboard,  with  an  oval 
base,  to  be  so  applied  as  to  include  both  eyes,  and  having,  at  its  apex,  which 
rests  above  the  point  of  the  nose,  an  opening  about  an  inch  in  diameter. 
Through  this  instrument,  fixed  perfectly  straight  and  firm,  the  patient  must 
look,  and  by  and  by  read.  He  is  obliged,  by  this  contrivance,  when  he 
wishes  to  see  or  read  anything,  to  turn  the  eyes  inwards  and  downwards. 

Frequently  looking  into  the  stereoscope,  and  endeavoring  to  bring  the  two 
images  to  coalesce,  so  as  to  see  the  object  single  and  as  if  it  stood  forward  in 
relief,  is  an  exercise  likely  to  be  useful  in  divergent  strabismus. 

VIII.  Excision  of  a  fold  of  conjunctiva. — In  slight  degrees  of  strabis- 
mus, where  division  of  a  muscle  would  probably  produce  too  great  an  effect, 
and  lead  perhaps  to  an  opposite  distortion,  Deiffenbach  had  recourse  to  the 
excision  of  a  vertical  and  pretty  broad  fold  of  conjunctiva,  on  the  temporal 
side  of  the  eye,  if  the  strabismus  was  convergent :  on  the  nasal,  if  divergent. 
The  edges  of  the  wound  contracting  as  it  heals,  and  the  areolar  tissue  be- 
coming condensed,  have  the  effect  of  drawing  the  eye  into  the  normal 
position.^ 

IX.  Cure  of  strabismus  hy  myotomy.  1.  History  and  principle  of  the 
operation. — The  fact  that  strabismus  is  not  dependent  on  any  organic  change 
in  the  muscle,  towards  which  the  eye  is  distorted,  has,  in  all  probability, 
been  the  cause  why  dividing  the  muscle^was  never  put  in  practice  till  recom- 
mended by  Stromeyer,^^  so  late  as  1838.  He  was  led  to  advise  a  trial  to  be 
made  of  dividing  the  adductor  in  cases  of  convergent  strabismus,  in  conse- 
quence of  his  attention  having  been  directed  to  the  cure  of  deformities  by 
the  cutting  across  of  contracted  muscles  and  tendons.  It  is  plain  that  the 
two  cases  are  not  strictly  analogous ;  for  the  division  of  a  muscle,  to  free  a 
part  which  is  confined  in  an  unnatural  position,  such  as  the  head  in  wry- 
neck, is  an  operation  somewhat  different  in  principle,  from  the  division  of 
the  adductor  in  convergent  strabismus.  The  latter  operation  does  not  sever 
a  contracted  indurated  muscle,  nor  liberate  the  eye  from  an  unnatural  posi- 
tion in  which  it  is  bound  down,  but  merely  abridges  the  exorbitant  activity 
of  one  force,  in  order  to  allow  another  force  an  opportunity  of  acting. 

Stromeyer  tried  the  operation  only  on  the  dead  body.     Pauli^'  was  the 
24 


3t0  STRABISMUS. 

first  to  attempt  it  on  the  living  :  but  the  eye  was  unsteady  ;  he  divided  the 
conjunctiva,  but  could  not  divide  the  muscle.  It  was  reserved  for  Dieffen- 
bach  to  prove  the  advantages  of  myotomy  or  tenotomy,  as  it  has  been  called, 
in  the  cure  of  strabismus,  which  he  did,  in  numerous  instances,  towards  the 
end  of  1839. 

2.  Condition  of  the  textures  of  the  eye. — The  healthy  or  unhealthy  condi- 
tion of  the  textures  of  the  eye  should  be  noticed,  and  especially  the  state  of 
the  conjunctiva  and  cornea. 

The  operation  is  more  difficult  of  execution,  if  the  eyeball  be  small  and 
sunk  in  the  orbit,  than  if  it  be  large  and  prominent. 

If  the  eyeball  be  large,  it  will  be  less  acted  on  by  the  inner  fibres  of  the 
levator  and  depressor,  unless  their  tendons  are  broad  in  proportion,  which 
does  not  appear  to  be  the  case.  In  such  circumstances,  therefore,  parallel- 
ism of  the  eyes  is  likely  to  be  restored  by  the  division  of  one  adductor. 

If  the  eye  has  suffered  much  from  inflammation,  which  is  sometimes  evi- 
dent from  specks  on  the  cornea,  and  in  other  cases  from  the  conjunctiva 
appearing  darker,  drier,  thicker,  and  less  movable  than  natural,  there  is  a 
probability  that  the  conjunctiva  and  the  structures  which  lie  between  the 
conjunctiva  and  the  sclerotica  are  abnormally  adherent,  a  circumstance  which 
is  apt  to  render  the  operation  difficult,  and  less  successful.  A  squinting 
child,  being  seized  with  scrofulous  ophthalmia,  is  very  likely  to  have  the  eye 
fixed  in  the  inner  canthus  by  adhesion  of  the  subconjunctival  textures,  till  on 
the  inflammation  subsiding,  and  the  eye  becoming  again  capable  of  being 
used,  the  unnatural  connections  are  gradually  elongated  into  cellular  bands, 
by  the  action  of  the  abductor.^* 

A  speck  on  the  cornea  of  a  squinting  eye  is  no  objection  to  the  operation, 
provided  the  other  eye  is  the  better  of  the  two ;  but  if  the  squinting  eye  is 
that  on  which  the  patient  chiefly  depends  for  vision,  the  distortion  may  be 
an  instinctive  provision,  by  which  he  sees  more  than  he  could  do,  were  the 
eye  straight.  In  such  a  case,  to  cure  the  strabismus  might  be  the  means  of 
materially  abridging  the  range  of  vision  of  the  eye,  and  ought  therefore  to 
be  avoided. 

Alternate  strabismus  may  be  a  means,  when  both  cornejB  are  partially 
opaque,  of  permitting  the  rays  of  light  to  penetrate  through  the  clear  por- 
tions of  the  corneoe,  and  thus  reach  the  retina.  Were  the  strabismus  in 
such  a  case  cured  by  an  operation,  an  artificial  pupil  in  each  eye  might  be 
required,  before  the  former  degree  of  vision  could  be  regained. 

3.  Extent  and  acuteness  of  vision. — The  extent  and  acuteness  of  vision  of 
each  eye  separately,  and  of  both  together,  should  be  carefully  examined 
before  proceeding  to  the  operation,  in  order  that  we  may  be  able  afterwards 
to  form  a  correct  estimate  of  its  effects. 

The  vision  of  a  squinting  eye  is,  in  general,  so  defective  that  the  patient 
cannot  read  an  ordinary  type  with  it.  In  some  cases,  it  does  not  serve  him 
to  read  a  large  type,  nor  even  to  know  one  person  from  another.  There  is 
reason  to  believe,  that  the  vision  of  the  one  eye  being  so  much  more  impaired 
than  that  of  the  other,  often  originates  in  the  wearing  of  a  shade  over  that 
eye.  The  imperfect  vision  occurs  about  the  same  time  as  the  mutual  con- 
vei'gence,  but  does  not  cause  it.  "  Reflex  or  sympathetic  irritation  of  the 
nerves  of  the  third  pair,"  says  Mr.  Elliot,  in  a  letter  to  me,  "  by  causing  an 
increased  action  of  the  muscles  which  they  supply,  gives  rise  to  the  mutual 
convergence,  or  new  moving  association  ;  and  as  the  mutual  convergence 
prevents  the  directing  of  both  eyes  on  the  same  object  at  the  same  time,  the 
clear-sighted  eye  will  obey  the  will  of  the  patient,  while  the  other  is  subser- 
vient to  the  moto-nervous  connection  of  the  two  organs." 

In  non-alternating  cases,  it  is  generally  possible  to  remove  the  distortion 


STRABISMUS.  3*71 

from  the  better  eye  to  the  worse,  by  bandaging  the  former,  and  thus  improv- 
ing the  vision  of  the  latter  by  use. 

In  some  rare  instances,  a  part  of  the  retina  to  one  side  of  the  vertex  is 
more  sensible  than  the  vertex  itself.  When  this  is  the  case,  the  distorted 
eye  remains  so,  although  the  opposite  eye  is  closed,  and  the  patient  regards 
an  object  straight  before  him ;  but  on  moving  the  object  to  one  side,  the  dis- 
torted eye  becomes  straight. 

Occasionally  the  distorted  eye  is  completely  amaurotic ;  and  in  this  case 
the  operation  must  be  regarded  merely  as  a  means  of  improving  the  patient's 
appearance. 

In  alternating  strabismus,  the  vision  of  the  two  eyes  is  about  equal.  In 
strabismus,  without  alternation,  the  degree  of  distortion  and  the  inferiority 
of  vision  of  the  worse  eye  are  generally  proportionate.  The  eye,  the  vision 
of  which  is  the  more  imperfect,  is  always  to  be  chosen  as  the  subject  of 
operation. 

When  the  vision  of  both  eyes  is  good,  but  the  convergence  great,  two 
operations  will  be  requii'ed.  The  convergence  being  slight,  although  the 
vision  of  the  worse  eye  is  very  bad,  one  operation  will  be  sufficient.  Limited 
abducting  power  and  smallness  of  the  eyeballs  are  more  likely  to  render 
necessary  the  division  of  the  second  adductor,  than  any  state  of  the  vision. 

4.  Date  and  permanence  of  the  strabismus. — There  are  children,  and  even 
adults,  who  occasionally  squint,  but  can  prevent  the  distortion  when  on  their 
guard.  A  recent  and  transient  strabismus  is  not  unfrequently  the  result  of 
intense  use  of  the  eyes,  mental  agitation,  or  irritation  communicated  from  the 
abdominal  viscera  to  the  brain.  Such  cases  should  be  treated  with  rest, 
purgatives,  tonics,  and  proper  exercise  of  the  eyes.  It  is  only  when  stra- 
bismus has  continued  for  a  considerable  length  of  time,  generally  for  years, 
and  has  attained  the  character  of  being  confirmed,  that  we  should  think  of 
remedying  it  by  operation. 

5.  Instruments  necessary  for  the  operation. — The  tendon  of  any  of  the 
recti  might  be  divided  in  many  different  ways. 

A  fold  of  conjunctiva,  over  the  tendon  of  the  adductor,  for  example,  might 
be  raised  with  a  dissecting  forceps,  the  fold  divided  by  the  stroke  of  a  small 
scalpel,  and,  by  another  stroke  or  two,  the  tendon,  thus  exposed,  might  be 
cut  across. ^^ 

A  small  snip  being  made  through  the  conjunctiva,  opposite  to  the  lower 
edge  of  the  adductor,  one  blade  of  a  pair  of  scissors  might  be  pushed  up 
behind  the  tendon,  the  scissors  closed,  and  the  tendon  and  conjunctiva 
divided  at  once.^° 

M.  Guerin's  operation  is  said  to  be  subconjunctival."*  He  pushes,  I  sup- 
pose, a  narrow  knife  through  the  conjunctiva,  and  between  the  tendon  and 
the  sclerotica.  Then,  turning  the  edge  of  the  knife  towards  the  tendon,  he 
divides  it,  leaving  the  conjunctiva  by  which  it  is  covered  entire. 

The  danger  that  the  sclerotica  might  be  opened  in  such  modes  of  operat- 
ing, especially  were  the  operation  attempted  by  an  inexperienced  hand,  is 
sufficiently  obvious  ;  and,  therefore,  a  safer,  although  a  little  more  operose, 
plan  of  proceeding  ought  to  be  adopted. 

The  instruments  more  immediately  necessary  for  the  operation  are : — 

1.  A  small  dissecting  forceps,  or  toothed  forceps,  such  as  that  represented 
in  Fig.  32,  page  241. 

2.  A  pair  of  small,  straight,  blunt-pointed  scissors,  which  cut  perfectly. 

3.  A  blunt  hook,  about  one-fortieth  of  an  inch  thick,  and  the  bent  part 
nine-twentieths  of  an  inch  long. 

4.  A  fine  sharp  hook,  such  as  is  commonly  contained  in  cases  of  eye- 
instruments. 


3T2 


STRABISMUS. 


Wire  specula,  such  as  tlie  speculum  represented  in  Fig.  53,  are  sometimes 

used  for  retracting  and  fixing  the 
Fig- 53.  eyelids;    but  the   fingers   of  an 

assistant  produce  less  uneasiness 
to  the  patient,  and  do  not  inter- 
fere so  much  with  the  manipula- 
tions of  the  operator. 

A  small  bit  of  sponge,   with 
cold  water,  should  be  at  hand. 

6.  Position  of  the  patient. — If 
chloroform  is  not  used,  and  the 
patient  is  an  adult,  he  should  be 
placed  on  a  seat  without  a  back, 
so  that  he  may  lean  his  head  on 
the  breast  of  an  assistant  stand- 
ing behind  him.  If  he  possesses 
ordinary  command  over  the  mus- 
cles of  the  squinting  eye  when 
the  opposite  eye  is  closed,  so 
that  he  can  turn  it  considerably 
from  its  distorted  position,  and 
keep  it  so,  one  assistant  may  be 
sufficient ;  but  if  he  cannot  do 
this,  a  second  assistant  is  neces- 
sary. If  the  patient  is  a  child, 
and  no  chloroform  given,  more  assistants  than  two  may  be  required ;  and  the 
patient,  being  wrapped  in  a  sheet,  so  that  his  arms  and  legs  are  kept  at  rest, 
is  to  be  laid  on  a  table,  with  his  head  on  a  pillow.  It  is  of  great  advantage, 
however,  to  put  a  child  about  to  undergo  the  operation  under  the  influence 
of  chloroform.  It  is  then  unnecessary  to  wrap  him  in  a  sheet.  If  chloro- 
form is  given  to  an  adult,  he  should  be  laid  in  the  horizontal  position. 

7.  Operation. — The  opposite  eye  being  covered  with  a  compress,  an  as- 
sistant with  the  fore-finger  of  one  hand  raises  the  upper  eyelid,  and  with  that 
of  the  other  depresses  the  lower. 

The  operator  now  desires  the  patient  to  turn  his  eye  as  much  as  he  can, 
in  the  direction  which  extends  the  muscle  about  to  be  divided.  If  the  case 
is  one  of  convergent  strabismus,  he  desires  him  to  look  outwards,  to  his 
temple ;  if  it  is  one  of  divergent  strabismus,  he  desires  him  to  look  inwards, 
to  his  nose. 

We  shall  suppose  the  case  to  be  one  of  convergent  strabismus.  The 
reader  will  easily  conceive  that  many  of  the  observations  regarding  the  cure 
of  convergent  strabismus  may  be  applied  to  that  of  the  divergent  variety,  by 
substituting  abductor  for  adductor. 

The  steps  of  the  operation,  then,  are  as  follows  : — 

1.  With  the  forceps,  the  operator  lays  hold  of  the  conjunctiva  trans- 
versely, midway  between  the  edge  of  the  cornea  and  the  caruncula  lachry- 
malis,  and  raises  it  in  a  horizontal  fold. 

2.  With  the  scissors,  he  snips  this  fold  through  vertically,  along  with  the 
subjacent  cellular  substance,  and  then  enlarges  the  incision  thus  begun,  up- 
wards and  downwards,  so  that  it  extends  to  half  an  inch  in  length.  Having 
done  this,  it  is  well  to  take  up  the  subconjunctival  fascia  with  the  forceps, 
and  divide  it  either  in  the  whole  extent  of  the  wound,  or  at  any  rate  oppo- 
site to  the  lower  and  upper  edge  of  the  tendon  of  the  muscle.  This  greatly 
facilitates  the  third  step  of  the  operation. 

The  incision  should  not  be  nearer  the  cornea  than  half  way  between  its 


STRABISMUS.  313 

edge  and  the  earuncula,  lest  in  attempting  to  pass  the  blunt  hook  under  the 
tendon,  the  operator  find  it  impossible  to  do  so,  from  the  close  attachment 
of  the  tendon  to  the  sclerotica ;  nor  ought  it  to  be  farther  from  the  cornea, 
else  the  0}}ierator  will  require  to  penetrate  deep  by  the  side  of  the  eyel)all,  to 
reach  the  muscle. 

The  conjunctiva  is  merely  to  be  slit  up  to  the  extent  specified;  it  is  not  to 
be  dissected  from  the  subconjunctival  fascia,  nor  is  any  portion  of  it  to  be 
cut  away.  In  this  way  the  wound  will  heal  more  readily,  and  the  eye  be 
less  apt  to  protrude  after  the  operation. 

The  incision  of  the  conjunctiva  is  generally  made  in  a  vertical  direction. 
In  operating  for  divergent  strabismus,  it  appears  to  be  Mr.  Elliot's  plan  to 
open  the  conjunctiva  horizontally.  Perhaps  the  incision  made  in  this  direction 
will  gape  less  than  a  vertical  one,  but  more  separation  of  the  membrane  from 
the  subjacent  fascia  will  be  required  to  bring  the  tendon  into  view.  A  fro3- 
neum  will  also  be  apt  to  form  between  the  cicatrice  of  the  conjunctiva  and 
the  external  canthus. 

3.  The  patient  again  everting  the  eye  as  much  as  he  can,  and  the  parts,  if 
obscured  with  blood,  being  sponged,  the  operator  insinuates  the  point  of  the 
blunt  hook  under  the  lower  edge  of  the  tendon  of  the  adductor,  and  slides  it 
up  between  the  tendon  and  the  sclerotica,  till  its  point  appears  above  the  up- 
per edge  of  the  tendon,  as  is  represented  in  Fig.  54.  If  there  is  any  difficulty 
in  bringing  out  the  point  of  the  hook  at  the  upper  edge  of  the  tendon,  from 
its  carrying  the  fascia  before  it,  the  operator  snips  this  through  with  his 
scissors,  and  frees  the  point  of  the  hook. 

In  this  part  of  the  operation,  unless  the  incision  be  nearer  than  usual  to 
the  cornea,  or  the  operator  takes  the  trouble  of  removing  a  portion  of  the 
fascia,  it  is  rarely  the  case  that  the  fibres  of  the  tendon  are  distinctly  per- 
ceived. They  are  obscured  by  the  fascia,  which  is  generally  by  this  time  in- 
filtrated with  blood.  The  ofjcrator,  therefore,  introduces  the  point  of  the 
hook  where  he  thinks  the  lower  edge  of  the  tendon  should  be  ;  and  pressing 
it  close  along  the  surface  of  the  sclerotica,  he  takes  up  on  the  hook  every- 
thing that  lies  between  the  sclerotica  and  the  surface  exposed  by  the  incision 
of  the  conjunctiva.  The  hook,  entering  the  cavity  of  the  ocular  capsule, 
where  the  cellular  connection  of  the  tendon  to  the  sclerotica  is  naturally  loose, 
is  easily  passed  beneath  the  tendon.  This  part  of  the  operation,  therefore, 
gives  little  pain,  unless  the  hook  is  not  sufBciently  bent,  or  the  bent  part  too 
long,  so  that  it  must  be  brought  out  over  the  eyelids,  and  by  putting  the 
muscle  on  the  stretch,  drag  severely  on  the  eyeball. 

It  is  seldom  that  the  patient  is  unable  to  evert  the  eye  sufficiently  to  allow 
the  first  and  second  steps  of  the  operation  to  be  performed,  with  no  farther 
assistance  than  what  has  now  been  mentioned  ;  but  it  sometimes  happens 
that  he  cannot  continue  the  eversion,  at  least  to  the  necessary  degree,  to  per- 
mit of  the  third  step.  When  this  is  found  to  be  the  case,  the  operator  lays 
hold  with  the  sharp  hook,  of  the  tunica  tendinea,  or,  in  other  words,  of  the 
tendon  of  the  muscle  where  it  is  exposed  through  the  incision  of  the  con- 
junctiva, and  without  passing  it  deeper  than  the  surface  of  the  sclerotica,  he 
moves  the  eye  into  the  everted  position.  This  is  effected  with  a  very  slight 
degree  of  traction.  He  then  intrusts  the  sharp  hook,  thus  fixed,  to  an  as- 
sistant, and  proceeds  to  pass  the  blunt  hook. 

If  artificial  eversion  is  called  for  at  the  commencement  of  the  operation, 
which  sometimes  is  the  case,  especially  in  children,  the  operator  passes  the 
sharp  hook  through  the  conjunctiva  and  into  the  tunica  tendinea,  about  one- 
fifth  of  an  inch  from  the  inner  edge  of  the  cornea,  and  having  drawn  the  eye 
into  the  position  required,  intrusts  the  sharp  hook  to  an  assistant,  till  the 
first,  second,  and  third  steps  of  the  operation  are  completed.  After  the  blunt 
hook  is  passed  under  the  tendon,  the  sharp  hook  may  be  removed. 


3U 


STRABISMUS. 


[We  cannot  agree  with  the  author  on  the  necessity,  and  much  less  on 
the  propriety  of  using  the  sharp  hook  to  effect  eversion  in  the  operation  in 
children.  It  can  as  readily  be  accomplished  by  seizing  the  conjunctiva  and 
subjacent  tissue  with  the  toothed  forceps,  and  thus  all  risk  is  destroyed  of 
mischief  from  the  patient  suddenly  inverting  the  eye  the  moment  the  point 
of  the  instrument  touches  the  conjunctiva — as  we  have  seen  frequently  to 
happen,  and  that,  too,  when  a  skilful  surgeon  was  operating. — H.] 

At  whatever  step  of  the  operation 
^^g-  ^*-  the  sharp  hook  is  used,  it  must  be 

fixed  in  the  tunica  tendinea.  It  is 
useless  to  fix  it  in  the  conjunctiva; 
as  this  membrane,  when  we  endea- 
vor to  move  the  eye  by  traction  on 
the  hook,  yields,  and  slides  away 
from  the  subjacent  textures.  To 
penetrate  the  sclerotica  with  the 
sharp  hook,  is  unnecessary. 

4.  The  operator  now  takes  the 
blunt  hook  in  his  left  hand,  and 
carrying  the  handle  of  it  towards 
the  temple,  with  the  scissors  he  im- 
mediately divides,  in  ordinary  cases, 
the  tendon  of  the  muscle  from  be- 
low upwards,  and  nearer  the  carun- 
cula  than  where  it  is  over  the  hook, 
as  is  represented  in  Fig.  54. 

In  this  manner  of  operating,  the 
muscle  will  most  frequently  be  di- 
vided just  where  the  tendinous  part 
meets  the  fleshy  fibres. 

If  the  distortion  is  slight,  the 
handle  may  be  carried  over  the  nose,  and  the  tendon  divided  nearer  the  cor- 
nea than  where  it  lies  over  the  hook,  and  close  to  its  insertion. 

If  the  distortion  is  great,  the  operator,  before  proceeding  to  use  the  scis- 
sors, should  separate  a  considerable  portion  of  the  internal  surface  of  the 
muscle  from  the  sclerotica.  Dr.  Ammon'^  does  this  by  pressing  the  blunt 
hook  repeatedly  towards  the  cornea,  and  back  again  towards  the  caruncula. 
Mr.  Elliot,^^  for  the  same  purpose,  introduces  a  second  hook,  and  steadies 
the  eye  by  means  of  the  one  already  under  the  tendon.  The  tendon  being  then 
drawn  into  view,  the  muscle  is  to  be  divided.  If  hypertrophied,  a  part  of  it 
should  be  cut  out,  which  is  best  accomplished  by  passing  a  ligature  under  it 
with  a  blunt  needle,  tying  the  ligature  upon  the  muscle,  dividing  the  latter 
nearer  the  caruncula  than  where  it  is  within  the  ligature,  and  lastly,  cutting 
off  the  ligature,  with  the  portion  of  the  muscle  which  it  embraces. 

If,  in  the  third  step  of  the  operation,  only  a  portion  of  the  tendon,  and 
not  its  whole  breadth,  appears  to  be  on  the  blunt  hook,  the  division  with  the 
scissors  should  not  be  immediately  proceeded  with  ;  but,  with  another  and 
smaller  blunt  hook,  the  operator  should  take  up  the  remaining  breadth  of 
the  tendon  ;  and  having  divided  this  portion  with  the  scissors,  proceed  to 
divide  the  principal  portion,  which  he  has  on  the  first  hook.  It  must  be  re- 
marked, however,  that  when  the  tendon  is  raised  and  drawn  forwards  on  the 
concavity  of  the  blunt  hook,  it  generally  assumes  a  round  and  contracted 
appearance. 

If  the  operator  has  any  doubt  about  his  having  divided  the  whole  of  the 
muscle,  he  should  not  proceed  to  ascertain  the  position  of  the  eye,  and  much 
less  incautiously  announce  to  the  patient  that  the  operation  is  finished,  until 


STRABISMUS.  315 

he  has  examined  with  the  blunt  hook,  and  snipped  across  any  portion  which 
may  have  escaped.  The  tuft  formed  by  the  minute  tedinous  fibres,  adhering 
to  the  sclerotica,  at  the  place  of  insertion,  will  show  distinctly  that  the  muscle 
has  been  divided.^* 

Such,  then,  is  the  operation  for  convergent  strabismus.  That  for  the 
divergent  variety  is  generally  considered  rather  more  difficult,  owing  to  the 
greater  narrowness  of  the  space  between  the  eyelids,  and  the  insertion  of  the 
abductor  being  farther  from  the  cornea  than  that  of  the  adductor.  As  to  this, 
a  good  deal  will  depend  on  the  size  and  prominence  of  the  eye. 

Upon  the  same  general  plan,  the  levator  or  depressor  is  to  be  divided,  in 
cases  of  distortion  upwards  or  downwards. 

I  have  described  the  operation  as  performed  with  the  aid  of  the  blunt  hook, 
as  being  the  safest  plan  to  be  followed  by  those  who  have  not  operated  much 
for  strabismus.  After  he  is  familiar  with  the  operation,  the  surgeon  will  often 
at  once  pass  the  blade  of  the  scissors  beneath  the  muscle,  after  exposing  it  by 
a  division  of  the  conjunctiva,  and  not  use  the  hook  at  all. 

8.  Immediate  effects  of  the  operation  on  the  relative  position  and  motion  of 
the  eyes. — If  the  adductor  or  abductor  has  been  divided,  certain  eflTects  are 
immediately  produced  on  the  mobility  of  the  eye  which  has  been  operated  on, 
and  on  the  relative  position  of  the  two  eyes. 

1.  The  compress  being  removed  from  the  opposite  eye,  the  patient  finds 
that  he  can  turn  the  eye  which  has  been  cut,  fully  and  with  a  feeling  of  free- 
dom, towards  the  temple  or  towards  the  nose,  according  as  the  adductor  or 
abductor  has  been  divided.  This,  which  he  could  not  do  before,  is  a  proof 
that  the  tendon  has  been  fairly  divided.  If  he  cannot  turn  the  eye  freely, 
there  is  reason  to  suspect  that  the  tendon  has  not  been  completely  divided, 
or  has  not  been  sufficiently  separated  from  the  sclerotica. 

2.  When  the  patient  looks  directly  before  him,  and  the  operation  is  com- 
plete and  successful,  the  distortion  which  previously  existed  is  removed,  and 
the  optic  axes  are  parallel.  In  some  cases  they  retain  their  parallelism  when 
he  turns  his  eyes  to  the  right,  if  the  right  adductor  or  left  abductor  has  been 
divided;  or  towards  the  left,  if  the  left  adductor  or  right  abductor  has  been 
the  subject  of  operation.  On  closing  the  eyes,  and  suddenly  raising  first  the 
upper  lid  of  the  one,  and  then  that  of  the  other,  the  opposite  eye  being  kept 
shut,  there  is  no  distortion  to  be  seen  in  either.  The  operation  on  one  eye 
has  removed  the  mutual  convergence,  and  restored  parallelism. 

After  the  division  of  one  adductor,  the  eye  may  be  observed  occasionally 
inverted.  If,  on  closing  the  clear-sighted  eye,  the  inverted  one  becomes 
straight,  and  on  raising  the  lid  of  the  closed  one,  both  eyes  are  straight,  there 
is  evidently  no  remaining  mutual  convergence,  and  by  exercising  the  eye 
which  has  been  operated  on,  the  other  being  bandaged,  the  cure  will  be 
established,  without  further  operation. 

3.  It  is  generally  believed,  that  when  the  operation  is  complete,  and  pro- 
mises to  be  successful,  the  eye  has  lost  the  power  of  being  turned  into  the  inner 
canthus,  when  the  adductor  has  been  cut,  or  into  the  outer  canthus,  when  the 
abductor  has  been  divided.  It  has  also  been  stated,  but  there  is  reason  to 
believe  upon  still  more  insufficient  grounds,  that  after  the  adductor  has  been 
cut,  if  the  patient  retains  the  power  of  turning  the  eye  nearer  to  the  nose 
than  the  centre  of  the  orbit,^^  either  in  a  horizontal  or  an  oblique  line,  the 
operation  has  not  been  completely  performed,  or  is  not  going  to  effect  an 
immediate  cure.  In  the  great  majority  of  cases  it  will  be  found,  that  the  eye 
can  be  inverted  considerably  beyond  the  centre,  but  not  so  much  as  to  conceal 
the  inner  edge  of  the  cornea.  This  remaining  power  of  inversion  is  commonly 
ascribed  to  the  action  of  the  internal  fibres  of  the  levator  and  depressor;  but 
M.  Bonnet  is  of  opinion  that  the  motion  arises  from  the  connection  still  sub- 


376  STRABISMUS. 

sisting  between  the  divided  muscle  and  the  ocular  capsule,  the  muscle  con- 
tinuing to  act  on  the  capsule,  and  thence  mediately  transmitting  its  influence 
to  the  eyeball.  Mr.  Elliot  mentions  to  me,  that  on  dividing  both  abductors, 
he  has  always  found  the  power  of  evertion  of  each  eye  to  be  natural,  imme- 
diately after  the  operation. 

If  the  patient,  after  the  adductor  has  been  divided,  retains  the  power  of 
turning  the  eye  into  the  inner  canthus,  so  as  to  conceal  the  whole  of  the  white 
of  the  eye  internal  to  the  cornea,  the  operator,  replacing  the  compress  and 
roller  over  the  opposite  eye,  should  immediately  proceed  to  examine  with  the 
blunt  hook,  whether  any  portion  of  the  tendon  has  escaped  division,  as  is 
very  apt  to  happen  at  its  lower  or  upper  edge,  or  whether  the  internal  surface 
of  the  muscle  is  still  adherent  to  the  sclerotica,  or  is  bound  to  it  by  any 
adventitious  connection.  Any  such  undivided  portion  of  the  tendon,  or 
unnatural  bands  of  attachment,  are  to  be  drawn  into  view  with  the  hook,  and 
snipped  through.  If  this  is  still  insufficient,  the  external  surface  of  the  tendon 
should  be  examined  in  the  same  manner,  and  its  cellular  union  to  the  fascia 
should  be  separated,  so  that  the  tendon  may  lie  loose  and  unattached,  as  far 
back  as  the  aperture  by  which  it  traverses  the  capsule,  which  is  about  half 
an  inch. 

4.  It  is  often  the  case  that,  notwithstanding  the  complete  division  of  the 
tendon,  and  its  being  carefully  separated  from  its  cellular  attachments,  the 
distortion  still  continues,  without  any,  or  with  merely  a  slight  diminution. 

At  one  period,  the  general  opinion  of  operators  regarding  such  cases 
appears  to  have  been,  that  the  disease  was  confined  to  the  worse  eye,  the 
better  eye  being  so  little  affected  as  to  pass  for  being  sound,  and  that  the 
want  of  success  attending  the  division  of  the  adductor  was  to  be  remedied  by 
dividing  the  levator  or  depressor,^^  or  one  or  other  of  the  obliqui.''''  Farther 
experience,  however,  has  shown  that  any  interference  with  these  muscles  is 
unnecessary,  if  the  adductor  be  carefully  examined,  and  liberated  from  the 
adventitious  adhesions  by  which  it  is  often  tagged  to  the  neighboring  parts. 

Another  notion,  at  one  time  pretty  general,  was  that,  although  the  original 
distortion  should  still  remain  in  some  degree  after  the  adductor  was  divided, 
the  operation  was  not  to  be  immediately  deemed  a  failure.  It  was  urged, 
especially  if  the  patient,  previously  to  the  operation,  had  been  unable  to  bring 
the  pupil  to  the  central  position,  that  the  abductor  might  require  time  to 
recover  its  contractile  power,  so  that  hours  or  days  might  elapse  before  the 
eye  reached  the  centre  of  the  orbit,  although  ultimately  a  perfect  cure  might 
be  obtained. 

This  gradual  amendment  is  not  to  be  trusted  to.  On  the  contrary,  an  eye 
that  is  not  placed  in  the  centre  of  the  orbit  at  the  termination  of  the  opera- 
tion, rarely,  if  ever,  assumes  of  itself  that  position  afterwards,  but  generally 
becomes  worse. ^^  It  is  not,  however,  by  making  a  clean  dissection  of  the 
whole  nasal  side  of  the  sclerotica,  nor  by  dividing  other  muscles  than  the  ad- 
ductor, that  the  rule  is  to  be  fulfllled,  always  to  leave  the  eye  straight. 

To  place  the  eye  in  the  central  position,  Mr.  Wilde,  having  bent  a  small 
sewing-needle,  and  armed  it  with  a  fine  ligature,  seizes  hold  of  the  end  of  the 
divided  muscles  where  it  is  attached  to  the  sclerotica,  and  passes  the  thread 
twice  through  it,  drawing  it  tight  the  second  time,  thus  obtaining  a  power 
by  which  the  eye  is  easily  moved  to  a  side.  He  then  attaches  the  ligature  by 
means  of  adhesive  plaster  to  the  cheek,  if  the  adductor  was  the  muscle  divid- 
ed ;  to  the  nose,  if  the  abductor.  It  should  not  be  removed  while  it  con- 
tinues on  the  stretch,  or,  in  other  words,  till  the  eye  has  completely  righted 
itself.  In  attaching  the  ligature  to  the  cheek  or  nose,  care  should  be  taken 
that  it  does  not  cross  the  cornea.^^ 

Mr.  Elliot,  from  a  careful  consideration  of  cases  in  which  the  division  of 


STRABISMUS,  3TT 

the  adductor  of  the  inverted  eye  failed  in  removing  its  distortion,  concluded 
that  the  disease  could  not  be  regarded  as  confined  to  one  eye  ;  since,  when 
the  better  eye  was  closed,  the  worse  one,  after  the  operation  as  well  as  before 
it,  became  straight ;  while  on  raising  the  lid  of  the  better  eye,  it  was  found 
inverted,  though  the  position  of  the  eyes  instantly  became  reversed  when  both 
were  opened.  The  simple  experiment  of  closing  the  better  eye  after  the 
operation  shows,  by  its  rendering  the  worse  eye  straight,  that  the  remaining 
distortion  which  is  seen  in  the  worse  eye  when  both  are  open,  does  not  de- 
pend on  any  shortening  of  the  fibres  of  the  levator,  depressor,  or  obliqui, 
requiring  that  they  should  be  cut,  or  on  any  semi-paralytic  state  of  the  ab- 
ductor, from  which  it  may  slowly  recover,  but  on  the  original  cause  of  the 
disease — a  morbid  action  of  the  motor  nerves. 

In  such  cases,  then,  of  mutual  convergence,  in  preference  to  the  division  of 
the  levator  or  depressor,  which,  though  it  might  restore  parallelism,  would 
leave  the  eye  prominent  and  limit  its  future  movements,  and  in  place  of  trust- 
ing to  exercise  of  the  eyes,  which,  though  it  might  succeed  in  some  instances, 
after  a  practice  of  weeks  or  months,  in  rendering  the  first  eye  straight,  would 
fail  to  do  so  in  those  cases  where,  from  various  causes,  such  as  a  speck  of  the 
cornea,  partial  cataract,  or  insensibility  of  the  vertex  of  the  retina,  the 
vision  of  the  eye  was  incapable  of  being  much  improved  by  exercise,  Mr. 
Elliot  had  recourse  to  the  immediate  division  of  the  same  muscle  of  the 
opposite  eye,  and  with  signal  success.  To  estimate  fully  the  merits  of  this 
improvement,  which  certainly  in  importance  stands  next  to  the  original  in- 
vention of  the  operation,  the  reader  should  study  with  care  the  cases  detailed 
by  Mr.  Elliot  in  his  paper  in  the  Edinburgh  Medical  and  Surgical  Journal, 
already  referred  to. 

5.  It  sometimes  happens  that  the  inversion  is  instantly  removed  from  the 
worse  eye  as  soon  as  its  adductor  is  divided,  and  appears,  though  not  in  the 
same  degree,  in  the  other  eye ;  or,  when  the  strabismus  is  divergent,  the  eye 
operated  on  becomes  straight,  and  the  other  everted. 

Mr.  Elliot  has  fully  established  the  immediate  division  of  the  same  muscle 
of  the  eye  to  which  the  distortion  has  shifted,  as  the  means  of  rendering  the 
eyes  parallel  in  such  cases. 

Whether  the  strabismus,  then,  be  convergent  or  divergent,  when  the  divi- 
sion of  the  adductor  or  abductor,  as  the  case  may  be,  of  the  worse  eye  fails  to 
restore  parallelism,  the  distortion  either  remaining  in  the  eye  which  has  been 
operated  on,  or  shifting  to  the  other,  in  consequence  of  continued  mutual 
convergence  or  divergence,  it  is  a  general  rule,  that  the  same  muscle  of  the 
better  eye  should  be  divided. 

Parallelism,  in  such  cases,  will  never  be  perfectly  restored  by  any  other 
means.  By  waiting,  before  cutting  the  second  eye,  and  exercising  the  one 
which  has  been  operated  on,  the  inversion  or  eversion  of  the  latter  may  be 
removed,  but  it  will  be  at  the  expense  of  the  former,  which  will  become  in- 
verted or  everted.  Besides,  it  is  desirable  to  operate  on  both  eyes,  as  this 
plan,  when  properly  managed,  always  effects  the  best  cure. 

In  operating  on  the  second  eye,  it  is  generally  sufficient  to  divide  the  ten- 
don, close  to  its  insertion,  without  interfering  at  all  with  its  cellular  attach- 
ments. This  caution  is  necessary,  lest,  by  separating  the  surfaces  of  the 
tendon  from  the  capsule  and  the  sclerotica,  eversion  of  either  eye  might  fol- 
low. This  cannot  happen,  if  the  distortion  is  mutual,  till  the  inversion  of 
the  first  eye  be  removed.  If  a  mere  division  of  the  tendon  does  not  remove 
the  convergence,  the  blunt  hook  should  be  reintroduced,  and  the  muscle 
separated  from  the  eyeball  to  the  necessary  extent.  It  is  generally  the  case, 
however,  that  the  instant  the  second  adductor  is  divided,  the  eyes  become 
parallel. 


378  STRABISMUS. 

It  is  probable  that  the  true  explanation  of  the  fact,  that  a  great  number  of 
those  who  have  been  operated  on  for  strabismus  still  squint,  is,  that  the  mu- 
tual affection  of  both  eyes  has  been  overlooked,  and  only  the  worse  eye 
operated  on.  Dr.  Lietch,*"  with  an  experience  of  264  cases,  states  that  the 
operation  "  often  affords  very  satisfactory  results,"  which  very  moderate 
testimony  in  its  favor  ought  probably  to  be  attributed  to  the  cause  now  men- 
tioned. 

Mr.  Duflfin's  account  of  the  effects  of  the  operation  for  divergent  strabismus 
is  still  less  encouraging.  He  states  that  the  eye  does  not  start  into  its  place 
as  soon  as  the  abductor  is  divided;  but  requires  several  days,  in  some  in- 
stances, before  it  is  reinstated ;  and,  that  although  a  considerable  improve- 
ment takes  place,  the  cure  is  very  seldom  perfectly  successful.  "The  capa- 
bility of  moving  the  eyes  towards  the  nasal  canthus  by  an  effort  of  the  will, 
remains,"  says  he,  "precisely  the  same  as  before.  Nothing  has  been  gained 
in  this  respect ;  the  patient  has  not  acquired  the  power  of  directing  both 
eyes  inwards  simultaneously.  In  fact,  all  the  apparent  advantage  obtained  is, 
that  when  quiescent,  the  pupils  of  both  eyes  occupy  the  visual  axis  of  their 
respective  orbits,  instead  of  only  one  doing  so,  while  the  other  is  directed 
outwards."" 

Such  undoubtedly  will  generally  be  the  state  of  matters,  after  an  operation 
on  one  eye  only,  for  mutual  divergence.  In  Mr.  Elliot's  hands,  cases  of  di- 
vergent strabismus,  by  the  division  of  both  abductors,  have  been  perfectly 
cured.  I  have  had  the  pleasure  of  examining  one  of  his  patients,  who  had 
been  affected  with  divergent  strabismus  for  thirty  years,  in  whom  the  cure  is 
complete ;  every  movement  of  the  eyes,  and  even  their  convergence  on  view- 
ing near  objects,  being  perfectly  normal. 

6.  Immediately  after  the  adductor  is  divided,  the  abductor  sometimes  acts 
too  powerfully,  and  turns  the  eye  towards  the  temple ;  but  in  two  or  three 
days  the  eye  generally  resumes  its  proper  position.  The  eversion  in  such 
cases  is  attributed  by  M.  Bonnet  to  too  free  a  dissection  of  the  conjunctiva ; 
but  it  is  probable  that  it  arises  oftener  from  too  much  separation  of  the  tendon 
from  the  sclerotica,  in  cases  of  moderate  distortion. 

7.  In  a  case  related  by  Mr.  DufBu,  in  which  the  distortion  was  inwards 
and  upwards,  the  effect  of  dividing  the  adductor  was,  that  the  eye  turned 
directly  upwards,  requiring  the  levator  to  be  cut  across. 

9.  iVound. — 1.  In  general,  only  a  few  drops  of  blood  are  lost  in  the  opera- 
tion. If  the  incision  of  the  conjunctiva  is  nearer  the  caruncula  than  the  dis- 
tance already  specified,  the  conjunctiva  extensively  separated  from  its  con- 
nections, or  the  fleshy  part  of  the  muscle  divided,  the  hemorrhage  may  be 
more;  but  is  scarcely  ever  such  as  to  impede  the  operation.*'^ 

2.  The  pain  which  attends  or  follows  the  division  of  one  of  the  recti  is 
generally  inconsiderable.  It  is  rare  to  find  that  the  eye  becomes  intolerant 
of  light,  or  affected  with  burning  heat  or  inflammatory  throbbing. 

3.  The  wound  of  the  conjunctiva  often  gaps  very  much,  especially  when 
the  abductor  has  been  cut;  but  the  edges  come  together  of  themselves  in  the 
motions  of  the  eye,  and  any  serous  or  sanguineous  infiltration  under  the  con- 
junctiva is,  in  general,  slight.  Some  operators  use  fine  stitches  to  bring  the 
edges  of  the  wound  together,  trusting  that  this  will  tend  also  to  prevent  un- 
natural prominence  of  the  eye. 

Left  to  itself,  the  wound  never  heals  by  the  first  intention,  but  it  rarely 
suppurates.  Lymph  is  effused  between  its  edges,  and  it  generally  closes  in  a 
fortnight  or  three  weeks.  In  some  cases,  however,  the  lips  of  the  divided 
conjunctiva  become  swollen,  red  and  elevated;  and  this  state  must  subside 
before  the  wound  heals.     Occasionally  the  sclerotica  close  to  the  caruncula 


STRABISMUS.  3T9 

throws  out  a  fungus,  which  hangs  by  a  pedicle,  and  may  grow  to  the  size  of  a 
pea.  The  application  of  caustics  to  the  fungus  is  of  little  or  no  use.  It  is 
better  to  lay  hold  of  it  with  the  forceps,  and  snip  it  off  with  the  scissors. 
Should  it  grow  again,  this  must  be  repeated.  The  wound  which  has  become 
fungous,  takes  several  months  to  heal. 

4.  In  one  instance  only  have  I  seen  disorganizing  inflammation  attack  the 
eyeball  after  the  operation  for  strabismus.  Called  into  consultation  in  this 
case,  I  was  informed  that  the  adductor  had  been  divided  without  difficulty 
twelve  days  before ;  but  that  the  patient  had  conducted  himself  imprudently, 
and  had  caught  cold.  I  found  the  eye  turned  towards  the  temple,  with  much 
swelling  and  inflammation  at  the  inner  canthus.  The  sclerotica  had  already 
sloughed  to  the  extent  of  about  one-third  of  an  inch  in  diarheter,  so  that  the 
choroid,  covered  by  a  lymphatic  exudation,  protruded.  Ulceration  was  ex- 
tending to  the  nasal  edge  of  the  cornea;  the  pupil  was  clear  and  small.  In  a 
few  days  the  choroid  gave  way  by  a  minute  opening,  and  allowed  the  vitreous 
humor  to  drain  out  of  the  eye.  At  my  third  visit  the  eye  was  in  a  state  of 
total  exophthalmia,  tense  and  much  protruded,  and  the  cornea  disorganized. 
Ultimately,  the  eye  shrunk.  The  patient  was  bled  at  the  commencement  of 
the  inflammatory  symptoms,  leeched  and  mercurialized.  Latterly,  opiates  and 
poultices  were  used. 

10.  After-treatment. — 1.  Afraid  of  reaction,  we  are  induced  to  put  the 
patient  to  bed,  directing  him  to  keep  his  eyes  shut,  and  the  one  operated  on 
covered  with  cold  wet  cloths.  So  little,  however,  is  the  tendency  to  reaction, 
that  laboring  people  not  unfrequently  tie  up  the  eye  with  a  handkerchief,  and 
with  the  aid  of  the  other  eye  resume  their  usual  employment  the  day  after  the 
operation,  without  experiencing  any  bad  effects.  There  seems  even  a  danger 
in  keeping  both  eyes  constantly  shut,  after  an  operation  for  convergent  stra- 
bismus; for  as  in  that  state  they  turn  upwards  and  inwards,  the  operated  one 
must  approach  its  former  position,  the  consequence  of  which  might  be  that 
the  muscle,  by  adhering  to  the  sclerotica  too  far  forwards,  would  cause  the 
distortion  to  return  to  a  certain  extent,  as  soon  as  the  process  of  healing  was 
complete.  The  danger  of  such  an  event  would  be  lessened  by  the  patient's 
employing  even  the  opposite  eye,  and  still  more  certainly  by  using  both  eyes, 
within  doors,  and  under  the  cover  of  a  shade.  A  green  veil  is  very  convenient, 
affording  warmth,  excluding  too  much  light,  and  allowing  a  free  use  of  the 
eyes. 

The  advice  commonly  given  is,  that  with  the  opposite  eye  tied  up,  the  pa- 
tient should  use  the  operated  one,  and  turn  it  frequently  in  the  direction  op- 
posed to  the  former  distortion ;  to  the  right,  if  the  right  adductor  has  been 
divided,  and  vice  versa.  The  exclusion  of  the  opposite  eye,  however,  if  it  has 
not  been  operated  on,  only  indulges  the  inclination  it  already  has  to  squint, 
and  the  turning  of  the  eyes  to  the  right,  if  the  right  adductor  has  been  divided, 
favors  a  continuance  of  mutual  convergence.  In  fact,  the  opposite  direction 
rather  should  be  given  to  the  eyes,  so  as  to  make  their  axis  diverge,  and  not 
converge.  After  the  abductor  is  divided,  the  patient  should  look  to  neither 
side ;  but  direct  his  eyes  straight  before  him,  or  even  towards  small  objects 
placed  a  few  inches  from  his  nose,  so  as  to  make  the  eyes  converge. 

2.  Three  or  four  times  a  day,  the  eye  should  be  fomented  with  warm  water, 
or  decoction  of  poppy  heads. 

3.  The  patient  should  eat  no  flesh,  nor  take  alcoholic  drinks  of  any  sort. 

4.  He  should  avoid  going  out  of  doors  with  the  eyes  uncovered,  over- 
heating himself,  exposing  himself  to  cold,  or  looking  intently  upon  minute 
objects,  as  in  reading  or  writing. 

5.  Puro-mucous  inflammation  of  the  conjunctiva  supervening  is  to  be  treated 
with  the  usual  remedies  for  catarrhal  ophthalmia. 


380  STRABISMUS. 

11.  Pathology  of  strahismus,  as  illustrated  hy  the  operation. — A  question 
naturally  occurs,  What  light  has  the  operation  thrown  on  the  pathology  of 
the  disease  ? 

1.  The  conjunctiva  and  subjacent  textures  have  not  unfrequently  been 
found,  especially  at  the  inner  canthus,  unnaturally  adherent  ;*^  sometimes 
thickened,  contracted,  and  infiltrated  to  such  a  degree,  that  they  felt  like 
cartilage  under  the  scissors." 

2.  In  general,  the  muscle  which  is  exposed  and  divided  appears  quite 
natural,  in  color,  consistence,  and  insertion.*^ 

3.  In  some  instances,  the  muscle  has  appeared  in  a  thickened  state,  and 
rounder  than  natural,  has  bled  more  than  usual,  has  been  more  difficult  to 
divide,  and  more  tendinous  than  common — in  a  word,  hypertrophied.*® 

4.  In  a  few  instances  it  has  been  atrophied.*'' 

5.  Bifurcation  of  the  fleshy  belly  of  the  adductor  has  been  met  with.*** 

6.  The  rectus  internus  has  been  found  displaced  upwards,  causing  distortion 
upwards  and  inwards. ^^ 

1.  Irregular  attachments  of  the  muscle  have  been  met  with,  its  insertion 
being  further  back  than  common,  and  bundles  of  fibres  inserted  behind  the 
proper  tendon.* 

12.  What  becomes  of  the  divided  muscle? — Whether  it  be  the  tendon  or 
the  fleshy  part  of  one  of  the  recti  which  is  divided,  the  muscle  contracts  re- 
markably in  breadth,  and  is  drawn  back  within  the  capsule.  Even  the  fleshy 
part,  which  lies  behind  the  capsule,  suffers  a  degree  of  retraction.  After  a 
time,  the  muscle  becomes  re-attached  to  the  sclerotica  by  cellular  adhesions. 

Dr.  Ammon  states,  that,  when  the  tendon  is  separated  from  the  sclerotica, 
and  cut  through,  the  muscle  retracts  less  than  when  the  fleshy  part  is  divided. 
If  the  fleshy  part  is  divided,  or  a  piece  of  it  cut  out,  the  muscle  contracts  so 
as  to  become  round  and  narrow,  and  the  space  left  between  the  cut  surfaces 
fills  with  blood,  which  also  surrounds  the  divided  ends.  By  and  by,  coagu- 
lable  lymph  is  effused.  Sometimes  the  wound  heals  speedily,  the  muscle  re- 
uniting, and  a  firm  mass  of  a  dark  color,  small  and  round  in  comparison  with 
the  original  structure,  occupying  the  space  between  the  divided  ends. 

The  muscle,  in  this  state,  is  described  by  Dr.  Ammon  as  presenting  the 
appearance  as  if  it  had  been  tied  for  some  time  with  a  ligature.  In  other 
cases  the  ends  do  not  reunite,  but  become  firmly  adherent  to  the  sclerotica, 
and  to  the  capsule. 

The  degree  of  retraction,  which  the  divided  muscle  undergoes,  varies  in 
different  cases,  and  consequently  the  place  of  its  adherence  to  the  sclerotica 
varies.  Bernoulli^*  calculated  that  the  greatest  contraction  of  the  recti,  in 
the  natural  motions  of  the  eye,  equalled  very  nearly  one-fifth  of  their  length. 
If  this  degree  of  contraction  takes  place  after  one  of  these  muscles  is  divided, 
the  divided  ends  will  be  separated  more  than  a  quarter  of  an  inch  from  one 
another,  and  the  point  of  readhesion  to  the  sclerotica  will  be  behind  the 
transverse  diameter  of  the  eyeball.  When  the  conjunctiva  and  subjacent 
textures  are  in  a  natural  state,  and  the  motions  of  the  eye  free,  the  muscle 
will  contract  to  at  least  a  fifth  of  its  natural  length ;  but  where  inflammation 
has  matted  the  parts  unnaturally  together,  the  contraction  will  be  much  less. 
In  a  case  of  relapse,  operated  on  a  second  time  by  Mr.  Lucas, *^  he  found 
the  new  insertion  of  the  muscle  to  be  only  about  one  line  and  a  half  behind 
its  original  attachment.  In  an  eye  dissected  by  Mr.  Hewett,^^  a  month  after 
division  of  the  adductor,  the  patient  having  died  of  phthisis,  the  muscle  had 
retracted  to  the  distance  of  three-quarters  of  an  inch  from  its  natural  attach- 
ment, but  still  remained  connected  to  the  eyeball  by  a  strong  band  of  cellu- 
lar tissue.  This  band  was  about  three  lines  in  width,  and  about  six  lines  in 
length,  and  was  attached  to  the  eyeball  about  two  lines  behind  the  original 


STRABISMUS.  381 

insertion  of  the  muscle.     In  this  case  the  retraction  of  the  muscle  must  have 
surpassed  considerably  one-fifth  of  its  natural  length. 

13.  Unfavorable  effects  of  the  operation. — Some  of  the  unfavorable  eifects 
which  are  apt  to  arise  from  the  operation  are  trivial,  but  others  are  important. 

1.  The  white  cicatrice  of  the  conjunctiva,  in  the  situation  of  the  wound,  is 
of  no  moment. 

2.  The  eye,  which  has  had  its  adductor  divided,  presents  a  greater  gap  be- 
tween the  cornea  and  caruncula  than  natural ;  the  caruncula  is  more  sunk, 
the  lids  more  open,  the  eye  more  prominent  and  convex  at  the  nasal  angle. 
If  the  plan  of  dividing  part  of  the  levator  or  depressor,  in  addition  to  the 
division  of  the  adductor,  were  followed,  the  eye  would  be  particularly  liable 
to  project. 

If  both  eyes  have  been  operated  on,  both  are  rendered  more  prominent 
than  natural ;  but  being  equally  so,  the  circumstance  attracts  less  notice. 
When  only  one  eye  projects,  and  the  projection  is  great,  the  physiognomy  is 
very  remarkably  and  disagreeably  affected.  This  affords  a  reason  for  operat- 
ing on  the  opposite  eye,  if  it  presents  the  slightest  degree  of  strabismus. 
If  we  venture  to  operate  on  a  straight  eye,  or  on  one  but  slightly  distorted, 
for  the  purpose  of  equalizing  the  projection  of  the  two,  the  tendon  should  be 
divided  close  to  its  insertion,  and  with  as  little  separation  of  its  cellular  con- 
nections as  possible,  for  fear  of  eversion. 

3.  Whether  one  eye  only,  or  both,  have  been  operated  on,  double  vision  is 
not  an  unfrequent  effect.  In  this  case  parallelism  of  the  eyes  has  not  been 
perfectly  restored.  If  the  adductor  of  one  eye  has  been  divided,  and  the 
eye  is  thereby  everted  in  any  degree,  double  vision  occurs  when  the  patient 
looks  straight  forward,  or  towards  the  other  side.  In  general,  this  effect 
gradually  subsides  as  the  eye  recovers  the  power  of  adduction,  by  the  action 
of  the  inner  fibres  of  the  levator  and  depressor,  and  the  readherence  of  the 
divided  muscle  to  the  sclerotica.  The  patient  should  be  instructed  to  look 
forward  at  objects,  and  to  avoid  looking  to  a  side,  especially  to  the  side 
which  increases  the  double  vision  by  causing  divergence ;  to  the  left,  for 
instance,  if  the  right  adductor  has  been  divided.  Except  where  each  eye, 
being  shaded  in  its  turn,  remains  straight,  tying  up  one  of  them  only  pro- 
longs the  evil. 

4.  One  of  the  most  annoying  consequences  of  the  operation  is  inordinate 
eversion  of  the  eye,  when  the  adductor  has  been  divided.  Too  great  a  sepa- 
ration of  the  muscle,  and  dividing  it  too  far  from  the  cornea,  are  the  causes 
of  this  effect,  which  is  still  more  apt  to  occur,  if,  in  addition  to  these  causes, 
the  motions  of  the  eye  had  been  previously  free  and  the  distortion  slight,  or 
if  both  eyes  have  been  cut.  Eversion  may  also  be  brought  on,  soon  after 
the  operation,  by  the  patient's  looking  too  much  to  the  side.  In  children, 
unless  the  wound  of  the  conjunctiva  is  small,  and  the  muscle  simply  divided, 
without  separating  it  much  from  the  sclerotica,  eversion  is  very  apt  to  occur 
sooner  or  later.  A  young  lady  from  the  West  of  Scotland,  calling  upon  me 
with  slight  convergent  squint,  I  advised  her  against  any  operation.  She 
went  to  Edinburgh,  where  she  was  to  be  operated  on  without  letting  her 
friends  know,  the  operation  was  so  very  easy,  and  she  was  to  return  with  her 
eye  straight  in  two  or  three  days.  Severe  inflammation  followed  the  opera- 
tion, with  great  swelling  of  the  eye,  requiring  the  application  of  leeches,  and 
keeping  her  in  bed  for  six  weeks.  The  eye  turned  to  the  temple,  and  thus 
she  went  home,  ashamed  to  let  herself  be  seen. 

Extreme  eversion  is  attended  by  a  disagreeable  expression  of  countenance, 
giddiness,  and  such  a  degree  of  double  vision  as  unfits  the  patient  for  pur- 
suing any  employment,  and  even  for  walking  about,  with  both  eyes  open. 

The  moment  the  surgeon  observes  a  tendency  to  eversion,  he  should  caution 


382  STRABISMUS. 

the  patient  against  turning  his  eyes  much  to  either  side,  and  especially  against 
such  lateral  motion  as  produces  divergence  of  the  optic  axes,  and  should 
recommend  him  to  look  always  straight  before  him,  and  to  exercise  his  eye 
frequently  on  near  and  small  objects.  If  the  opposite  eye  does  not  become 
distorted  on  being  closed,  it  should  be  bandaged  for  four  or  five  weeks.  If 
the  eversion  continues  after  this,  the  abductor  should  be  divided.  If  the  eye 
is  inverted  after  an  operation  for  divergent  strabismus,  the  adductor  may 
require  to  be  divided,  should  such  exercise  of  the  eyes  as  tends  to  diminish 
the  convergence,  viz  :  looking  forward  at  distant  objects,  prove  unsuccessful. 
The  division  of  the  antagonist  muscle,  in  either  case,  will  allow  the  eye  to 
resume  its  position  in  the  centre  of  the  orbit,  and  the  lateral  motions  will  be 
performed  by  the  re-adhering  muscles,  and  by  the  levator  and  depressor. 

The  mutual  divergence  which  generally  exists  in  cases  of  eversion,  occurring 
after  division  of  the  adductor,  may  be  remedied  by  operating  on  either  abduc- 
tor. In  a  patient  operated  on  by  Mr.  Charles  W.  Gr.  Guthrie,"  after  the 
adductor  of  the  inverted  eye  was  divided,  it  gradually  became  everted.  The 
case  was  now  one  of  mutual  divergence.  After  some  weeks,  the  abductor  of 
the  better  eye  alone  was  divided,  which  cured  the  eversion  of  the  other  eye, 
without  any  interference  with  its  abductor.  Mr.  Guthrie's  explanation  or 
theory  is  not  satisfactory.  He  mentions  that  from  a  train  of  reasoning  he 
was  led  to  select  the  better  eye,  as  an  operation  on  it  alone  would  cure  the 
eversion.  This  is  not  the  case.  The  division  of  the  other  abductor  would 
with  equal  certainty  have  removed  the  mutual  divergence,  though  objection- 
able on  account  of  the  prominence  it  would  have  left  from  the  division  of  two 
recti  of  the  same  eye. 

Alternating  eversion,  on  looking  to  either  side,  sometimes  follows  an  ope- 
ration for  convergent  strabismus.  After  division  of  the  adductor  of  one  eye, 
for  example,  it  has  happened  that  the  patient,  on  looking  at  any  object 
placed  straight  before  the  eyes,  directed  the  axes  of  both  correctly,  so  that 
no  obliquity  could  be  detected,  and  vision  was  single.  If,  however,  without 
turning  his  head,  he  regarded  any  object  placed  a  little  to  either  side,  the  eye 
of  that  side  was  instantly  everted  to  a  very  considerable  extent. 

In  a  case  of  this  sort,  in  which  the  left  adductor  had  been  divided  by  Mr. 
DufBn,^*  when  the  object  was  placed  to  the  left  side,  the  eyeball  was  so  much 
everted  that  two-thirds  of  the  cornea  were  concealed  in  the  outer  angle  of  the 
orbit,  the  opposite  pupil  occupying  its  proper  position.  When  the  object 
was  placed  to  the  right  side,  the  right  eye  was  everted  in  the  same  manner, 
while  the  left  remained  straight. 

In  another  case,  related  by  Mr.  Duffin,  the  same  alternating  eversion  hap- 
pened after  both  adductors  had  been  divided.  The  patient  could  direct  both 
pupils  with  the  utmost  precision,  when  the  object  was  placed  immediately 
before  her;  but  if  it  was  removed  even  a  few  inches  to  either  side,  and  she 
continued  to  look  at  it  without  turning  her  head,  the  abductor  of  the  eye  on 
the  side  to  which  the  object  was  moved  immediately  exerted  an  undue  ascend- 
ancy, and  drew  the  pupil  so  much  to  the  outer  angle  that  vision  instantly 
became  double,  and  a  most  ungainly  cast  supplanted  the  original  distortion. 
If  unfortunately  alternating  eversion  does  not  occur,  the  same  exercise  of 
the  eyes,  as  has  already  been  recommended,  should  be  followed.  Avoiding 
as  much  as  possible  lateral  movements  of  his  eyes,  the  patient  should  look  at 
small  objects  placed  near  and  straight  before  him.  In  Mr.  Duffin's  cases, 
the  mutually  controlling  power  of  the  muscles  of  the  two  eyes  gradually 
returned,  so  as  to  render  any  operation  on  the  abductors  unnecessary. 

14.  Relapse. — The  same  general  principles  which  guide  us  in  operating, 
or  in  refraining  f^-om  operating,  on  the  second  eye,  arid  in  exercising  the  eyes 
immediately  after  the  operation,  are  to  be  applied  in  cases  of  relapse. 


STRABISMUS,  383 

1.  It  not  unfrequently  happens  that,  although  the  eye  which  has  been  ope- 
rated on  occupies  its  proper  position  immediately  after  the  operation,  it 
becomes  occasionally  inverted  a  week  or  two  afterwards.  If  the  inversion  is 
removed  by  closing  the  other  eye,  which  in  its  turn  does  not  become  inverted, 
as  is  seen  on  suddenly  raising  its  lid,  the  good  eye  must  be  bandaged, 
and  the  other  regularly  exercised,  till  the  cure  is  complete  and  permanent. 
The  same  plan  is  to  be  followed,  if  occasional  eversion  follows  the  operation, 
the  opposite  eye  remaining  free  from  any  implication. 

2.  By  operating  on  the  worse  eye  only,  its  position  is  sometimes  perfectly 
remedied  for  the  first  few  days,  after  which  the  strabismus  is  very  apt  to  return 
to  the  same  eye,  although  not  in  the  same  degree,  for  the  patient  is  never  able 
to  conceal  any  part  of  the  cornea  in  the  inner  canthus,  after  the  division  of 
the  adductor.  In  other  cases,  the  distortion  settles  in  the  better  eye.  The  same 
is  very  apt  to  happen  in  alternating  cases,  if  only  one  eye  has  been  operated 
on.  Under  any  of  these  circumstances,  Mr.  Elliot's  plan  should  immediately 
be  adopted,  viz  :  the  division  of  the  same  muscle  of  the  second  eye,  as  the 
surest  means  of  removing  the  mutual  convergence. 

If  the  patient  refuses  to  submit,  exercise  of  the  eyes,  or  what  a  French 
critic  calls  orthojjJithalmic^^  \n'SiCtice,  must  be  tried.  In  such  cases,  bandaging 
either  eye  is  useless,  as  it  only  substitutes  the  inversion  of  the  one  eye  for 
that  of  the  other,  and  would  confirm  the  distortion  in  the  eye  which  was  co- 
vered. Such  exercise  as  everts  the  eye  which  has  been  operated  on  for  con- 
vergent strabismus,  seems,  at  first  sight,  to  be  indicated  in  such  t;ases,  and  is 
the  practice  usually  followed;  but  a  little  reflection  will  show  that  this  is  the 
very  means  to  confirm  the  mutual  convergence.  Mr.  Elliot,  therefore,  re- 
commends that  the  patient  should  be  directed  to  look  to  that  side  which  will 
cause  the  two  eyes  slightlv  to  diverge  from  each  other ;  to  the  left  side,  if  the 
right  adductor  has  been  divided,  and  vice  versa.  If  the  right  adductor,  for 
example,  has  been  divided,  its  incomplete  power  of  inversion  will  cause  the 
two  eyes  to  diverge  a  little,  when  the  patient  looks  fully  to  the  left  with  the 
left  eye.  Mr.  Elliot  calls  this  side  practice,  and  acknowledges  that  it  would 
be  the  most  likely  plan  possible  to  increase  the  original  evil,  were  this  really, 
as  is  too  generally  supposed,  confined  to  the  inverted  eye ;  but  urges  its 
success  as  a  strong  proof  of  the  truth  of  his  views  regarding  the  mutual 
aff"ection  of  the  eyes  in  strabismus. 

The  cause  of  relapse  has  been  attributed  by  some  to  the  muscle  readhering 
too  soon,  and  too  near  its  former  attachment.  To  prevent  such  an  occurrence, 
the  eye  has  sometimes  been  drawn  forcibly  outwards  a  day  or  two  after  the 
operation,  while  the  adhesions  might  still  be  ruptured  ;  a  very  rough  treat- 
ment, which  is  not  to  be  recommended.  A  repetition  of  the  operation  has 
also  been  had  recourse  to,  on  the  ground  that  the  abductor,  opposed  by  the 
reunion  of  the  adductor  to  the  sclerotica,  requires  a  second  opportunity  of 
contracting.  It  is  thought  that  this  opportunity  will  be  afforded  to  it,  by 
again  separating  the  adductor  from  the  sclerotica,  and  that  by  this  means  the 
cure  will  be  accomplished.  That  a  continued  inversion,  however,  of  the  same 
eye,  after  the  first  operation,  does  not  depend  on  any  impaired  contractile 
power  of  the  abductor,  is  evident  from  the  fact,  that  the  patient  can,  not 
only  bring  the  eye  to  the  central  position  before  it  is  operated  on,  but  evert 
it  more  or  less  on  shutting  the  opposite  eye.  If  the  abductor  can  do  this 
before  the  adductor  is  divided,  it  will  be  still  easier  for  it  to  do  so  after  the 
operation.  The  fault  in  cases  of  relapse  does  not  lie  at  all  in  the  abductor, 
but  in  the  reciprocal  affection  of  the  two  eyes  not  being  overcome,  and  per- 
haps not  understood. 

In  repeating  the  operation  very  sharp  scissors  are  necessary  to  divide  the 
cicatrice.  The  incision  of  the  conjunctiva  requires  to  be  free,  in  order  to  get 
through  the  effused  lymph,  behind  which  the  muscle  is  to  be  exposed.     It  is 


384  STRABISMUS. 

more  difficult  to  pass  the  blunt  hook  than  in  a  first  operation.  The  parts 
bleed  more,  but  the  reaction  is  not  greater. 

If  the  operation,  in  the  first  instance,  has  been  performed  according  to  the 
rules  already  laid  down,  and  the  better  eye  operated  on  as  well  as  the  wonse, 
it  is  not  likely  that  a  repetion  of  the  operation  will  be  required  in  any  case. 

The  only  admissible  excuse  for  repeating  the  operation  would  be  a  convic- 
tion, on  the  part  of  the  operator,  that  he  had  not  separated  the  tendon  com- 
pletely. The  operation  may  fail,  if  a  slip  of  tendon,  however  slight,  remains 
undivided.  The  operator  being  satisfied  that  the  operation  was  complete,  he 
should  abandon  any  idea  of  repeating  it  on  the  same  eye,  and  operate  on  the 
other  eye,  which  will  both  remove  the  strabismus  and  make  the  eyes  equally 
prominent. 

3.  Relapse  seldom  supervenes  after  both  adductors  are  divided.  When  it 
does,  Mr.  Elliot  tells  us  that  it  is  easily  removed  by  exercise.  If  the  relapse 
affects  one  eye,  and  the  distortion  is  removed  by  closing  the  other,  which  does 
not  become  distorted  in  its  turn,  this  eye  is  to  be  bandaged  till  the  vision  of 
the  eye  which  had  relapsed  becomes  improved,  and  parallelism  is  restored. 
If  the  eye  which  is  closed  does  become  distorted,  bandaging  is  useless,  and 
the  patient  must  be  directed  to  practice  looking  to  either  side,  till  the  eyes 
are  accustomed  to  their  new  association.  In  a  case  related  by  Mr.  Elliot,  in 
which  both  adductors  were  divided,  the  right  eye  being  the  worse  of  the  two, 
for  three  days  the  eyes  remained  straight.  The  right  eye  then  gradually 
relapsed,  so  that  nearly  all  the  white  internal  to  the  cornea  was  concealed, 
while  the  patient  looked  straight  forward  with  the  left.  In  this  case,  the 
usual  mode  of  exercising  the  right  eye,  by  directing  the  patient  to  look  dex- 
trad,  whenever  he  had  an  opportunity,  was  followed  by  an  advantageous 
result.  If  the  vertex  of  the  retina  of  the  distorted  eye  is  insensible,  band- 
aging the  opposite  eye  would  be  worse  than  useless.  Side-practice  must  be 
tried. 

4.  In  cases  of  divergent  strabismus,  in  which  both  abductors  have  been 
divided,  it  sometimes  happens  that  a  slight  eversion  of  one  or  other  eye  gene- 
rally of  the  worse  one,  occurs  some  days  after  the  operation.  The  patient  is 
to  practise  looking  forward  at  near  and  small  objects. 

15.  Orthophthalmic  practice. — Success  in  curing  strabismus  depends  much 
on  the  patient's  persevering  in  well-directed  practice. 

Three  varieties  of  practice  have  been  referred  to  in  the  preceding  pages ; 
viz  :  the  parallel,  the  diverging,  and  the  converging. 

1.  If,  in  any  case,  parallelism  can  be  produced  by  covering  the  better  eye, 
it  ought  to  be  bandaged,  and  the  other  eye  exercised.  If,  by  a  continuance 
of  this  parallel  practice,  the  sight  of  the  worse  eye  is  made  to  equal  that  of 
the  better,  a  permanent  curg,  Avithout  operation,  will  be  the  result. 

After  an  operation  for  strabismus,  if  the  distortion  relapses,  is  confined  to 
the  eye  operated  on,  and  is  attributable  merely  to  an  effort  made  by  its  levator 
and  depressor,  parallel  practice  will  be  all  that  is  required. 

The  only  effect,  on  the  other  hand,  of  bandaging  one  eye  in  cases  of  distor- 
tion involving  both  eyes,  either  before  or  after  operation,  is  reversing  the 
position  of  the  eyes,  so  that  the  utmost  to  be  gained  by  such  a  practice  would 
be  a  permanent  change  of  the  inversion  or  eversion  from  the  one  to  the  other, 
by  producing  a  change  in  their  relative  powers  of  vision. 

2.  If,  after  an  operation  on  one  adductor,  there  is  any  relapse,  or  renewal 
of  the  mutual  convergence,  as  will  be  shown  by  inversion  of  the  worse  eye, 
the  patient  must  employ  Mr.  Elliot's  side-practice,  or  diverging  practice. 
For  instance,  if  the  left  eye  was  the  worse,  and  its  adductor  only  was  divided, 
and  there  is  a  relapse,  let  the  patient  look  to  his  right.  By  this  plan  the 
inverting  power  of  the  left  eye  is  no  doubt  increased ;  but  the  mutual  con- 


STRABISMUS.  385 

vergence  is  diminished,  and  the  relapse  may  be  cured.  If  both  adductors 
were  divided,  in  a  case  where  the  left  eye  was  the  worse,  and  there  is  a  relapse, 
the  patient  should  look  to  his  left,  by  which  means  divergence  will  be  pro- 
duced as  well  as  eversion  of  the  worse  eye. 

3.  If  the  case  has  been  one  of  mutual  divergent  strabismus,  and  one  or 
both  abductors  have  been  cut,  the  patient  should  avoid  side-practice,  and 
look  at  near  and  small  objects,  placed  straight  before  him.  This  is  converg- 
ing practice,  which  is  required  also  in  cases  of  diplopia  and  eversion  after 
division  of  one  or  both  adductors.  One  of  the  best  modes  of  using  converg- 
ing practice,  is  for  the  patient  to  look  frequently  at  two  reflected  images, 
placed  at  the  true  concourse  of  the  optic  axes,  as  in  the  stereoscope. 

16.  Ultimate  good  effects  of  the  operation. — The  ultimate  good  effects  of 
the  operation  refer  to  the  mobility  of  the  eye,  and  the  state  of  vision. 

1.  In  successful  cases,  the  distortion  is  permanently  removed,  the  eye 
occupies  its  natural  position  in  the  orbit,  the  axes  of  the  two  eyes  are  paral- 
lel when  distant  objects  are  regarded,  and  converge  equally,  and  in  the 
proper  degree,  when  the  object  is  near.  The  motion  of  the  eye  is  free  and 
uncontrolled.  If  the  case  was  one  of  convergent  strabismus,  the  eye  does 
not  rest  in  the  centre  of  the  orbit,  as  perhaps  it  did  immediately  after  the 
operation,  but  turns  naturally  to  the  nose.  This  movement  of  adduction  is 
often  quite  perfect.  It  is  effected  by  the  reunited,  or  at  least  readhereut, 
muscle,  and  by  the  innermost  fibres  of  the  levator  and  depressor. 

2.  For  some  time  after  the  operation,  the  eye  cannot  be  used  with  much 
freedom,  and  this  the  patient  may  confound  with  a  new  degree  of  weakness 
of  sight.  As  the  tenderness  arising  from  the  wound  subsides,  the  vertex  of 
the  retina,  which  is  its  most  sensitive  part,  is  readily  turned  towards  objects, 
and  the  range  of  vision  is  increased.  A  squinting  eye  often  mars  the  vision 
of  the  straight  eye,  perhaps  by  the  confusion  arising  from  diplopia,  perhaps 
by  the  kind  of  struggle  as  to  which  eye  shall  be  directed  on  the  object,  so 
that  the  person  sees  better  when  the  squinting  eye  is  closed ;  when  the  ope- 
ration has  been  successful  in  restoring  the  natural  movements  of  the  eye,  he 
sees  better  with  both  his  eyes  open,  than  he  did  before  when  the  squinting 
one  was  shut. 

So  far  a  decided  improvement  is  effected,  and  this  the  patient  is  apt  to 
mistake  for  an  increase  in  the  acuteness  of  vision.  The  fact  is,  there  is  never 
any  immediate  change  in  the  visual  power  of  the  eye,  as  is  ascertained  by 
trying  it  with  the  letters  of  the  same  printed  book  with  which  it  was  tested 
before  operation.  The  retinal  power  never  suffers  any  diminution  from  the 
operation,  unless  in  those  rare  cases  where  disorganizing  inflammation  is 
produced;  and  in  some  instances,  there  follows  a  considerable  improvement 
in  vision.  An  increase  in  sensorial  power  is  most  likely  to  follow  the  opera- 
tion, where  the  imperfection  has  been  the  efiect  of  the  strabismus,  the  sensi- 
bility of  the  retina  having  become  blunted,  and  a  sub-amaurotic  state  pro- 
duced, by  disuse.  Careful  examination  shows,  however,  that  the  augmenta- 
tion of  sensorial  power  is  seldom  great,  that  it  is  much  oftener  fancied  than 
real,-'^'  and  that,  in  general,  it  would  be  incorrect  to  attribute  the  improvement 
to  anything  else  than  a  return  of  the  power  of  moving  the  eyes  without 
restraint,  and  of  directing  both  of  them  simultaneously  upon  objects.  This 
sort  of  improvement,  which  is  equivalent  with  the  restoration  of  the  very  im- 
portant function  of  single  vision  with  two  eyes,  is  often  very  striking,  espe- 
cially when  the  patient  has  been  successfully  operated  on  for  the  alternating 
variety  of  strabismus. 

Patients  with  convergent  strabismus  are  often  myopic.  But  it  would 
appear,  that  they  sometimes  suppose  themselves  so,  merely  from  their  being 
oljliged  to  bring  objects  near  to  their  face,  in  order  to  see  them  with  both 
25 


386 


STRABISMUS. 


eyes  together,  so  that  the  whole  defect  lies  in  want  of  ability  to  moderate  the 
convergency  of  the  optic  axes.  After  the  eyes  are  restored  to  parallelism  by 
operation,  such  patients  find  that  they  are  not  myopic,  but  see  at  the  ordi- 
nary distance. 

Convergent  strabismus  may  be  so  extreme,  as  to  deprive  the  patient  almost 
totally  of  the  use  of  sight,  till  relieved  by  an  operation;  but  cases  of  this 
kind  should  not  be  confounded  with  amaurosis.  In  a  case  operated  on  by 
Mr.  Duffin,*^  the  patient  was  unable  to  turn  the  pupils  sufficiently  towards 
the  centre  of  the  orbit  to  expose  the  whole  of  the  cornea  to  view.  Both  eyes 
were  liberated  by  operation  at  the  same  sitting,  but  a  considerable  time 
elapsed  before  the  pupils  finally  attained  their  proper  position.  They  did  so, 
however,  in  a  considerable  degree  before  the  patient  left  the  room.  Mr. 
Duffin  says,  that  "she  was  almost  entirely  amaurotic  before  the  operation, 
and  recovered  her  vision,  so  as  to  distinguish  small  objects,  within  an  hour 
afterwards ;"  but  the  probability  is,  that  there  was  nothing  really  amaurotic 
in  a  case  where  the  recovery  was  so  rapid. 


'  Heuermann,  in  his  "  Ahhandlung  der  neues- 
ten  chirurgische  Operationen,"  published  at 
Copenhagen  and  Leipsick  in  1756,  says,  that 
Chevalier  Taylor  pretended  to  cure  strabismus 
by  a  section  of  the  tendon  of  the  superior  ob- 
lique. 

In  1827-8,  Mr.  Anthony  White,  surgeon  to 
the  Westminster  Hospital,  frequently  recom- 
mended, in  his  clinical  observations,  the  ope- 
ration of  dividing  the  adductor  muscle  as  an 
eligible  surgical  process,  and  looked  out  for 
squinting  animals,  in  order  that  he  might  try 
the  effect  of  the  section  first  on  them,  before  he 
should  apply  it  to  the  human  subject. 

*  Cavarra,  Journal  IJebdomadaire  des  Pro- 
gr§s  des  Sciences  Medicales;  Tome  i.  p.  309; 
Paris,  1836. 

'  Op.  cit.  pp.  310,  311. 

*  Dr.  Cavarra  mentions,  that,  if  in  a  living 
animal,  we  divide  the  crus  cerebelli,  the  animal 
immediately  begins  to  squint.  Division  of  the 
medullary  part  of  the  cerebellum,  pons  Varo- 
lii, or  lateral  part  of  the  medulla  oblongata, 
produces  the  same  effect.  If,  instead  of  divid- 
ing, we  compress  the  crus  cerebelli  of  a  living 
animal,  strabismus,  he  says,  is  produced;  and 
if  the  compression  ceases,  the  eye  recovers  its 
natural  powers  of  motion.  The  effect  produced 
in  such  experiments  is  not  so  much  strabismus, 
as  luseitas  from  palsy. 

'  London  Medical  Gazette;  Vol.  xlv.  p.  954. 

'  In  illustration  of  the  distinction  between 
inversion  or  eversion  and  mutual  convergence 
or  divergence,  I  may  mention  the  case  of  a 
patient  at  present  under  my  care,  who  is  al- 
most blind  of  the  right  eye,  in  consequence  of 
its  having  been  struck  with  a  potato  some 
months  ago.  His  left  eyo  is  incompletely 
amaurotic,  so  that  he  cannot  read  with  it.  The 
left  side  of  his  face  is  slightly  paralytic.  When 
ho  regards  an  object  straight  before  him,  he 
keeps  his  eyes  turned  to  the  right,  so  that  the 
right  eye  is  everted  and  the  left  inverted;  but 
he  can  turn  them  to  the  left,  and  in  this  move- 
ment their  pupils  continue  at  the  same  distance 
from  one  another,  so  that  their  axes  are  paral- 
lel. On  closing  his  eyes  and  suddenly  opening 
the  right,  it  is  always  everted;  on  suddenly 
opening  the   left,  it  is  always  inverted.     On 


shutting  the  left  eye,  the  right  becomes  cen- 
tral ;  on  shutting  the  right,  the  left  remains 
inverted,  but  on  moving  the  object  sinistrad 
the  eye  becomes  central,  showing  the  vertex  of 
the  retina  to  be  comparatively  insensible.  The 
left  eye,  therefore,  looks  sideways  at  objects ; 
the  right  eye  does  not  look  at  all,  but  obeys 
the  association  of  motion.  When  the  left  eye 
is  closed,  the  right  occupies  its  normal  place, 
and  uses  the  little  sight  it  has;  but  this  it  does 
only  when  the  left  eye  is  shut.  As  the  ej'es 
are  parallel  in  this  case,  there  is  no  strabismus. 
If,  bj'  bandaging  the  left  eye  and  exercising 
the  right,  the  right  could  be  made  to  see 
better  than  the  left,  the  patient  would  look  in 
the  natural  way. 

'  Lancet,  September  19,  1840,  p.  928.  lb., 
Obtober  31,  1840,  p.  192:  lb.  December  5, 
1840,  p.  386:  Edinburgh  Medical  and  Sur- 
gical Journal,  Vol.  Iv.  p.  370 ;  Ediaburgh, 
1841. 

*  Lucas'  Practical  Treatise  on  the  Cure  of 
Strabismus,  p.  48;  London,  1840. 

°  Duffin's  Practical  Remarks  on  the  New 
Operation  for  the  Cure  of  Strabismus,  p.  62 ; 
London, 1840. 

*°  Collections  from  the  unpublished  Medical 
Writings  of  C.  II.  Parry,  M.  D.,  p.  571;  Lon- 
don, 1825. 

"  Commentaries  on  some  of  the  Diseases  of 
Children;  Part  i.  p.  127;  London,  1815. 

'■^  Parry,  Op.  cit.  p.  672. 

'  ^  London  Medical  Gazette,  Vol.  xxvii.  p. 
642. 

'*  Boyer,  Traite  des  Maladies  Chirurgicales; 
Tome  V.  p.  607;  Paris,  1816. 

'*  Pflege  sesunder  und  geschwachter  Augen, 
p.  41 ;  Frankfurt,  1802. 

'"  The  goggles  mentioned  in  the  text  are  to 
be  had  of  Mr.  Alexander,  Optician,  Exeter. 

'^  Smith's  Complete  System  of  Opticks;  Re- 
marks, p.  31;  Cambridge,  1738. 

'^  Dissertation  sur  la  Cause  du  Strabisme; 
Memoires  de  I'Academie  Royale  des  Sciences, 
pour  1743,  p.  338  ;  12mo  ;  Amsterdam,  1748. 

'"  Medical  Times  and  Gazette;  August  27, 
1853,  p.  216. 

"  Op.  cit.  p.  312. 


LUSCITAS. 


38t 


^'  Recueil  de  Meraoires  et  d'Obsorvations,  p. 
410  ;  Montpellier,  1783. 

"  Philosophical  Transactions  for  1778;  Vol. 
Ixvii.  Part  i.  p.  80. 

^'  From  a  series  of  experiments  which  he 
afterwards  made,  he  came  to  the  conclusion 
that  the  insensible  spot  at  the  bottom  of  this 
child's  eye  was  four  times  the  area  of  that  ia 
the  eyes  of  others. 

'^'  Krankheiten  des  menschlichen  Auges,  p. 
234;  Berlin,  1819. 

^'^  Dicffenbach's  Operative  Chirurgie;  Vol. 
ii.  p.  166;  Leipzig,  1848. 

^^  Beitrage  zur  operativen  Orthopadik;  p. 
22;  Hanover,  1833. 

^^  Ammon's  Monatsschrift  fUr  Medicin,  Au- 
genheilkunde  und  Chirurgie;  vol.  iii.  p.  321; 
Leipzig.  1840. 

^'  Duffin,  Op.  cit.  p.  78. 

"  Clay,  Lancet,  January  2,  1841,  p.  496. 

""  Hall,  London  Medical  Gazette,  Vol.  xsvii. 
p.  284. 

^'  London  Medical  Gazette,  Vol.  xxviii.  p. 
37. 

^^  Die  Behandlung  des  Schielens  durch  den 
Muskelschnitt,  p.  6;  Leipzig,  1840. 

^^  Edinburgh  Medical  and  Surgical  Journal, 
Vol.  Iv.  p.  376. 

^■'  Lucas,  Op.  cit.  p.  73. 

''^  It  is  well  known  that,  when  we  look  at  an 
object  straight  before  us,  the  pupil  is  not  in 
the  centre  even  of  the  aperture  of  the  eyelids, 
much  less  of  the  orbit.  The  phrase  centre  of 
the  orbit  is  used  for  the  sake  of  brevity,  though 
not  strictly  correct. 

^^  Summary  of  seventy-six  Operations  by 
Mr.  Listen;  Lancet,  July  18,  1840,  p.  610. 

^''  Franz,  London  Medical  Gazette,  Vol.  xxvi. 
p.  690. 

'*  Lietch,  Edinburgh  Monthly  Journal  of 
Medical  Science;  Vol.  i.  p.  171;  Edinburgh, 
1841. 


"  Dublin  Journal  of  Medical  Science;  Nov., 
1845;  p.  210. 

'"  Lietch,  Op.  cit.  p.  178. 

"  Op.  cit.  pp.  100,  104. 

*^  In  a  boy,  of  hemorrhagic  diathesis,  whose 
life  had  been  in  danger  several  times  from 
hemorrhage  after  slight  injuries,  and  who  was 
operated  on  by  Mr.  Lane,  the  bleeding  con- 
tinued, with  occasional  intermissions,  for  six 
days  and  five  nights,  in  spite  of  the  usual  re- 
medies, both  general  and  local.  The  prostra- 
tion was  so  great  that  transfusion  was  had 
recourse  to,  and  with  success.  Lancet,  October 
31,  1840,  p.  185. 

'^  Lucas,  London  Medical  Gazette,  Vol. 
xxvii.  p.  73. 

"  Duffin,  Op.  cit.  p.  43. 

■"  Ammon,  Op.  cit.  p.  16. 

■"^  Lucas,  Op.  cit.  p.  58 :  Dieffenbach  iiber 
das  Schielen,  p.  107:  Berlin,  1842. 

■■^  Franz,  London  Medical  Gazette;  Vol. 
xxvii.  p.  41. 

"  Dieffenbach,  Op.  cit.  p.  98. 

"  Ibid.  p.  101. 

'"  Ibid.  p.  98:  Ammon,  Op.  cit.  p.  15. 

^^  Commentarii  Academife  Petropolitanse, 
Tom.  i.  p.  304;  Petropoli,  1728. 

'"■  Op.  cit.  p.  83. 

"London  Medical  Gazette;  Vol.  xxvii.  p. 
654. 

*''  Report  on  the  Result  of  the  Operations  for 
the  Cure  of  Squinting,  performed  at  the  Royal 
Westminster  Ophthalmic  Hospital,  between  the 
18th  April  and  30th  October,  1840;  p.  11; 
London,  1840. 

"  Op.  cit.  p.  25. 

'"  Orthoj)hthalm!e,  from  li)6ic,  strairjlit,  and 
o0u.Ktji.oc,  eye. 

"  Sir  Charles  Bell's  Practical  Essays,  pp.  77, 
78,  S2;  Edinburgh,  1841. 

'^  Op.  cit.  p.  46. 


SECTION  V. LUSCITAS,  OR  IMMOVABLE  DISTORTION  OF  THE  EYEBALL. 

From  luscus,  blind  of  an  eije.     Syn. — Strabismus  passivus. 

The  word  luscitas  has  been  used  in  various  senses  by  authors  on  the  diseases 
of  the  eye.  Plenck  employs*  it  as  synonymous  with  oblique  vision,  or  that 
state  of  the  eyes  in  which  the  patient,  seeing  little  or  nothing  when  he  looks 
directly  forwards,  perceives  objects  situated  on  one  side,  but  without  any 
distortion  of  the  eye ;  while  Beer  understands^  by  luscitas,  that  the  eye  is 
turned  to  one  or  other  side  and  is  there  completely  fixed,  so  that  the  patient 
is  unable  to  move  it.  Luscitas,  in  this  sense,  is  often  confounded  with  stra- 
bismus ;  but  in  the  latter  affection,  the  patient  is  able  to  move  the  distorted 
eye,  so  as  to  direct  it  upon  any  object  as  soon  as  he  closes  the  sound  eye, 
while  to  effect  the  same  purpose  in  luscitas,  he  must,  as  the  eye  is  fixed,  rotate 
the  head. 

Causes. — Palsy  of  the  rectus  internus,  attended  generally  by  a  similar 
affection  of  the  rectus  superior,  rectus  inferior,  and  levator  palpebrse  superi- 
oris,  while  the  rectus  externus  retains  its  power,  and  rolls  the  eye  outwards, 
is  the  most  frequent  cause  of  immovable  distortion.  Palsy  of  the  abductor, 
again,  will  cause  luscitas  towards  the  nose.  Injuries  of  the  head,  and  affec- 
tions of  the  brain,  by  causing  palsy  of  one  or  other  of  the  recti,  may  pro- 
duce luscitas.     Thus,  in  chronic  hydrocephalus,  I  have  seen  both  eyes  turned 


388  OSCILLATION   OF   THE   EYEBALL. 

to  the  right,  the  patient  having  entirely  lost  the  power  of  moving  them  to 
the  left.  I  was  consulted  in  a  case  of  luscitas  of  the  right  eye,  the  left  being 
amaurotic.  The  luscitas  has  been  preceded  by  exophthalmos  and  palsy  of  the 
right  side  of  the  face,  but  these  symptoms  had  subsided.  The  right  eye  was 
turned  completely  into  the  inner  canthus,  and  no  effort  of  the  patient,  or 
pressure  of  the  finger,  could  move  it.  In  this  state,  the  patient  saw  to  work 
as  a  weaver.  Injuries  of  the  muscles  of  the  eyeball,  or  of  their  nerves,  or 
matting  together  of  the  orbital  cellular  substance  from  inflammation,  may 
produce  luscitas  ;  also  the  pressure  of  tumors  within  the  orbit,  or  a  congenital 
deficiency  of  one  of  the  recti.* 

Prognosis. — Luscitas  is  often  incurable.  The  turning  of  the  eye  outwards 
or  inwards,  in  palsy  of  the  muscles,  may  cease,  and  the  eye  be  again  directed 
forwards,  merely  in  consequence  of  the  palsy  extending  to  the  rectus  ex- 
ternus  or  internus.  If  the  palsy  be  cured,  not  merely  will  the  luscitas  cease, 
but  the  natural  movements  of  the  eye  be  restored. 

Treatment. — Except  in  cases  of  injury  of  the  muscles,  or  their  nerves,  and 
of  orbital  tumors,  the  general  treatment  of  luscitas  is  that  already  recom- 
mended for  palsy  of  the  muscles  of  the  eyeball.  Dieffenbach*  recommends 
cauterization  with  nitrate  of  silver  over  the  palsied  muscle,  excision  of  a  fold 
of  conjunctiva  in  the  same  situation,  and  division  of  the  opposite  muscle. 
Cauterization  excites  the  weak  muscle,  and  produces  a  contraction  of  the 
conjunctiva.  Excision  draws  the  eye  towards  the  proper  direction,  by  means 
of  the  cicatrice  which  follows.  Division  of  the  opposite  muscle  allows  the 
eye  to  approach  the  central  position. 


'  Doctrina    de    Morbis    Oculoruin,    p.    2H;  Anatoiiiio    des    raensclilischen    Auges,  p.    64; 

Viennas,  1777.  Hamburgh,  1S28. 

^  Lehre    von    den  Augenkrankheiten;    Vol.  *  Die  Operative  Chirurgie;  Vol.  ii.  p.  166; 

ii.  p.  667;  AVien,  1817.  Leipzig,  ISiS. 

^  See  Schon's  Handbuch  der  Pathologischen 


SECTION  VI. — TETANUS  OCULI. 


A  fixed  state  of  the  eyeball,  from  tonic  spasm  of  all,  or  several,  of  the 
recti,  is  styled  tetanus  oculi. 

The  state  of  the  eyes  and  eyelids  in  trismus  and  tetanus  merits  greater 
attention  than  has  been  bestowed  on  it. 

In  a  case  of  trismus  related^  by  Mr.  Harkness,  the  patient,  after  stiffness 
in  his  jaw,  which  was  the  first  symptom,  felt  stiffness  and  weight  in  the  eye- 
lids, which  prevented  him  from  opening  them  readily.  He  had  also  a  slight 
degree  of  dimness,  and  a  want  of  power  over  the  ball  of  the  eye,  which  re- 
mained, according  to  his  sensations,  fixed  in  his  head,  and  was  slightly  drawn 
inwards.     The  eyelids  were  for  three  or  four  days  much  swollen. 


'  Medico-Chirurgical  Transactions;  Vol.  ii.  p.  286;  London,  1813. 


SECTION  Vn. — OSCILLATION  OP  THE  EYEBALL. 
Syn. — Resolutio  oculorum,  Celsus. 

Symptoms. — In  oscillation,  the  eyeball  is  affected  with  an  almost  perpetual 
motion ;  sometimes  rotatory,  as  if  on  its  antero-posterior  axis ;  in  other  cases, 
circumductory.     The  latter  is  affected  by  consecutive  contractions  of  the 


OSCILLATION  OF  THE   EYEBALL.  389 

recti;  the  former,  by  alternate  contractions  of  the  obliqui.  The  libratory  or 
controlling  actions  of  all  the  muscles  seem  weakened,  so  that  the  eye  is 
affected  Avith  a  sort  of  paralysis  agitans.  The  patient  is  in  general  not  con- 
scious of  the  abnormal  motions,  from  any  particular  feeling  which  he  has  in 
the  eyes,  nor  can  he  restrain  them.  They  go  on  even  when  the  lids  are  closed, 
but  cease  during  sleep.  The  rotatory  motion  varies  in  extent,  from  a  scarcely 
perceptible  degree,  to  perhaps  nearly  a  quadrant.  In  some  cases,  the  motion 
seems  to  be  rather  from  side  to  side,  but  often  so  small  in  degree  and  so  rapid, 
that  it  is  difificult  to  say  what  is  exactly  its  direction. 

Patients  affected  with  partial  amaurosis  often  complain  of  all  objects  ap- 
pearing to  them  in  a  state  of  tremor.  In  such  cases,  we  naturally  expect  to 
find  the  eyeballs  oscillatory ;  but  very  often  no  oscillation  can  be  detected, 
so  that  we  are  led  to  refer  the  apparent  tremor  to  some  peculiar  morbid  state 
of  the  retina  or  internal  optic  apparatus.  On  the  other  hand,  those  who  are 
affected  with  oscillation,  generally,  though  not  always,  make  mention  of  an 
apparent  unsteadiness  and  tremor  of  objects.  I  have  known  a  patient  with 
this  disease  complain  of  great  deficiency  of  sight,  from  an  apparent  waving 
of  all  objects  up  and  down.  In  another  case,  the  oscillatory  movement  was 
very  marked,  so  long  as  the  eyes  were  directed  towards  any  object ;  but  when 
I  held  up  the  upper  lid  of  one  eye,  and  desii'ed  the  patient  to  shut  the  other 
eye,  the  oscillation  instantly  and  totally  ceased,  and  the  pupil  turned  up  under 
the  lid.  To  this  patient  all  objects  appeared  tremulous,  and  from  this  cause, 
along  with  a  degree  of  amaurosis,  very  indistinct.  The  pupils  were  large, 
and  the  aqueous  humor  superabundant.  The  case  had  all  along  been  re- 
garded as  one  of  mere  myopia.  In  another  case,  I  observed  that  the  oscilla- 
tion ceased  whenever  the  patient  looked  down,  but  became  very  great  whenever 
she  looked  up.  Convergence  of  the  eyes,  as  in  reading,  seemed  in  this  case  to 
remove  the  oscillation.  When  both  eyes  were  open,  the  oscillation  was  strik- 
ing; but  if  one  eye  was  closed,  the  other  became  perfectly  steady,  there  being 
in  this  respect  some  analogy  to  strabismus. 

Oscillation  is  often  attended  by  short-sightedness,  generally  by  asthenopia, 
and  a  sensation  of  weariness  in  the  eyes,  sometimes  by  tremulousness  of  the 
iris,  and  pain  deep  in  the  orbits,  and  in  the  head.  Oscillation  occasionally 
accompanies  strabismus. 

It  is  surprising  how  little,  in  some  cases,  oscillation  disturbs  vision.  For 
instance,  a  girl  of  17,  whose  case  is  recorded^  by  Sir  Charles  Bell,  read  with 
perfect  ease,  and  yet  there  was  no  cessation  of  the  motion  of  the  eye.  She 
threaded  her  needle,  without  any  apparent  difficulty,  and  then  showed  how  she 
could  sew,  which  was  with  the  usual  nimbleness.  All  objects  seemed  to  this 
patient  in  their  natural  state  of  rest,  or  of  motion.  When  she  looked  at  her- 
self in  the  glass,  she  saw  her  eye  rapidly  moving. 

Causes — A  congenital  want  of  pigmentum  nigrum,  as  in  the  albino,  is 
generally  attended  by  oscillation.  We  generally  observe  this  symptom  in 
congenital  cataract,  and  it  becomes  more  marked  as  the  patient  advances  in 
years ;  hence  a  reason  for  operating  early  in  such  cases.  It  also  often  attends 
congenital  amaurosis,  complete  or  incomplete,  as  well  as  the  loss  of  vision, 
which  follows  deep-seated  scrofulous  inflammation  of  the  eyeball.  I  have 
seen  oscillation,  with  alternating  strabismus  convergens,  follow  ophthalmia 
neonatorum.  Fatiguing  employments  of  the  sight  always  increase  this  un- 
steadiness of  the  eyes  ;  while  it  generally  subsides  after  a  period  of  rest.  In 
one  instance,  I  observed  oscillation  of  both  eyes  attendant  on  apoplexy,  along 
with  palsy  of  the  left  side  of  the  body,  diminished  power  of  the  right  abduc- 
tor oculi,  and  a  degree  of  amaurosis.  Dr.  Wallace  mentions^  a  case  in  which 
an  incessant  motion  of  the  eyes,  resembling  those  of  a  child  with  congenital 
cataract,  was  brought  on  by  over-dosing  with  hydriodate  of  potash. 


390  INJURIES  OF  THE  EYEBALL. 

Treatment. — Even  in  the  most  favorable  cases  of  congenital  cataract  at- 
tended by  oscillation,  this  symptom  diminishes  very  slowly  after  the  pupil 
becomes  clear,  from  the  removal  of  the  opaque  lens.  If  incomplete  amau- 
rosis has  accompanied  the  cataract,  the  oscillation  continues  unchanged.  In 
cases  of  oscillation  attending  incomplete  amaurosis,  and  accompanied  by  pain 
deep  behind  the  eyes,  the  occasional  application  of  leeches  to  the  temple 
relieves  the  pain,  and  lessens  the  oscillation.  I  have  known  a  gradual  im- 
provement take  place  in  congenital  cases,  much  beyond  expectation.  Rest 
of  the  eyes,  and  a  course  of  tonic  medicines,  are  indicated  in  most  other  cases 
of  oscillation ;  but,  it  must  be  confessed,  they  are  rarely  productive  of  a  per- 
manent or  complete  cure. 

Diefifeubach  and  others^  have  divided,  sometimes  the  rectus  internns  and 
externus,  sometimes  the  obliqui,  with  the  view  of  relieving  oscillation;  but, 
on  the  whole,  the  results  have  not  been  encouraging. 


'  Nervous  System  of  the  Human  Body;  Ap-        '  Dieffenbach  iiber   das   Schielen,    p.    199; 
pendix,  p.  xlii.  ;  London^  18.30.  Berlin,  1842  :     Chelius.  Ilandbuch  der  Augen- 

^  Lancet,  26  March,  1836,  p.  9.  heilkunde ;  Vol.  i.  p.  394;  Stuttgart,  1843. 


SECTION  Vni. — NYSTAGMUS. 

From  viv^ra^ta,  I  nod. 

This  term  is  used  to  signify  an  involuntary  motion  of  the  eyeball  from  side 
to  side.  It  is  a  clonic  convulsion  of  the  recti,  symptomatic  of  various  nervous 
diseases,  as  hysteria,  epilepsy,  chorea,  &c.  In  a  case  of  compressed  brain, 
from  effused  blood,  attendant  on  fractured  skull,  I  saw  this  pendulum-like 
movement  of  the  eyes  continued  for  some  hours  before  death.  It  went  on  unin- 
terruptedly, even  with  the  lids  shut.  Dr.  Bright^  describes  nystagmus  as 
attendant  on  cerebral  pressure,  in  a  case  of  suffocation  from  the  fumes  of 
burning  coals. 

^  Report  of  Medical  Cases;  Vol.  ii.  p.  220;  London,  1831. 


CHAPTER   XII. 

INJURIES  OF  THE  EYEBALL. 


In  the  first  and  second  Sections  of  Chapter  IV.  we  have  considered  inju- 
ries of  the  rauco-cutaneous  membrane,  which  covers  the  anterior  surface  of 
the  eyeball.  We  have  now  turned  our  attention  to  those  implicating  the 
proper  texture  of  the  organ ;  and  here  I  shall  take  the  opportunity,  before 
entering  on  the  enumeration  of  the  particular  injuries  which  we  are  so  fre- 
quently called  on  to  treat,  to  warn  practitioners  against  the  neglect  of  deple- 
tion, and  especially  the  neglect  of  general  bloodletting,  in  cases  of  injury  of 
the  eye.  The  smallness  and  apparent  slightness  of  such  injuries  are  apt  to 
lead  to  inattention,  of  which  total  loss  of  sight  may  be  the  result.  Other 
remedies  are  no  doubt  necessary,  both  local  and  general,  such  as  mercury 
where  internal  inflammation  threatens  ;  but  this,  as  well  as  local  means,  is  not 
so  apt  to  be  overlooked  as  the  taking  away  of  blood  from  the  system.  Many 
cases  have  occurred  in  my  practice,  in  which  vision,  lost  for  weeks,  has  been 
speedily  regained  by  venesection. 


FOREIGN   SUBSTANCES  IMBEDDED   IN   THE   CORNEA.  391 

SECTION   I. — INJURIES   OF   THE   CORNEA. 

§  1.    Contusion  of  the  Cornea. 

Foreign  bodies,  of  small  bulk,  impinging  with  violence  against  the  cornea, 
and  immediately  flying  off,  sometimes  produce  very  severe  inflammation,  end- 
ing in  ulceration  of  the  part  struck,  infiltration  of  matter  between  the  lamellae 
of  the  cornea,  and  other  dangerous  efi"ects.  The  cornea  is  sometimes  perma- 
nently misshapen  after  a  blow.  I  have  never  seen  this,  however,  except  in 
cases  where  at  the  same  time  the  lens  were  dislocated. 

§  2.  Foreign  Substances  imbedded  in  the  Cornea. 

It  is  a  common  occurrence  for  minute,  hard,  angular,  and  sometimes  ignited 
particles,  to  be  projected  with  such  force  as  to  penetrate,  not  merely  through 
the  epithelium,  but  through  the  anterior  elastic  lamina,  of  the  cornea,  and 
into  its  proper  substance ;  for  instance,  a  chip  of  steel,  a  spark  from  the 
anvil,  a  minute  fragment  of  stone,  a  splinter  of  wood,  or  a  particle  of  glass. 
Imbedded  within  the  cornea,  a  small  foreign  body  of  this  description  does  not 
produce  so  constant  a  flow  of  tears,  so  much  spasm  of  the  orbicularis  palpe- 
brarum, nor  such  speedy  inflammation  of  the  external  tunics  of  the  eye,  as  it 
would  do,  were  it  fixed  on  the  external  surface  of  the  cornea. 

Generally,  in  a  few  hours  after  the  extraneous  substance  is  imbedded  in  the 
cornea,  the  adjacent  portion  becomes  hazy  and  opaque,  the  opacity  extending 
according  to  the  violence  of  the  inflammatory  symptoms  which  succeed.  The 
conjunctiva  and  sclerotica  around  the  cornea  redden,  and  the  pain  is  varied 
in  kind,  and  more  or  less  severe,  according  as  the  one  or  the  other  of  these 
tunics  is  chiefly  affected  with  inflammation.  If  the  conjunctiva  is  the  chief 
seat  of  the  increased  vascularity,  the  patient  feels  as  if  the  eye  were  filled 
with  sand  ;  if  there  is  considerable  sclerotitis,  pulsatory  circumorbital  pain  is 
excited.  Inflammation  of  the  iris  may  even  be  brought  on,  ending  in  effu- 
sion into  the  pupil,  especially  if  there  already  exist  a  predisposition  to  iritis, 
or  an  inflammatory  tendency  be  present  in  the  constitution.  In  the  mean 
time,  the  part  covering  and  in  contact  with  the  foreign  body,  killed  perhaps 
by  the  impetus  with  which  it  was  struck,  or  scarred  by  the  ignited  state  of 
the  particle,  is  gradually  reduced  to  the  state  of  a  slough,  which  being 
loosened  by  the  processes  of  ulceration  and  suppuration,  at  length  drops  out 
along  with  the  foreign  substance.  An  ulcer  of  the  cornea  is  thus  left,  more 
or  less  deep,  which  in  general  heals  up  readily,  leaving  a  leucoma  or  opaque 
cicatrice.  If  the  foreign  body  be  an  unignited  particle  of  iron,  and  be  allowed 
to  remain  till  it  becomes  oxidized,  a  brown  speck  is  produced  by  the  deten- 
tion of  the  oxide  in  the  substance  of  the  cornea.     (Seep.  251.) 

Occasionally  it  happens  that  the  inflammation  of  the  cornea  is  very  severe, 
and  gives  rise  to  infiltration  of  matter  between  its  lamellae.  The  foreign 
body  being  removed,  and  the  inflammation  abated  by  antiphlogistic  means, 
the  matter  is  generally  absorbed  ;  but  if  the  case  is  still  neglected,  the  purulent 
effusion  may  increase,  hypopium  may  be  added  to  the  onyx  which  already 
exists,  and  the  eye  will,  in  all  probability,  be  destroyed.  This  result  is  particu- 
larly apt  to  follow,  when  rude  attempts  are  made  by  common  work-people  to 
remove  particles  of  whinstoue  and  iron,  imbedded  in  the  cornea.  From  the 
journals  of  the  Glasgow  Eye  Infirmary,  I  could  quote  several  lamentable 
cases  of  this  sort,  in  which  a  conceited  mechanic,  having  attempted  with  a 
common  penknife,  the  removal  of  foreign  substances  from  the  cornea,  violent 
inflammation  followed,  ending  in  extensive  ulceration,  onyx,  hypopium,  sta- 
phyloma, and  of  course  entire  loss  of  vision. 

It  is  sometimes  the  case,  after  a  foreign  body  has  lain  imbedded  for  a  time 


FOREIGN   SUBSTANCES   IMBEDDED   IN   THE   CORNEA. 

in  the  cornea,  that  a  layer  of  new  substance  is  formed  over  it,  so  that  the  in- 
flammation at  first  excited  by  its  presence  ceases,  and  it  remains  through  life, 
without  giving  rise  to  any  farther  irritation.  I  have  frequently  seen  this 
happen  to  grains  of  gunpowder  and  sometimes  to  particles  of  coal  driven 
into  the  cornea  by  explosions  in  the  fire. 

In  other  cases,  the  shape  of  the  foreign  substance,  or  the  manner  in  which 
it  is  fixed  in  the  cornea,  may  prevent  it  from  either  dropping  out,  or  becom- 
ing invested  in  the  manner  now  mentioned ;  it  will  continue,  therefere,  to 
produce  irritation  and  inflammation,  which  may  prove  destructive  to  vision. 
I  shall  have  occasion,  under  the  head  of  Penetrating  Wounds  of  the  Cornea, 
to  quote  a  case  which  occurred  in  Mr.  Wardrop's  practice,  which  will  illus- 
trate this  point. 

When  we  proceed  to  remove  a  foreign  particle  imbedded  in  the  cornea,  we 
are  directed  to  bandage  up  the  sound  eye,  or  close  it  with  the  fingers ;  but  it 
often  proves  of  advantage  in  fixing  the  injured  eye,  for  the  patient  to  direct 
the  opposite  one  towards  some  object  placed  before  him.  The  patient  being 
seated  in  a  good  light,  the  assistant,  standing  behind  him,  supports  the  head, 
raises  the  upper  eyelid,  and  prevents  the  eyeball  from  rolling  upwards.  If 
no  assistant  be  at  hand,  we  may  fix  the  head  of  the  patient  against  the  wall, 
or  lay  him  on  a  table  and  separate  the  lids  with  the  fingers  of  the  hand  which 
does  not  hold  the  instrument  with  which  the  foreign  particle  is  to  be  removed. 
Adams'  speculum  may  be  used  with  advantage,  for  elevating  the  upper  lid, 
and  fixing  the  eyeball.  If  an  assistant  be  present,  and  the  eye  still  continues 
restless,  the  conjunctiva  of  the  globe  may  be  seized  with  forceps.  If  this  be 
done  with  dexterity,  the  eye  is  rendered  quite  quiet.  If  extremely  irritable, 
the  patient  may  be  put  under  the  influence  of  chloroform. 

When  merely  fixed  in  the  anterior  elastic  lamina,  and  not  beneath  it,  foreign 
particles  may  sometimes  be  removed  from  the  cornea  with  the  edge  of  the 
small  silver  spatula.  (See  Fig.  35,  p.  251.)  If  more  deeply  imbedded,  the 
point  of  a  cutting  instrument,  such  as  a  cataract  needle  or  knife,  must  be  used 
for  dislodging  the  offending  body.  This  is  not  accomplished,  in  many  cases, 
without  fairly  passing  the  point  of  the  instrument  under  the  particle  of  iron 
or  stone,  so  as  to  lift  it  out  of  the  cornea ;  and  so  firmly  is  the  foreign  body 
grasped  in  many  cases,  that  even  this  plan  will  not  succeed,  unless  the  portion 
of  the  cornea  external  to  the  foreign  particle  is  first  fairly  divided,  and  then 
pressure  applied  in  the  way  described. 

Dr.  Jeauueret  proposes  the  removal  of  iron  spicule  from  the  cornea,  by 
keeping  the  eye  open  in  a  wine  glassful  of  a  solution  of  from  one  to  three 
grains  of  sulphate  of  copper  in  an  ounce  of  water.* 

Dr.  Jacob  tells  us,  that  when  he  meets  with  a  case  in  which  a  particle  of 
iron  has  been  allowed  to  remain  until  it  has  produced  a  stained  ulcer,  he 
scrapes  the  surface  with  the  point  of  the  needle,  after  removing  the  foreign 
body,  in  order  to  prevent  any  permanent  stain. ^  Autenrieth,  after  the  foreign 
body  is  removed,  proposes  to  dissolve  the  remaining  rust  with  diluted  muriatic 
acid.*  Ammon  in  such  cases  removes  both  the  foreign  body,  and  a  minute 
portion  of  the  external  lamellae  of  the  cornea,  with  the  extraction  knife.* 
These  three  modes  of  practice  appear  highly  objectionable.  When  the  patient 
does  not  present  himself  till  some  days  after  tlie  accident,  the  surgeon  must 
examine  the  part  carefully,  both  throwing  the  light  upon  it  with  a  lens,  and 
looking  at  it  through  the  ophthalmic  microscope,  to  ascertain  whether  the 
foreign  body  be  still  present,  as  he  may  otherwise  be  deceived  by  the  brown 
oxide  adhering  to  the  spot.  The  brown  spot  will  generally  separate  of  itself 
and  drop  off,  in  eight  or  ten  days. 

[We  recently  removed  from  cornea  of  one  of  the  outdoor  patients  of  Wills 
Hospital,  an  angular  piece  of  iron  of  ^qVo.  of  an  inch  in  its  greatest  length, 


FOREIGN    SUBSTANCES   IMBEDDED   IN   THE   CORNEA.  393 

which  had  been  deeply  imbedded  in  the  cornea  over  five  months.  The  patient 
was  a  laborer,  who,  whilst  adjusting  a  rail  with  a  hammer  on  the  railroad, 
felt  something  strike  his  eye,  which  gave  rise  to  great  pain  and  lachrymation. 
He  sought  aid  of  the  medical  practitioner  residing  in  the  village  near  to 
where  the  accident  happened,  who  assured  him  that  there  was  nothing  in  his 
eye  ;  that  the  particle  which  had  made  his  eye  sore  had  fallen  out,  and  that 
he  would  soon  be  relieved  ;  his  eye,  however,  grew  worse  rather  than  better, 
and  after  remaining  under  the  same  adviser  for  more  than  three  months  with- 
out obtaining  the  least  amelioration  of  his  sufferings  which  had  then  become 
very  intense,  he  came  to  the  city  for  advice. 

When  he  first  presented  himself  at  the  hospital,  we  found  him  suffering 
with  well  defined  iritis,  associated  with  conjunctivitis,  slight  cloudiness  of  the 
whole  cornea;  more  marked,  however,  towards  the  upper  and  outer  margin, 
where  there  was  a  white  opaque  spot  of  about  the  size  of  a  pin's  head,  which 
was  smooth,  and  perfectly  continuous  with  the  surface  of  the  cornea.  Hav- 
ing received  from  the  patient  the  history  of  his  case,  we'examined  this  spot 
with  great  care,  to  ascertain,  if  possible,  the  presence  of  any  body  there 
which  might  be  the  cause  of  all  the  irritation,  but  without  any  signal  success. 
With  a  high  magnifying  lens,  we  could  perceive  in  the  centre  of  the  opacity 
a  reddish  brown  spot,  so  exceedingly  minute  as  to  lead  us  to  attribute  it  to 
the  presence  of  some  brown  oxide  in  the  cicatrix  of  the  wound,  and  we  did 
not  therefore  feel  justified  in  making  any  exploration  of  the  substance  of  the 
cornea.  We  prescribed  active  antiphlogistic  treatment.  Finding,  however, 
that  the  irritation  was  not  relieved  by  this  plan,  and  being  unable  in  conse- 
quence of  the  history  of  the  case  to  divest  our  mind  of  the  idea  of  something 
being  imbedded  beneath  this  opacity,  we  determined  to  explore  it.  We,  there- 
fore, provided  ourself  with  a  straight  cataract  needle,  with  which  we  divided 
the  greater  part  of  the  thickness  of  the  cornea  until  the  point  struck  on  the 
particle  of  iron,  and  when  we  had  divided  all  the  cornea  covering  it,  it  gushed 
out,  being  thrust  forward  by  a  discharge  of  the  aqueous  humor,  for  it  had 
become  imbedded  in  the  posterior  part  of  the  cornea,  and  would  have  prob- 
ably before  long  become  detached  and  have  fallen  into  the  anterior  chamber. 
He  was  immediately  conscious  of  the  relief  of  pain  afforded  by  the  opera- 
tion. His  eye  was  dressed  by  means  of  the  gauze  and  collodion,  so  as  to 
prevent  all  motion  of  the  ball,  and  belladonna  was  applied  over  the  brow. 
The  wound  of  the  cornea  healed  very  rapidly ;  the  inflammation  subsided, 
the  patient  not  experiencing  the  least  pain  from  the  day  the  operation  was 
performed,  and  he  has  speedily  recovered  the  use  of  his  eye  without  a  resort 
to  any  other  treatment. — H.] 

When  the  extraneous  body  is  removed  by  art,  it  leaves  a  depression  in  the 
cornea,  which  in  general  is  soon  filled  up,  and  the  surrounding  opacity  is 
gradually  removed.  It  is  often  the  case  that,  in  removing  foreign  particles 
fixed  in  the  cornea,  a  considerable  portion  of  its  epithelium  is  abraded;  but 
this  is  reproduced  perfectly  transparent,  unless  acetate  of  lead  in  solution  is 
afterwards  used,  as  it  too  often  is,  for  bathing  the  eye.  This  application 
renders  the  cicatrice  opaque. 

The  eye  should  be  fomented  three  or  four  times  a  day,  with  warm  water, 
and  the  eyelids  painted  over  with  extract  of  belladonna.  This  greatly  re- 
lieves the  intolerance  of  light  attendant  on  every  sort  of  abrasion  or  ulcera- 
tion of  the  cornea.  Bleeding  with  leeches,  or  from  a  vein  of  the  arm,  is 
highly  beneficial,  and  must  on  no  account  be  neglected  when  much  irritation 
has  been  produced ;  the  patient  should  be  purged,  and  should  remain  at  rest, 
without  attempting  to  use  the  eyes,  till  all  danger  of  inflammation  is  past. 
When  a  deep  ulcer  of  the  cornea  has  formed  in  consequence  of  such  injuries 


394  PENETRATING   WOUNDS   OF   THE   CORNEA, 

as  we  have  now  been  considering,  evacuation  of  the  aqueous  humor  is  one  of 
the  remedies  which  act  most  beneficially. 

§  3.  Punctured  Wounds  of  the  Cornea. 

Punctured  wounds  of  the  cornea,  even  when  they  do  not  penetrate,  must 
be  watched  with  great  care,  as  the  inflammation  which  follows  is  sometimes 
rapidly  destructive.  I  have  seen  a  prick  with  a  needle  produce,  in  the  course 
of  a  few  days,  during  which  the  case  was  neglected,  such  a  degree  of  inflam- 
mation, as  ended  in  a  copious  deposition  of  lymph  and  pus  between  the 
lamellce  of  the  cornea,  and  in  the  anterior  chamber.  Bleeding  at  the  arm, 
the  liberal  application  of  leeches,  purgatives,  rest,  and  a  strict  antiphlogistic 
i-egimen,  will  be  required.  Against  the  inflammation  of  the  iris,  which  is 
apt  to  arise,  and  end,  if  neglected,  in  closure  of  the  pupil,  calomel  with 
opum  internally,  and  belladonna  externally,  are  to  be  employed. 

§  4.   Incised  Wounds  of  the  Cornea. 

We  meet  with  incised  wounds,  which  implicate  little  more  than  the  ante- 
rior elastic  lamina  of  the  cornea.  Such  a  wound  causes  for  a  time  diplopia  of 
the  affected  eye.  The  edges  of  such  a  wound  swell  and  gape  :  there  is  a  fear 
sometimes  that  it  may  ulcerate  and  form  a  perforation  through  the  cornea  ; 
but  it  in  general  contracts,  gradually,  and  heals,  leaving  a  linear  cicatrice.  I 
have  known  such  an  injury,  inflicted  with  the  point  of  scissors,  prove  the 
cause  of  asthenopia. 

§  5.  Penetrating  Wounds  of  the  Cornea — Loss  of  the  Aqueous  Humor — 
Prolapsus  of  the  Iris — Fistula  of  the  Cornea — Ophthalmitis  and  other  Ef- 
fects of  Wounds  of  the  Cornea. 

As  the  wounds  which  penetrate  through  the  cornea  into  the  anterior  cham- 
ber, vary  much  in  their  nature,  being  either  clean  incised  or  lacerated ;  in 
their  extent,  from  a  mere  puncture  to  the  whole  breadth  of  the  cornea ;  and 
in  their  situation,  being  sometimes  at  the  edge,  and  in  other  cases  near  the 
centre  of  the  cornea :  so  their  effects  are  very  different  in  different  instances. 
We  meet  with  penetrating  wounds  of  the  cornea,  so  small  and  so  oblique, 
that  they  give  rise  to  no  discharge  of  aqueous  humor,  and  heal  by  the  first 
intention,  leaving  scarcely  any  cicatrice ;  in  other  cases,  the  wound,  for  weeks, 
permits  the  aqueous  humor  to  ooze  through  it,  but  at  length  unites,  and  per- 
haps leaves  the  eye  without  any  serious  permanent  defect ;  while  in  a  third 
set,  the  wound  inflames,  suppurates,  and  leaves  an  opaque  cicatrice,  which 
interferes  more  or  less  with  vision,  according  to  its  situation  and  extent.  We 
sometimes  find  that  the  irregularity  of  the  cornea  at  the  wounded  part,  inde- 
pendently of  opacity,  gives  rise  to  considerable  obscurity  of  sight,  and  occa- 
sionally to  double  vision  when  objects  are  regarded  with  the  injured  eye 
singly.  While  wounds  with  clean  cutting  instruments  are  much  less  danger- 
ous, those  inflicted  with  thick  and  irregular  bodies,  such  as  a  nail,  a  packing 
needle,  or  the  pjong  of  a  fork,  may  cause  great  opacity,  with  swelling  and 
suppuration  of  the  cornea  in  less  than  24  hours.  Such  cases,  after  a  contin- 
uance of  violent  inflammation,  are  apt  to  end  in  atrophy  of  the  eye. 

In  nine  cases  out  ten,  penetrating  wounds  of  the  cornea  are  followed  by  the 
instantaneous  escape  of  a  considerable  portion  of  aqueous  humor,  and  a  pro- 
trusion of  the  iris.  The  latter  consequence  is  much  more  apt  to  occur,  if  the 
opening  in  the  cornea  is  situated  near  its  edge.  The  prolapsus  results  partly 
from  the  iris  losing  the  support  of  the  aqueous  humor  which  has  been  evac- 
uated, partly  from  the  push  made  by  the  rest  of  that  fluid  to  escape  also  by 
the  wound.     The  pupil  is  dragged  towards  the  prolapsed  portion  of  the  iris, 


PROLAPSUS   OF   THE   IRIS.  395 

and,  as  but  too  often  the  prolapsus  remains  unreduced,  the  iris  unites  to  the 
lips  of  the  wound,  and  the  deformity  is  permanent.  The  lens  being  wounded 
in  many  of  those  cases,  cataract  is  observed  as  soon  as  the  state  of  the  cornea 
permits  the  interior  of  the  eye  to  be  seen.  Such  is  often  the  result  when 
children  wound  their  eyes  with  such  bodies  as  a  penknife,  fork,  pair  of  scissors, 
or  bit  of  glass. 

The  loss  of  the  aqueous  humor,  although  regarded  by  the  ancients  as  equiv- 
alent to  the  loss  of  vision,  is  speedily  repaired  by  the  resecretion  of  that  fluid. 
The  replacement  of  the  prolapsed  iris  is  a  matter  of  much  gi'eater  difficulty. 
It  is  often  impossible  to  effect  this  replacement.  Mr.  Lawrence  states  he  has 
never  seen  it  accomplished.^  We  may,  however,  occasionally  succeed,  by  the 
following  means,  if  they  be  employed  within  an  hour  or  two  after  the  accident, 
and  especially  if  it  is  the  pupillary  portion  of  the  iris  which  is  prolapsed : — 

The  first  thing  to  be  done  is,  to  produce  as  much  contraction  as  possible 
of  the  radiating  fibres  of  the  iris,  by  belladonna.  This  is  best  effected  by 
dropping  into  both  eyes  a  solution  of  3  or  4  grains  of  atropine  in  an  ounce 
of  water.  The  sound  pupil  expanding,  helps  by  sympathy  to  dilate  that  of 
the  wounded  eye.  If  atropine  is  not  at  hand,  extract  of  belladonna,  diffused 
in  water,  must  be  used  in  the  same  way,  and  also  smeared  upon  the  eyelids. 

The  next  thing  is,  to  place  the  patient  under  the  influence  of  chloroform. 
This  not  only  aids  in  dilating  the  pupils,  but  obviates  entirely  any  resistance 
or  restlessness  on  the  part  of  the  patient,  during  our  attempts  to  replace  the 
prolapsed  iris.  We  probably  find  the  eye  already  inflamed,  intolerant  of  light, 
and  acutely  painful.  The  cornea  will,  in  general,  be  more  or  less  flaccid  ;  and, 
on  attempting  to  fix  the  eye,  there  is  apt  to  follow  a  further  discharge  of 
aqueous  humor.  These  symptoms  are  moderated  by  the  influence  of  the 
chloroform. 

The  patient  being  placed  in  the  horizontal  position,  we  next  have  recourse 
to  friction  of  the  eye  through  the  upper  eyelid,  continued  for  some  minutes, 
and  then  sudden  exposure  of  the  eye  to  a  bright  light.  This  is  a  means 
which  must  not  be  hastily  abandoned,  but  tried  repeatedly,  patiently,  and 
for  several  minutes  at  a  time.  The  object  is  to  press  back  the  protruding 
iris  through  the  wound  of  the  cornea,  by  moving  the  eyelid  circularly  over 
the  surface  of  the  eyeball.  If  this  does  not  succeed,  we  should  endeavor, 
with  the  curette  or  a  small  blunt  probe,  so  to  press  upon  the  protruding  por- 
tion of  iris,  that  the  aqueous  humor  contained  behind  it  is  dislodged.  If  this 
is  effected,  we  may  have  the  satisfaction  of  seeing  the  iris  slip  back  into  its 
place. 

In  the  course  of  from  15  to  30  minutes,  the  atropine  or  belladonna  will 
have  probably  operated  on  the  unprolapsed  portion  of  the  iris,  so  as  to  dilate 
that  portion  of  the  pupil  which  is  free,  and  perhaps  to  drag  back  into  its 
natural  place  the  prolapsed  portion.  If  the  prolapsus  still  continues,  our 
attempts  by  friction,  and  with  the  curette  or  probe,  are  now  to  be  renewed. 
If  we  are  successful,  it  is  recommended  that  the  wound  be  touched  with  a 
sharp  pencil  of  lunar  caustic,  which  serves  to  prevent  any  further  discharge 
of  the  aqueous  humor.^ 

If  the  prolapsus  of  the  iris,  notwithstanding  the  action  of  the  atropine  or 
belladonna,  and  our  attempts  to  replace  it  with  the  curette  or  probe,  still 
continues  unreduced,  it  ought  to  be  punctured,  or  a  snip  made  in  it  with  the 
point  of  a  pair  of  fine  scissors.  This  allows  the  aqueous  humor  which  lies  behind 
the  prolapsed  portion  to  escape,  and  favors  the  return  of  the  iris  into  its  natural 
situation,  which  we  must  now  endeavor  to  accomplish  by  the  means  already 
indicated.'' 

Should  all  our  attempts  to  reduce  the  prolapsed  portion  of  iris  fail,  we 
have  still  a  choice  left  of  snipping  it  off  with  the  scissors,  or  of  leaving  it 


396  FISTULA   OF   THE   CORNEA, 

slowly  to  contract  and  disappear.  The  former  is  certainly  the  preferable 
practice ;  for  if  left  to  itself,  it  long  proves  a  cause  of  irritation.  It  for  a 
time  increases  in  size,  instead  of  diminishing,  and  thereby  drags  the  pupil 
more  to  one  side,  and  leaves  a  broader  cicatrice  than  if  it  had  been  excised. 
If  the  patient  refuses  to  permit  this  to  be  done,  the  prolapsed  portion  may 
be  touched  every  second  day  with  nitras  argenti.  Under  this  treatment  it 
adheres  to  the  cornea,  gradually  shrinks,  becomes  covered  with  a  lymphatic 
effusion,  and  at  length  disappears,  the  pupil  being  left  pei'manently  disfigured, 
and  vision  more  or  less  abridged,  according  to  the  size  and  situation  of  the 
cicatrice. 

Very  extensive  divisions  of  the  cornea  are  less  liable  to  be  attended  with 
prolapsus  of  the  iris,  than  those  which  are  more  limited.  Thus,  the  section 
of  the  cornea  in  extraction  of  the  cataract  is  rarely  followed  by  immediate 
prolapsus,  while  a  quarter-section,  such  as  is  made  in  forming  an  artificial 
pupil  by  excision,  generally  produces  a  protrusion  of  the  iris.  The  same  holds 
with  regard  to  accidental  wounds.  The  cornea  has  been  known  to  be  divided 
completely  across  by  a  sharp  instrument,  without  any  prolapsus  of  the  iris, 
and  to  be  cnred  with  only  a  slight  linear  cicatrice.**  In  cases,  however, 
of  complete  diametral  division  of  the  cornea,  with  a  penknife,  piece  of  glass, 
&c.,  very  frequently  the  iris,  though  it  has  not  prolapsed,  unites  to  the  cornea, 
and  the  lens,  having  been  touched,  is  rendered  opaque.^ 

The  penetrating  wounds  of  the  cornea,  of  which  we  have  been  speaking, 
are  those  made  by  foreign  substances  which  are  Immediately  withdrawn,  as 
the  point  of  a  penknife,  fork,  or  pair  of  scissors,  sharp  pieces  of  wire  or  wood, 
splinters  of  metal  or  stone  projected  against  the  eye,  and  the  like.  It  some- 
times happens,  however,  that  the  body  with  which  the  injury  is  inflicted,  is 
left  sticking  in  the  cornea. 

Case  244. — On  the  29th  June,  1843, 1  was  raised  out  of  bed  at  2  A.M.,  to  extract  a  fishing- 
hook  from  a  man's  cornea,  where  it  had  been  fixed  since  the  previous  evening  about  8 
o'clock.  The  point  of  ihe  hook  had  penetrated  into  the  anterior  chamber,  and  the  barb 
was  covered  in  the  substance  of  the  cornea.  By  seizing  it  firmly  with  a  pair  of  forceps 
and  drawing  it  steadily,  I  managed  to  make  it  retrace  its  path,  which  I  scarcely  expected 
to  have  done  without  enlarging  the  wound.  Next  day,  the  eye  looked  well;  but  the  iris, 
from  the  escape  of  aqueous  humor,  was  in  contact  Avith  the  cornea.  I  dilated  the  pupil  by 
belladonna,  and  in  two  days  the  eye  was  perfectly  well. 

I  have  referred  at  page  392  to  the  following  instance  : — 

Case  245. — A  patient  applied  at  Mr.  Wardrop's  hospital,  with  considerable  redness  of 
the  left  eye,  and  great  intolerance  of  light.  On  the  temporal  edge  of  the  cornea  there  was 
an  opaque  spot,  to  which  the  pupil,  which  was  irregular,  adhered.  Fourteen  weeks  before, 
when  twisting  a  piece  of  gold  wire,  a  small  portion  of  it  broke  off  and  struck  the  eye. 
Three  days  after  the  accident,  intense  inflammation  came  on,  with  severe  pain,  which  con- 
tinued for  five  weeks,  and  resisted  active  depletion.  From  this  period,  the  pain  became 
less  acute.  A  few  days  after  applying  at  the  hospital,  a  portion  of  gold  wire  was  observed 
projecting  beyond  the  surface  of  the  cornea,  and  a  considerable  portion  seemed  to  be  im- 
pacted in  the  opaque  spot.  It  was  easily  extricated  by  means  of  a  pair  of  forceps,  and 
was  followed  by  a  discharge  of  the  aqueous  humor.  The  portion  of  wire  was  fully  3  lines 
in  length,  and  one  extremity  had  penetrated  into  the  anterior  chamber.  The  patient  felt 
much  relieved  immediately  after  the  extraction  of  the  foreign  substance,  and  the  inflam- 
mation and  opacity  soon  subsided.'" 

It  sometimes  happens  that  a  perforating  wound  of  the  cornea,  close  to  the 
edge  of  the  sclerotica,  and  entering  the  anterior  chamber,  becomes  closed  by 
the  conjunctiva  healing  over  it,  although  the  proper  substance  of  the  cornea 
does  not  heal,  so  that  the  aqueous  humor  flows  out  through  the  opening  in 
the  cornea,  and  elevates  the  conjunctiva  in  the  form  of  a  vesicle.  If  this  swel- 
ling be  removed  with  the  scissors,  a  large  quantity  of  thin  fluid  escapes,  and 
at  the  bottom  of  the  cavity  which  has  thus  been  laid  open,  an  orifice  will  be 
detected,  leading  into  the  anterior  chamber.  If  nothing  further  is  done,  the 
conjunctiva  heals,  but  the^s^w^a  cornece,  as  it  is  termed,  remains,  and  the  vesi- 


f 


FOREIGN   BODIES   IN   THE   AQUEOUS   CHAMBERS.  39Y 

cular  swelling  returns.  To  close  the  fistulous  aperture  it  is  necessary,  after 
snipping  off  the  conjunctiva,  to  touch  the  orifice  in  the  cornea  with  a  pointed 
lunar  caustic  pencil." 

Wounds  of  the  cornea,  with  chips  of  iron  or  stone,  sent  with  great  force 
against  the  eye,  and  implicating  perhaps  the  iris  and  the  lens,  are  apt  to  be 
followed  by  phlegmonous  ophthalmitis.  If  the  cornea  and  sclerotica  are 
wounded  at  their  junction,  the  iris  protrudes,  the  pupil  is  dragged  towards  the 
wound,  and,  after  the  wound  has  healed,  sympathetic  inflammation  of  the 
opposite  eye  is  apt  to  ensue.  The  division  of  parts  in  a  wound  of  the  eye 
may  be  confined  to  the  cornea ;  but  the  effects  of  the  injury  may  spread  to  the 
interior  of  the  eye,  as  in  the  following  case : — 

Case  246. — A  wound  of  the  cornea,  -with  a  chip  of  iron,  caused  considerable  inflamma- 
tion of  the  conjunctiva  and  sclerotica,  great  muddiness  of  the  anterior  chamber  from  ef- 
fused lymph,  and  a  gold-green  color  of  the  iris.  As  the  anterior  chamber  cleared,  lymph 
was  seen  deposited  on  the  crystalline  capsule ;  this  was  gradually  absorbed,  and  the  lens 
was  seen  to  be  transparent;  but  behind  it  there  was  an  opaque  concave  appearance  of  a 
yellowish-green  color,  probably  from  lymph  effused  on  the  surface  of  the  retina.  The  eye 
retained  a  mere  perception  of  light  and  shade. 

In  a  case,  reported  by  Mr.  Pollock,  the  violent  inflammation  resulting  from 
the  cornea  being  cut  across  by  a  stroke  with  a  whip,  was  followed  by  fatal 
tetanus.*^ 


'  Medical  Times  and  Gazette ;  April  24, 1852.  '  Gibson's  Practical  Observations  on  the  For- 

p.  428.  mation  of  an  Artificial  Pupil,  p.  42  j  London, 

"  Dublin  Hospital  Reports;  Vol.  v.  p.  372;  1811. 

Dublin.  1830.  '  Rognetta,  Cours  Public  d'Ophthalmologie ; 

'  Zeitschrift  fur  die  Ophthalmologie;  Vol.  ii.  Lancette  Franfaise,  7  Janv.  1837. 

p.  332;  Dresden,  1832.  "  Demours,  Traite  des  Maladies  des  Teux,  PI, 

*  Ibid.,  p.  331.  53:  Paris,  1818. 

'  Lectures  in  the   Lancet;   Vol.  x.  p.  482;  '°  Lancet;  Vol.  x.  p.  475;  London,  1826, 

London,  1826.  "  Medical  Gazette;  Vol.  v.  p.  224;  London, 

"  See   case  of  prolapsus   iridis,  successfully  1829. 

treated  by  Dr.  Macfarlane;   Glasgow  Medical  '^  Medical   Gazette;  Vol.  xxxix.   p,   1006; 

Journal,  Vol.  i.  p.  104;  Glasgow,  1828.  London,  1847. 


SECTION  II. FOREIGN  BODIES  IN  THE  AQUEOUS  CHAMBERS. 

In  many  instances  of  penetrating  wound  of  the  cornea,  the  foreign  body 
enters  completely  into  the  anterior  chamber.  We  sometimes  find  that  it  is 
adhering  to  the  inner  surface  of  the  cornea,  or  that  it  has  fallen  to  the  bottom 
of  the  anterior  chamber ;  more  frequently,  that  it  is  fixed  in  the  iris  or  in 
the  capsule  of  the  lens ;  rarely,  that  it  has  passed  behind  the  iris  so  as  to  lie 
in  the  posterior  chamber.  In  all  these  cases  we  proceed  immediately  to  its 
removal,  unless  it  be  of  very  small  size.  A  grain  of  gunpowder,  for  example, 
which,  having  passed  through  the  cornea,  is  fixed  on  the  anterior  surface  of 
the  iris,  or  perhaps  even  a  particle  of  metal  of  the  same  size,  we  should  allow 
to  remain.  It  has  repeatedly  happened  that  the  point  of  a  cataract  knife  or 
needle,  breaking  off  in  the  anterior  chamber,  has  been  left  there,  and  has 
become  oxidized  and  dissolved.*  We  cannot  calculate  on  the  removal  of 
larger  and  rougher  metallic  fragments  in  this  manner.  If  they  are  fixed  in 
the  iris,  or  if  they  are  impacted  between  the  cornea  and  the  iris,  although 
without  any  laceration  of  the  latter,  they  will  almost  certainly  bring  on  iritis; 
and  even  if  merely  in  contact  with  the  crystalline  capsule,  cataract  is  the 
invariable  result.  Remove  a  metallic  fragment  from  these  several  situations, 
and  iritis  and  cataract  may  be  prevented.     In  doing  this,  however,  there  is  a 


398  FOREIGN   BODIES   IN   THE   AQUEOUS   CHAMBEES. 

danger  of  wounding  the  iris,  of  tearing  it  from  the  choroid,  with  effusion  of 
blood,  of  opening  the  capsule,  so  as  to  admit  the  aqueous  humor  into  contact 
with  the  lens,  which  will  cause  cataract,  of  the  iris  prolapsing  after  the  foreign 
body  is  removed,  and  of  disorganizing  inflammation  from  the  operation,  end- 
ing in  atrophy  of  the  eye. 

The  difficulty  of  removing  a  foreign  body  depends  much  on  whether  it  is 
free  in  the  aqueous  humor,  impacted  between  the  cornea  and  iris  or  lens,  or 
actually  fixed  by  its  angles  or  extremities  in  the  substance  of  one  or  other  of 
these  structures. 

Great  advantage  is  obtained,  when  we  are  about  to  proceed  to  the  extrac- 
tion of  such  bodies,  by  placing  the  patient  in  the  horizontal  position,  and 
bringing  him  fully  under  the  influence  of  chloroform.  If  this  is  not  done, 
but  the  patient  is  seated,  his  head  should  lean  against  the  breast  of  an  assist- 
ant, standing  behind  him  ;  and  if  the  eye  is  unsteady,  the  conjunctiva,  near 
the  inner  canthus,  should  be  seized  with  a  pair  of  forceps. 

The  extraction  of  a  foreign  body  from  the  anterior  chamber  may  sometimes 
be  accomplished  by  means  of  a  hook,  or  a  small  pair  of  forceps  (smaller  than 
that  represented  in  Fig.  32,  page  241),  introduced  through  the  wound  of  the 
cornea  already  present,  or  through  an  enlargement  of  the  wound  effected  with 
the  cataract  knife ;  but  in  other  cases,  either  this  cannot  be  done,  or  it 
would  be  improper  to  attempt  it,  and  we  must  make  a  new  and  sufficient 
opening  with  the  cataract  knife,,  about  the  10th  of  an  inch  from  the  edge  of 
the  sclerotica.  If  the  incision  be  made  closer  to  the  sclerotica  than  this, 
protrusion  of  the  iris  is  more  likely  to  occur.  I  have  seen  the  application  of 
belladonna,  in  a  case  in  which  an  angular  fragment  of  steel  was  impacted 
between  the  iris  and  the  cornea,  dilate  the  pupil  and  carry  the  foreign  body 
along  with  the  iris  to  the  very  edge  of  the  cornea ;  but  I  do  not  consider  this 
as  a  practice  to  be  generally  followed  preparatory  to  extracting  the  foreign 
substance  by  an  incision  of  the  cornea,  as  I  think  it  favors  prolapsus  of  the 
iris.  Not  unfrequently  it  happens  that  as  soon  as  the  incision  is  made  through 
the  cornea,  the  foreign  body  is  forced  out  along  with  the  aqueous  humor,  so 
that  we  are  saved  from  any  trouble  of  extracting  it  with  instruments.  A 
common  forceps,  to  act  within  the  anterior  chamber,  requires  a  pretty  large 
incision ;  a  smaller  one  suffices  for  the  introduction  and  working  of  a  blunt 
hook,  the  guarded  hook  of  Schlagintweit,  or  the  canula-forceps. 

Case  247. — While  a  workman  was  chipping  brass,  a  sharp  fragment  of  that  substance, 
about  1^  line  long,  was  projected  into  one  of  his  eyes.  Twelve  days  after  the  accident, 
he  came  to  me,  when  I  found  the  bit  of  brass  adhering  to  the  internal  surface  of  the 
cornea.  There  was  no  visible  wound  or  cicatrice,  but  a  considerable  degree  of  iritis  was 
present.  I  bled  him  at  the  arm,  put  him  on  calomel  and  opium,  and  dilated  the  pupil 
with  belladonna.  By  these  means,  the  inflammation  and  pain  of  the  eye  were  reduced, 
and  I  proceeded  to  extract  the  foreign  body.  At  the  distance  of  the  10th  of  an  inch  from 
the  sclerotica,  I  opened  the  cornea  to  the  extent  of  fully  more  than  two  lines,  taking  care 
to  keep  the  knife  in  the  wound  till  some  of  the  aqueous  humor  had  oozed  out,  thus  pre- 
venting a  prolapsus  of  the  iris,  which  is  very  apt  to  follow  the  sudden  discharge  of  that 
fluid.  I  next  introduced  a  small  hook,  and  drew  the  bit  of  brass  along  the  surface  of  the 
cornea,  till  it  reached  the  wound,  through  which  it  was  readily  extracted.  In  a  few 
days  the  eye  was  perfectly  well. 

Cane  248. — A  man  came  to  me  Avith  a  thorn  in  his  eye.  The  point  of  it  was  fixed  in 
the  iris,  and  its  thicker  extremity  in  the  cornea.  The  accident  had  happened  three  weeks 
before,  and  the  wound  of  the  cornea  by  which  the  thorn  had  entered,  was  healed  over. 
During  these  three  weeks,  the  presence  of  the  thorn  had  caused  no  inflammation,  and  very 
little  irritation.  I  opened  the  cornea  at  its  temporal  edge,  the  thorn  being  near  its  nasal 
edge.  With  Schlagintweit's  hook  I  was  unable  to  unfix  it  from  the  cornea.  As  I  drew 
it  with  the  hook,  the  iris  tore,  and  the  eye  filled  with  blood. 

It  is  remarkable,  how  little  irritation  is  sometimes  produced,  for  a  consid- 
erable length  of  time,  by  a  foreign  body  in  the  anterior  chamber.     Rognetta'' 


INJURIES   OF   THE   IRIS.  399 

saw  a  fragment  of  stoneware,  of  the  size  of  a  pea,  remain  eight  days  behind 
the  cornea,  without  producing  any  severe  effects.  The  external  wound  had 
cicatrized.  Left  beyond  a  certain  time,  such  a  substance  would  infallibly 
destroy  the  eye.  It  is  an  interesting  fact,  however,  of  which  Ammon^,  Salo- 
mon,* and  Griillich^  have  recorded  examples,  and  an  instance  of  which  I  have 
myself  seen,  that  a  foreign  body  lying  in  the  anterior  chamber,  sometimes 
excites  an  exudation  of  lymph  from  the  parts  with  which  it  is  in  contact ;  that 
this  exudation,  becoming  organized,  forms  a  sort  of  capsule  over  or  around 
the  foreign  particle ;  and  that,  in  consequence  of  this  taking  place  the  irrita- 
tion caused  by  the  presence  of  the  foreign  body  ceases.  This  is  an  event, 
however,  which  we  must  by  no  means  regard  as  affording  ground  for  delay 
in  removing  foreign  bodies  from  the  aqueous  chambers. 


'  Lawrence's  Lectures  in  the   Lancet;  Vol.  iind  Augenheilkunde;  Vol.  xiii.  p.  418;  Berlin, 

ix.  p.  531 ;  London,  1826.  1829. 

^  Cours  public  d'Ophtlialmologie ;   Lancette  *  Ibid.,  Vol.  xiv.  p.  457  ;  Berlin,  1830. 

Fran^aise,  10  Janvier,  1837.  '  Amnion's  Zeitschrift  fiir  die  Ophthalmolo- 

'  Grafe  und  Walther,  Journal  der  Chirurgie  gie  ;  Vol.  i.  p.  336  ;  Dresden,  1831. 


SECTION  ni. — INJURIES  OF  THE  IRIS. 
Fifj.  Wardrop,  PI.  X.  Figs.  2,  3. 

In  addition  to  prolapsus,  of  which  we  have  already  spoken,  the  more  com- 
mon injuries  of  the  iris  are,  in  the  first  place,  punctures  and  lacerations 
•through  the  cornea;  secondly,  displacement;  and,  thirdly,  separation  of  the 
ciliary  edge  of  the  iris  from  the  choroid. 

I  once  saw  the  iris  become  of  a  green  color,  from  exposure  of  the  eye  to 
a  blast  of  steam.  Blows  on  the  eyes  also  cause  greenness  of  the  iris,  prob- 
ably from  blood  being  effused  into  its  substance. 

The  iris  is  abundantly  supplied  with  red  blood.  Hence  it  generally  bleeds 
on  being  injured,  and  sometimes  so  profusely  as  to  fill  the  aqueous  chambers. 
It  is  also  very  liable  to  adhesive  inflammation,  effusing  fibrine  from  its  in- 
jured vessels,  and  thereby  becoming  morbidly  connected  to  the  neighboring 
textures. 

1.  Punctures  and  lacerations  of  the  iris  are  apt  to  be  followed  by  dilata- 
tion of  the  aperture,  so  as  to  form  a  permanent  false  pupil.  Inflammation  is 
to  be  guarded  against  in  such  cases,  and  combated  by  the  treatment  for  iritis ; 
namely,  bleeding,  mercury,  and  belladonna. 

Case  249. — A  gentleman  punctured  his  left  cornea  near  its  upper  outer  edge  with  one 
of  the  points  of  a  pair  of  compasses.  There  was  a  distinct  wound  of  the  iris,  stretching 
from  its  great  circumference  to  within  a  little  way  of  the  edge  of  the  pupil.  The  aque- 
ous humor  distilled  through  the  wound  of  the  cornea  for  fourteen  days.  The  iris  ap- 
proached gradually  to  the  cornea,  and  after  the  wound  in  the  latter  was  closed,  the 
anterior  chamber  seemed  almost  obliterated  by  the  closeness  of  the  two  to  each  other. 
The  wound  in  the  iris  continued  long  open,  and  the  iris  was  evidently  thinned  around  the 
wound.  The  pupil  had  scarcely  any  motion,  and  vision,  probably  from  spherical  aberra- 
tion being  impei-fectly  obviated,  was  obscure.  By  and  by,  the  iris  retreated  to  its  natural 
place,  no  cataract  ensued,  and  vision  became  perfect.  A  year  or  two  after,  a  vesicular 
swelling  formed  on  the  iris  at  the  part  wounded,  fluid  being  deposited  between  the  proper 
substance  of  the  iris  and  the  uvea. 

Foreign  bodies,  such  as  a  minute  piece  of  metal  or  stone,  left  in  contact 
with  the  iris,  become  incapsulated,  as  has  already  been  explained. 

Penetrating  wounds  of  the  cornea  are  often  attended  at  once  by  laceration 
and  protrusion  of  part  of  the  iris.  The  lacerated  and  protruding  part  appears 
as  a  flaccid  whitish  membrane,  and  ought  to  be  snipt  off. 

In  scrofulous  children,  punctured  wounds  of  the  cornea  and  iris  often  end 


400 


INJURIES   OF   THE   IRIS. 


Fig.  55. 


in  closure  of  the  pupil  and  wasting  of  the  eye.  A  red  fungous  growth  some- 
times takes  place  from  an  injured  iris,  and  protrudes  through  the  wound  of 
the  cornea. 

2.  Blows  on  the  eye  (for  instance,  with  the  fist)  are  not  unfrequently  fol- 
lowed by  displacement  of  a  considerable  portion  of  the  iris.  The  pupil  is 
greatly  enlarged,  and  one-half,  perhaps,  of  the  iris  is  thrust  out  of  sight,  so 
that  the  pupil  extends  on  one  side  to  the  very  edge  of  the  cornea.  This 
accident  is  generally  attended  by  effusion  of  blood  into  the  eye,  and  is  fol- 
lowed by  amaurosis. 

3.  The  connection  between  the  iris  and  the  choroid  is  much  less  firm  in  man 

than  in  quadrupeds  ;  and  the  consequence 
is  that  smart  blows  on  the  human  eye  are 
apt  to  separate  a  portion  of  one  of  these 
membranes  from  the  other,  so  as  to  form  a 
false  pupil.  (Fig.  55.)  The  stroke  of  a 
whip,  horse's  tail,  or  twig  of  a  tree,  is  fre- 
quently the  cause  of  this  accident.  We 
have  no  means,  in  such  cases,  of  bringing 
back  the  iris  to  its  former  situation.  Bel- 
ladonna dilates  the  false  pupil  as  well  as 
the  natural  one,  narrowing  the  portion  of 
the  iris  between  them.     The  vision  of  the 

eye  is,  in  general,  much  debilitated  after 
this  sort  of  accident. 
In  a  young  gentleman  who  came  under  my  care,  the  iris  was  partially 
separated  by  a  blow  with  a  squib,  the  natural  pupil  was  at  the  same  time* 
much  dilated,  and  vision  obscured.  After  venesection  and  the  use  of  calo- 
mel and  opium,  the  false  pupil  began  to  diminish  in  size,  and  the  natural 
pupil  also  contracted.  Vision  became  almost  perfect,  but  the  false  pupil  did 
not  close ;  nor  have  I  ever  seen  the  edge  of  the  iris  return  in  such  cases  to 
its  natural  place. 

A  lady,  shaking  a  piece  of  cloth,  was  struck  on  the  right  eye  with  a  button, 
which  lay  in  it.  The  result  was  detachment  of  the  iris  at  two  separate  places, 
and  cataract. 

When  the  iris  is  unhealthy  in  its  structure,  as  it  often  is  when  we  operate 
on  it  for  the  formation  of  an  artificial  pupil  by  separation,  it  is  very  apt  to 
return  towards  the  choroid;  not  so  in  such  accidental  separations  as  we  are 

now  considering,  where  the  iris  is  perfectly 
healthy,  and  its  radiating  fibres  retain 
their  full  power  of  contraction. 

Sometimes  the  greater  part  of  the  iris 
is  detached,  in  which  case  it  shrinks  to  a 
very  narrow  circle.  (Fig.  56.)  In  a  case 
which  I  saw,  all  that  remained  of  the  iris 
was  a  narrow  floating  shred ;  the  lens  was 
opaque,  and  lay  deep  in  the  vitreous  hu- 
mor; yet  with  the  eye  in  this  state,  the 
patient  discerned  the  fingers.  In  such  cases, 
the  eye,  though  generally  quite  amaurotic, 
is  highly  intolerant  of  light,  and  must  be 
■■"~^^~  covered  with  a  shade. 

In  other  cases,  a  blow  on  the  eye  at  once 
tears  the  iris  across  from  its  ciliary  to  its  pupillary  edge,  and  separates  part 
of  it  from  the  choroid.     Fig.  51  shows  this  sort  of  injury  in  a  patient  of  the 


Fig.  56. 


TRAUMATIC   CATARACT. 


401 


Glasgow  Eye  Infirmary.  Sucli  cases  are  always  attended  with  effusion  of 
blood  into  the  eye,  so  that,  till  this  is  absorbed,  the  state  of  the  iris  cannot 
be  seen ;  afterwards  we  find,  generally,  the  lens  dislocated,  the  vitreous  humor 
dissolved,  the  iris  tremulous,  and  the  retina  insensible. 


Fig.  57, 


Fig.  58. 


When  with  a  penetrating  wound  of  the  cornea  there  is  combined  a  detach- 
ment of  the  iris,  we  often  observe  that  the  lens  and  its  capsule  become  opaque, 
the  vitreous  humor  dissolves,  and,  as  in  the  instance  represented  in  Fig.  58, 
the  eyeball  enlarges,  and  the  choroid  shines  through  the  attenuated  sclerotica. 
The  case  here  represented  originated  in  a  penetrating  wound  with  a  fork,  and 
the  choroid  staphyloma  grew  so  large  that,  after  fruitlessly  evacuating,  from 
time  to  time,  the  dissolved  vitreous  humor  by  which  it  was  distended,  I  was 
'obliged  to  remove  a  portion  of  the  sclerotica  and  choroid  with  the  scissors, 
after  which  the  eye  shrunk  to  a  size  permitting  it  to  be  easily  covered  by 
the  lids. 


SECTION  rv. — INJURIES  OF  THE  CRYSTALLINE  LENS  AND  CAPSULE. 

§  1.    Traumatic  Cataract. 
Fig.  Wardrop,  PI.  IX.  Fig.  1. 

1.  It  is  a  very  rare  accident,  but  of  which  I  have  witnessed  an  instance, 
that  a  sharp  body  pushed  through  the  cornea,  scratches,  but  does  not  pene- 
trate, the  crystalline  capsule.  The  consequence  is  a  permanent  whitish 
mark. 

2.  Penetrating  wounds  of  the  crystalline  capsule,  by  pointed  or  cutting 
instruments  passing  through  the  cornea  or  sclerotica,  are  speedily  followed 
by  opacity  of  the  lens.  This  consequence,  commonly  attributed  to  the  en- 
trance of  the  aqueous  humor  within  the  capsule,  seems  unavoidable,  how  small 
soever  the  puncture  may  be.  A  woman  came  under  my  care,  to  whom  it  had 
happened  that  as  she  was  shaking  a  piece  of  cloth  smartly,  a  pin  was  pro- 
jected from  the  cloth  into  her  right  eye.  It  entered  about  the  middle  of  the 
cornea,  and  punctured  the  capsule  immediately  behind  the  edge  of  the  pupil. 
The  result  was  complete  lenticular  cataract,  and  partial  opacity  of  the  cap- 
sule. If  the  wound  is  more  considerable,  we  often  see  part  of  the  lens  exuding 
from  the  capsule,  and  presenting  a  bluish  white  appearance,  so  that  it  looks 
like  an  effusion  of  lymph.  The  edges  of  the  puncture  or  wound  of  the  cap- 
sule are  apt  to  inflame,  and  become  of  a  chalky  white  color.  If  they  unite, 
so  that  the  aqueous  humor  is  no  longer  admitted  into  contact  with  the  lens, 
the  progress  of  the  cataract  will  be  arrested.  If  the  wound  of  the  capsule 
is  considerable  and  does  not  heal,  the  whole  lens  soon  becomes  opaque,  and 

26 


402  DISLOCATION   OP   THE   LENS. 

in  young  or  middle-aged  persons  is  gradually  absorbed,  so  that  the  pupil  again 
becomes  clear,  and  a  certain  degree  of  vision  is  often  recovered. 

The  injury  which  produces  traumatic  cataract  is  apt  to  be  followed  by  iritis, 
and  adhesions  between  the  iris  and  the  capsule.  The  pupil  should  therefore 
be  as  soon  as  possible  brought  under  the  influence  of  belladonna  or  sulphate 
of  atropia,  and  kept  so  till  all  danger  of  inflammation  is  past,  or  even  till 
the  lens  has  disappeared.  Cold  cloths  should  be  applied  constantly  over  the 
injured  eye.     The  iritis  is  to  be  combated  by  depletion  and  mercury. 

Still  more  serious  eifects  are  apt  to  arise  in  cases  of  penetrating  wounds 
of  the  cornea  and  lens ;  such  as  retinitis  and  choroiditis.  These  may  occur 
with  or  without  injury  of  the  iris.  In  scrofulous  children,  such  an  accident 
not  unfrequently  gives  rise  to  amaurosis  and  atrophy  of  the  eye.  Tremulous- 
ness  of  the  iris,  absorption  of  the  vitreous  humor,  with  coarctation  of  the 
retina  and  ossification  of  the  capsule,  and  sometimes  of  the  lens,  are  amongst 
the  sequelae  of  such  wounds  as  we  are  now  considering.  In  an  eye  which 
has  wasted  in  consequence  of  such  a  wound,  the  lens  or  the  capsule,  having 
become  the  seat  of  calcareous  deposition,  may  be  the  cause  of  great  irrita- 
tion, requiring  the  opaque  crystalline  to  be  extracted.  Sometimes,  after  the 
lens  is  absorbed,  a  funnel-shaped  opaque  membrane  is  seen  behind  the  seat 
of  the  lens.  This  is  the  retina,  pressed  into  a  conical  form  by  an  effusion 
between  it  and  the  choroid,  while  the  vitreous  humor  has  undergone  absorp- 
tion. Such  an  eye  is  boggy,  and,  on  pressing  it  with  the  finger,  the  retina 
can  be  raised  more  into  view.  When  the  choroid  inflames,  after  wounds  of 
the  lens,  the  sclerotica  becomes  thinned,  and  the  eyeball  assumes  an  elongated 
conical  form. 

Mr.  Barton,  of  Manchester,  from  the  fact  that  punctured  wounds  of  the 
capsule  are  often  followed  by  opacity  and  thickening  of  that  membrane,  with 
contracted  adherent  pupil,  proposes  to  treat  such  cases,  from  the  first,  by 
extraction  of  the  lens.  He  introduces  Beer's  knife  through  the  cornea  as  far 
as  the  centre  of  the  pupil,  then  raises  the  handle  so  as  to  depress  the  point, 
and  keeps  it  there  for  a  few  moments,  till  he  ascertains  wiiether  the  lens  will 
escape  by  merely  making  a  slight  pressure  with  the  knife  kept  in  this  position. 
This  in  many  instances  takes  place ;  but  if  he  finds  it  too  hard  to  pass  in 
this  way,  he  extends  the  incision,  and  finishes  the  operation  with  the  scoop.* 
If  the  case  appears  likely  to  demand  this  mode  of  treatment,  it  should  at 
once  be  had  recourse  to,  as  chronic  inflammation  is  apt  to  introduce  atrophy 
of  the  eye  and  insensibility  of  the  retina.  These  results  are  prevented  by 
extraction. 

The  wounded  lens  is  often  broken,  and  soon  becomes  soft  and  disorganized. 
It  is  swollen  considerably  when  in  this  state,  and  presses  painfully  against 
the  uvea.  For  extraction  in  such  circumstances,  Mr.  Walker,  of  Manchester, 
used  a  grooved  double-edged  knife,  which  being  introduced  at  the  edge  of 
the  cornea,  and  pushed  through  the  centre  of  the  lens,  and  through  the  pos- 
terior capsule,  allows  the  soft  lenticular  substance  to  be  discharged  along  the 
groove. 

3.  Blows  on  the  eye  are  often  followed,  months  or  years  after  the  accident, 
by  lenticular  or  capsulo-lenticular  cataract.  The  capsule,  and  sometimes  the 
lens,  is  apt,  under  such  circumstances,  to  be  ossified.  Even  the  least  com- 
plicated of  such  cases  are  not  favorable  for  operation,  as  the  retina  is  scarcely 
ever  sound. 

§  2.  Dislocation  of  the  Lens. 

Fig.  Sichel,  PL  XIX.  Figs.  1,  3,  4. 

We  may  distinguish  the  following  varieties  of  this  injury : — 

1.  Days,  weeks,  or  months  after  a  slight  blow  or  mere  tap  on  the  eye,  the 


DISLOCATION   OF   THE   LENS.  403 

lens,  loosened  from  its  natural  connections,  becomes  tremulous,  floats  in  the 
vitreous  humor,  or  drops  through  the  pupil  into  the  anterior  chamber.  In 
consequence  of  a  blow  on  the  right  eye,  a  woman  who  consulted  me  saw 
dimly,  and  could  read  a  large  type  only  when  she  held  the  book  near  the  eye. 
The  pupil  was  natural;  the  lens  transparent,  but  tremulous.  Occasionally  it 
happens  that  the  patient  cannot  recall  to  his  recollection  the  receiving  of  any 
blow  on  the  eye,  so  that  cases  of  this  kind  are  sometimes  regarded  as  spon- 
taneous dislocations  of  the  lens.^  There  is  reason  to  believe  that  occasionally 
they  actually  are  so ;  that  from  disease  of  the  vitreous  humor  the  suspensory 
ligament  of  the  crystalline  comes  to  be  separated  in  part  from  the  choroid, 
so  that  the  lens  may  be  seen  for  a  time  waving  backwards  and  forwards  in  the 
eye ;  and  that  ultimately  an  entire  separation  taking  place,  it  may  either  drop 
down  into  the  dissolved  vitreous  humor,  or  come  through  the  pupil.  The 
lens  which  is  thus  dislocated,  may  either  be  opaque  or  transparent.  In  gene- 
ral it  is  inclosed  in  the  capsule,  and  when  it  is  so,  and  at  the  same  time 
transparent,  its  edge  reflects  the  light  in  such  a  manner  as  to  produce  the 
appearance  of  its  being  surrounded  by  a  narrow  gilt  ring.  In  general,  no 
pain  nor  inflammation  of  the  eye  attends  such  cases,  but  the  pupil  is  com- 
monly dilated,  and  the  retina  not  perfectly  sensible.  It  sometimes  happens, 
however,  that  severe  pain  attends  such  dislocations,  especially  if  the  loose 
lens  get  fixed  within  the  verge  of  the  pupil,  or  impacted  between  the  iris  and 
the  cornea.'  I  have  seen  choroid  staphyloma  of  the  lower  half  of  the  eye 
ensue  from  a  dislocated  lens  being  allowed  to  remain  in  the  latter  situation. 

Case  250. — Dr.  James  Brown  brought  to  me,  for  consultation,  a  lad  of  17,  a  potter, 
under  the  following  circumstances.  His  right  eye  had  been  destroyed  in  childhood.  For 
a  considerable  time  he  had  been  troubled  with  muscas  volilantes  before  his  left  eye.  On 
the  1st  September,  1831,  he  received  a  very  slight  blow  on  the  eye,  with  a  bit  of  potter's 
clay,  thrown  at  him  in  sport  by  one  of  his  fellow-workmen.  On  the  morning  of  the  4th, 
he  found,  on  rising  out  of  bed,  that  he  saw  indistinctly,  and  went  out  to  wash  his  eye  at 
a  well,  supposing  that  the  dimness  of  sight  arose  from  matter  adhering  to  the  eyelids. 
This  produced  no  difference  in  the  sight ;  on  which  one  of  his  neighbors  looked  at  the 
eye,  and  told  him  that  he  saw  something  wagging  in  the  inside  of  it.  He  immediately 
came  to  Dr.  Brown,  who  discovered  the  lens  lying  at  the  bottom  of  the  anterior  chamber. 
It  seemed  quite  transparent  even  on  the  5th  when  I  saw  him,  and  was  so  much  reduced 
in  size  as  to  move  freely  about  on  every  inclination  of  the  head.  Its  lower  edge,  where 
it  rested  on  the  floor  of  the  anterior  chamber,  was  somewhat  square,  as  if  absorption  had 
been  going  on  more  rapidly  there  than  elsewhere.  The  upper  edge  of  the  pupil  was  not 
covered  with  the  lens,  so  that  he  saw  over  it.  Belladonna  was  applied  on  the  afternoon 
of  the  5th,  the  pupil  dilated,  and  that  evening  the  lens  fell  back  through  the  pupil  into 
the  posterior  chamber.  Next  day  he  had  no  pain,  and  saw  well,  but  the  iris  was  evi- 
dently tremulous. 

I  had  no  doubt  that  in  this  case  the  dislocated  lens  would  entirely  dis- 
solve; but  the  rest  of  the  eye,  unfortunately,  appeared  not  to  be  in  a  sound 
state,  and  the  patient  was  likely  to  become  amaurotic. 

2.  From  a  penetrating  wound  or  from  a  blow,  the  capsule  bursts,  and  the 
lens  comes  into  contact  with  the  uvea.  This  dislocation  is  generally  attended 
by  considerable  pain  and  inflammation,  sometimes  running  on  into  suppura- 
tion within  the  eye,  and  often  followed  by  amaurosis.  If  the  lens  is  soft  it 
may  dissolve,  especially  in  young  people,  and  the  pupil  clear.  If  hard,  it  is 
merely  somewhat  reduced  in  size,  and  is  apt  to  come  forward  from  time  to 
time  into  the  anterior  chamber,  and  again  slip  back  through  the  pupil. 

Case  251. — A  stout  countryman,  whilst  working  in  a  quarry,  received  a  blow  with  a 
piece  of  stone  on  his  right  eye,  four  weeks  before  I  saw  him.  He  put  himself  under  the 
care  of  the  ignorant  pretender  to  whom  I  have  referred  at  page  391,  who  allowed  him  to 
remain  without  anything  being  done  which  could  eflfectually  relieve  him  of  the  incessant 
and  excruciating  pain  which  he  suffered  in  the  eye  and  head.  The  sclerotica  was  in- 
tensely inflamed,  the  cornea  unnaturally  prominent  and  somewhat  hazy,  the  iris  in  con- 
tact with  the  cornea,  and  the  lens,  broken  in  pieces  and  apparently  swollen,  lay  in  con- 


404  DISLOCATION   OF   THE   LENS. 

tact  Avitli  the  iris  and  cornea.  Immediately  below  the  cornea,  the  sclerotica  presented  a 
concave  depression,  where  it  had  been  struck. 

It  -was  evident  that  the  capsule  had  burst;  and  that  the  lens,  being  pressed  forward, 
had  obliterated  the  aqueous  chambers ;  an  accident  always  productive  of  severe  pain.  I 
immediately  opened  the  cornea  by  a  small  section  at  its  upper  edge,  and  instantly  the 
soft  disorganized  lens  was  evacuated.  The  patient  had  four  grains  of  calomel  and  two  of 
opium  at  bedtime.  The  pain  entirely  ceased  in  the  course  of  the  afternoon,  and  never 
returned.  On  the  7th  day  after  the  extraction,  he  left  Glasgow,  to  return  to  the  country. 
There  was  still  considerable  zonular  redness ;  shreds  of  opaque  capsule  occupied  the 
dilated  pupil ;  the  lower  part  of  the  sclerotica  still  presented  a  concavity,  instead  of  its 
natural  convexity ;  vision,  which  from  the  violence  of  the  injury  and  long  neglect  of 
proper  means  of  relief,  there  was  reason  to  fear  had  been  altogether  lost,  appeared  in 
some  slight  degree  to  be  returning,  the  patient  perceiving  light  and  shadow  when  he 
looked  to  his  right. 

A  remarkable  circumstance  in  the  case  just  now  narrated,  was  the  perma- 
nent flattening  given  to  the  sclerotica  by  the  momentary  pressure  of  the 
stroke.  We  are  not  surprised  that  the  eye  should  be  bent  for  a  moment 
from  its  natural  shape;  but  that  this  effect  should  continue,  is  a  thing  not 
easily  explained.  We,  however,  see  it  happen  to  the  eye  not  unfrequently ; 
and  in  the  following  case  the  cornea  presented  itself  in  this  deformed  state : — 

Case  252. — An  angular  fragment  of  iron,  about  half  an  inch  long,  chipped  off  by  a 
chisel,  penetrated  the  right  cornea  of  Samuel  Lamont,  within  a  line  of  its  upper  margin. 
Though  immediately  removed,  it  produced  cataract  and  dislocation  of  the  lens,  as  in  the 
last  case,  with  very  violent  inflammation,  which  continued  unabated  for  five  weeks  before 
the  patient  came  to  the  Glasgow  Eye  Infirmary,  notwithstanding  bloodletting,  leeching, 
and  blistering.  The  lens  was  extracted  by  l)r.  Rainy,  with  the  same  striking  relief 
which  extraction  generally  affords  in  such  cases.  The  cornea,  at  his  admission,  was  more 
convex  in  its  horizontal  than  in  its  vertical  section,  as  if  it  had  been  compressed  laterally. 
This  form,  which  it  permanently  retained,  sei'ved  materially  to  impair  tlie  patient's 
vision.  The  retina  appeared  to  be  sound,  and  he  saw  with  considerably  more  distinct- 
ness when  he  viewed  objects  through  a  four-inch  convex  glass. 

3.  The  capsule  bursts  from  a  blow,  and  the  lens  having  passed  through 
the  pupil,  lies  impacted  between  the  iris  and  the  cornea.  The  lens  may  con- 
tinue transparent  for  many  days  after  dislocation  into  the  anterior  chamber. 
If  hard,  it  may  remain  for  years  in  that  situation.  I  have  known  the  burst 
capsule  accompany  the  lens  into  the  anterior  chamber,  in  which  case  they 
sometimes  become  the  seat  of  calcareous  deposition. 

Case  253. — James  Lang,  aged  66,  applied  at  the  Glasgow  Eye  Infirmary,  on  the  22d 
August,  1831.  Nine  weeks  previously,  he  received  a  blow  with  a  piece  of  wood,  on  the 
right  eye.  The  blow  had  ruptured  the  capsule,  and  the  lens  was  lying  in  front  of  the 
iris.  The  pupil  was  much  dilated.  He  had  been  greatly  distressed  since  the  accident, 
with  circumorbital  pain  during  the  night,  so  that  he  had  had  little  or  no  sleep.  There 
was  not  much  redness  of  the  eye.  Pulse  84.  The  left  eye  was  glaucomatous,  and  he 
thought  the  vision  of  this  eye  had  failed  since  the  accident  which  had  happened  to  the 
right. 

The  upper  half  of  the  cornea  being  opened  in  the  way  usually  practised  for  extraction, 
the  lens  immediately  escaped,  followed  by  some  dissolved  vitreous  humor.  The  lids  of 
both  eyes  were  brought  together  by  strips  of  court  plaster,  and  he  was  desired  to  keep 
his  eyes  quiet,  as  if  he  were  asleep. 

Next  morning,  he  told  us  he  had  slept  more  during  the  preceding  night,  than  he  had 
done  during  the  whole  nine  weeks  he  had  suffered  from  the  accident.  He  now  complained 
little  or  none  of  the  pain.  There  had  been  considerable  watery  discharge  from  the  eye. 
The  pupil  remained  widely  dilated.  It  was  uncertain  whether  he  discerned  light  with 
the  eye. 

On  the  24th,  the  edges  of  the  incision  were  accurately  in  apposition.  The  pupil  was 
still  dilated,  and  the  retina  apparently  insensible  to  light. 

On  the  9th  September,  he  was  dismissed,  the  eye  perfectly  free  from  uneasiness,  but 
without  any  return  of  vision. 

This,  then,  was  a  case  of  rupture  of  the  crystalline  capsule  from  a  blow  on 
the  eye,  a  large  hard  lens  passing  through  the  pupil,  and  lodging  in  contact 
-with  the  cornea  for  nine  weeks,  without  becoming  cataractous,  or  undergoing 


DISLOCATION   OF   THE   LENS.  405 

any  sensible  diminution  in  size,  but  causing  incessant  uneasiness,  and  during 
the  night  severe  circumorbital  pain.  The  practice  adopted  was  simply  ex- 
traction of  the  lens,  which,  under  such  circumstances,  must  be  regarded 
exactly  as  a  foreign  body.  The  patient  did  not  require  a  single  opiate,  and 
had  scarcely  a  twinge  of  pain  after  the  lens  was  removed. 

[A  lens  dislocated  into  the  anterior  chamber  will  sometimes,  if  allowed  to 
remain  there,  not  only  give  rise  to  inflammation  of  the  iris  by  pressure  on  that 
body,  but  also  cause  sloughing  of  the  cornea,  as  occurred  in  a  case  which 
recently  applied  for  relief  "at  Wills'  Hospital.  The  subject  of  the  accident 
was  an  Irishwoman,  half  intoxicated,  about  35  years  of  age,  who  had  about 
two  weeks  previous  received  a  blow  from  a  fist,  probably  in  a  drunken 
brawl,  for  we  could  get  no  very  straight  account  from  her  of  how  the  accident 
happened.  Since  then,  however,  she  had  sufi'ered  intensely  with  circumorbital 
and  sandy  pain,  and  been  entirely  unable  to  see  out  of  the  eye.  It  was  ex- 
ceedingly sensitive,  and  it  was  only  by  much  persuasion  that  we  succeeded  in 
getting  a  good  view  of  its  actual  condition. 

Both  the  conjunctiva  and  sclerotic  were  injected,  the  cornea  bulged  forward 
by  the  pressure  of  an  enlarged  opaque  lens  in  the  anterior  chamber,  which, 
resting  by  its  posterior  surface  on  the  iris,  had  already  set  up  inflammation 
in  that  structure.  The  outer  third  of  the  cornea  was  quite  clear,  enabling  us 
to  see  this  condition  of  the  iris;  but  the  rest,  the  part  pressed  upon  by  the 
dislocated  lens,  was  quite  cloudy,  and  this  cloudiness  was  separated  from  the 
transparent  portion  by  a  well-defined  white  ring,  indicating  a  threatening 
slough  of  the  central  two-thirds  of  the  cornea. 

We  admitted  her  into  the  hospital  for  the  purpose  of  extracting  the  lens 
and  placing  her  under  appropriate  treatment.  On  her  reaching  the  wards  it 
was  ascertained  that  she  was  so  filthily  clad  and  so  covered  with  vermin  as  to 
require  her,  for  the  sake  of  the  other  patients,  to  be  sent  home  with  the  person 
who  accompanied  her,  who  appeared  to  be  quite  respectable,  to  be  cleansed, 
and  then  brought  back  with  proper  clothing  to  wear.  This,  it  was  promised, 
should  be  done.  But  it  was  the  last  we  saw  of  her,  and  we  have  but  little 
doubt  that,  if  she  did  not  obtain  proper  relief  elsewhere,  the  eye  has  ere  this 
been  completely  destroyed. — H.] 

4.  A  blow  separates  the  capsule,  inclosing  the  lens,  completely  from  its 
natural  connections  ;  the  lens,  suifering  disorganization,  assumes  a  fluid  form, 
the  capsule  becomes  thickened  and  opaque  ;  and  this  cataracta  cystica  swims 
behind  the  pupil  in  a  superabundant  aqueous  humor. 

5.  The  lens,  forced  out  of  the  capsule,  is  seen  floating  deep  in  the  dissolved 
vitreous  humor.  This  variety  of  dislocation  of  the  lens  generally  arises  from 
a  blow  on  the  eye,  which  fills  the  aqueous  chambers  with  blood.  The  blood 
is  slowly  absorbed  ;  and  then  the  lens  is  seen  deep  behind  the  pupil.  If  we 
puncture  the  cornea,  the  aqueous  humor  escapes,  and  the  lens  floats  forward 
to  the  iris  or  to  the  cornea. 

Case  254. — We  have  an  illustration  of  this  variety  of  dislocation  of  the  lens,  in  the  right 
eye  of  Mary  Mains,  aged  50,  admitted  at  the  Glasgow  Eye  Infirmary  on  the  7th  Septem- 
ber, 1831. 

A  month  before  her  admission,  she  received  a  blow  with  the  fist  on  the  right  orbital 
region.  The  integuments  had  been  divided  above  the  eyebrow,  but  the  wound,  at  her 
admission,  had  perfectly  healed,  although  the  cicatrice  was  still  tender  to  the  touch.  The 
right  pupil  was  dilated,  the  iris  tremulous,  the  humors  glaucomatous,  the  sclerotica  and 
conjunctiva  slightly  injected  with  blood,  and  she  had  violent  hemicrania.  She  could,  with 
the  affected  eye,  still  distinguish  the  fingers  and  other  large  objects.  Pulse  78 ;  much 
thirst;  bowels  bound. 

On  the  admission,  then,  of  the  patient,  there  was  no  appearance  of  dislocation  of  the 
lens.  There  was  amaurosis,  and,  from  the  tremulousness  of  the  iris,  there  was  strong 
reason  to  suspect  a  fluid  state  of  the  vitreous  humor.  I  took  the  opportunity  to  remark 
to  the  students,  that  this  was  one  of  those  cases  which  are  apt  to  be  mistaken  for  examples 


406  DISLOCATION   OF   THE   LENS. 

of  sympatlietic  amaurosis,  arising  from  an  injury  of  some  of  the  branches  of  the  fifth  pair. 
She  had  received  a  cut  above  the  eyebrow,  and,  had  she  not  been  conscious  that  her  eye 
was  struck  as  well  as  her  brow,  we  might  have  been  led  to  suppose,  perhaps,  that  the  cut 
on  the  brow  was  the  cause  of  the  failure  of  sight. 

This  patient  was  bled  at  the  arm  to  the  extent  of  25  ounces ;  had  6  grains  of  calomel 
and  2  of  opium  at  bedtime  ;  and,  next  morning,  a  dose  of  sulphate  of  magnesia.  On  the 
9th,  the  hemicrania  was  much  relieved.  She  was  ordered  a  pill  of  2  grains  of  calomel 
and  1  of  opium  every  night.  On  the  10th,  she  told  us  that  the  pain  had  returned  on  the 
afternoon  of  the  9th,  and  that  it  still  continued  severe.  The  conjunctiva  and  sclerotica 
were  more  inflamed.  She  was  cupped  on  the  right  temple,  and  ordered  to  take  two  of  the 
pills  at  bedtime.  The  pain  was  relieved  by  the  cupping.  On  the  12th,  the  salts  were 
repeated.  On  the  13th,  the  pain  continued  mitigated,  and  the  redness  was  less.  On  the 
14th,  she  told  us  that  the  pain  had  set  in  again  in  the  afternoon  of  the  13th,  and  had 
continued  severe  until  about  eight  in  the  evening,  when  it  ceased,  and  that  she  found  her 
vision  had  become  much  better  than  it  was  the  day  before.  At  the  visit  we  found  the  eye 
free  from  pain,  and  she  saw  so  much  better,  that  she  could  distinguish  one  individual  from 
another.  The  tremulousness  of  the  iris  was  not  so  observable,  but  the  pupil  was  more 
dilated.  The  lens  had,  from  the  previous  day,  become  movable,  and  was  seen,  of  a  glau- 
comatous appearance,  bobbing  about  on  every  motion  of  the  head,  at  a  considerably  greater 
distance  than  natural  behind  the  pupil.  The  upper  part  of  the  dilated  pupil  was  clearer 
than  the  rest,  the  lens  being  partially  sunk. 

Such  dislocation  of  the  lens  as  occurred  in  this  case,  we  may  call  secondary. 

It  did  not  result  immediately  from  the  injury,  but  from  the  vitreous  humor 

undergoing  a  still  farther  degree  of  dissolution  than  it  had  suffered  at  the 

patient's  admission,  a  month  after  the  injury. 

6.  The  choroid,  sclerotica,  and  capsule  being   rent  by  a  blow,  the  lens 

escapes  out  of  the  eye,  and  lies  under  the  conjunctiva. 

Case  255. — The  annexed  figure  represents  the  efi"ects  of  two  diiferent  accidents,  which, 

at  the  interval  of  some  years,  befell  the  right  eye  of 
Fig.  59.  ^^  ^^^  man,  the  first  patient  in  whom  I  happened  to 

meet  with  a  subconjunctival  dislocation  of  the  lens. 
On  inquiring  into  the  history  of  his  case,  he  told  me 
that  the  separation  of  the  iris,  represented  in  the 
figure,  had  been  the  result  of  the  earlier  accident, 
but  that  the  tumor  which  I  saw  at  the  upper  part 
of  his  eye  was  the  consequence  of  a  recent  fall  on  the 
corner  of  a  chair.  The  tumor  had  exactly  the  form 
of  the  lens,  and  the  natural  pupil  was  dragged  to- 
wards it.  On  slitting  up  the  conjunctiva,  the  crys- 
talline was  easily  withdrawn.  The  opening  through 
the  choroid  and  sclerotica,  by  which  it  had  escaped, 
seemed  already  perfectly  united.  The  retina  was 
nowise  impaired,  notwithstanding  the  serious  effects 
produced  on  the  other  textures  of  the  eye,  by  the 

two  accidents,  and  with  a  cataract-glass  the  patient  could  read  an  ordinary  type. 

Mr.  Dixon  records  a  case  in  which  both  lens  and  iris  had  disappeared  from 
the  eye,  in  consequence  of  a  blow.  The  sclerotica  bore  marks  of  having  been 
ruptured,  and  Mr.  D.  regarded  the  case  as  a  subconjunctival  dislocation  both 
of  the  iris  and  the  lens.  The  retina  retained  its  sensibility,  so  that  through  a 
hole  in  a  card  and  a  convex  lens,  the  patient  could  read.* 

Y.  The  cornea  is  sometimes  accidentally  divided  by  a  sharp  instrument, 
and  the  capsule  being  opened  at  the  same  time,  the  lens  escapes  from  the  eye. 

Ca&e  256. — This  accident  happened  to  a  little  boy,  who  was  cutting  a  stick  with  a  pen- 
knife. He  immediately  ran  to  his  father's  gardener,  who  observed  some  clear  substance 
issuing  from  the  wound.  After  the  inflammatory  symptoms  were  subdued  and  the  wound 
had  healed,  it  was  found  that  vision  was  very  imperfect.  I  was  consulted  whether  it  were 
likely  to  be  restored.  On  passing  a  lighted  candle  before  the  eye,  no  inverted  image  was 
to  be  seen.  I  concluded,  therefore,  that  the  lens  was  gone.  On  trying  how  the  little  boy 
could  see  through  a  thick  convex  lens,  I  found  he  saw  no  better  than  without  it.  This 
showed  that  the  eye  was  incompletely  amaurotic. 

In  such  circumstances  as  were  present  in  Case  250,  of  course  no  operation 
is  necessary.     We  leave  the  lens,  already  reduced  in  size,  to  be  dissolved. 


DISLOCATION   OF   THE   LENS.  40Y 

But  if  it  is  inclosed  in  the  capsule,  the  lens  will  not  dissolve  ;  and  ought, 
therefore,  to  be  extracted. 

In  pei'forming  extraction  under  such  circumstances,  it  is  advisable  to  pass 
a  curved  needle  through  the  sclerotica  and  fix  it  in  the  lens  ;  then  open  the 
cornea  in  the  usual  way ;  and  with  the  needle  push  the  lens  out  of  the  eye. 
If  this  precaution  is  not  taken,  on  the  section  of  the  cornea  being  made,  the 
dislocated  lens  is  apt  to  fall  immediately  back  through  the  pupil,  deep  into 
the  vitreous  humor,  whence  it  will  be  difficult  to  fish  it  up,  and  extract  it,  by 
a  hook. 

In  the  2d  variety,  where  the  dislocated  lens  presses  against  the  uvea,  if  the 
pain  and  inflammation  are  not  immediately  subdued  by  venesection,  bella- 
donna, and  calomel  with  opium,  extraction  is  the  most  effectual  means  both 
of  relieving  the  patient,  and,  should  the  retina  be  sound,  of  securing  useful 
vision  in  the  injured  eye.  If  the  lens  is  soft,  a  small  section  of  the  cornea 
will  be  sufficient  for  its  removal. 

In  the  3d  variety,  where  the  lens  lies  in  front  of  the  iris,  there  is,  in  general, 
still  less  ground  for  hesitation  as  to  the  propriety  of  extraction.  When  a 
hard  bulky  lens  lies  in  contact  with  the  cornea,  let  the  cornea  be  opened,  as 
in  common  extraction  of  the  cataract,  care  being  taken,  however,  to  pass  the 
knife  behind  the  dislocated  lens,  in  order  to  prevent,  if  possible,  the  lens 
from  slipping  back  through  the  pupil,  and  sinking  into  the  vitreous  humor, 
which,  in  cases  of  this  sort,  we  generally  find  in  a  fluid  state.  To  secure 
ourselves  against  this,  the  needle  may  first  of  all  be  introduced,  as  above 
directed. 

In  cases  of  the  4th  and  5th  varieties,  the  dislocated  lens  or  cataracta 
cystica  is  perhaps  left  for  years,  bobbing  about  in  the  posterior  chamber  on 
every  movement  of  the  eye  or  head ;  occasionally  passing  through  the  pupil, 
and  returning  again  into  the  posterior  chamber  ;  till,  on  some  particular  occa- 
sion, more  irritation  being  excited  by  its  presence  in  the  anterior  chamber 
than  usual,  iritis  comes  on  with  great  pain  in  the  eye  and  head,  contraction 
of  the  pupil,  and  an  impossibility  of  getting  the  dislocated  body  to  retire,  as 
it  had  been  wont  to  do,  into  the  posterior  chamber.  Under  these  circum- 
stances, although  unfavorable  for  an  operation,  extraction  is  performed,  to 
free  the  patient  from  the  severe  pain  attending  the  iritis,  and  to  save  the 
sound  eye  from  the  danger  of  sympathetic  inflammation.  It  were  better  to 
have  recourse  to  the  operation  immediately  after  the  occurrence  of  the  acci- 
dent. 

I  have  recommended  extraction  as  the  most  advisable  operation  in  most 
cases  of  dislocated  lens.  Peculiar  circumstances,  however,  may  lead  the 
surgeon  merely  to  remove  it,  with  the  needle,  from  the  anterior  or  posterior 
chamber,  leaving  it  in  the  situation  which  the  cataractous  lens  is  made  to  as- 
sume in  the  operation  of  depression  or  reclination.  This  is  best  effected  by 
a  bent  needle,  passed  through  the  sclerotica,  and  the  point  of  it  inserted  into 
the  back  of  the  lens.  In  young  people,  in  whom  the  lens  is  soft,  division 
may  be  practised  either  through  the  cornea  or  the  sclerotica ;  and  as  it  is 
difficult  to  lacerate  the  capsule  or  break  up  the  lens  in  such  cases,  advantage 
may  be  taken  of  the  plan  of  steadying  the  dislocated  body  by  a  needle  passed 
through  the  sclerotica,  on  the  one  side  of  the  eye,  while  a  second  needle,  en- 
tered on  the  opposite  side,  is  used  to  effect  the  division.-^ 

The  patient,  in  whose  eye  a  dislocated  lens  floats  occasionally  through  the 
pupil,  having  found  relief  from  pain  when  the  lens  slipped  back  into  the  fluid 
vitreous  humor,  may  be  averse  to  any  operation.  Irritation  being  set  up, 
however,  when  the  lens  falls  forward  into  the  anterior  chamber,  the  pupil  is 
apt  to  contract,  and  the  plan  of  lying  supine,  and  allowing  it  by  its  own 
gravity  to  fall  back  through  the  pupil,  he  finds  no  longer  to  succeed.     Under 


408  WOUNDS   OF   THE   SCLEROTICA   AND   CHOROIDEA. 

these  circumstances,  dilatation  of  the  pupil  by  the  solution  of  atropine,  while 
the  patient  remains  lying  on  his  back,  will  often  accomplish  the  desired 
object. 

I  have  seen  several  other  cases  of  dislocation  of  the  lens  under  the  con- 
junctiva, besides  the  one  related  and  figured  above.  In  one  of  them,  the 
injury  was  the  consequence  of  the  patient  being  gored  by  a  cow,  and,  in 
this  case,  the  eye  was  partially  amaurotic.  In  another,  in  was  totally  so. 
This,  as  well  as  the  Tth  variety  of  dislocated  lens,  requires  no  further  illus- 
tration. 


'  London  Medical  Gazette  ;  Vol.  v.  p.  784 ;  lens,  by   Neumann,    Edinburgh   Medical  and 

London,  1830.  Surgical  Journal;  Vol.    Ixxv.   p.   120;    Edin- 

^  Lusardi  sur  la  cataracte  Congeniale,  p.  29;  burgh,  1851  :  Bowman,  Lectures  on  the  Parts 

Paris,    1827.      Ammon's    Zeitschrift   fiir    die  concerned  in  the  Operations  on  the  Eye,  pp. 

Ophthalmologie ;  Vol.  i.  p.  260;  Dresden,  1831.  132,  133,  135  ;  London,  1849  :  Balfour,  Medi- 

In    the   fifth  volume  of  Ammon's    Zeitschrift,  cal    Times,  March    15,   1851,   p.    291 :  Dixon, 

Dr.  Lorch  relates  a  case,  in  which  dislocation  Lancet,  February  14,  1852,  p.  171. 

of  the  lens  occurred  in  both  eyes,  after  a  fall  ^  Lancet,  November  27,  1852,  p.  486. 

on  the  back  of  the  head.  '  Dixon,  Lancet,  October  1,  1853,  p.  313. 

'  See  cases  of  spontaneous  dislocation  of  the 


SECTION  V. — WOUNDS   OF   THE   SCLEROTICA  AND   CHOROIDEA. 

If  the  sclerotica  is  penetrated  by  a  thorn,  it  should,  if  entire,  be  carefully 
drawn  out.  If  it  has  broken  short,  it  is  more  difficult  to  remove.  Mr. 
White  Cooper,  in  a  case  of  this  kind,  adopted  the  following  plan  with  success. 
Having,  with  a  sharp  cataract  needle,  made  a  superficial  incision  on  each 
side  of  the  thorn,  he  grasped  it  with  a  pair  of  fine  forceps,  and  smartly 
twitched  it  out.*  The  same  plan  may  be  available  when  a  thorn  sticks  in  the 
cornea,  and  is  broken  off  on  a  level  with  its  surface. 

From  the  retina  being  generally  implicated,  wounds  of  the  sclerotica  and 
choroid  are  more  dangerous  to  vision  than  wounds  of  the  cornea.  Indeed, 
rupture  or  laceration  of  the  sclerotica  scarcely  ever  happens,  without  loss 
of  vision. 

Incised  wounds  of  the  conjunctiva  and  sclerotica  are  instantly  followed  by 
a  protrusion  of  the  choroid,  which  we  have  no  other  means  of  repressing, 
than  by  directing  the  patient  to  keep  the  eyelids  shut  as  much  as  possible,  so 
as  to  give  a  degree  of  support  to  the  eyeball.  The  protruding  choroid  will 
gradually  shrink,  and  we  need  neither  puncture  it,  nor  snip  it  away.  The 
wound  never  heals  without  leaving  a  considerable  cicatrice,  the  space  between 
the  edges  of  the  divided  sclerotica  being  filled  up  by  an  effusion  of  lymph, 
Avhich  gradually  assumes  the  appearance  and  texture  of  a  membrane.  The 
conjunctiva  sometimes  heals  in  cases  of  this  kind,  while  the  sclerotica  con- 
tinues open,  with  the  choroid  projecting  through  it. 

I  have  seen  a  small  puncture  of  the  sclerotica  and  choroid,  near  the  edge 
of  the  cornea,  give  rise  to  tremulousness  of  the  iris  and  incomplete  amau- 
rosis, followed  some  years  after  by  opacity  and  ossification  of  the  lens.  In 
other  cases,  I  have  met  with  prolapsus  of  the  iris  through  a  punctured  wound 
in  the  same  situation.  When  the  edge  of  the  cornea,  and  that  of  the  scle- 
rotica are  divided,  the  choroid  muscle  or  annulus  albidus  being  wounded, 
and  the  iris  dragged  to  one  side,  not  merely  is  the  injured  eye  lost,  but  sym- 
pathetic ophthalmitis  of  the  opposite  eye  is  likely  to  follow. 

A  very  dangerous  class  of  wounds  of  the  eye  are  those  inflicted  by  arrows 
shot  by  children  in  play,  and  by  the  sharp  end  of  the  shuttle  leaping  from 
the  steam-loom.     The  cornea,  in  some  cases,  and  the  sclerotic  and  choroid,  in 


FOREIGN   BODIES   IN   THE   VITREOUS   HUMOR.  409 

others,  are  laid  open,  the  cavities  fill  with  blood,  the  retina  is  rendered  in- 
sensible, and  the  eye  is  ultimately  left  disfigured  and  atrophic. 

When  both  sclerotic  and  choroid  are  divided  in  a  considerable  extent,  the 
vitreous  humor  immediately  issues  from  the  wound,  which  also  bleeds  pro- 
fusely. The  vitreous  cells  become  injected  with  blood,  and  form  a  fungus- 
like protrusion  from  the  wound,  which  it  is  proper  to  snip  oif  with  the  scissors. 
In  other  respects,  this  case  is  to  be  treated  as  has  been  already  mentioned. 
Besides  the  use  of  antiphlogistic  means,  the  eyelids  must  be  kept  shut.  Most 
frequently  vision  is  entirely  destroyed  by  the  loss  of  vitreous  humor,  the  in- 
jury done  to  the  retina,  and  the  violent  inflammation  of  the  eye  which  follows 
the  accident.  The  inflammation,  however,  is  not  so  violent  where  much  of 
the  vitreous  humor  is  lost,  as  where  only  a  small  quantity  escapes,  nor  is  the 
form  of  the  eye  necessarily  lost,  although  it  has  l)een  emptied  of  a  great  part 
of  its  contents.  An  aqueous  fluid  fills  the  cavity  of  the  eye.  If  almost  all 
the  vitreous  humor  has  been  evacuated,  the  membranes  shrink,  and  the  eye 
remains  in  a  dwarfish  state ;  it  is  movable,  and  can  be  covered  by  a  glass 
eye. 

If  the  lens  has  been  left  in  the  eye,  it  becomes  opaque  ;  but  frequently  the 
lens  escapes  through  the  wound  along  with  the  vitreous  humor.  An  opaque 
deposition  at  the  bottom  of  the  eye  is  not  an  unfrequent  result  of  penetrat- 
ing wounds  of  the  sclerotica  and  choroid,  as  I  shall  have  occasion  to  state 
more  fully,  under  the  head  of  Non-malignant  Tumors  of  the  Eyeball,  in  a 
subsequent  chapter. 


'  London  Journal  of  Medicine;  Vol.  iii.  p.  975;  London,  1851. 


SECTION  VI. — FOREIGN  BODIES  IN  THE  VITREOUS  HUMOR. 

Foreign  bodies,  such  as  fragments  of  glass,  wood,  iron,  or  stone,  may  be 
driven  into  the  vitreous  humor,  either  through  the  cornea  and  pupil,  wound- 
ing and  displacing  the  lens  in  their  passage  ;  through  the  cornea  and  iris, 
lacerating  the  latter  and  generally  wounding  the  lens ;  or  through  the  scle- 
rotica and  choroid,  in  which  case  the  retina  is  apt  to  be  torn  and  destroyed. 
They  are  often  sent  with  such  violence  into  the  eye  that  they  sink  entirely 
out  of  view ;  the  patient  is  not  conscious  that  anything  has  lodged  in  the 
eye ;  he  merely  supposes  it  to  have  been  cut  or  injured  externally ;  and  a 
hurried  or  superficial  examination  by  the  surgeon  may  not  reveal  the  full 
extent  of  the  mischief  which  has  been  inflicted.  The  blood  effused  into  the 
eye,  in  such  cases,  is  gradually  absorbed,  the  inflammation  is  combated  by 
the  usual  remedies,  the  wound  contracts  and  heals,  with  dragging  perhaps  or 
closure  of  the  pupil,  opacity  of  the  lens,  and  insensibility  of  the  retina.  But 
the  eye  still  continues  irritable,  the  iris  assumes  a  greenish  or  reddish  hue, 
the  sclerotica  becomes  thinned,  and  the  eye  soft  and  atrophic.  By  and  by 
the  eye  may  become  the  seat  of  acute  pain,  which  sometimes  intermits  for 
weeks  or  months,  and  is  then  renewed  with  very  painful  severity.  At  length, 
the  wound,  which  had  previously  been  cicatrized,  opens,  and  allows  the 
foreign  substance  to  protrude.  It  is  drawn  forth,  and  often  proves  of  a  size 
so  large  as  to  excite  the  wonder  of  all  concerned  how  it  had  lain  so  long  con- 
cealed within  the  eye,  or  how  it  had  been  capable  of  lodging  there  at  all.^ 
Under  such  circumstances,  sympathetic  ophthalmitis  of  the  sound  eye  is  apt 
to  be  excited  during  the  pressure  of  the  foreign  body  in  the  eye,  or  after  it  is 
extracted. 

In  severe  wounds  of  the  eye,  in  which  there  is  a  suspicion  of  a  foreign 


410  AMAUROSIS   FROM   BLOWS. 

body  having  passed  into  its  interior,  a  careful  examination  of  the  injured 
organ  should  be  instituted,  while  the  patient  is  under  the  influence  of  chloro- 
form. The  immediate  extraction  of  the  foreign  substance  will  not  merely 
prevent  a  great  amount  of  immediate  suffering  from  the  state  of  the  wounded 
organ,  but  may  be  the  means  of  saving  the  sight  of  the  sound  eye  from  being 
lost  from  sympathetic  inflammation. 


'  See  case  by  O'Beirne  of  a  nail  three-quar-  about  balf  an  inch  long,  retained  in  the  eye 

ters  of  an  inch  long,  retained  in  the  eye  three  three  years  and  a  half;  Archives  Generales  de 

weeks;  Dublin  Medical  Press,  July  7,  1841,  p.  Mcdecine,  October,  1842,  p.  210. 
11 ;  case  by  De  Castelman,  of  a  splinter  of  steel. 


SECTION  VII. — PRESSURE  AND  BLOWS  ON  THE  EYE. 

§  1.  Amaurosis  from  Pressure. 

Beer  relates  the  following  instance  of  the  bad  effects  of  pressure  exercised 
on  the  eyeball : — 

Case  257. — A  man,  Avbo  bad  previously  enjoyed  excellent  sight,  happened  to  be  in  a 
company  of  friends,  when  suddenly  a  stranger  stepped  behind  him,  and  clapped  bis  hands 
upon  his  eyes,  desiring  him  to  tell  who  stood  behind  him.  Unable  or  unwilling  to  answer 
this  question,  he  endeavored  to  remove  the  hands  of  the  other  person,  who  only  pressed 
them  the  firmer  on  the  eyes,  till  at  length  withdrawing  them  so  as  to  allow  the  eyes  to 
be  opened,  the  man  found  that  he  saw  nothing,  and  continued  ever  afterwards  blind, 
without  any  apparent  lesion  of  the  eyes.' 

§  2.  Amaurosis  from  Bloios. 

Blows  on  the  eye  are  often  productive  of  temporary  or  permanent  amau- 
rosis, with  scarcely  any  visible  change  in  the  organ ;  whence  we  may  con- 
clude that  the  blow  has  affected  the  retina  by  concussion,  congestion,  extra- 
vasation, or  laceration.  It  is  unfortunate  that  such  cases  of  traumatic 
amaurosis  are  ofteu  neglected,  till  the  blindness  is  confirmed;  for  much  may 
be  done  for  their  relief  if  they  be  taken  in  proper  time.  The  following  cases 
illustrate  the  danger  of  neglect,  and  the  good  effects  of  appropriate  treat- 
ment : — 

Case  258. — Mr.  N.  applied  to  me  on  the  18th  of  January,  1829,  on  account  of  the 
efiects  of  a  blow  which  he  had  received,  eight  days  before,  with  a  pretty  heavy  piece  of 
metal,  on  the  temporal  side  of  the  left  eye.  He  was  a  man  of  about  40  years  of  age,  of 
sound  constitution,  and  his  eyes  had  been  good  till  this  accident.  Any  inflammation  or 
irritation  produced  by  the  blow  had  already  subsided,  although  almost  nothing  had  been 
done  in  the  way  of  treatment.  The  vision  of  the  eye  was  lost,  except  when  he  turned  it 
very  much  to  the  left,  so  much,  indeed,  as  to  look  almost  behind  him.  AVhen  he  did  so, 
he  saw  indistinctly  any  object  situated  to  his  left.  Forwards  or  to  the  right  he  saw  no- 
thing, everything  being  darkened  by  the  appearance  of  a  thick  gauze  or  mist.  A  bright 
light,  as  a  gas  flame,  was  the  only  object  capable  of  producing  a  sensation,  when  the  eye 
was  directed  forwards.  The  amaurosis  was  so  considerable,  and  had  been  neglected  for 
so  many  days,  that  I  pronounced  a  very  doubtful  prognosis,  but  urged  the  adoption  of 
active  measures. 

Thirty  ounces  of  blood  were  taken  from  the  arm  on  the  evening  of  the  18th.  He  took 
two  pills,  each  containing  three  grains  of  blue  pill  mass  and  two  grains  of  aloes,  and  was 
ordered  two  thrice  a-day.  On  the  19th,  he  thought  he  saw  objects  somewhat  less  indis- 
tinctly, but  still  only  when  he  looked  much  to  the  left  hand.  When  he  looked  forwards, 
he  saw  as  if  gauze  threads  were  moving  before  him,  and  the  lamp  appeared  of  various 
colors.  Twenty-four  leeches  were  applied  round  the  eye.  On  the  20th,  his  vision  was 
so  far  improved,  that  he  could  make  out  the  large  characters  on  the  back  of  a  quarto 
book  when  he  looked  at  it  sideways.  He  could  recognize  any  ordinary  object,  as  a  tea- 
cup, held  towards  his  left  side,  but  lost  sight  of  it  entirely  as  it  was  moved  in  front  of 
him.  A  blister  was  applied  to  the  left  temple  and  behind  the  left  ear.  On  the  22d, 
there  was  a  great  improvement  in  vision.     He  could  now  tell  the  hour  on  a  watch,  even 


BURSTING   OP   THE   EYE   FROM   BLOWS,  411 

when  he  looked  straightforwards,  and  compared  the  apparent  impediment  of  vision  to 
branches  of  trees,  whereas  it  formerly  had  the  appearance  of  a  uniform  cloud.  The 
mouth  being  considerably  affected  by  the  pills,  they  were  omitted.  The  blister  was  re- 
applied. On  the  24th,  the  blister  was  discharging  well,  the  mouth  was  very  sore,  and 
the  vision  much  improved.  He  could  read  a  newspaper  with  the  left  eye,  and  said  that 
the  branches  of  trees  which  appeared  before  him  were  now  broken,  and  looked  like 
grains  of  sand  separated  one  from  another.  On  the  26th,  he  stated  that  he  knew  an  in- 
crease of  vision  daily.  The  mouth  was  still  very  sore.  The  blister  was  repeated.  After 
this,  the  vision  continued  progressively  to  improve,  and  by  the  middle  of  February  was 
all  but  perfect. 

Case  259. — John  Eobertson,  aged  17,  was  admitted  at  the  Glasgow  Eye  Infirmary,  on 
the  13tli  June,  1831,  six  weeks  after  receiving  a  blow  with  a  stick  on  the  left  eye.  The 
lids  swelled  very  much  at  the  time,  so  that  he  could  not  open  the  eye  for  some  days. 
When  able  to  open  it,  he  found  the  vision  almost  entirely  lost,  all  that  he  retained  of  it 
being  a  mere  perception  of  light  and  shade.  We  observed  that  the  pupil  moved  sympa- 
thetically with  the  other,  but  upon  being  exposed  by  itself,  it  contracted  very  feebly,  on 
exposure  even  to  bright  light.     Pulse  78;  tongue  foul. 

He  was  bled  at  the  arm,  and  ordered  two  mercury  and  aloes  pills  thrice  a-day.  Next 
day,  he  could  discern  objects.  The  pills  not  having  purged  him,  he  was  ordered  a  dose 
of  calomel  and  jalap.     In  a  few  days,  the  eye  was  perfectly  well. 

If  it  were  necessary,  I  could  quote  several  similar  cases,  showing  the  good 
efifects  of  depletion,  counter-irritation,  and  mercurialization,  in  amaurosis 
consequent  to  those  blows  on  the  eye,  which  are  probably  productive  of  con- 
gestion of  the  choroid  and  retina,  but  unattended  by  any  other  considerable 
lesion  of  these  important  structures. 

§  3.  Effusion  of  Blood  into  the  Eye  from  Blows. 

The  internal  textures  of  the  eye  frequently  give  way  under  a  blow ;  the 
bloodvessels  of  the  choroid  or  of  the  iris  burst,  and  fill  the  cavities  of  the 
eye  more  or  less  with  blood.  Sometimes  the  bottom  only  of  the  anterior 
chamber  seems  to  contain  effused  blood;  but  if  we  dilate  the  pupil  by  bella- 
donna, and  examine  the  eye  catoptrically,  we  generally  find  that  neither  the 
deep  erect  nor  the  inverted  image  is  visible,  showing  that  the  surface  of  the 
lens  is  covered  with  blood.  Vision  is  hazy  under  such  circumstances.  Some- 
times the  aqueous  humor  is  quite  changed  in  color  from  effused  blood,  and 
the  cells  of  the  vitreous  humor  are  also  filled  with  that  fluid.  The  cornea,  in 
such  cases,  presents  a  deep  uniform  chocolate  hue,  through  which  neither 
pupil  nor  iris  can  be  seen.  The  vitreous  body  is  generally  disorganized 
under  such  circumstances,  and  the  retina  rendered  insensible  ;  although  in 
some  rare  instances  it  happens,  that  as  the  effused  blood  is  absorbed,  vision 
is  restored. 

If  we  puncture  the  cornea  in  cases  of  this  kind,  there  is,  in  general,  a  pro- 
fuse discharge  of  bloody  watery  fluid.  If  the  puncture  is  small,  it  heals  in 
24  hours,  and  may  be  repeated  from  time  to  time,  without  any  ill  eflects. 
The  vitreous  humor  may  also  be  evacuated  through  a  puncture  of  the 
sclerotica. 

The  same  treatment  should  be  followed,  as  in  amaurosis  from  blows. 

§  4.  Bursting  of  the  Eye  from  Bloios. 

In  consequence  of  blows  on  the  eye,  with  the  fist,  sticks,  stones,  and 
various  projectiles,  and  from  falls  on  the  eye,  we  frequently  meet  with  lacera- 
tion of  the  sclerotica  and  choroid,  with  or  without  rupture  of  the  conjunc- 
tiva. Sometimes,  though  not  so  frequently,  we  meet  with  laceration  of  the 
cornea,  which  is  more  resisting  than  the  sclerotica.  The  place  of  the  eye- 
ball most  apt  to  burst  under  a  blow  is  immediately  anterior  to  the  insertion 
of  the  recti.  The  conjunctiva,  from  its  laxity,  sometimes  escapes,  while  the 
sclerotica,  owing  to  the  tension  produced  by  its  contents,  is  unable  to  with- 


412  GUNSHOT   WOUNDS   OF   THE   EYE. 

stand  the  efifects  of  a  blow,  and  consequently  gives  way.  From  a  blow  with 
the  fist,  I  hare  found  the  sclerotic  and  conjunctiva  rent  behind  the  cornea, 
the  humors  evacuated,  the  eye  flat,  and  the  cornea  sunk  back  into  a  con- 
cavity. I^ext  day,  the  eye  has  been  plump,  and  the  cornea  pretty  natural, 
the  cavities  filled  with  blood,  and  the  retina  insensible.  As  I  have  already 
mentioned,  I  have  repeatedly  seen  the  sclerotic  and  choroid  ruptured,  with 
the  lens  propelled  through  the  lacerated  opening,  so  as  to  lie  immediately 
under  the  conjunctiva,  which  remained  entire. 

Case  260. — A  gentleman  accidentally  struck  his  right  eye  with  his  thumb,  and  rup- 
tured the  cornea  at  its  upper  edge,  giving  occasion  to  a  large  prolapsus  of  the  iris.  On 
examining  his  left  eye,  I  found  it  presenting  a  distinct  arcus  senilis  a  little  way  within 
the  verge  of  the  cornea,  while  between  the  arcus  and  the  sclerotica  the  cornea  seemed 
thin  and  transparent.  This  transparent  space  was  the  seat  of  the  rupture  of  the  cornea, 
which  had,  I  presume,  been  weak,  and  therefore  unable  to  withstand  the  sudden  force 
applied  to  the  eye.  The  wound  contracted  sloAvly,  and  healed,  with  the  pupil  dragged 
upwards.     The  capsule  of  the  lens  soon  after  became  opaque. 

In  cases  of  bursting  of  the  eye  from  a  blow,  whether  the  laceration  is 
through  the  cornea  or  through  the  sclerotica,  considerable  ha^morrhagy 
generally  takes  place,  especially  when  the  choroid  has  also  given  way.  The 
humors  are  also  often  partly,  and  sometimes  almost  wholly  evacuated,  so  that 
a  dwarfish  deformed  eyeball  is  left  after  the  lacerated  part  heals  up.  If  the 
lens,  or  shreds  of  the  iris,  project  through  the  wound,  they  should  be  re- 
moved, as  they  will  prevent  the  wound  from  healing. 


'  Pflege  gesunder  und  geschwiiehter  Augen,  p.  10;  Frankfurt,  1802. 


SECTION   Vin. — GUNSnOT   WOUNDS  OF   THE   EYE. 

1.  Under  this  head,  I  may  notice  some  of  the  effects  of  gunpowder  ex- 
ploded into  the  eye.  It  is  generally  the  lower  portion  of  the  cornea  which 
sufiers  most  from  this  accident ;  but  in  an  instance  which  came  under  my 
observation,  as  the  person  was  in  the  act  of  stooping  to  the  ground  when  the 
powder  exploded,  only  the  upper  half  of  each  cornea  received  the  injury,  and 
was  left  opaque.  I  have  repeatedly  seen  grains  of  powder  propelled  through 
the  cornea  into  the  lens,  so  as  to  cause  cataract.  In  one  case,  a  grain  of 
powder,  propelled  through  the  cornea,  traversed  also  the  lower  part  of  the 
iris,  in  which  it  left  a  considerable  opening,  and,  striking  the  lens,  produced 
cataract.  Gradually  the  opaque  substance  cleared  away  behind  the  false 
pupil,  and  vision  was  restored.  The  natural  pupil  remained  much  longer 
cataractous,  but  at  length  it  cleared  also.  The  patient  saw  well  with  a  cata- 
ract-glass. 

2.  Injuries  of  the  eye  from  grains  of  small  shot  are  not  unfrequent. 

Mr.  Lawrence  mentions*  that  he  once  saw  complete  blindness  caused  by  a 
single  grain,  which  merely  struck  the  sclerotica  obliquely,  and  did  not  enter. 
A  spent  shot  bruises  the  eye,  but  may  not  penetrate ;  it  causes  ecchymosis, 
and  by  concussion  of  the  retina,  may  produce  blindness.  It  may  lodge  be- 
neath the  conjunctiva. 

Striking  the  eye  obliquely,  a  grain  of  shot  may  glance  off,  and  leave  the 
appearance  of  a  furrow  in  the  conjunctiva.  The  cornea,  injured  in  this  way, 
appears  to  lose  its  vitality,  becomes  opaque,  and  falls  into  a  state  of  ulcera- 
tion. 

If  the  grain  strikes  point-blank,  and  passes  through  the  sclerotica,  it  is 
almost  always  fatal  to  vision  ;  and  the  same  result  follows,  if  the  grain  per- 
forates the  cornea  and  passes  deep  into  the  eye.     But  if  it  lodges  in  the  an- 


GUNSHOT  WOUNDS  OF  THE  EYE.  413 

terior  chamber,  the  retina  may  retain  its  sensibility,  the  grain  sinking  in  the 
aqueous  humor.  An  incision  is  to  be  made,  under  such  circumstances,  with 
the  extraction  knife,  and  the  grain  removed.  If  this  is  not  done,  it  may 
become  incapsulated.  If  the  grain  passes  very  obliquely  through  the  sclero- 
tica, it  may  wound  the  lens,  and  remain  in  the  vicinity  of  the  iris.  In  this 
case,  the  retina  retains  for  a  while  its  sensibility ;  by  and  by,  the  eye  becomes 
atrophic. 

It  not  unfrequently  happens  that  grains  of  shot  traverse  one  or  other  eyelid, 
and  then  penetrate  into  the  eyeball ;  and  that  they  lodge  also  in  the  cellular 
membrane  of  the  orbit.  Symptoms  of  inflammation  within  the  cranium  are 
not  uncommon  after  such  injuries,  and  the  patient  is  often  affected  with  severe 
neuralgia. 

The  question  whether  a  grain  has  penetrated  into  the  eyeball  is  generally 
settled  by  our  finding  a  shot-hole  in  the  cornea  or  the  sclerotica,  when  the 
accident  has  actually  been  of  this  serious  kind.  Through  the  shot-hole  there 
is  generally  a  small  protrusion  of  the  iris  or  the  choroid. 

In  one  case  which  I  saw,  a  grain  passed  through  the  sclerotica,  close  to 
the  cornea.  Yision  was  instantly  extinguished.  Severe  inflammation  fol- 
lowed ;  the  iris  became  of  a  dark  greenish  hue  ;  the  pupil  was  deformed,  the 
iris  being  broader  towards  the  wound  than  in  the  rest  of  its  extent ;  and 
the  eye  was  boggy.  In  another  case,  a  grain  passed  through  the  lower  lid 
into  the  eyeball.  The  wound  in  the  sclerotica  presented  the  appearance  of  a 
slit,  through  which  oozed  the  vitreous  humor.  The  pupil  was  rather  con- 
tracted, and  muddy  from  effused  lymph.  Yision  with  the  w^ounded  eye  was 
dim,  yet  the  patient  saw  everything  with  it.  The  conjunctiva  became  che- 
mosed.  Gradually  the  pupil  cleared,  but  opacity  of  the  lens  ensued.  The 
interior  of  the  eye  suppurated,  and  matter  was  discharged  by  the  wound  in 
the  sclerotica.  Demours  has  figured  a  case  in  which  a  grain  of  small  shot 
passed  through  the  cornea,  detached  the  iris  from  the  choroid,  and  produced 
opacity  of  the  lens.^  He  relates  another  case,  in  which  a  double  grain 
passed  into  the  sclerotica,  near  the  edge  of  the  cornea,  and  remained  fixed, 
the  one  grain  being  without  and  the  other  within,  till  he  extracted  them. 
The  sight  of  the  eye  was  saved.^ 

Any  attempt  to  remove  a  lead  pellet  from  the  eye,  when  it  has  passed  either 
through  the  cornea  or  the  sclerotica  into  the  vitreous  body,  I  should  suppose 
would  be  fruitless,  and  likely  to  irritate  the  eye  and  lead  to  inflammation. 
Left  in  the  vitreous  humor,  the  pellet  will  probably  sink  down  into  contact 
with  the  retina.  Vision,  as  far  as  I  have  seen,  is  totally  destroyed  by  such 
an  accident ;  and  I  have  never  known  of  the  foreign  body  coming  to  the  sur- 
face, so  that  it  might  be  extracted,  although  Stbber  relates  a  case  in  which 
this  seems  to  have  happened,  and  in  which  vision  was  restored.*  I  have 
never  known  sympathetic  ophthalmitis  excited  by  the  presence  of  a  pellet  in 
the  eye.  Should  such  a  consequence  arise,  the  eye  should  be  treated  as  Mr. 
Barton  has  recommended  in  cases  of  fragments  of  percussion  caps  lodged  in 
the  eye.  Severe  neuralgia  is  a  consequence  of  such  wounds  as  we  are  now 
considering.  A  gentleman,  by  whom  I  was  consulted,  submitted  to  have  the 
eye  extirpated  on  account  of  the  pain  he  continued  to  suffer.  This  was  done 
by  an  eminent  surgeon  in  Edinburgh.  Immediately  after  the  operation,  the 
eyeball  was  cut  to  pieces,  but  no  pellet  was  found.  The  neuralgia,  however, 
subsided. 

Case  261. — A  young  man  was  looking  up  towards  a  tree,  upon  which  was  seated  a 
■woodcock  his  master  was  about  to  fire  at ;  upon  the  young  man's  giving  the  signal,  the 
sportsman  fired,  and  several  grains  of  the  small  shot,  rebounding  from  the  boughs,  struck 
the  lad,  perforating  the  eyelids  and  skin  of  the  forehead.  One  entered  the  left  eyeball, 
immediately  above  the  upper  edge  of  the  cornea.     The  surgeon  tried  to  trace  the  grains 


414  GUNSHOT   WOUNDS   OF   THE   EYE. 

of  small  shot  with  the  probe,  into  the  cellular  membrane  of  the  orbit,  but  could  not  touch 
any  of  them.     The  lad  was  leeched  and  purged. 

I  saw  him  nine  days  after  the  accident,  when  the  eye  presented  the  appearance  repre- 
sented in  the  annexed  figure.  There  was  a  red  vesicle-like  protrusion  of  the  choroid  at 
the  place  where  the  grain  had  entered  the  eye,  and  round  this  the  sclerotica  was  con- 
siderably depressed.  The  iris  was  deficient  at  its  upper  part,  where  it  had  been  torn 
through  by  the  grain  of  shot.  Behind  the  pupil  there  appeared  a  reddish  white  cloud, 
the  remains  of  the  blood  effused  into  the  vitreous  humor.  The  patient  retained  a  bare 
perception  of  light  and  shadow  with  this  eye. 

The  right  pupil  was  large  and  sluggish.     With  this  eye  the  patient  could  read  the  large 
letters  of  a  title  page.     It  appeared  probable  that  some 
pirr.  60.  grains  of  small  shot  were  lodged  in  the  cellular  mem- 

brane of  the  right  orbit. 

In  the  course  of  some  months  the  vision  of  the  right 
eye  improved,  while  the  left  eye  became  more  and  more 
atrophic,  the  lower  part  of  the  cornea  sinking  into  a  con- 
cave form,  and  the  humors  behind  the  pupil  assuming  a 
yellow\sh-green  color. 

Case  262. — Mr.  H.,  aged  50,  came  from  Camborne,  in 
Cornwall,  and  first  consulted  Dr.  Butter,  at  Plymouth, 
in  September,  1830,  on  account  of  total  blindness  in 
his  left  eye,  accompanied  occasionally  with  great  pain. 
He  had  also  some  degree  of  amaurosis,  with  photopsia, 
of  his  right  eye.  The  following  was  the  history  of  his 
case : — 

On  the  19th  February,  1827,  whilst  shooting,  a  gun  was 
fired  at  a  woodcock  by  another  person,  and  a  shot  lodged  in 
his  left  ej^eball,  producing  instant  blindness.  For  a  fort- 
night afterwards,  he  did  not  suffer  greatly ;  but  during  the 
four  years  and  a  half  preceding  his  application  to  Dr.  Butter,  the  pain  would  at  times 
flash  so  suddenly  and  intensely  through  his  left  eye  and  head,  and  so  seriously  disturb 
the  visual  functions  of  his  sound  or  right  eye,  that  in  whatever  occupation  he  was 
engaged,  his  sufferings  obliged  him  to  desist  for  a  time,  and  to  apply  leeches  and  other 
remedies.  The  fear  of  losing  the  sight  of  his  sound  eye  from  sympathy,  added  to  the 
pain  of  his  left,  induced  him  to  seek,  and  even  to  urge,  the  extraction,  if  possible,  of  the 
shot,  which  he  knew,  from  his  acute  feelings,  must  be  situated  in  some  very  sensitive 
part  of  his  left  eye. 

The  left  eye  was  rather  less  in  size  than  the  right.  It  was  entirely  free  from  inflam- 
mation. Oa  the  nasal  side  of  the  eye,  a  fistulous  opening  was  perceived  a  little  behind 
the  edge  of  the  cornea.  A  fine  gold  probe  could  be  passed  through  this  opening,  nearly 
into  the  posterior  chamber.  It  was  evidently  the  entrance  of  the  shot.  The  iris  was  not 
materially  altered.     Behind  it  a  cataract  was  distinctly  seen. 

Dr.  Butter,  in  consultation  with  Mr.  Luscombe,  agreed  to  dissuade  Mr.  H.  against 
an  operation,  or  any  attempt  to  search  for  a  shot  the  position  of  which  was  extremely 
doubtful  and  uncertain ;  but  it  was  the  wish  of  the  patient  that  some  trial  should  be 
made. 

On  the  9th  September,  1831,  Dr.  B.  extracted  the  cataract,  which  consisted  of  calcare- 
ous matter  and  spiculse  of  bone.  He  afterwards  syringed  out  some  gritty  matter.  It  was 
hoped  that  the  removal  of  this  bony  lens  would  be  followed  with  corresponding  relief,  but 
in  this  hope  the  parties  were  disappointed. 

On  the  23d  February,  1833,  Mr.  H.  returned  to  Plymouth,  and  requested  Dr.  B.  to  make 
a  farther  attempt  for  the  removal  of  the  shot,  which  his  feelings  denoted  still  to  remain 
within  his  eye.  He  pointed  to  a  bluish  and  prominent  part  of  the  eyeball  under  which  he 
thought  the  shot  was  lodged.  Dr.  B.  hooked  up  the  prominent  portion  of  the  sclerotica, 
cut  it  oflf  with  the  scissors,  and  made  an  aperture  sufficiently  large  to  enable  him  to 
explore  with  the  probe  the  cavity  of  the  eye,  and  to  allow  the  exit  of  the  vitreous 
humor.  Still  no  shot  was  found.  Mr.  H.  determined  to  have  his  whole  eye  extirpated 
at  a  future  period,  should  his  complaints  not  be  alleviated  by  the  suppuration  following 
this  second  attempt. 

On  the  23d  September,  1833,  Dr.  B.  removed  the  whole  of  the  left  eyeball,  with  the 
lachrymal  gland,  and  divided  the  optic  nerve  close  to  the  foramen  opticum,  fearing  lest  he 
might  still  miss  the  object  of  pursuit.  On  dissection  of  the  extirpated  parts,  he  had  the 
satisfaction  to  find  a  duck-shot  impacted  so  firmly  in  that  part  of  the  optic  nerve  which 
joins  the  retina,  that  a  considerable  effort  was  required  to  detach  it  from  its  bed,  in  which 
it  must  have  been  fixed  for  six  years  and  six  months. 

At  the  end  of  a  fortnight,  the  patient  was  nearly  well,  but  for  three  weeks  afterwards 


GUNSHOT   WOUNDS   OF   THE   EYE.  415 

■was  detained  on  account  of  adhesions  ■which  formed  between  the  lids  and  subjacent  parts, 
and  ■whicli  Dr.  B.  repeatedly  divided.  Some  morbid  sensations  ■were  felt  in  the  ophthal- 
mic division  of  the  fifth  pair,  and  also  in  the  ramifications  of  the  superior  maxillary,  for 
■which  Dr.  B.  prescribed  carbonate  of  iron.  Mr.  H.  retui-ned  home,  forty-seven  days  after 
the  operation  ;  the  strength  of  his  right  eye  increasing  daily,  and  the  neuralgic  complaints 
becoming  mitigated. ^ 

3.  Mr.  Watson  notices^  two  cases  in  which  small  portions  of  exploded  per- 
cussion caps  having  struck  the  eyeball,  complete  blindness  was  the  immediate 
consequence,  although  the  eye  retained  its  natural  appearance  and  no  serious 
wound  seemed  to  have  been  produced. 

I  have  seen  several  instances  of  one  of  the  fragments,  into  which  a  per- 
cussion cap  breaks  when  it  is  exploded,  entering  the  eye.  This  may  happen 
either  in  shooting  with  percussion  caps,  or  in  discharging  them  with  a  ham- 
mer, as  children  sometimes  do  for  amusement.  In  such  cases  the  injured  eye 
is  exceedingly  liable  to  be  lost,  while  sympathetic  inflammation  may  endanger 
the  other  eye,  especially  if  the  foreign  body  is  left  unextracted. 

Sometimes  a  fragment  of  an  exploded  cap  fixes  in  the  cornea,  but  is  not 
detected,  being  immediately  hid  in  the  whitish  scarred  substance  of  the 
cornea.  After  some  days,  a  blackish  point  is  seen  protruding  from  the 
slough.  This  is  the  bit  of  cap,  which,  being  extracted,  is  found  to  be  rough 
and  angular. 

The  fragment,  traversing  the  cornea,  may  lodge  in  the  anterior  chamber, 
or  fix  itself  in  the  iris,  or  lens  ;  but  more  frequently  it  passes  into  the  poste- 
rior chamber.^  The  wound  made  by  the  entrance  of  the  fragment  generally 
heals  without  difficulty,  so  that  in  a  few  days  it  is  sometimes  not  easy  to  detect 
it,  especially  if  it  has  been  in  the  sclerotica.  Immediately  after  the  accident, 
the  changes  produced  are  so  like  those  observed  in  penetrating  wounds  of  the 
eye,  when  no  foreign  body  remains  in  it,  that  it  is  impossible  to  ascertain,  at 
first,  whether  the  cap  is  in  the  eye  or  not.  Vision  is  more  or  less  affected 
immediately  after  the  injury,  according  as  the  lens,  retina,  and  other  struc- 
tures are  implicated. 

Severe  inflammation  sometimes  sets  in  immediately,  the  iris  becomes  of  a 
greenish  hue,  the  lens  grows  opaque,  and  there  is  great  pain.  If  the  cornea 
is  now  laid  open,  with  the  view  of  extracting  the  foreign  body,  pus  flows 
from  the  interior  of  the  eye.  It  not  unfrequently  happens,  however,  that  for 
a  length  of  time,  varying  from  a  few  days  to  a  month  after  the  accident,  the 
eye  appears  to  be  recovering;  but  at  the  expiration  of  that  time,  it  is  sud- 
denly seized  with  most  acute  pain,  attended  with  chemosis,  and  sometimes 
with  haziness  of  the  cornea.  In  a  day  or  two,  the  pain  may  become  mitigated, 
or  for  a  while  it  may  entirely  subside  ;  but  this  cessation  is  only  temporary. 
The  pain  recurs  and  subsides  at  uncertain  periods,  until  the  vision  of  the 
injured  eye  is  entirely  destroyed.  The  eyeball  is  left  in  a  state  of  chronic 
inflammation,  and  the  health  of  the  patient  is  much  affected  by  the  long-con- 
tinued irritation  occasioned  by  the  injury,  the  depletory  and  reducing  treat- 
ment used,  and  the  anxiety  he  is  under  for  his  sight ;  for  at  this  stage  the 
vision  of  the  other  eye  becomes  affected  by  the  inflammation  extending  to  it 
by  sympathy. 

Mr.  Barton,  of  Manchester,  thinks  that  the  sympathetic  inflammation,  in 
those  cases,  is  occasioned  by  the  presence  of  a  fragment  of  cap  in  the  injured 
eye,  and  that  the  only  means  of  preventing  such  inflammation,  or  of  allaying 
it  when  it  has  arisen,  is  the  removal  of  the  fragment.  He  has  treated  many 
cases  on  this  principle,  which  appears  to  be  perfectly  just. 

The  patient  being  placed  in  a  convenient  position,  and  brought  into  a  state 
of  insensibility  by  the  inhalation  of  chloroform,  the  operator  forms,  by  means 
of  Beer's  knife,  a  large  flap  of  the  cornea.  The  knife  may  now  be  directed 
through  the  pupil  and  lens,  so  as  to  give  an  opportunity  for  the  lens  to  come 


416  DISLOCATION   OP   THE    EYEBALL. 

away,  along  with  part  of  the  vitreous  humor,  and  perhaps  the  fragment  of 
cap.  If  there  is  no  appearance  of  the  foreign  body  in  what  is  discharged 
from  the  eye,  the  flap  of  the  cornea  is  to  be  seized  with  a  pair  of  forceps,  and 
cut  away  with  curved  scissors.  A  dose  of  laudanum  is  then  given,  and  a 
linseed-meal  poultice  applied  over  the  eyelids.  If  chloroform  is  not  used,  the 
operation,  being  very  painful,  must  be  performed  as  rapidly  as  possible.  The 
eye  is  so  exceedingly  sensitive,  that  attempts  to  search  for  the  fragment  of 
the  cap  cannot  be  endured.  In  all  Mr.  Barton's  cases,  the  cap  was  found  in 
the  poultice,  or  in  the  coagulum  which  closed  the  opening  into  the  eye,  one 
or  more  days  after  the  operation. 

The  fragments  of  caps  taken  from  the  eye,  after  being  within  it  for  months, 
were  only  tarnished ;  they  bore  no  appearance  of  undergoing  changes  similar 
to  those  which  take  place  in  pieces  of  steel  during  their  exposure  to  the 
humors  of  the  eye ;  they  were  always  of  considerable  size,  and  their  angles 
sharp. ^ 

The  same  practice  may  be  extended,  with  good  effects,  to  other  cases  of 
foreign  substances  lodged  within  the  eye. 

4.  The  eyeball  most  frequently  bursts  in  cases  where  it  is  struck  by  musket- 
shot  ;  but  occasionally  it  escapes  with  apparently  little  injury,  the  ball  pene- 
trating between  the  eye  and  the  orbit.  Exophthalmia,  or  inflammatory  dis- 
organization of  the  eye  with  protrusion,  is  very  apt  to  follow  in  either  of 
these  cases.  When  this  symptom  does  occur,  either  the  humors  should  be 
evacuated  by  a  free  and  deep  incision,  so  as  to  allow  the  eyeball  to  shrink  and 
become  quiet;  or  if  it  has  become  solid  from  thickening  of  its  coats,  it  ought 
to  be  extirpated.  If  such  practice  is  not  followed,  the  patient  is  generally 
doomed  to  suffer  extreme  pain  for  a  length  of  time;  and  the  enlarged  eyeball 
is  even  apt,  by  pressure,  to  produce  absorption  of  the  roof  of  the  orbit,  and 
fatal  inflammation  of  the  dura  mater  and  brain. 

5.  What  is  styled  the  loitid  of  a  ball  has  been  known  to  produce  amaurosis. 


'  Lectures  in  the  Lancet;  Vol.  ix.  p.  531;  the  whole  of  an  exploded  cap  was  extracted 

London,  1S2G.  from  the  anterior  chamber,  Annales  d'Oculis- 

■'  Traite  des  Maladies  des  Yeux;  Planche  52,  tique,  Tome  i.  p.  433;  Charleroi,  1839. 
fig.  1 :  Paris,  1818.  *  On  Injuries  of  the  Eye  by  Percussion  Caps, 

^  Ibid. ;  Tome  ii.  p.  503.  see    Crompton,  Medical  Gazette ;  Vol.  xxi.  p. 

*  Annales    d'Oculistique,    Tome    iii.  p.    73;  175;  London,  1837.     Case  of  a  fragment  fixed 

Bruxclles,  1840.  in  the  lens,  by  Stievenart,  Annales  d'Oculis- 

'  Medical  Gazette;  Vol.  xiii.  p.  888;  London,  tique,  Tome  i.  p.  439  ;  Charleroi,  1839.     Fixed 

1834.  in  the  Iris  and  extracted,  by  Cunier;  Ibid.  p. 

"  Edinburgh  Medical  and  Surgical  Journal;  440.     Extracted    from    the    vitreous    body,    in 

Vol.  xliv.  p.  106  ;  Edinburgh,  1S35.  Barton's     method,   AValker's    Oculists'    Vade- 

'  See  case  by  Laurent  and  Cunier,  in  which  mecum,  p.  323;  London,  1843. 


SECTION  IX. — DISLOCATION  OF  THE  EYEBALL. 

I  have  already  liad  occasion  (page  60)  to  quote  two  cases  of  disloca- 
tion of  the  eyeball,  by  foreign  substances  thrust  between  the  eye  and  the  orbit; 
and  I  have  explained,  that  by  being  dislocated,  is  to  be  understood  that  the 
eyeball  is  extruded  beyond  the  fibrous  layer  of  the  eyelids.  The  optic  nerve, 
with  the  eye  in  that  state,  is  put  on  the  stretch,  the  lids  can  no  longer  be  brought 
together,  and  vision  is  in  general  lost  till  reduction  is  accomplished.  Such 
an  accident  is  most  likely  to  happen  to  those  who  have  the  eyeballs  lai'ge  and 
the  orbits  shallow ;  for,  in  such  persons,  it  is  possible,  by  pressing  the  lids 
above  and  below,  to  get  a  view,  not  merely  of  one-half  of  the  eye,  but  par- 
tially even  to  the  back  of  it. 

If  the  foreign  body  by  which  the  dislocation  has  been  produced  be  still  in 


EVULSION   OP   THE  EYEBALL.  41t 

the  orbit,  it  must,  of  course,  be  removed  before  reduction  be  attempted. 
After  this  is  effected,  the  eye  is  to  be  pressed  steadily  back  into  its  place. 
The  pressure  being  continued  for  some  time,  the  eyeball  will  generally  be 
found  to  start  suddenly  back  into  the  orbit,  and  vision  to  be  immediately 
restored. 

From  the  obliquity  of  the  base  of  the  orbit,  it  is  evident  that  towards  the 
temple,  the  eyeball  stands  in  a  considerable  degree  exterior  to  that  cavity ; 
and  hence  it  is  that  a  severe  blow  on  the  eye,  for  instance  with  a  racket 
ball,  is  capable  of  producing  dislocation.  Covillard,  in  his  Observations  latro- 
cMrurgiques,  relates  a  case  of  this  sort.  He  tells  us  that  the  dislocation  was  so 
complete,  that  when  he  arrived,  immediately  after  the  accident,  he  found  one 
of  the  patient's  friends  with  scissors  in  his  hand,  ready  to  cut  the  eye  away. 
Covillard  reduced  it,  and  the  patient's  vision  was  preserved.^ 

Case  263. — A  cora-porter,  returning  home  intoxicated,  and  staggering  about  his  room, 
struck  his  right  eye  against  a  small  iron  hook  or  nail  in  a  dresser,  which,  entering  at  the 
outer  angle  of  the  upper  lid,  drove  the  eye  from  its  socket.  Brought  by  his  wife  to 
ISIercer's  Hospital,  Dublin,  at  half-past  12  o'clock  at  night,  he  was  very  unruly,  and 
holding  a  large  check  apron  close  up  to  his  eye,  he  kept  constantly  rubbing  and  pressing 
it.  Dr.  Jameson  found  the  eyeball  out  of  the  orbit,  firmly  fixed  and  immovable,  elastic 
to  the  touch,  and  devoid  of  all  power  of  vision.  The  cornea  was  dry,  and  rather  opaque, 
the  pupil  moderately  contracted,  and  uninfluenced  by  the  light  of  a  candle.  The  reflec- 
tion of  the  conjunctiva  from  the  lid  to  the  globe  was  partially  torn  through.  The  margin 
of  the  upper  lid  was  not  visible,  being  behind  the  globe,  and  spasmodically  contracted. 

Restraining  the  patient  with  diSiculty,  Dr.  Jameson,  with  two  fingers  of  his  left  hand, 
elevated  the  upper  lid,  pressing  at  the  same  time  with  the  fingers  and  thumb  of  his  right 
on  the  ball  of  the  eye,  which  was  immediately  drawn  back  with  a  snap,  the  lids  closing 
over  it. 

In  a  few  days,  after  cold  applications,  venesection,  and  a  purge,  the  patient  was  dis- 
missed cured,  vision  being  complete.^ 

Weld  mentions,^  that  at  Richmond  in  Virginia,  it  was  nothing  uncommon 
to  meet  with  persons  deprived  of  one  or  both  eyes  from  the  horrid  practice 
of  gouging,  in  which  the  combatant,  having  twisted  his  forefingers  in  the  side- 
locks  of  his  adversary's  hair,  applied  his  thumbs  so  as  to  force  the  eye  out  of 
the  socket. 


'  Louis  snr  plusieures  Maladies  du  Globe  do  '  Travels  through  the  States  of  North  Amer- 

rCEil,  Memoires  de  I'Acadeniie  Royals  de  Chi-  ica,  by  Isaac  Weld,  jun.;  Vol.  i.  p.  192;  London, 

rurgie;  Tome  siii.  p.  266  ;  12mo  :  Paris,  1774.  1800. 

^  Dublin  Med.  Press,  Jan.  5,  1853 ;  p.  1. 


SECTION  X. — EVULSION  OF  THE  EYEBALL. 

The  eyeball  is  often  blown  out  by  musket-sliot ;  but  cases  of  its  being  torn 
out  of  the  socket  by  other  means  are  rare.  A  remarkable  instance  is  related 
in  the  first  volume  of  Grlife  and  Walther's  Journal.  A  cart-wheel  went  over 
the  side  of  the  head,  and  tore  out  the  eyeball,  along  with  seven  lines'  length 
"of  the  optic  nerve,  the  muscles  of  the  eye  being  left  behind,  and  the  orbit 
uninjured.  The  patient,  a  man  of  75  years  of  age,  recovered  without  any 
bad  symptom. 

Case  264.— A  fisherman  of  Ostend,  aged  49,  coming  home  one  evening  very  drunk, 
stumbled  in  the  act  of  undressing  himself,  and  fell  with  all  his  weight  against  the  room- 
door.  In  the  fall,  the  right  orbitary  region  struck  against  the  ring  of  the  key  which  was 
in  the  lock  of  the  door,  and  as  the  key  was  worn  thin  by  long  use,  it  divided  vertically 
the  upper  lid,  entered  the  orbit,  and  acting  as  a  kind  of  lever  or  curette,  extirpated  the 
eye,  completely  severing  its  connections  with  the  orbit,  so  that  it  rolled  upon  the  floor. 
The  patient  was  so  drunk  that  he  could  form  no  notion  of  the  severity  of  the  injui-y  he 
had  sustained;  but,  continuing  to  undress  himself,  went  to  bed,  and  fell  asleep.  His 
27 


418  THE   OPHTHALMIiE  IN   GENERAL. 

■wife,  on  rising  in  the  morning,  was  astonished  at  the  quantity  of  blood  which  her  husband 
had  lost  from  a  wound  of  the  lid,  apparently  slight ;  but  her  astonishment  changed  to 
fear,  when  she  found  on  the  floor  an  eye. 

Dr.  Verhaeghe,  who  was  immediately  sent  for,  found  the  man  in  bed,  his  clothes  satu- 
rated with  blood,  the  upper  lid  divided  to  the  extent  of  six  lines,  the  orbit  filled  with 
coac^ula,  and  portions  of  some  of  the  muscles  of  the  eye  hanging  out  between  the  lids. 
The  bleeding  had  entirely  ceased. 

The  eye  was  entire;  its  muscles  had  been  torn  across  at  different  distances  from  their 
insertions  into  the  sclerotica ;  the  superior  oblique  and  rectus  superior  were  so  at  three 
quarters  of  an  inch.  The  optic  nerve  was  divided  at  about  an  inch  from  the  sclerotica. 
The  key  was  bent  into  an  obtuse  angle,  from  the  fall  against  it  of  so  heavy  a  weight. 

The  patient  being  taken  to  the  hospital,  the  remains  of  the  muscles  were  replaced  in 
the  orbit,  and  the  wound  of  the  lid  united  by  a  stitch.  Cold  water  dressing  was  applied 
and  low  diet  enjoined,  under  which  the  patient  speedily  recovered.' 


'  Annales  d'Oculistique;  Tome  xxvl.  p.  99;  Bruxelles,  1851. 


CHAPTER    XIII. 


THE  OPHTHALMIJE,  OR  INFLAMMATORY  DISEASES  OF 
THE  EYEBALL  AND  CONJUNCTIVA. 

SECTION  I. — THE  OPHTHALMIA  IN  GENERAL. 

Under  the  term  inflammation  is  included,  first  of  all,  that  state  of  parts 
characterized  by  increased  redness,  unnatural  heat,  sicelling,  and  pain.  This 
state,  indeed,  is  generally  regarded  as  strictly  inflammation,  denoted  by  its 
four  primary  phenomena.  The  morbid  changes,  which  I  shall  presently 
enumerate,  are  considered  as  so  many  secondary  phenomena,  apt  to  succeed, 
but  which  do  not  necessai'ily  succeed  to  this,  the  first  stage  of  every  inflam- 
matory disease.  So  long  as  the  part  affected  exhibits  nothing  else  than  in- 
creased redness,  unnatural  heat,  swelling,  and  pain,  and  so  long  as  these 
continue  to  augment,  the  disease  is  merely  developing  itself.  An  inflamma- 
tory attack  having  perhaps  reached  the  greatest  degree  of  violence  of  which 
this  first  stage  is  susceptible,  may,  without  any  new  local  phenomena  being 
manifested,  gradually  subside  through  the  means  employed  for  its  cure,  or  by 
the  natural  resolution  of  the  disease. 

On  the  other  hand,  the  disease  may  go  on,  and  manifest,  with  greater  or 
less  rapidity,  one  or  more  of  the  following  seven  secondary  phenomena  of 
inflammation,  namely,  effusion  or  exudation;  adhesion;  supjniration ;  idcer- 
ation  ;  mortification  ;  gramdation ;  and  cicatrization.  Effusion  or  exudation 
may  consist  either  of  serum,  of  liquor  sanguinis,  yielding  coagulable  lymph 
or  fibrin,  or  of  red  blood.  Suppuration  may  either  take  place  upon  a  secret- 
ing surface,  or  form  an  abscess  within  the  texture  of  the  part  affected.  The 
part  inflamed  may  pass  through  several  of  these  states  in  succession,  or 
several  of  them  may  exist  together  at  the  same  time. 

There  is  also  a  tertiary  set  of  inflammatory  phenomena,  depending  on  the 
secondary ;  such  as  opacity,  insensibility,  change  of  form,  hypertrophy,  atrophy, 
induration,  softening,  &c.* 

Inflammation,  in  whatever  part  of  the  body,  and  consequently  in  whatever 
part  of  the  eye  it  originates,  may  terminate  in  any  of  the  processes  now 
enumerated.  Even  those  parts  which  in  their  normal  state  are  destitute  of 
vessels,  as  the  cornea,  the  crystalline,  or  the  vitreous  body,  suffer  from  inflam- 


THE   OPHTHALMIiE   IN   GENERAL.  419 

mation,  and  exhibit  similar  changes  to  those  which  occur  in  structures  directly- 
supplied  with  blood. 

The  secondary  and  tertiary  phenomena  of  inflammation  are  always  modified 
by  the  structure  of  the  part  affected.  Every  different  texture  of  the  eye  pos- 
sessing.both  physical  and  vital  properties  peculiar  to  itself,  suffers  differently 
from  the  several  processes  of  inflammation.  In  general,  the  modifications  of 
inflammation  from  difterences  of  texture  in  the  parts  affected,  are  displayed 
with  much  distinctness  in  this  organ ;  in  some  cases,  however,  these  modifi- 
cations can  be  judged  of  only  from  their  consequences,  and  by  minute  obser- 
vation of  the  derangement  which  remains  in  the  organization,  or  in  the 
function,  of  the  part  which  had  suffered ;  while  in  other  cases,  from  the 
delicate  texture  of  the  part,  or  its  hidden  situation  in  the  eye,  the  modifica- 
tions in  question  may  escape  detection. 

The  conjunctiva,  sclerotica,  cornea,  iris,  and  retina,  present  a  series  of  the 
modifications  of  inflammation,  to  which  I  have  just  now  referred,  sufficiently 
distinct  to  convince  the  most  sceptical  of  the  truth  of  what  I  have  been  as- 
serting, and  sufficiently  striking  to  rouse  the  most  inattentive  to  research. 
The  muco-cutaneous  conjunctiva  secreting  a  flood  of  purulent  matter,  as  in 
the  contagious  ophthalmias — the  fibrous  sclerotica  affected  for  months  with 
rheumatic  inflammation — the  cornea  losing  entirely  its  transparency,  becom- 
ing infiltrated  with  pus,  or  destroyed  layer  after  layer  by  a  penetrating  ulcer 
— the  iris  pouring  out  coagulable  lymph,  and  this  lymph  forming  the  medium 
of  morbid  adhesions,  so  that  the  pupil  is  deprived  of  its  natural  power  of 
expanding  and  contracting — the  retina,  without  any  manifestation  of  pain, 
losing  in  a  few  hours  all  sensibility  to  its  natural  stimulus ;  these  are  facts  in 
which  are  displayed  some  of  the  modifications  of  inflammatory  action  more 
distinctly  and  strikingly  than  they  are  manifested  in  any  other  part  of  the 
body. 

Each  organ  of  the  body,  when  inflamed,  besides  more  or  less  of  the  general 
signs  of  inflammation,  manifests  certain  symptoms  which  are  peculiar  to  itself. 
Thus,  intolerance  of  light  and  lachrymation  are  special  symptoms  afforded 
by  the  eye,  and  bear  a  similar  relation  to  the  functions  of  this  organ,  as  diffi- 
culty of  breathing  does  to  the  lungs,  or  delirium  to  the  brain.  Even  such 
special  symptoms,  however,  are  modified,  according  to  the  particular  texture 
of  the  eye  which  is  inflamed. 

There  are  other  circumstances  besides  differences  of  texture  which  modify 
the  inflammatory  affections  of  the  eye,  rendering  also  this  subject  very  extensive 
in  the  discussion,  and  causing  the  diseases  to  be  occasionally  very  perplexing 
in  the  treatment.  They  are  under  the  influence  of  peculiarities  of  constitution, 
and  of  constitutional  diseases,  and  are  subject  to  innumerable  variations  from 
the  influence  of  sympathies.  Scrofula,  syphilis,  and  gout  are  each  of  them 
capable  either  of  exciting  inflammation  in  different  parts  of  the  eye,  or  of  com- 
municating to  an  inflammation,  excited  by  other  causes,  such  differences  in 
character,  as  often  to  render  it  difficult  to  recognize  a  disease,  with  which  we 
are  M'ell  acquainted  in  its  simple  or  idiopathic  form. 

The  general  rule,  established  by  pathological  observations  of  every  part  of 
the  body,  that  inflammation  in  a  great  measure  limits  itself  not  merely  to  one 
organ,  but  even  to  one  tissue,  certainly  holds  with  regard  to  the  eye.  As  we 
have  bronchitis,  pneumonia,  and  pleuritis,  designating  inflammation  of  the  va- 
rious tissues  of  the  lungs,  and  as  we  meet  with  inflammation  of  the  peritoneum, 
of  the  proper  substance  of  the  bowels,  and  of  their  lining  membrane  ;  so  we  find 
the  different  tissues  of  the  eye  separately  affected,  obliging  us  to  recognize 
conjunctivitis,  sclerotitis,  iritis  and  the  like,  as  individual  diseases. 

By  the  influence  of  local  sympathy,  however,  inflammation  of  one  texture 
of  the  eye  never  takes  place  without  extending,  in  some  degree,  to  the  tex- 


420  THE  OPHTHALMIA  IN  GENERAL. 

tures  witli  which  the  first  affected  is  in  contact.  By  the  same  influence,  in- 
flammation originating  in  one  texture  of  the  eye  is  communicated  to  several 
of  the  other  textures,  the  disease  of  the  superficial  tunics  being  communicated 
to  those  more  deeply  seated,  and  conversely  that  of  the  internal  parts  spread- 
ing outwards ;  and,  while  each  texture  obeys  its  own  laws  of  morbid  action, 
the  whole  organ  in  this  way  may  become  involved  by  what  had  at  first  a  very 
limited  existence,  and  perhaps  a  very  trivial  aspect. 

We  speak  of  conjunctiviti's,  sclerotitis,  corneitis,  iritis,  retinitis,  and  the  like; 
but  it  must  be  understood  that  the  inflammation  in  none  of  those  affections  is 
confined  to  the  particular  texture  indicated  by  the  name.  The  disease  com- 
mences, indeed,  and  has  its  chief  seat  in  the  particular  texture  indicated  ; 
but  the  neighboring  parts  are  always  more  or  less  involved.  Thus,  in  iritis, 
the  membrane  of  the  aqueous  humor,  the  crystalline  capsule,  the  sclerotica, 
the  conjunctiva,  the  choroid,  and  even  the  retina,  are  alFected  ;  so  that  iritis  is 
an  abbreviated  mode  of  expressing  an  inflammation  which  in  general  involves 
almost  the  whole  textures  of  the  eye.  The  iris,  however,  is  the  focus  of  the 
morbid  action ;  and  the  part,  which  from  its  situation,  its  functions,  and  the 
morbid  changes  which  it  undergoes,  exhibits  the  most  striking  signs  of  the 
disease,  the  chief  indications  for  treatment,  and  the  most  remarkable  effects 
of  the  remedies  employed. 

We  are  not  to  suppose,  even  in  those  ophthalmise,  the  focus  of  which  is  one 
or  other  of  the  exterior  textures  of  the  eye,  and  which  we  designate  therefore 
by  such  names  as  conjunctivitis,  corneitis,  or  sclerotitis,  that  the  internal  tex- 
tures do  not  suffer.  Dr.  Rognetta  relates,"  that  an  old  man,  who  had  some 
short  time  before  been  attacked  with  an  apparently  slight  conjunctivitis  of 
one  eye,  accompanied  by  photophobia,  having  died  in  one  of  the  Parisian 
hospitals,  of  inflammation  in  the  chest,  he  dissected  the  eye,  and  found,  to  his 
astonishment,  all  the  internal  tissues  inflamed ;  even  the  hyaloid  and  the  re- 
tina were  red.  The  same  author  has  remarked,^  that  many  chronic  cases  of 
ophthalmia,  seemingly  of  no  great  severity,  but  refi-actory  to  ordinary  treat- 
ment, depend  on  a  habitually  congestive  state  of  the  whole  vascular  tree  of 
the  orbit.  Even  conjunctivitis  is  far  from  being  a  simple  tegumentary  or 
extei'nal  affection. 

When  we  reflect,  then,  on  the  innumerable  combinations  which  may  take 
place  among  the  inflammatory  diseases  of  the  eye,  and  the  many  causes  by 
which  these  diseases  may  be  modified,  we  shall  be  convinced,  I  think,  that  of 
all  the  subjects  requiring  descriptions  and  explanations  of  morbid  actions 
and  changes,  there  can  be  few  more  difficult  than  those  diseases  which  have 
been  swept  together  with  so  indiscriminating  a  hand  under  the  name  of  oph- 
thalmia. To  consider  these  actions  and  changes  individually,  and  only  in  a 
single  texture  of  the  eye  at  once,  may  seem  to  lessen  the  difficulty ;  for  in- 
stance, to  consider  inflammation  of  the  cornea,  and  to  exhibit  to  ourselves  in 
order,  effusion  of  serum,  effusion  of  coagulable  lymph,  secretion  of  pus,  for- 
mation of  abscess,  ulceration,  mortification,  and  cicatrization,  according  as 
each  of  these  processes  manifests  itself  in  the  cornea.  But  to  do  all  this  is 
to  consider  and  to  exhibit  what  never  takes  place  separately  in  nature.  Un- 
less this  be  kept  in  mind  by  those  who  begin  to  study  the  inflammatory  dis- 
eases of  the  eye,  they  will  be  not  a  little  perplexed  by  the  diversified  compli- 
cations of  morbid  phenomena,  which  they  will  meet  at  every  step  of  their 
progress. 

A  knowledge  of  the  inflammatory  diseases  of  the  eye  has  been  greatly  re- 
tarded by  the  practice  of  confounding  them  all  under  the  general  name  oph- 
thalmia, and  thus  overlooking  both  the  seat  of  the  disease,  and  the  peculiar 
nature  of  the  inflammation.     The  consequence  of  thus  viewing  all  these  dis- 


THE   OPHTHALMIiE  IN   GENERAL.  421 

eases  without  discrimination,  has  been  a  method  of  treating  them  equally 
preposterous.  In  fact,  in  the  practice  of  those  who  have  had  no  opportuni- 
ties of  properly  studying  the  diseases  of  the  eye,  the  same  routine  of  remedies 
is  used  in  every  case  in  which  the  eye  appears  inflamed ;  and  it  often  happens, 
that  it  is  not  till  this  routine  is  exhausted,  and  the  eye  in  some  of  its  essential 
parts  becoming  seriously  disorganized,  that  a  suspicion  arises  of  there  being 
something  peculiar  or  specific  in  the  case.  Even  from  the  slight  view  which 
we  have  already  taken  of  the  subject,  it  is  evidently  impossible  that  the  in- 
flammatory affections  of  parts  so  widely  differing  in  structure  and  function  as 
those  combined  in  the  eye,  can  be  treated  at  once  indiscriminately  and  suc- 
cessfully. We  find,  for  example,  that  the  remedies  which  in  the  course  of  a 
few  days  are  often  sufficient  completely  to  remove  inflammation  of  the  con- 
junctiva, only  aggravate  inflammation  of  the  sclerotica  or  iris  ;  while  the 
plan  of  treatment  which  speedily  cures  sclerotitis  or  iritis,  if  trusted  to  in  con- 
junctivitis, would  expose  the  eye  to  almost  certain  destruction.  Great  ad- 
vantages will  accrue,  then,  from  the  adoption  of  an  accurate  classification  of 
the  ophthalraise.  One  advantage  of  no  inconsiderable  moment  will  be,  that 
we  shall  conduct  our  examinations  of  the  inflammatory  diseases  of  the  eye 
which  may  come  under  our  care,  with  much  more  accuracy  than  we  could 
possibly  do,  were  we  to  employ  the  vague  nomenclature  in  common  use. 
Having  noted  exactly  the  disease  which  is  before  us,  we  shall  be  able  both  to 
ascertain  to  our  own  satisfaction,  the  effects  of  the  remedies  which  we  employ, 
and  to  communicate  our  experience  to  others,  which,  without  a  just  classifica- 
tion and  perspicuous  nomenclature,  it  is  utterly  impossible  to  do. 

Into  the  following  table  the  name  of  no  disease  is  admitted,  the  distinct 
and  separate  existence  of  which  I  have  not  either  ascertained  in  the  course 
of  my  own  observations,  or  been  convinced  of  upon  good  authority.  It  is 
not  offered  as  a  complete,  nor  as  a  strictly  scientific  classification  of  the  in- 
flammations of  the  eye,  but  as  a  mere  enumeration  bearing  chiefly  upon  prac- 
tical views.  It  would  be  an  easy  task  to  increase  the  catalogue  of  the  oph- 
thalraiiE,  especially  of  their  sub-species  and  varieties.  The  reader  who 
chooses  to  see  how  far  this  sort  of  thing  may  be  carried,  I  would  refer  to  a 
paper  on  Corneitis,  by  Dr.  Schindler,  in  the  third  volume  of  Ammon's  Mo- 
natsschrift.  Each  texture  of  the  eye  might  easily  be  exhibited  in  the  same 
way,  under  an  endless  variety  of  nosological  distinctions,  a  plan  quite  incon- 
sistent with  the  nature  of  a  work,  the  object  of  which  is  to  describe  those 
aggregated  phenomena  which  are  most  commonly  met  with  in  practice. 

I.  CONJUNCTIVITIS. 

I.    CONJUNCTIVITIS  SIMPLEX, 
n,    CONJUNCTIVITIS  PURO-MUCOSA, 

1,  Conjunctivitis  catarrhalis. 

a.   Sporadic,     b.  Epidemic,     c.  Miasmatic. 
2    Conjunctivitis  purulenta  vel  contagiosa.     (Egyptian  ophthal- 
mia.) 

3.  Conjunctivitis  purulenta  neonatorum. 

a.  Catarrhal,     b.  Leucorrhceal.     c.  Gonorrhceal.     d.  Traumatic. 

4.  Conjunctivitis  purulenta  gonorrhoica. 

ni.    CONJUNCTIVITIS  ERUPTIVA. 

1.  Conjunctivitis  aphthosa  ve?  pustulosa. 

2.  Conjunctivitis  phlyctenulosa.     (Scrofulous  ophthalmia.) 

3.  Conjunctivitis  erysipelatosa. 

4.  Conjunctivitis  morbillosa. 

5.  Conjunctivitis  scarlatinosa. 


422 


THE  OPHTHALMIA  IN  GENERAL. 


The  conjunctiva  suffers  in  various  other  cutaneous  diseases ;  as,  in  syphl 
litic  lepra,  purpura,  pompholyx,  variola,  herpes,  elephantiasis,  &c. 
II.  SCLEROTITIS. 

(Rheumatic  ophthalmia.) 


(Variolous  ophthalmia.) 


I.    SCLEROTITIS  IDIOPATHICA. 
II.    SCLEROTITIS  SCROFULOSA. 

III.  CORNEITIS. 

1.  Corneitis  idiopathica. 

2.  Corneitis  scrofulosa. 

3.  Corneitis  postvariolosa. 

4.  Corneitis  arthritica. 
IT.  IRITIS. 

1.  Iritis  idiopathica  ve?  rheuraatica. 

2.  Iritis  syphilitica.     (Syphilitic  ophthalmia.) 

3.  Iritis  syphiloidea. 

4.  Iritis  gonorrhoica. 

5.  Iritis  scrofulosa. 

6.  Iritis  arthritica.     (Arthritic  ophthalmia.)    ' 
Y.  AQIJO-CAPSULITIS. 

YI.  CHOROIDITIS. 
RETINITIS. 

1.  Retinitis  idiopathica. 

2.  Retinitis  lactautium. 
CHRYSTALLINO-CAPSULITIS  et  CRYSTALLINITIS. 
HYALOIDITIS. 
OPHTHALMITIS. 

1.  Ophthalmitis  idiopathica. 

2.  Ophthalmitis  phlebitica. 

3.  Ophthalmitis  postfebrilis. 

4.  Ophthalmitis  reflexa  vel  sympathetica. 

APPENDIX. 

1.  Compound   ophthalmiae,   as,   the    scrofulo-catarrhal,   catarrho- 
rheumatic,  &c. 

2.  Traumatic  ophthalmia. 
Under  this  head,  might  be  enumerated  conjunctivitis  trauma- 
tica, corneitis  traumatica,  iritis  traumatica,  and  so  on. 

3.  Artificial  ophthalmiie. 

4.  Intermittent  ophthalmise. 


YII. 


YIIL 

IX. 

X. 


(Ocular  phlegmon.) 


*  Pathologists  have  recently  directed  much 
of  their  attention  to  the  nature  of  the  process 
by  which  the  phenomena  noticed  in  the  text 
are  produced,  or,  in  other  words,  to  the  theory 
of  inflammation. 

Microscopical  observations  show  that  the 
redness  of  inflammation  is  owing  to  an  accu- 
mulation and  stagnation  of  the  rod  corpuscles 
of  the  blood,  in  the  extreme  arteries,  capilla- 
ries, and  radicles  of  the  veins  of  the  affected 
part.  The  red  corpuscles,  thus  stagnant  within 
the  minute  bloodvessels,  appear  as  if  fused 
into  a  uniform  mass. 

The  immediate  cause  of  the  accumulation 
and  stagnation  of  the  red  corpuscles  has  been 
supposed  to  be  a  retardation  of  the  flow  of 
blood,  arising  from  dilatation  of  the  small  ar- 
teries; but  it  has  been  shown  by  the  observa- 
tions of  Mr.  Paget  and  Mr.  Wharton  Jones, 
that  so  far  from  retardation  being  the  result  of 
dilatation  of  the  small  arteries,  acceleration  of 


the  flow  of  blood  invariably  takes  place.  From 
his  observations  on  the  bat  and  frog,  Mr. 
Wharton  Jones  has  shown  that  the  first  estab- 
lishment of  accumulation  of  red  corpuscles  in 
the  capillaries  is  owing  to  constriction  of  the 
small  arteries  leading  to  the  part,  whereby  the 
red  corpuscles  are  no  longer  subjected  to  the 
vis  d  tergo.  The  accumulating  corpuscles  at 
the  same  time,  by  virtue  of  their  attractions, 
become  aggregated  together,  and  adherent  to 
the  walls  of  the  vessels. 

The  constriction  of  the  small  arteries  is 
owing  to  the  irritation  of  the  exciting  cause  on 
the  nerves  of  the  arteries.  But  subsequently, 
relaxation  of  the  walls  of  the  arteries,  with 
dilatation,  may  take  place  from  suspension  of 
nervous  influence.  The  effect  of  this  may  be 
re-establishment  of  the  circulation,  and  resolu- 
tion of  the  inflammation.  If  the  stagnation, 
however,  is  already  to  any  great  extent,  reso- 
lution will  not  so  readily  take  place,  but,  on 


REMEDIES   FOR  THE   OPHTHALMIA. 


423 


the  contrary,  the  inflammation  may  be  aggra- 
vated. The  increased  pulsation  which  occurs 
at  this  time  is  owing  to  the  diminished  con- 
tractile power  of  the  arteries,  permitting  their 
walls  to  yield  easily  to  the  impulse  of  the 
heart. 

Exudation  or  effusion  follows  on  stagnation; 
the  effused  matter  being  first  serous,  and  after- 
wards consisting  of  liquor  sanguinis,  and  there- 
fore lymphatic  or  fibrinous.  When  extravasa- 
tion of  red  corpuscles  takes  place,  this  is  owing 
to  giving  way  of  the  walls  of  some  vessels. 

The  general  mass  of  blood,  when  the  inflam- 
mation of  any  part  is  severe,  shows  an  increase 
in  the  quantity  of  fibrine,  and  a  decrease  of 
red  corpuscles;  and  the  result  of  this  is  the 
appearance  called  the  huffy  coat,  in  blood 
drawn  from  a  vein. 

When  resolution  takes  place,  there  is  dilata- 
tion of  the  small  arteries,  and  a  loosening  and 
breaking  up  of  the  agglomerated  red  corpus- 
cles, whereby  they  yield  anew  to  the  via  H  tei-go, 
and  are  carried  along  in  the  circulation.  By 
and  by,  the  vessels  recover  their  usual  calibre, 
and  the  nervous  influence  returns. 

Adhesion  is  the  result  of  a  change  in  the 
effused  lymph  or  liquor  sanguinis,  by  which  it 
becomes  coagulated,  while  there  are  formed  in 
it,  as  in  a  blastema,  the  elements  of  areolar 
tissue  and  bloodvessels. 

A  different  kind  of  organic  element,  namely, 
the  pus-globule,  capable  of  no  further  develop- 


ment, being  formed  in  the  effused  matter,  the 
result  is  suppuration.  Suspended  in  a  fluid, 
called  the  liquor  puris,  pus-globules  may  un- 
dergo absorption,  but  are  more  frequently  dis- 
charged on  the  mucous  surfaces  of  the  body, 
or,  collecting  so  as  to  form  an  abscess,  escape 
by  a  perforation  of  the  integuments. 

Mortification  is  the  death  of  the  inflamed, 
part,  of  the  blood  stagnant  in  it,  and  of  the 
effused  matter.  Ulceration  is  a  variety  of 
mortification,  in  which  the  dead  tissues  are 
thrown  off  in  minute  molecules,  instead  of  se- 
parating in  the  form  of  a  large  slough. 

The  reparation  of  parts  which  have  suffered 
from  mortification  or  ulceration  is  stj'led  gra- 
nulation, and  is  accomplished  by  the  develop- 
ment of  areolar  tissue  and  vessels  in  the  effused 
fibrine,  by  which  the  parts  are  invested,  and 
which  is  more  or  less  covered  by  pus.  The 
round  bodies  called  granulations,  on  the  sur- 
face of  a  healing  sore,  examined  with  the  mi- 
croscope, are  found  to  consist  of  cells  of  various 
shapes,  and  in  different  stages  of  development 
into  the  above-named  tissues. 

The  healing  process  is  completed  by  cicatri- 
zation, or  the  investment  of  the  part  with  a 
new  epidermis  or  epithelium. 

^  Cours  public  d'Ophthalmologie,  Lancette 
Franjaise,  9  Fevrier  1837. 

^  Annales  d'Oculistique,  1"  vol.,  Suppl.  p, 
47;  Bruxelles,  1842. 


SECTION  n. — REMEDIES  FOR  THE  OPHTHALMLai. 

Before  proceeding  to  describe  the  different  inflammations  of  the  eye,  and 
explain  the  treatment  particularly  required  for  each,  it  may  not  be  improper 
to  offer  a  few  rules  of  universal  application  in  the  treatment  of  these  diseases, 
and  to  make  some  general  remarks  on  the  classes  of  remedies  employed  for 
their  cure. 

General  Rules. — 1.  It  is  a  general  rule  of  great  importance  in  the  treatment 
of  any  ophthalmia,  to  discover  the  cause  whence  it  has  arisen,  and,  if  possible, 
to  remove  that  cause,  if  it  is  still  in  operation.  The  cause  may  be  local,  or 
it  may  be  constitutional ;  but  in  any  case,  if  it  be  allowed  still  to  operate,  it 
is  evident  that  everything  in  the  way  of  remedy  must  prove  comparatively  or 
entirely  ineffectual. 

2.  In  treating  the  various  forms,  varieties  and  degrees  of  the  ophthalmise, 
it  is  an  essential  object  to  have  a  clear  conception  of  the  accompanying  con- 
stitution ;  for  without  rectifying  the  state  of  the  constitution,  we  shall  often 
fail  in  curing  the  attending  local  complaint.  The  previous  diseases,  also,  of 
the  patient  should  be  ascertained. 

3.  The  eye,  and  the  body  at  large,  must  be  defended  from  new  sources  of 
irritation.  The  original  cause  may  be  removed,  but  the  disease  may  still  con- 
tinue, being  kept  up  by  other  causes,  of  a  nature  very  different  from  the  origi- 
nal one,  but  equally  detrimental.  The  primary  cause  is  often  local,  and  the 
secondary  causes  constitutional.  After  the. first  is  removed,  the  second  are 
liable  to  be  overlooked. 

4.  As  the  exercise  of  the  function  of  the  eye  would  be  a  source  of  con- 
siderable excitement  to  it  when  suffering  under  inflammation,  rest  of  the  organ 
ought  generally  to  be  enjoined.  It  is  necessary  even  to  exclude  the  light,  in 
most  instances,  by  the  use  of  a  shade  over  both  eyes.     But  this  is  not  proper 


424  REMEDIES   FOR   THE   OPHTHALMIA. 

in  every  case.  Oq  the  contrary,  we  are  obliged  sometimes  to  encourage  pa- 
tients to  admit  the  light,  and  even  to  use  the  eyes.  In  some  cases  rest  of  the 
body  is  indispensable,  especially  in  the  acute  stage  of  the  internal  ophthalmiae. 

5.  It  is  of  great  moment  to  examine  the  diseased  organ  carefully,  and 
thoroughly,  from  time  to  time ;  in  some  cases  daily  or  even  oftener.  Many 
children  lose  their  sight  in  the  puro-mucous  ophthalmise,  no  examination  of 
their  eyes  ever  being  made,  till  the  cornea  are  destroyd.  The  practitioner 
must  never  decline  the  examination  of  the  eyes,  from  any  real  or  fancied 
difficulty. 

Remedies. — The  remedies  which  may  occasionally  be  required  for  the  cure 
of  the  ophthalmiae  are  very  numerous  ;  those  which  are  most  frequently  used, 
and  in  general  with  complete  success,  are  few  and  simple.  They  are  not  all, 
however,  of  one  kind,  but  of  very  diiferent  kinds.  Nay,  for  the  same  species 
of  ophthalmia,  as  will  be  seen  by  and  by,  remedies  of  diametrically  opposite 
effects  are  found  useful.  Common  sense  will  dictate  that  it  is  not  meant  to 
employ  discordant  remedies  together,  nor  even  perhaps  one  after  the  other 
in  the  exact  order  in  which  they  are  enumerated.  Particular  circumstances 
of  the  case  must  often  determine  the  choice  of  the  remedies. 

1.  Bloodletting. — Opening  a  vein  of  the  arm,  applying  leeches  round  the 
eye  and  dividing  the  inflamed  conjunctiva,  are  the  three  modes  of  taking 
away  blood  commonly  had  recourse  to  in  this  class  of  diseases.  Opening  the 
temporal  artery,  the  external  jugular  vein,  or  the  nasal  vein,  or  cupping  the 
temples,  is  seldom  necessary.  The  three  modes  of  bleeding  first  enumerated 
cannot  be  substituted  one  for  another,  and  we  should  often  run  a  risk  of  losing 
the  eye,  were  we  to  attempt  to  cure  by  local,  what  will  readily  yield  to  general 
bleeding,  and  vice  versa.  For  instance,  bleeding  at  the  arm,  by  depressing 
too  much  the  general  strength  of  the  patient,  rather  aggravates  in  general 
than  alleviates  the  scrofulous  ophthalmise,  while  bleeding  with  leeches,  by 
removing  local  turgesceuce,  greatly  relieves  them ;  a  check  is  readily  put  to 
most  of  the  internal  ophthalmiae  by  general  bloodletting,  while  local  has 
comparatively  but  little  effect ;  in  chronic  puro-mucous  conjunctivitis,  much 
more  good  is  done  by  scarifying  the  inside  of  the  eyelids,  than  could  be  ac- 
complished by  leeching  or  phlebotomy.  Neither  is  it  unimportant  in  what 
order  of  succession  we  employ  these  three  modes  of  taking  away  blood. 
Leeching,  for  example,  when  considerable  synocha  is  present,  produces  much 
more  effect  if  preceded  by  general  bleeding ;  and  especially  if  the  leeches  are 
applied  within  a  few  hours  after  the  impetus  of  the  circulating  system  has  by 
that  means  been  moderated. 

There  is  no  inflammatory  disease  of  the  eye  which  is  curable  by  bleeding 
alone.  I  regard  as  foolish,  the  attempts  to  cure  the  contagious  or  Egyptian 
ophthalmia  by  taking  away  blood  from  an  artery  or  vein  in  very  large  quanti- 
ties, or  till  the  inflamed  membrane  grows  pale  from  depletion;  ^rsi,  because 
even  were  this  paleness  produced,  it  would  be  no  test  of  the  disease  being 
subdued ;  secondly,  because  a  degree  of  bloodletting  sufficient  to  produce 
even  an  approach  to  such  an  effect,  would  leave  the  patient  in  a  state  of  great 
and  unnecessary  debility  ;  and  thirdly,  because  the  disease  can  be  cured  by  a 
milder  plan  of  treatment.  All  the  ophthalmiae  require  other  remedies  besides 
the  taking  away  of  blood ;  and,  therefore,  while  we  value  this  means  of  cure 
very  highly,  we  must  by  no  means  trust  to  it  alone  in  any  case.  When  prac- 
titioners placed  their  sole  reliance  on  depletion  in  the  purulent  ophthalmiae, 
the  results  were  truly  disastrous.*^ 

In  taking  away  blood  from  the  arm  in  any  inflammatory  disease  of  the  eye, 
the  opening  should  be  made  large,  so  as  to  insure,  if  possible,  a  considerable 
effect  on  the  impetus  of  the  circulation.     The  quantity  to  be  removed  will 


REMEDIES   FOR   THE   OPHTHALMIA.  425 

vary  from  10  to  20  or  30  ounces,  according  to  the  constitution  of  the  patient, 
and  the  circumstances  of  the  disease. 

Leeches  ought  to  be  applied,  in  general,  rather  over  the  nasal  vein,  on  the 
temple,  or  forehead,  or  behind  the  ear,  than  on  the  loose  skin  of  the  eyelids. 
The  number  applied  may  vary  from  one  to  twenty  or  more.  Two  or  three 
over  the  nasal  vein  will  do  as  much  good  as  twice  that  number  on  the  lids. 
A  leech-glass  assists  in  placing  them  on  the  spot  indicated.  In  infants,  we 
often  find  much  good  effected,  by  one  leech  on  the  middle  of  the  upper  eye- 
lid ;  and  in  some  chronic  cases  of  inflamed  and  thickened  conjunctiva,  one  or 
two  on  the  internal  surface  of  the  lids  prove  useful.  Leeches  to  the  mucous 
membrane  of  the  adjacent  nostril  unload  the  vessels  of  the  eye,  and  especially 
of  the  conjunctiva.  It  has  been  proposed  in  variolous  ophthalmia,  and  some 
other  cases,  to  continue  for  a  number  of  hours  in  succession  a  discharge  of 
blood  by  leeches  behind  the  ears;  as  soon  as  one  set  drop  off,  supplying  their 
place  by  others.  This  is  termed  by  the  French  applying  leeches  en  perma- 
9ience. 

I  by  no  means  deny  the  efficacy  of  opening  the  temporal  artery,  or  taking 
away  iDlood  by  scarifying  and  cupping  the  temples ;  but  these  modes  are  more 
difficult  of  execution,  and  are  attended  with  a  greater  degree  of  irritation  and 
pain  than  simple  venesection,  and  the  application  of  leeches.  They  also  pre- 
clude, in  many  instances,  the  use  of  other  means  which  are  likely  to  be  useful; 
as,  blisters  to  the  temple  and  behind  the  ear.  The  tight  bandage  necessary 
after  arteriotomy  is  also  objectionable  in  cases  of  ophthalmia,  the  painful 
degree  of  pressure,  and  the  development  of  heat,  which  it  produces,  being 
apt  to  increase  the  uneasiness  of  the  eye  and  head.  Where  general  blood- 
letting is  necessary,  as  in  iritis,  cupping  cannot  be  trusted.  It  does  not  pro- 
duce the  same  effect  on  the  momentum  of  the  circulation  as  phlebotomy.  I 
have  seen  many  patients  who  owed  the  loss,  or  at  least  the  irreparable  dete- 
rioration, of  their  sight,  to  their  having  been  merely  cupped  for  iritis,  when 
they  should  have  been  bled  at  the  arm.  Twelve  or  fifteen  ounces  of  blood, 
taken  by  a  pretty  large  opening  from  the  bend  of  the  arm,  has  much  more 
effect  in  checking  any  of  the  internal  ophthalmias,  than  twice  that  quantity 
taken  by  cupping.  We  always  find  the  blood  buffy  in  iritis,  especially  syphi- 
litic iritis,  and  often  require  to  open  a  vein  in  the  arm  three  or  four  times 
before  the  disease  is  subdued.  Trust  such  cases  to  cupping,  and  the  pupil 
is  probably  left  contracted,  the  sensibility  of  the  retina  impaired,  or  the  eye- 
ball flexible  from  a  state  of  commencing  atrophy  ! 

Scarification  of  the  conjunctiva  of  the  eyelids,  and  sometimes  of  that  cover- 
ing the  eyeball,  is,  in  certain  cases,  a  valuable  means  of  cure,  from  which  we 
are  not  to  be  deterred  by  the  theoretical  notion,  that  the  infliction  of  mechan- 
ical injury  on  a  part  already  actively  inflamed  cannot  be  advantageous. 
Ample  experience  convinces  me  that  scarification  is  useful,  not  only  when 
inflammation  of  the  conjunctiva  is  on  the  wane,  but  often  even  in  the  acute 
stage,  and  especially  when  considerable  chemosis  is  present.  One  or  two 
incisions  of  the  conjunctiva,  with  a  lancet,  the  point  of  which  is  rounded  off, 
being  made  along  the  whole  length  of  the  inner  surface  of  either  eyelid,  a 
very  considerable  discharge  of  blood  will  probably  take  place,  and  if  the  lids 
be  properly  managed,  blood  will  continue  to  flow  for  a  considerable  time. 
For  this  purpose,  the  lid  ought  neither  to  be  held  constantly  everted  till  the 
bleeding  ceases,  nor  allowed  to  fall  back  into  continued  contact  with  the  eye- 
ball, in  either  of  which  ways  little  blood  will  be  obtained ;  but  the  lid  ought 
to  be  alternately  everted  and  permitted  to  return  to  its  natural  position,  by 
which  means  the  divided  vessels  are  refilled,  and  thus  a  prolonged  flow  of 
blood  is  insured.  A  bit  of  sponge  wrung  out  of  hot  water  is  to  receive  the 
blood,  but  not  to  touch  the  incision,  unless  when  the  blood  seems  to  be  about 


426  REMEDIES   FOR   THE   OPHTHALMIA. 

to  cease  flowing,  when  the  coagula  may  be  wiped  away,  to  make  the  wound 
bleed  again. 

Scarification  of  the  conjunctiva  covering  the  eyeball,  has  generally  been 
performed  by  incisions  concentric  with  the  edge  of  the  cornea ;  but  Mr. 
Tyrrel  suggested'^  that  it  was  better  to  make  the  incisions  in  a  radiated  direc- 
tion from  the  cornea,  and  corresponding  to  the  intervals  between  the  insertion 
of  the  recti  muscles.  He  recommended  this  plan  in  acute  purulent  ophthal- 
mia, a  disease  in  which  the  conjunctiva  is  generally  much  swollen.  He 
thought  that  in  the  common  method  of  scarifying  the  eyeball,  the  vessels 
passing  to  the  corneal  portion  of  the  conjunctiva  must  be  in  great  part,  if 
not  entirely  divided,  and  the  tendency  to  destruction  of  the  cornea  thereby 
augmented ;  whereas  in  the  method  of  scarifying  which  he  suggested,  the 
principal  vessels  of  the  conjunctiva  bulbi  should  not  be  injured,  and  yet  the 
loaded  state  of  the  membrane  should  be  relieved.  Unfortunately,  however, 
in  severe  cases,  where  there  is  much  chemosis,  the  lids  are  generally  so 
swollen  as  to  render  it  impossible  to  make  the  radiating  incisions  which  he 
described. 

Along  with  scarification,  we  may  class  the  snipping  across  of  individual 
enlarged  vessels,  running  over  the  surface  of  the  eyeball,  which  is  sometimes 
useful,  but  not  unfrequently  employed  when  quite  unnecessary.  The  mode 
which  I  find  most  efficacious,  is  to  raise  a  small  fold  of  the  conjunctiva  with 
the  forceps,  and  snip  it  through  with  the  scissors.  This  fold  rarely  contains 
the  enlarged  vessel  which  we  wish  to  cut  across,  but  it  is  now  exposed ;  with 
a  small  hook  it  is  easily  raised  from  the  surface  of  the  sclerotica,  and  then 
divided. 

The  practice  of  removing  with  the  scissors  a  circular  portion  of  the  con- 
junctiva round  the  edge  of  the  cornea,  as  was  advised  by  Scarpa^  in  cases  of 
nebula,  appeared  to  have  been  almost  entirely  laid  aside,  when  it  was  revived 
by  Sanson,  as  a  means  of  treating  gonorrhoeal  ophthalmia.  He  excised,  by 
means  of  forceps  and  scissors,  the  ocular  conjunctiva,  and  immediately  after- 
wards cauterized  the  palpebral  conjunctiva  with  the  solid  nitrate  of  silver.* 
I  conceive  such  excision  to  be  an  unnecessary  measure  ;  besides,  it  is  in  acute 
cases  almost  impracticable,  on  account  of  the  great  swelling  of  the  lids,  and 
their  state  of  tension  from  the  swollen  condition  of  the  conjunctiva.  When 
the  swelling  has  subsided,  so  as  to  make  the  operation  practicable,  a  cure 
can  be  effected  without  it.  If  accomplished,  symblepharon  appears  not  un- 
likely to  follow. 

2.  Paracentesis  cornece,  or,  evacuation  of  the  aqueous  humor,  has  been  highly 
recommended  by  Mr.  Wardrop,*  as  a  mode  of  depletion  in  some  kinds  of  oph- 
thalmia. Although  in  certain  cases  an  invaluable  remedy,  it  is  rather  too 
nice  an  operation  to  have  come  into  general  use. 

The  opening  through  the  cornea,  by  which  the  aqueous  humor  is  to  be  dis- 
charged, may  be  made  with  any  of  the  knives  commonly  used  for  extracting 
the  cataract,  or  with  a  broad  iris-knife.  It  is  sufficient  that  the  point  of  the 
instrument  be  introduced  so  that  it  makes  a  puncture  into  the  anterior  cham- 
ber ;  this  should  be  done  at  the  distance  of  yV  inch  from  the  sclerotica,  at 
any  part  of  the  circumference  of  the  cornea.  When  the  knife  has  penetrated 
into  the  anterior  chamber,  it  may  be  withdrawn  a  little,  and  the  blade  turned 
on  it  axis,  when  the  aqueous  humor  will  readily  escape.  It  is  better  not  to 
remove  the  instrument  altogether,  till  the  fluid  is  observed  to  be  discharged  ; 
for  if  the  incision  be  not  sufficiently  large,  and  the  knife  taken  away  before 
the  aqueous  humor  flows  out,  the  elasticity  of  the  cornea  closes  the  wound, 
and  either  hinders  the  evacuation  from  being  so  sudden,  and  consequently  so 
efficacious,  or  entirely  prevents  it.  The  operation,  therefore,  which  is  neces- 
sary to  discharge  the  aqueous  humor,  is  merely  the  first  step  of  the  section 


REMEDIES  FOR  THE   OPHTHALMIiE,  42T 

of  the  cornea,  made  in  extracting  the  cataract,  or  what  is  called  the  punc- 
turation. 

The  chief  difficulty  in  performing  the  operation,  arises  from  the  pain  occa- 
sioned by  the  necessary  pressure  on  an  inflamed  eyeball  whilst  keeping  open 
the  eyelids ;  but  until  a  sufficient  portion  of  the  cornea  is  brought  into  view, 
and  the  eye  completely  under  the  management  of  the  operator,  the  introduc- 
tion of  the  knife  should  not  be  attempted.  The  upper  lid  should  be  elevated 
by  the  fingers  of  the  assistant,  or  by  the  retractor  (Fig.  53,  p.  312) ;  while 
the  operator,  with  the  fore  and  middle  fingers  of  the  hand  which  does  not 
hold  the  knife,  presses  down  the  lower  lid,  applying  their  points  over  its  edge, 
in  such  a  manner  that  they  touch  the  eyeball,  and  can  be  made  to  exercise  any 
degree  of  pressure  upon  it  which  may  be  necessary.  Before  the  assistant 
raises  the  upper  lid,  the  patient  should  be  directed  to  look  downwards ;  and 
then  the  assistant  employs  a  sufficient  pressure  to  keep  the  eye  in  that  position. 

As  the  patient  is  very  apt  to  start  when  he  first  feels  the  instrument  com- 
ing in  contact  with  his  eye,  it  is  useful  to  touch  the  cornea  repeatedly  with 
the  back  of  the  knife  till  all  risk  of  starting  is  over ;  and  as  soon  as  its 
extremity  rests  on  the  part  where  the  puncture  is  to  be  made,  the  knife  may 
readily  be  raised  on  its  point,  and  carried  into  the  anterior  chamber. 

3.  Ancesthetics. — As  a  valuable  means  of  reducing  inflammation  in  different 
textures  of  the  eye,  and  of  relieving  the  pain  and  intolerance  of  light  which 
attend  some  of  the  ophthalmiaj,  may  be  mentioned  the  inhalation  of  the  vapor 
of  sulphuric  ether  or  of  chloroform.  -  Bringing  the  patient  for  a  few  minutes 
into  the  insensible  state,  by  means  of  one  or  other  of  these  agents,  gives 
marked,  and  often  permanent  relief,  in  scrofulous  conjunctivitis,  corneitis, 
and  sympathetic  ophthalmitis.  The  inhalation  should  be  practised  while  the 
patient  lies  supine,  and  may  be  repeated  daily  or  every  second  day.^ 

4.  Purgatives  act  in  two  ways  in  the  cure  of  the  inflammatory  diseases  of 
the  eye ;  namely,  as  depletory,  and  as  sympathetic  means.  They  reduce  the 
quantity  of  circulating  fluid,  as  well  as  remove  the  contents  of  the  bowels, 
and  from  the  continuity  of  the  investing  membrane  of  the  eye  with  the  lining 
membrane  of  the  alimentary  canal,  they  prove  a  very  effectual  remedy  in  al- 
most all  kinds  of  ophthalmia.  An  active  purge  of  calomel  and  jalap  is  often 
sufficient  of  itself  to  check  an  attack,  when  employed  early.  In  the  course  of 
diseases  of  this  class,  occasional  laxatives  are  always  necessary ;  while  in 
many  cases,  especially  in  children,  nothing  but  a  continued  use  of  purgatives 
will  effect  a  cure. 

5.  Emetics  and  nauseants  are  of  essential  service  in  the  treatment  of  vari- 
ous inflammatory  affections  of  the  eye,  not  only  when  there  is  reason  to  sup- 
pose that  an  overloaded  state  of  the  digestive  organs  is  concerned  in  keeping 
up  irritation,  but  as  a  means  of  lowering  the  circulation,  and  relaxing  the 
skin.''  In  chronic  cases,  the  sorbefacient  effects  of  this  class  of  remedies  are 
also  highly  useful,  promoting  the  absorption  of  unhealthy  depositions,  and 
thus  assisting  in  restoring  the  transparent  front  of  the  eye  to  its  natural  con- 
dition. 

6.  Diaphoretics  are  useful  in  lowering  inflammatory  action  in  the  eye,  espe- 
cially when  suppressed  perspiration  has  been,  as  it  often  is,  the  exciting  cause 
of  an  ophthalmia.  The  eye,  being  invested  by  a  continuation  of  the  integu- 
ments, partakes  in  the  good  effects  of  a  renewed  secretion  from  the  skin. 
We  seldom  indeed  think  of  treating  any  ophthalmia  by  diaphoretics  alone  ; 
but  after  depletion,  we  employ  this  class  of  remedies  as  valuable  adjuvants 
in  the  cure.  Under  this  head,  may  be  mentioned  the  warm  pediluvium  at 
bed-time,  and  the  tepid  and  warm  bath. 

Y.  Sorhefacients. — The  efficacy  of  mercury  in  inflammations  of  the  eye  has 
long  been  established.^     Without  the  aid  of  this  medicine,  we  might  regard 


428  REMEDIES   FOR   THE   OPHTHALMIA. 

the  internal  ophthalmise,  and  especially  inflammation  of  the  iris,  as  nearly  in- 
curable. It  is  chiefly  as  a  sorbefacient  that  mercury  proves  so  Useful  in  the 
internal  ophthalmiee,  powerfully  promoting  the  removal  of  effused  coagulable 
lymph,  by  an  increased  action  of  the  absorbents.  Whether  it  accomplishes 
this  directly,  by  actually  stimulating  the  absorbents,  or  merely  favors  their 
action,  by  abating  in  some  unknown  mode  the  inflammation,  in  which  the 
effusion  originates,  we  are  unable  to  say ;  but  the  sad  result  of  the  internal 
ophthalmi^e,  when  neglected,  and  the  admirable  effect  of  mercury  in  preserv- 
ing the  open  and  transparent  state  of  the  pupil,  in  these  diseases,  are  placed 
beyond  all  doubt. 

In  the  diseases  to  which  I  have  alluded,  we  employ  mercury,  so  as  to  affect 
the  constitution,  and  in  this  way  to  operate  on  the  eye  ;  but  in  other  cases  we 
use  it  in  smaller  doses,  in  the  expectation  of  deriving  benefit  from  its  well- 
known  effects  on  the  secretory  organs  concerned  in  digestion. 

The  iodide  of  potassium  may  often  be  employed  with  advantage,  in  cases 
where  mercury  disagrees,  or  when  we  are  obliged  to  discontinue  that  medicine 
on  account  of  its  affecting  the  mouth. 

8.  Tonics. — The  scrofulous  ophthalmia,  and  almost  all  others  in  the 
chronic  stage,  are  benefited  by  this  class  of  medicines,  of  which  cinchona  is 
by  far  the  most  powerful.  The  treatment  of  the  scrofulous  ophthalmia^  with 
sulphate  of  quina  is  an  improvement  in  ophthalmic  medicine,  perhaps  scarcely 
less  important  than  the  treatment  of  iritis  with  mercury.  The  former  diseases 
are  much  more  frequent  in  their  occurrence  than  the  latter,  and  scarcely  less 
dangerous  in  their  effects  upon  the  transparent  parts  of  the  eye.^ 

The  mineral  acids,  and  the  chalybeates,  are  also  highly  valuable  tonic  re- 
medies for  certain  kinds  and  stages  of  the  ophthalmioe. 

Arsenic  is  a  tonic,  and  like  other  remedies  of  that  class,  acts  by  imparting 
a  healthy  energy  to  the  capillaries.  It  proves  useful  in  some  chronic  inflam- 
mations of  the  eye,  attended  by  hemicrania.  I  have  found  it  particularly 
serviceable  in  scrofulous  sclerotitis." 

The  shower  bath,  tepid  or  cold,  and  cold  bathing  generally,  must  be  re- 
garded as  valuable  remedies  of  the  tonic  class. 

9.  Anodynes. — We  are  naturally  led  to  employ  anodynes  in  the  hope  of 
assuaging  the  pain  attending  many  of  the  ophthalmias ;  but  this  is  perhaps 
not  their  most  important  effect.  Two  of  the  most  painful  ophthalmias  are 
the  rheumatic  and  catarrho-rheumatic.  Laudanum,  rubbed  on  the  forehead 
and  temples,  does  much  to  relieve  the  pain ;  or  if  opium  be  taken  internally, 
considerable  alleviation  is  procured  ;  but  much  more  good  is  effected  when 
this  medicine  is  administered  with  calomel.  Calomel  with  opium  may  be  re- 
garded as  almost  specific  in  the  rheumatic  and  catarrho-rheumatic  ophthal^ 
mise.  Either  remedy  by  itself  is  much  less  eflficacious.  The  opium  acts  not 
merely  as  an  anodyne,  but  as  a  dirigent,  preventing  the  calomel  from  running 
off  by  stool,  and  insuring  its  being  taken  into  the  system. 

Opium,  in  vapor,  and  in  fomentation,  is  employed  directly  to  the  eye  in 
certain  states  of  inflammation. 

Tincture  of  tobacco,  rubbed  round  the  orbit,  proves  advantageous  in  allay- 
ing the  pain  which  attends  some  ophthalmifE." 

10.  Mydriatics. — A  very  peculiar  set  of  narcotics,  of  inestimable  value  in 
ophthalmic  medicine,  consists  of  belladonna,  hyoscyamus,  and  stramonium, 
which  have  the  power  of  dilating  the  pupil.'''  They  are  used  in  a  variety  of 
ways,  but  chiefly  in  moist  extract  smeared  on  the  eyebrow  and  eyelids.  As 
in  all  the  internal  ophthalmias  there  is  a  disposition  to  closure  of  the  pupil, 
one  of  these  narcotics  is  applied  once  or  oftener  in  the  24  hours  to  oppose 
this  tendency.     If  severe  inflammation  is  already  present  in  the  iris,  they 


REMEDIES  FOR  THE   OPHTHALMIA.  429 

have  little  effect ;  but  if  the  attack  is  incipient,  or  if  it  be  already  yielding 
to  the  influence  of  bloodletting  and  mercury,  the  pupil  is  speedily  expanded. 

Belladonna  and  hyoscyamus,  employed  in  fomentation,  vapor,  or  friction, 
or  given  internally,  are  of  great  use  in  relieving  the  intolerance  of  light  and 
lachrymation  attendant  on  scrofulous  conjunctivitis  and  corneitis."  They  also 
possess  a  remarkable  power  in  soothing  irritation,  and  in  bringing  on  a 
healing  action  in  ulceration  of  the  cornea.  There  are  few  ophthalmia3,  in 
fact,  in  which  benefit  is  not  derived  from  the  anodyne  effects  of  this  class  of 
remedies,  independently  of  their  power  over  the  pupil. - 

An  elegant  and  convenient  mode  of  obtaining  the  specific  effects  of  bella- 
donna, is  the  application  to  the  conjunctiva  of  a  solution  of  a  salt  of  atropia. 
A  solution  even  of  half  a  grain  of  the  sulphate  in  a  pint  of  water,  will  dilate 
the  pupil,  when  used  as  a  lotion  to  the  eye  ;  but  a  solution  of  one  or  two 
grains  to  the  ounce  of  water  is  commonly  employed. 

11.  Hydrocyanic  acid. — If  a  small  glass  tube,  open  at  both  ends,  and  con- 
taining a  little  hydrocyanic  acid,  is  held  by  a  finger  at  each  end,  so  that  the 
fluid,  or  even  its  vapor  only,  is  in  contact  with  the  skin  for  a  few  minutes,  a 
very  peculiar  feeling  of  numbness  is  felt  in  the  tips  of  the  fingers  for  some 
time.  The  vapor  arising  from  the  acid,  when  gently  heated,  is  presumed  to 
be  productive  of  the  same  sedative  effect  on  the  nerves  of  the  eye,  and 
through  them  on  the  bloodvessels.  It  is  applied  by  opening  the  eye,  for  a 
few  minutes,  into  a  small  phial,  the  mouth  of  which  is  shaped  as  an  eye-cup,  a 
few  drops  of  the  concentrated  acid  being  previously  placed  at  the  bottom  of 
the  phial. 

It  is  chiefly  in  the  chronic  stage  of  corneitis,  and  in  opacities  of  the  cor- 
nea, that  benefit  is  derived  from  this  application  of  the  vapor  of  hydrocyanic 
acid.  It  appears  hurtful  when  there  is  ulceration,  or  when  there  is  any  ten- 
dency in  the  eye,  from  injury,  to  fall  into  disorganization. 

12.  Refrigerants — Emollients. — From  the  abnormal  feeling  of  heat  which 
attends  most  of  the  ophthalmice,  the  application  of  cold  water  may  be  re- 
garded as  a  remedy  to  which  the  patient  is  prompted  by  instinct.  It  un- 
doubtedly relieves  for  a  time,  yet  in  the  internal  ophthalmiae  it  is  positively 
injurious,  while  in  many,  or  even  in  most  other  cases,  its  use  is  followed  by  a 
degree  of  reaction  which  is  detrimental.  Incipient  inflammation  of  the  ex- 
ternal covering  of  the  eye  may  sometimes  be  checked  by  cold  lotions  ;  but 
even  in  these  cases,  the  same  good  may  generally  be  obtained  from  tepid 
applications,  without  the  risk  of  any  hurtful  reaction  ;  exactly  as  the  skin  in 
fever  is  cooled  with  less  risk  by  the  tepid,  than  by  the  cold  effusion.  A  tepid 
lotion  soothes  and  relaxes  the  inflamed  membranes  of  the  eye,  and  being 
evaporated  at  the  expense  of  the  superabundant  heat  of  the  parts,  acts,  in 
fact,  as  a  refrigerant,  as  well  as  an  emollient.  Poppy  decoction  answers  very 
well  for  this  purpose. 

Cataplasms  applied  over  the  eyes,  though  occasionally  useful,  often  prove 
injurious  by  leading  to  the  omission  of  proper  remedies.  Many  an  eye  bursts 
under  a  poultice,  especially  in  ophthalmia  neonatorum,  and  scrofulous  oph- 
thalmia. If  we  order  poultices,  then,  we  must  not  neglect  to  examine,  from 
day  to  day,  the  eye  over  which  they  are  applied.  Long  continued,  they  cause 
a  severe  pustular  eruption  on  the  lids. 

13.  Detergents — Astriyigents — StimidaMs — Escharotics.. — Under  this  head 
we  include  the  innumerable  substances  applied  to  the  surface  of  the  eye,  for 
the  purpose  not  merely  of  cleaning  away  discharge  and  constringing  the 
tissues  with  which  they  come  in  contact,  but  of  influencing  the  vital  powers 
of  the  parts.  The  same  substance,  in  different  degrees  of  concentration, 
may  sometimes  serve  as  a  detergent,  an  astringent,  a  stimulant,  or  an  escha- 
rotic. 


430  REMEDIES   EOR   THE   OPHTHALMIA. 

Ill  the  internal  ophthalmige,  and  especially  in  the  acute  stage,  the  appli- 
cation of  stimulants  is  useless  or  destructive ;  while  in  conjunctival  inflamma- 
tions, more  is  efifected  by  their  means  than  by  almost  any  other  kind  of  remedy. 
Such  astringents  as  alum,  muriate  of  ammonia,  sulphate  of  zinc,  and  sulphate 
of  copper,  have  been  in  a  considerable  degree  superseded  by  nitrate  of  silver 
and  muriate  of  mercury.  Acetate  of  lead,  from  the  opaque  and  generally 
indelible  precipitate  its  solution  forms  on  any  abraded  or  ulcerated  spot  of  the 
conjunctiva  or  cornea,  ought  to  be  entirely  dismissed  from  ophthalmic  prac- 
tice. Indeed,  when  an  ulcer  is  present  on  the  cornea,  all  saline  solutions 
should  be  avoided,  unless  necessary  to  save  the  structure  from  disorganiza- 
tion, as  all  of  them  throw  down  a  precipitate,  which  adheres  to  the  ulcer, 
and  tends  to  render  the  cicatrice  opaque.     (See  p.  261.) 

Muriate  of  mercury  is  scarcely  employed  except  in  a  very  weak  state  of 
solution.  In  this  form  it  is  often  used  as  an  astringent  collyrium.  Its  solu- 
bility is  generally  assisted  by  the  addition  of  muriate  of  ammonia,  and  the 
collyrium,  of  which  it  forms  an  ingredient,  often  contains  also  other  sub- 
stances, such  as  opium  and  belladonna. 

Nitrate  of  silver  is  applied  in  solution,  in  salve,  and  in  the  solid  form. 
The  average  strength  of  the  solution  is  4  grains  to  1  ounce  of  distilled  water, 
but  in  the  treatment  of  the  purulent  ophthalmioe,  10  grains  or  more  may  be 
proper.  The  mode  of  applying  it  is  to  pour  about  a  dozen  of  drops  into  an 
empty  wine-glass,  take  them  up  with  a  camel-hair  brush,  and  touch  with  this 
the  inflamed  conjunctiva.  The  solution  should  be  spread  over  the  upper 
sinus  of  the  membrane,  and  not  confined  to  the  lower.  The  application 
should,  in  general,  be  repeated  every  eight  hours.  In  "acute  cases,  once  a 
day  is  too  seldom.  The  solution  is  immediately  decomposed  by  the  muriate 
of  soda  present  in  the  tears  and  conjunctival  mucus,  and  flows  out  from  ))e- 
tween  the  lids  of  a  milky  appearance,  from  the  precipitation  which  has  taken 
place  of  horn  silver.  Long  continued,  this  solution  tinges  the  conjunctiva 
of 'an  indelible  olive  hue,  and  sometimes  blackens  permanently  the  cicatrice 
which  follows  its  application  to  an  ulcer  on  the  cornea.     (See  p.  261.) 

A  nitrate  of  silver  salve  seems  to  have  been  first  proposed  by  Dr.  llyan,^* 
for  specks,  and  afterwards  by  Mr.  Cleoburey^^  for  ulcers  of  the  cornea.  Dr. 
Ryan  used  1  drachm  of  nitrate  of  silver  to  the  ounce  of  axunge ;  Mr.  Cleo- 
burey  only  5  grains.  Mr.  Guthrie'^  has  introduced  into  practice  this  sort  of 
salve,  of  various  degrees  of  strength,  up  to  that  of  80  grains  to  the  ounce, 
not  merely  as  a  remedy  for  ulcers  and  specks,  but  for  diiferent  ophthalmias, 
even  in  the  acute  stage.  Of  whatever  strength  it  is  to  be,  the  opium  which 
Mr.  Cleoburey  puts  into  his  salve,  and  the  liquor  diacetatis  plumbi  which 
Mr.  Guthrie  adds  to  his,  ought  to  be  omitted.  The  nitrate  of  silver  is  to  be 
carefully  levigated  in  a  mortar,  and  the  fatty  matter  with  which  it  is  to  be  mixed 
washed  with  boiling  distilled  water,  so  that  all  foreign  ingredients,  and  par- 
ticularly common  salt,  may  be  excluded,  and  thus  the  decomposition  of  the 
nitrate  in  the  ointment  retarded  as  long  as  possible.*' 

This  ointment,  of  the  strength  of  10  grains  or  upwards  to  the  ounce,  is 
applied  to  the  conjunctiva,  on  the  principle  that  no  two  diseases  can  exist 
together  at  one  and  the  same  time.  The  ointment,  being  a  powerful  stimu- 
lant, is  supposed  to  excite  a  greater,  more  healthy,  and  more  transitory  degree 
of  inflammation  than  that  already  existing.  It  is  chiefly  in  the  granular  or 
sarcomatous  stage  of  the  puro-mucous  ophthalmia)  that  this  salve  is  useful. 
In  applying  it,  it  ought  not  to  be  put  in,  in  a  lump,  upon  the  inside  of  the  lids, 
as  in  this  way  it  is  apt  to  affect  only  the  part  of  the  conjunctiva  which  it  first 
touches,  and  may  even  produce  sloughing  of  that  part.  It  ought  to  be  taken 
up  on  the  point  of  a  greasy  camel-hair  brush,  and  the  lids  being  everted  and 
wiped  dry,  the  salve  is  to  be  pencilled  upon  the  palpebral  conjunctiva.     An 


REMEDIES   FOR  THE   OPHTHALMIA,  431 

immediate  chemical  effect  is  produced  on  the  surface  of  the  membrane,  the 
nitrate  being  partially  decomposed  by  the  mucus  of  the  conjunctiva,  and 
reduced  to  the  state  of  a  chloride.  Some  complain  but  little  of  its  effects, 
and  are  able,  in  half  an  hour  or  less,  to  open  the  eyes,  and  walk  out  into  the 
street ;  others  suffer  severely  for  three  or  four  hours. 

Solid  nitrate  of  silver  is  sometimes  applied^^  to  the  conjunctiva  of  the  lids 
in  a  state  of  inflammation,  and  is  perhaps  a  more  manageable  remedy  than 
the  strong  salve.  Both  these  applications  require  to  be  used  with  great 
caution ;  as,  employed  carelessly,  they  are  apt  to  destroy  the  transparency  of 
the  cornea,  just  as  quicklime  does,  and  to  cause  sloughing  of  the  conjunctiva 
or  of  the  cornea,  and  lead  to  symblepharon. 

The  red  precipitate  and  the  sub-nitrate  of  mercury  are  employed  only  in 
the  form  of  salves,  and  these  are  made  of  various  degrees  of  strength. 

From  its  property  of  dissolving  mucus  and  pus,  a  solution  of  potass  forms 
one  of  the  best  detergent  coUyria.  For  this  purpose,  from  two  to  six  drops 
of  aqua  potassse  may  be  added  to  the  ounce  of  water.  If  it  is  thought  neces- 
sary to  color  this  collyrium,  a  few  drops  of  tincture  of  catechu  may  be  added. 

A  solution  of  tannin  has  been  employed  as  an  astringent  application  to  the 
eye,  generally  of  the  strength  of  from  10  to  20  grains  to  an  ounce  of  water,*^ 
but  sometimes  much  stronger. 

A  vinous  solution  of  opium  is  applied  either  pure  or  diluted,  and  in  most 
chronic  inflammations  of  the  eyes  proves  highly  useful.^  It  also  assists  in 
preventing  relapses.  The  Germans  use  Sydenham's  liquid  laudanum,  which 
contains  twice  as  much  opium  as  our  viuum  opii.  Some  practitioners  em- 
ploy a  vinous  solution  of  opium,  without  aromatics. 

14.  Counter-irritants,  including  rubefacient  liniments,  blisters,  and  issues, 
are  of  much  service  in  the  treatment  of  the  ophthalmias,  especially  in  the 
chronic  stage.  By  their  means  the  bloodvessels  of  a  neighboring  part,  for 
example  of  the  neck,  are  excited,  those  of  the  eye  are  thereby  relieved,  and 
the  absorbents  are  thus  favored  in  their  action.  Next  to  the  cantharides 
plaster,  one  containing  tartrate  of  antimony  is  the  most  useful  counter-irri- 
tant. Such  remedies  do  most  good  when  there  is  least  fever  or  irritation  in 
the  system.  If  the  counter-irritant  disturbs  the  general  health,  it  aggra- 
vates the  local  disease. 

Having  thus  gone  over  the  chief  classes  of  remedies  employed  in  the  treat- 
ment of  the  ophthalmias,  I  may  mention  that  much  is  to  be  effected  also,  in 
the  cure  of  these  diseases,  by  dietetical  regulations,  using  dietetical  in  its 
original  and  extensive  sense,  so  as  to  comprehend  under  it  every  particular 
in  the  mode  of  life.  Thus,  attention  to  cleanliness,  by  the  removal  of  morbid 
discharges  from  the  eyes,  pure  air,  early  going  to  rest,  quiet  sleep,  repose  of 
mind,  regulated  diet,  proper  exercise,  and  many  similar  observances,  are  in 
a  high  degree  conducive  to  recovery ;  while  a  neglect  of  one  or  more  of 
these  rules  is  often  the  cause  of  prolonged  and  severe  attacks  of  inflamma- 
tion, in  different  textures  of  the  eye. 

Alcohol,  in  all  its  forms,  ought,  in  almost  every  instance,  to  be  avoided, 
as  likely  to  increase  the  heart's  action,  which  is  not  wanted.  The  state  of 
the  capillaries  must  be  improved  in  many  of  the  ophthalmice  by  appropriate 
tonics ;  but  fermented  liquors  would  rarely  answer  this  intention. 


'"I  have  seen  eases  of  ophthalmia  where  ^  Medico-Chirurgical  Transactions;  Vol.  xxi. 

160  or  170  ounces  were  said  to  have  been  taken  p.  414;  London,  1S3S.     London  Medical  Ga- 

(uDsuccessCully  however)  in  the  space  of  three  zette;  Vol.  xxiii.  pp.  571,  702,  S15. 

daj's;  and  I  have  been  told  by  other  practi-  '   Trattato    delle    principali    Malattie    degli 

tioners  that  they  have  been  in  the  habit  of  Occhi;  Vol.  i.  p.  246;  Pavia,  1816. 

drawing  70   or  80    ounces  at  one   bleeding."  *  JuUiard,  De  I'Emploi  de  I'Exeision  et  de  la 

Calvert's  lleflections  on  Fever,  p.  3;  London,  Cauterisation   dans  rOphtbalmie   Blennorrha- 

1815.  gique;  p.  73;  Paris,  1835. 


432 


REMEDIES  FOR  THE   OPHTHALMIA. 


'  Medico-Chirurgical  Transactions  ;  Vol.  iv. 
p.  153  ;  London,  1813. 

^  Medical  Gazette;  Vol.  xxxix.  p.  1077; 
London,  1847. 

'  Dobson,  Medical  and  Philosophical  Com- 
mentaries;  Vol.  iii.  p.  411;  Edinburgh,  1784. 

^  Riverius  (Opera,  p.  263;  Francofurti, 
1674),  quotes  with  approbation  the  practice  of 
Zacutus  Lusitanus,  who  cured  an  ophthalmia 
in  seven  days  by  mercurial  inunction,  after  a 
year's  trial  had  been  made  of  other  remedies 
without  effect. 

Cheyne  (Natural  Method  of  curing  the  Dis- 
eases of  the  Body,  p.  125  ;  London,  1742)  states 
sethiops  mineral  to  be  an  effectual  remedy  in 
inflammation  of  the  eyes. 

Warner  (Description  of  the  Human  Eye, 
Ac,  p.  39;  London,  1773)  recommends  mer- 
curials, with  opium,  in  inflammation  of  the 
conjunctiva. 

Plenck  (De  Morbis  Oculorum,  p.  80;  Vienna, 
1777)  recommends  the  internal  use  of  mercury 
in  gonorrhoeal  and  venereal  ophthalmice. 

Dr.  Robert  Hamilton  published  in  Duncan's 
Medical  Commentaries  (Vol.  ix.  p.  191;  Lon- 
don, 1785)  an  account  of  the  good  effects  of 
calomel  and  opium  in  inflammatory  diseases. 
He  speaks  of  the  efficacy  of  mercury  in  oph- 
thalmia as  a  fact  long  established. 

Ware  (Remarks  on  the  Ophthalmy,  &c.,  pp. 
97,  101:  3d  Edition;  London,  1793)  gave  cor- 
rosive sublimate  successfully  in  a  variety  of 
cases. 

By  turning  to  Beer's  Bibliotheca  Ophthal- 
mica  (Vol.  i.  p.  55,  and  Vol.  ii.  p.  85 ;  Vindo- 
bonse,  1799)  the  reader  will  find  that  he  was 
well  acquainted,  at  the  time  of  that  publica- 
tion, both  with  the  effects  of  iritis  and  with  the 
power  of  mercury  in  preventing  effusion  of 
lymph  into  the  pupil.  He  says  that  bloodlet- 
ting being  premised,  there  is  no  remedy  so 
powerful  in  subduing  violent  ophthalmia  and 
in  preventing  suppuration  and  effusion  of 
lymph  as  mercurj'. 

Muir  (Edinburgh  Medical  and  Surgical 
Journal;  Vol.  vii.  p.  244;  1811)  recommended 
salivation  in  ophthalmia. 

Beer  (Lehre  von  den  Augenkrankheiten; 
Vol.  i.  pp.  450,  563;  Wien,  1813)  advised  calo- 
mel with  opium  in  idiopathic  iritis ;  in  syphi- 
litic iritis,  calomel  with  opium,  or  corrosive 
sublimate. 

Dr.  Farre  (Preface  to  second  edition  of 
Saunders  on  Some  Practical  Points  relating  to 
the  Diseases  of  the  Eye,  p.  xxxviii.;  London, 
1818)  stated  his  belief,  that  mercurial  action 
by  itself  might  subdue  iritis  in  its  acute  stage; 
a  doctrine  pregnant  with  danger. 

^  In  the  first  volume  of  the  JNIedical  Observa- 
tions and  Inquiries,  published  in  1763,  Dr. 
.Fothergill  and  Dr.  Fordyce  recommended  a 
decoction  of  powdered  cinchona  bark  as  a 
remedy  for  scrofulous  conjunctivitis.  In  de- 
coction, and  in  other  forms,  there  can  be  no 
doubt  that  benefit  must  have  been  derived 
from  bark  in  the  bands  of  succeeding  practi- 
tioners. At  the  same  time,  some  authors  have 
spoken  unfavourably  of  this  remedy,  in  the 
very  ophth.ilmia  for  which  it  was  praised  by 
Fothergill  and  Fordyce.  "Bark  and  other 
tonics,"  says  Mr.  Lloyd  in  his  Treatise  on 
Scrophula,  p.  314,  "have  been  especially  re- 


commended in  this  species  of  ophthalmy ;  but 
though  I  have  witnessed  their  exhibition  in 
numerous  cases,  I  never  observed  that  they 
exerted  the  least  power  over  this  particular 
disease." 

In  ophthalmia  neonatorum,  Mr.  Saunders 
(1811)  advised  extract  of  bark,  and  Mr.  Ryall 
(1828)  sulphate  of  quina. 

In  1828,  Mr.  A^^allace  published,  in  the  four- 
teenth volume  of  the  Medico-Chirurgical  Trans- 
actions, a  favorable  account  of  the  effects  of 
cinchona  in  iritis,  after  fever. 

"  Of  the  value  of  sulphate  of  quinine,"  says 
Dr.  Jacob,  "as  a  remedy  in  most  forms  of 
ophthalmia,  when  occurring  in  debilitated  or 
scrofulous  subjects,  or  after  long  confinement  in 
an  unwholesome  room,  or  after  the  injudicious 
use  of  mercury,  I  am  fully  aware  ;  and  I  know 
of  no  curative  means  which  merit  more  the 
attention  of  the  ophthalmic  surgeon."  Trans- 
actions of  King  and  Queen's  College  of  Physi- 
cians ;  Vol.  V.  p.  477;  Dublin,  1828. 

In  1828,  a  child  was  regularly  brought  to 
my  house  from  a  distance  of  seven  miles,  la- 
boring under  obstinate  phlyctenular  conjuncti- 
vitis, for  which  I  tried  many  remedies  without 
avail.  One  daj-,  when  the  child  was  brought 
in,  some  sulphate  of  quina  was  lying  on  the 
table,  and  it  struck  me  it  was  worthy  of  a  trial 
in  so  obstinate  a  disease.  It  cured  the  child 
in  a  few  days.  Other  cases  of  the  same  disease 
yielded  in  the  same  favorable  manner.  I  in- 
troduced the  remedy  at  the  Glasgow  Eye  Infir- 
mary, extending  its  use  to  scrofulous  corneitis 
and  ophthalmia  tarsi,  and  in  November,  1828, 
published  some  account  of  its  beneficial  effects 
in  those  diseases,  in  the  Glasgow  Medical 
Journal. 

'"  Medical  Gazette;  Vol.  xii.  p.  18;  London, 
1833. 

"  Noble's  Treatise  on  Ophthalmy;  p.  209; 
Birmingham,  1801.  Vetch,  in  Medico-Chi- 
rurgical Transactions;  Vol.  xvi.  p.  357;  Lon- 
don, 1830. 

'^  Though  the  effect  of  certain  vegetable 
substances  in  dilating  the  pupil  was  known  to 
the  ancients,  and,  as  Pliny  informs  us  in  the 
13th  chapter  of  the  25th  book  of  his  Natural 
History,  advantage  taken  of  it  in  operating  on 
the  eye,  the  application  of  such  substances  for 
the  purpose  of  combating  the  contraction  of 
the  pupil  which  is  apt  to  occur  in  iritis,  appears 
altogether  modern.  Indeed,  I  am  not  aware 
that  Darwin  (Zoonomia;  Vol.  iii.  p.  132;  Lon- 
don, 1801)  was  preceded  in  the  suggestion, 
that  the  power  of  belladonna  in  dilating  the 
pupil  might  be  of  advantage  in  some  oph- 
thalmia;. 

On  the  medical  history  of  belladonna  and 
other  mydriatics,  see  Pulteney,  Philosophical 
Transactions;  Vol.  i.  part  i.  p.  62;  London, 
1758.  Himly,  Krankheiten  und  Missbildungen 
des  menschlichen  Auges;  Vol.  i.  p.  18;  Ber- 
lin, 1843. 

It  would  be  important  to  know  what  plants 
possess  the  power  of  dilating  the  pupil.  Ani- 
sodus  luridus,  a  native  of  Nepal,  is  said  to  do 
so.  Baratta  (Osservazioni  Praticbe  sulle  Ma- 
lattie  degli  Occhi;  Tomo  i.  p.  139;  Milano, 
1818)  tried  conium  maculatum,  aconitum  neo- 
montanum,  digitalis  purpurea,  rhus  radicans, 
crocus   sativus,  arnica  montana,  and  papaver 


BLOODVESSELS  IN   THE   OPHTHALMIiE. 


433 


somniferum ;  but  none  of  them  dilated  the 
pupil. 

"  Barratta,  loc.  cit. :  Ammon's  Zeitschrift 
fiir  die  Ophthalmologie ;  Vol.  i.  p.  417 ;  Dres- 
den, 1831  :  Dupuytren,  Lejons  Orales  de  Cli- 
nique  Chirurgicale,  Tome  iv.  p,  129;  Paris, 
1834. 

"  Transactions  of  the  Association  of  Fellows 
and  Licentiates  of  the  King  and  Queen's  Col- 
lege of  Physicians  in  Ireland;  Vol.  iv.  p.  257; 
Dublin,  1824. 

'*  Review  of  the  different  Operations  per- 
formed on  the  Eyes,  p.  60;  London,  1826. 


'°  London  Medical  and  Physical  Journal  for 
September,  1828. 

'''  London  Medical  and  Surgical  Journal  for 
October,  1831,  p.  325. 

"  Walker,  Lancet  for  1830-1;  Vol.  ii.  p. 
619.     Julliard,  Op.  cit.  p.  73. 

"  Annales  d'Oculistique ;  Tome  xxiv.  p. 
118;  Bruxelles,  1850.  London  Journal  of 
Medicine;  Vol.  vi.  p.  268. 

*°  AVare,  Remarks  on  the  Ophthalmy,  &c., 
p.  46;  London,  1795. 


SECTION  rrr. — objective  and  subjective  symptoms  op  the  ophthalmia. 

A  tolerably  correct  notion  may  in  general  be  formed  of  the  kind  of  oph- 
thalmia which  is  present,  either,  in  thejirst  place,  by  looking  at  the  inflamed 
eye,  and  particularly  by  observing  the  arrangement  of  the  enlarged  blood- 
vessels, without  hearing  the  patient's  account  of  his  sensations ;  or,  in  the 
second  place,  by  learning  from  the  patient  the  kind  of  pain  with  which  he  is 
affected,  without  looking  at  the  eye.  Of  course,  before  proceeding  to  treat 
any  particular  case,  we  avail  ourselves  of  all  the  symptoms,  anatomical  and 
physiological ;  both  what  are  offered  to  the  direct  examination  of  our  own 
senses,  and  what  we  must  receive  on  the  testimony  of  the  patient. 

§  1.  Arrangements  of  the  Bloodvessels. 

We  meet  with  four  arrangements  of  the  external  vessels,  in  the  ophthal- 
raise ;  namely,  the  reticular,  the  zonular,  the  fascicular,  and  the  varicose. 


Fig.  61. 


Fig.  62. 


1.  The  network  observed  in  the  first  of  these  arrangements  (Fig.  61),  is 
seated  in  the  conjunctiva  ;  the  vessels  by  which  it  is  formed  are  comparatively 
large  and  tortuous ;  they  anastomose  freely  with  one  another,  and  can  be 
shoved  or  drawn  aside,  by  pressing  or  dragging  the  eyelids  with  the  finger. 
This  arrangement  resides  in  the  superficial  conjunctival  network,  derived  from 
the  lachrymal  and  palpebral  branches  of  the  ophthalmic  artery,  and  is  cha- 
racteristic of  puro-mucous  conjunctivitis. 

2.  In  zonular  inflammation  (Fig.  62),  the  vessels  are  small  and  hair-like; 
they  are  never  very  tortuous,  but  run  like  radii  towards  the  cornea,  thus 

28 


434 


PAIN  IN  THE   OPHTHALMIuE. 


forming  not  a  network,  but  a  halo,  over  which  the  conjunctiva  is  easily  made 
to  slide.  This  arrangement  resides  in  the  deep-seated  conjunctival  or  sclero- 
tic network,  formed  from  the  oculo-muscular  and  anterior  ciliary  branches  of 
the  ophthalmic  artery,  and  is  symptomatic  of  sclerotitis  and  iritis. 

3.  In  the  preceding  arrangements,  the  enlarged  vessels  are  spread  pretty 
equally  over  the  eyeball ;  but  in  the  fascicular  (Fig.  63),  the  redness  com- 
monly occupies  only  one  side  of  the  eye,  and  often  consists  of  a  few  vessels 
only,  running  towards  the  cornea,  and  terminating  in  a  phlyctenula  or 
aphtha.  This  arrangement,  then,  belongs  to  the  eruptive  varieties  of  con- 
junctivitis. 


Fisr.  63. 


Fig.  64. 


4.  Large  tortuous  vessels,  derived  from  those  belonging  to  the  recti  mus- 
cles, constitute  the  varicose  arrangement  (Fig.  64),  which  we  meet  with  most 
frequently  in  the  chronic  stage  of  arthritic  and  some  other  internal  ophthal- 
miae.  The  vessels  in  question  are  branches  of  one  or  other  of  the  seven 
trunks,  which,  advancing  towards  the  cornea,  are  visible  in  every  eye ;  namely, 
one  from  the  rectus  externus,  and  two  from  each  of  the  other  recti. 

These  four  arrangements  of  vessels  are,  in  general,  perfectly  distinct ;  but, 
in  some  cases,  they  are  combined.  They  may  be  obscured  by  what  is  termed 
ckemosis ;  an  inflammatory  oedema  of  the  areolar  tissue  under  the  conjunctiva, 
so  that  this  membrane  is  raised  from  the  sclerotica,  and  so  much  swollen  as 
sometimes  to  overlap  the  edge  of  the  cornea,  or  even  protrude  from  between 
the  eyelids.  When  chemosis  is  present,  nothing  can  be  seen  of  the  particu- 
lar distribution  of  the  vessels.  In  the  compound  ophthalmise,  again,  such 
as  the  catarrho-rheumatic,  &c.,  two  or  more  of  the  arrangements  may  be 
combined. 

In  the  acute  stage  of  any  of  the  ophthalmise,  the  blood  distends  the  arteries 
chiefly,  and  hence  the  vessels  appear  of  a  bright  red.  In  the  chronic  stage, 
the  veins  become  dilated,  and  show  a  livid  hue. 

§  2.  Kinds  of  Pain. 

Two  diflFerent  varieties  of  pain  attend  the  ophthalmise  ;  the  one  character- 
istic of  the  inflammations  of  the  conjunctiva,  the  other  of  those  affecting  the 
sclerotica  and  iris.  The  former  is  uniformly  compared  by  the  patient  to  the 
feeling  of  sand  in  the  eyes  ;  it  is  experienced  chiefly  during  the  day,  and  espe- 
cially when  the  patient  tries  to  use  the  eyes ;  the  latter  is  pulsatory,  affects 
the  circumorbital  region  as  much  as  the  eye  itself,  and  is  strikingly  nocturnal , 
commencing  after  sunset,  increasing  in  violence  till  after  midnight,  and  abat- 
ing towards  sunrise,  being  scarcely  felt  during  the  day,  but  returning  about 
the  same  hour  in  the  evening.  The  external,  gritty,  diurnal  pain  arises  from 
pressure  on  the  nerves  of  the  conjunctiva  and  eyelids ;  the  internal,  pulsatory, 
nocturnal  pain  depends  on  pressure  on  the  ciliary  nerves,  but  is  often  re- 
ferred, not  so  much  to  the  eye,  as  to  the  branches  of  the  fifth  nerve,  radi- 
ating from   the  orbit,   especially  the  supra-orbitary  branch.     Ophthalmias 


PURO-MUCOUS  CONJUNCTIVITIS.  435 

attended  by  the  conjunctival  or  sandy  pain  only,  are  generally  curable  by 
external  applications  ;  those  accompanied  by  the  circum orbital  or  pulsatory 
pain,  always  require  venesection.  Pure  retinitis  is  without  pain,  and  is 
therefore  a  deceptive  disease. 


SECTION  IV. — SIMPLE   OR   PHLEGMONOUS   CONJUNCTIVITIS. 

Si/)i. — Taraxis.     Ophthalmia  angularis.     Conjunctivite  franche,  Rognetta. 
Fig.  Dalrymple,  PI.  XIII.  Fig.  1. 

By  simple  or  phlegmonous  conjunctivitis  is  to  be  chiefly  understood  an 
idiopathic  inflammation  of  the  conjunctiva,  in  which  there  is  manifested  neither 
puro-mucous  discharge,  nor  the  appearance  of  any  cutaneous  eruption.  The 
elaborate  descriptions  of  Slade,^  Rognetta,^  and  Desmarres,^  would  lead  us  to 
suppose  that  such  a  disease  was  a  common  and  rather  severe  one ;  whereas  it 
is  neither.  Cases  occasionally  occur,  in  which  a  portion  of  the  ocular  con- 
junctiva, rarely  more  than  that  covering  the  nasal  or  temporal  side  of  the  eye- 
ball, becomes  injected  and  slightly  swollen.  The  inflamed  portion  of  the 
membrane  generally  presents  a  triangular  form,  but  is  easily  distinguished 
from  a  pterygium.  Such  cases  I  have  been  in  the  habit  of  designating  by  the 
name  taraxis,  the  ancient  term  for  the  slightest  degree  of  ophthalmia.  This 
afi'ection  sometimes  occurs,  as  a  red  patch,  on  the  corresponding  side  of  each 
eyeball. 

A  dose  of  purgative  medicine,  and  a  mild  astringent  wash,  have  generally 
sufficed  to  dissipate  this  inflammation.  Rarely  has  if  been  necessary  to  apply 
two  or  three  leeches  over  the  nasal  vein. 

Symptomatic  inflammation  of  the  conjunctiva  maybe  simple  or  phleg- 
monous ;  such  as  that  which  attends  subconjunctival  phlegmon,  already  de- 
scribed (see  p.  262);  and  that  which  occurs  in  attendance  on  inflammation  of 
other  textures  of  the  eye,  as  on  sclerotitis  or  corneitis. 


»  Oplithalmia.    By  J.  Slade,  M.  D.,  p.  23  ;         '  Traite  tlieorique  et  pratique  des  Maladies 
London,  1838.  des  Yeux,  p.  167  ;  Paris,  1847. 

*  Traite  philosophique  et  clinique  d'Ophthal- 
mologie,  p.  275 ;  Paris,  1844. 


SECTION  V. — PURO-MUCOUS   CONJUNCTIVITIS  IN  GENERAL. 
Syn. — Lippitudo,  Celsus.     Ophthalmoblennorrhoea. 

The  muco-cutaneous  membrane  which  lines  the  eyelids  and  invests  the  an- 
terior surface  of  the  eyeball,  is  apt  to  sufler  either  from  inflammation,  like 
that  by  which  the  other  parts  of  the  mucous  system  are  commonly  attacked, 
namely,  a  puro-mucous,  blennorrhceal,  or  catarrhal  inflammation;  or  to  be  af- 
fected with  diseases  evidently  partaking  of  the  nature  of  cutaneous  eruptions. 
The  conjunctiva  thus  resembles  the  membrane  of  the  fauces,  which  sometimes 
is  aflfected  with  catarrhal,  and  at  other  times  with  aphthous  inflammation;  or 
the  continuation  of  the  lining  membrane  of  the  urethra  over  the  glans  penis, 
and  inside  the  prepuce,  which  in  one  case  we  see  aff"ected  with  a  species  of 
gonorrhoea,  and  in  another  with  pustular  or  herpetic  eruptions. 

Symptoms. — There  are  certain  syrapton)s  characteristic  of  the  genus  coti- 
junctivitis  puro-mucosa,  whether  it  arise  from  the  influence  of  cold,  or  from 
contagion,  and  whether  the  contagion  be  derived  from  the  eye  of  another 


436  PURO-MUCOUS  CONJUNCTIVITIS. 

person,  or  depend  upon  the  application  of  puriform  matter  from  other  quarters, 
as  that  of  leucorrhoea  or  gonorrhoea.  All  these  causes  are  capable  of  exciting 
puro-mucous  conjunctivitis ;  contagion  of  any  sort  always  producing  a  much 
more  severe  disease  than  the  mere  influence  of  cold.  The  symptoms  of  puro- 
mucous  conjunctivitis  are  analogous  to  those  which  attend  the  blennorrhoeal  or 
purulent  inflammations  of  other  mucous  membranes,  as  of  the  Schneiderian 
membrane  in  catarrh,  or  the  lining  of  the  urethra  in  gonorrhcEa.  The  most 
striking  character  of  this  genus  is,  no  doubt,  the  puriform  discharge.  I  need 
scarcely  say  that  the  pus  is  secreted  by  the  conjunctiva;  it  is  merely  an  in- 
creased and  changed  discharge  of  mucus,  and  not  the  effect  of  ulceration. 

Puro-mucous  ophthalmia,  from  whatever  cause  it  originates,  commences  in 
the  conjunctiva  and  is  at  first  confined  to  that  tunic ;  but  in  severe  cases,  the 
other  textures,  and  especially  the  cornea,  are  apt  to  suffer,  and  thus  the  eye 
may  be  destroyed. 

Stages. — Puro-mucous  conjunctivitis  presents  four  stages.  The  j^rsi,  which 
is  generally  so  short  as  to  pass  unobserved,  is  the  stage  of  pure  inflammation. 
The  second  is  marked  by  discharge,  more  or  less  puriform,  and  is  often  at- 
tended by  chemosis,  and  swelling  of  the  eyelids.  In  the  third,  the  cornea  is 
affected,  becoming  opaque,  infiltrated  first  with  serum,  then  with  pus,  softened, 
and  more  or  less  deeply  ulcerated,  so  that  the  front  of  the  eye  is  apt  to  give 
way,  the  iris  to  protrude,  and  the  case  to  end  in  staphyloma.  The  fourth 
stage  is  characterized  chiefly  by  the  papillary  structure  of  the  palpebral  con- 
junctiva remaining  hypertrophied,  and  presenting  a  granular  or  sarcomatous 
appearance,  while  the  lids,  in  this  state,  rubbing  on  the  cornea,  render  this 
part  of  the  eye  vascular  and  nebulous. 

During  the  course  of  puro-mucous  inflammation  of  the  conjunctiva,  the 
membrane  is  often  enormously  dilated,  all  its  folds  becoming  amplified,  so  that 
instead  of  being  hid  between  the  eyelids  and  eyeball,  they  actually  protrude 
externally.  Its  secreting  surface  is  also  greatly  changed  by  abnormal  nutri- 
tion ;  so  that  its  papillae,  which  in  the  natural  state  are  small  and  sessile,  be- 
come distinctly  visible  to  the  naked  eye,  and  project  from  the  inside  of  the 
lids  like  so  many  granulations.  There  is  not  much  new  production  in  all  this, 
but  chiefly  an  inflammatory  amplification  of  natural  structure. 

The  destruction  of  the  cornea  in  the  puro-mucous  ophthalmiae  is  to  be  attri- 
buted, not  altogether  to  a  vital,  but  partly  to  a  mechanical  cause;  not  alto- 
gether to  excessive  inflammatory  action  in  the  cornea  itself,  but  partly  to  the 
pressure  caused  by  the  enormously  distended  conjunctiva  of  the  eyelids  and 
eyeball.  Other  causes,  no  doubt,  concur,  in  the  puro-mucous  inflammations  of 
the  conjunctiva,  to  produce  opacities  of  the  cornea,  detachment  of  its  epi- 
thelium, and  ulceration ;  and,  in  particular,  its  maceration  in  a  flood  of 
purulent  fluid,  not  sedulously  removed  by  lotions  and  injections.  But  the 
destruction  of  the  cornea  by  infiltration  of  serum  and  pus,  by  ramollissement 
and  ulceration,  may  be  referred  in  no  small  degree  to  the  pressure  of  the 
chemosed  conjunctiva,  interfering  mechanically  with  the  due  nutrition  of  the 
part.  A  circular  groove  of  ulceration  on  the  edge  of  the  cornea,  at  the 
place  covered  by  the  chemosed  conjunctiva,  is  a  frequent  occurrence,  and 
seems  attributable  to  excessive  absorption  excited  directly  by  pressure, 
although  it  must  be  noticed  that  troughing  ulcers,  as  they  have  been  termed, 
occur  also  where  there  is  no  chemosis.  Destruction  of  the  cornea  is  much 
more  apt  to  happen  in  those  subjects,  in  whom  the  lids,  from  original  con- 
formation, sit  close  upon  the  eyeball,  the  sinuses  of  the  conjunctiva  being 
small  and  the  fissura  palpebrarum  short,  than  in  those  in  whom  we  find  the 
opposite  conditions.     I  have  remarked  this  especially  in  infants. 

With  respect  to  the  discharge  from  the  conjunctiva  in  the  puro-mucous 
ophthalmise,  it  may  be  well  to  recollect,  that  "mucus,  as  a  copious  fluid 


PURO-MUCOUS   CONJUNCTIVITIS.  43T 

secretion,  has,"  as  Mr.  Simon  states,  "no  existence  in  health;  the  only 
natural  secretion  of  a  mucous  membrane  is  its  epithelium,  which  ought  not 
to  exist  in  quantity  sufficient  for  any  evident  discharge.  If  the  secretion  be 
hurried,  it  immediately  begins  to  assume  the  forms  and  physical  characters 
of  pus."^  The  discharge  of  puriform  fluid  from  the  inflamed  conjunctiva 
goes  on  without  any  breach  of  surface,  and  the  fluid  discharged  possesses  in 
itself  no  acrid  or  erosive  property.  Pent  up,  however,  between  the  lids  and 
the  eyeball,  it  irritates  greatly  the  inflamed  organ,  and  the  allowing  of  it  to 
remain  there  increases  in  a  high  degree  the  risk  of  disorganization  of  the 
cornea.  The  discharge  irritates  mechanically ;  it  produces  the  feeling  of  a 
foreign  body  in  the  eye,  which  feeling  is  removed  when  the  discharge  is 
cleaned  away.  This  mechanical  irritation  excites  more  inflammation ;  but 
besides  this,  if  the  discharge  is  of  a  specific  kind,  as  gonorrhceal,  its  pre- 
sence inoculates  one  portion  of  the  conjunctiva  after  another. 

The  granular  stage  of  the  puro-mucous  ophthalmia  is  of  indefinite  dura- 
tion. Worn  out  by  long-continued  suffering,  the  patient  is  apt  to  become 
hectical,  and,  when  this  is  the  case,  the  eyes  prove  incurable. 

PatJiological  anatomy. — The  following  account  of  the  pathological  ana- 
tomy of  the  ophthalmia  neonatorum,  by  M.  Dequevauviller,  may  be  con- 
sidered applicable  to  the  puro-mucous  inflammations  of  the  conjunctiva 
generally : — 

1.  The  appearances  of  inflammation  are  dissipated  by  death ;  the  red  color  of  the  con- 
junctiva has  given  place  to  a  livid  tint,  the  turgescence  has  sunk  away,  and  the  membrane 
is  loose  and  wrinkled. 

2.  The  nebulous  state  of  the  cornea  has  subsided. 

3.  The  lamellas  of  the  cornea  are  separated  from  one  another  by  thin  fluid,  and  are  less 
adherent  than  in  the  normal  state. 

4.  In  the  state  of  ramollissement,  the  lamellae  are  reduced  by  the  slightest  scraping  to 
the  state  of  a  thick,  yellowish-white  liquid,  similar  to  what  is  seen  when  the  scalpel  is 
drawn  along  a  softened  fibrous  membrane. 

5.  When  the  cornea  has  been  deeply  ulcerated,  the  surface  of  the  ulcer  appears,  when 
viewed  through  a  lens,  smooth;  but  after  two  or  three  hours'  maceration  in  water  or 
alcohol,  a  thin  pellicle  may  be  removed  from  the  surface  of  the  ulcer.  It  is  then  easy  to 
separate  the  lamellae  with  the  point  of  the  scalpel,  and  to  perceive  in  each  of  them  an 
opening,  as  if  formed  by  an  eviporte-pikce,  of  which  the  diameter  is  more  considerable  in 
proportion  as  the  lamina,  which  is  perforated,  is  the  more  superficial.  The  lamina  form- 
ing the  bottom  of  the  ulcer  is  slightly  opaque,  but  those  beneath  it  may  be  transparent. 

6.  If  there  is  procidentia  iridis,  it  is  the  free  edge  of  the  membrane,  which  has  fsillen 
into  the  ulcer.  The  larger  the  opening,  the  more  considerable  the  portion  of  prolapsed 
iris.  When  only  a  small  part  is  prolapsed,  the  pupil  assumes  the  form  of  an  irregular 
ellipse,  one  end  of  which  corresponds  to  the  opening  in  the  cornea.  If  the  portion  is 
great,  the  pupil  disappears  completely.  In  this  case,  sometimes  the  opposite  ciliary  edge 
is  detached  and  drawn  towards  the  ulcer.  Whatever  be  the  color  of  the  iris,  the  hernia 
always  presents  a  uniform  black  hue.  Adhesions  are  generally  found  between  the  iris 
and  the  membrane  which  covers  in  the  ulcer. 

7.  If  the  cornea  be  extensively  destroyed,  neither  the  lens  nor  the  greater  part  of  the 
vitreous  body  is  to  be  found.  If  the  case  is  recent,  the  iris  is  glued  to  the  debris  of  the 
cornea,  and  the  pupil  widely  open.  If  not  recent,  the  eye  is  shrunk  to  the  bottom  of  the 
orbit,  solid,  and  the  different  elements  of  its  structure  scarcely  recognizable.* 

Oure. — A  treatment,  partly  antiphlogistic  and  soothing,  partly  stimulating 
and  smarting,  is  the  most  successful  in  the  cure  of  all  the  puro-mucous 
ophthalmise. 


'  General    Pathology,   by   John   Simon,   p.        ^  Archives  Centrales  de  Medecine,  4^  Serie, 
112;  London,  1850.  Tome  ii.  p.  9  ;  Paris,  1813. 


438  CATARRHAL  OPHTHALMIA. 


SECTION  VI CATARRHAL  OPHTHALMIA. 

Syn, — Catarrhus  oculi,  Langenbeck.     Ophthalmia  purulenta  mitior.     Conjunctivitis  puro- 

mucosa  catarrhalis. 

Fig.  Wardrop,  PI.  I.  Fig.  1.    Dalrymple,  PI.  I.  Fig.  1.  PI.  VII.  Fig.  6,    Sichel,  PI.  IT.  Figs.  1, 2. 

There  are  three  ophthalmiae,  which  are  frequently  excited,  especially  in 
adults,  by  atmospheric  influences ;  namely,  the  catarrhal,  the  rheumatic,  and 
the  catarrho-rheumatic.  The  first  of  these  is  a  puro-mucous  or  blennorrhoeal 
inflammation  of  the  conjunctiva ;  the  second,  an  affection  of  the  fibrous  scle- 
rotica ;  while  in  the  third,  both  the  conjunctiva  and  sclerotica  are  attacked, 
the  symptoms  of  catarrhal  being  united  to  those  of  rheumatic  ophthalmia. 

Symptoms. — The  inflammation  in  the  catarrhal  ophthalmia,  which  is  by  far 
the  most  common  disease  of  the  eye  in  adults,  is  almost  entirely  confined  to 
the  conjunctiva  and  Meibomian  follicles.  The  symptoms  are  redness  and 
swelling  of  the  internal  surface  of  the  eyelids,  reticular  redness  of  the  scle- 
rotic conjunctiva,  sandy  pain,  and  adhesion  of  the  eyelids  in  the  morning. 

1.  The  conjunctival  secretion  is  increased  in  quantity,  and  occasionally 
becomes  opaque,  thick,  and  puriform ;  but  in  many  cases  remains  transpa- 
rent, its  superabundant  quantity  giving  to  the  eye  an  appearance  of  more 
than  usual  moistness,  and  communicating  to  the  patient  a  feeling  of  gluey- 
ness ;  while  the  Meibomian  secretion,  also  increased  in  quantity  and  changed 
by  disease,  concretes  on  the  edges  of  the  lids  and  amongst  the  eyelashes,  and 
binds  them  together  during  the  night. 

2.  In  mild  cases,  the  redness  is  chiefly  in  the  conjunctiva  lining  the  eyelids. 
On  the  white  of  the  eye,  the  vessels  are  arranged  in  a  network  (Fig.  61)  ;  and 
can  be  moved  in  every  direction,  by  pressing  the  eyelid  against  the  eyeball 
with  the  finger,  showing  that  they  reside  in  the  conjunctiva.  Not  unfrequently 
we  observe  spots  of  extravasated  blood  beneath  the  conjunctiva,  or  even  a 
pretty  general  but  slight  ecchymosis.  In  severe  cases,  chemosis  takes  place, 
even  to  a  great  extent;  so  much  so,  that  if  only  general  treatment  be  em- 
ployed, as  bloodletting  and  purging,  while  local  means  are  neglected,  the 
cornea  may  assume  a  nebulous  appearance  from  being  infiltrated  with  serum, 
ulcerate  at  its  edge,  become  the  seat  of  abscess,  burst,  and  be  more  or  less 
extensively  disorganized. 

3.  In  catarrhal  ophthalmia,  the  patient  uniformly  complains  of  a  feeling  of 
pricking  or  roughness  of  the  eye,  or  as  if  sand,  hot  ashes,  or  broken  glass  was 
under  the  upper  eyelid ;  a  sensation  which  never  attends  the  pure  rheumatic 
ophthalmia,  and  may  therefore  be  regarded  as  strikingly  diagnostic.  So  dis- 
tressing, even  at  the  beginning  of  an  attack  of  catarrhal  ophthalmia,  is  the 
sensation  as  if  sand  or  some  other  foreign  body  were  under  the  upper  eyelid, 
that  I  have  repeatedly  been  requested  to  visit  patients  in  whom  this  disease 
was  commencing,  who  supposed  that  some  particle  of  dust  had  actually  got 
into  that  situation;  and  in  one  instance  I  was  called  in  the  night  to  visit  a 
medical  gentleman,  who  was  so  convinced,  from  the  feelings  which  he  ex- 
perienced, that  this  was  the  case,  that  he  had  made  various  attempts,  with  his 
dressing-probe,  to  free  himself  from  the  imaginary  offending  substance.  The 
chief  cause  of  the  sandy  pain  is  the  rubbing  of  the  very  sensitive  eyelids  over 
the  turgid  vessels  of  the  sclerotic  conjunctiva.  The  presence  of  flakes  of 
puriform  mucus  also  excites  this  feeling. 

The  exacerbation  in  catarrhal  ophthalmia  is  in  the  evening,  and  is  attended 
with  itchiness  of  the  eyes  and  photophobia,  but  is  relieved  by  going  to  bed, 
and  the  patient  sleeps,  in  general,  without  interruption  during  the  night. 
The  pain  is  renewed  when  the  patient  attempts  to  use  the  eyes  in  the  morn- 
ing, owing  to  the  motion  of  the  inflamed  surfaces.     In  the  catarrhal  ophthal- 


CATARRHAL  OPHTHALMIA.  439 

mia,  the  patient  is  generally  free  from  headache ;  whereas  in  the  rheumatic, 
one  of  the  most  remarkable  symptoms  is  supra-orbital  or  circum-orbital  pain, 
severely  aggravated  during  the  night,  the  exacerbation  in  this  disease  being 
from  6  P.  M.  till  6  A.  M.  When  headache  does  attend  catarrhal  ophthalmia, 
it  is  seated  across  the  forehead,  as  if  in  the  frontal  sinuses,  and  is  felt  most 
in  the  morning. 

4.  Catarrhal  ophthalmia  is  often  attended  by  symptoms  of  inflammation 
of  the  lining  membrane  of  the  nostrils,  fauces,  and  trachea.  In  the  other 
cases,  the  affection  being  confined  to  the  eye,  is  an  uncomplicated  mucous 
conjunctivitis.  In  female  children  of  two  or  three  years  old,  catarrhal  oph- 
thalmia is  not  unfrequently  present  along  with  a  puro-mucous  discharge  from 
the  vagina.  In  such  cases,  the  ophthalmia  is  sometimes  mild,  but  often  pretty 
severe,  and  the  discharge  distinctly  purulent. 

Causes. — Atmospheric  changes,  and  especially  exposure  to  cold  and  wet, 
are  the  chief  exciting  causes  of  catarrhal  ophthalmia.  Night-watching,  and 
exposure  to  the  night  air,  after  being  much  heated,  or  in  a  state  of  intoxica- 
tion, frequently  give  rise  to  the  disease.  Sailors,  soldiers  on  board  transports, 
and  others  on  board  ship,  are  often  attacked  by  it,  especially  those  who  sleep 
near  a  port-hole,  or  open  hatchway;  also  soldiers  in  hospital,  especially  those 
who  sleep  near  the  door,  a  window,  or  any  aperture  admitting  a  draught  of 
air.  The  nightmen  of  Paris  are  subject  to  this  disease,  which  they  term  la 
mitte.^  Wet  feet  is  a  cause  which  some  of  my  patients  have  particularly 
mentioned.  A  delicate  female  was  violently  attacked  with  this  disease  in  both 
eyes,  in  consequence  of  riding  outside  a  stage  coach  from  Edinburgh  to  Glas- 
gow. Another  lady  owed  her  first  attack  to  bathing  in  the  sea;  and  for 
many  months  was  liable  to  a  relapse  on  any  slight  exposure,  or  over-exercise 
of  the  sight.  Reading  or  writing  to  a  late  hour  in  the  night,  sometimes  brings 
on  catarrhal  ophthalmia,  or  what  we  should  rather  call  simple  mucous  con- 
junctivitis, the  discharge  being  scarcely  puriform.  If  those  who  have  become 
long-sighted  from  age,  read  or  write  without  glasses,  this  disease  is  apt  to  be 
the  result.  Prolonged  suckling  sometimes  brings  on  puro-mucous  conjunc- 
tivitis, attended  with  more  than  common  irritation  of  the  eyes.  The  affection 
called  hay-fever  is  apt  to  be  attended  with  considerable  inflammation  of  the 
conjunctiva,  of  catarrhal  character.  An  individual  who  has  once  labored 
under  catarrhal  ophthalmia  is  more  likely  to  be  attacked  again ;  one  of  my 
patients  had  three  attacks  between  May  and  January. 

Efidemic. — In  many  instances,  catarrhal  ophthalmia  has  been  known  sud- 
denly to  attack  about  the  same  time  a  great  number  of  persons,  who  happened 
to  be  exposed  to  the  same  general  exciting  causes.  Assalini,  for  example, 
relates  that,  in  May,  1192,  several  battalions  of  the  Duke  of  Modena's  troops 
arrived  at  Reggio  to  quell  some  riots.  These  troops  passed  the  first  night 
after  their  arrival  under  the  spacious  porticos  of  a  convent  looking  to  the 
north,  in  the  lowest  part  of  the  town,  and  near  the  trenches  of  the  citadel. 
Many  of  the  soldiers  contracted  a  violent  catarrhal  ophthalmia,  which  was 
attributed  to  the  dust  of  the  straw  on  which  they  had  slept,  and  not  to  the 
moist  and  cold  air  of  the  place,  which  no  doubt  was  the  true  cause,  and  which 
was  so  much  the  more  likely  to  prove  hurtful,  as  these  men  had  been  accus- 
tomed to  close  and  comfortable  quarters.^ 

Catarrhal  ophthalmia  has  been  known  to  spread  itself  still  more  exten- 
sively, attacking  a  great  proportion  of  the  inhabitants  of  a  town  or  district, 
so  as  to  obtain  the  name  of  epidemic  ophthalmia.  In  17*78,  it  attacked  the 
whole  neighborhood  about  Newbury,  in  Berkshire  ;  and,  in  the  same  year,  it 
prevailed  in  several  of  the  English  camps,  where  it  was  known  by  the  name 
of  the  ocular  disease.  In  the  winter  of  1803,  a  catarrhal  ophthalmia  pre- 
vailed almost  generally  in  Paris,  and  received  from  the  people  the  name  of 


440  CATARRHAL  OPHTHALMIA. 

cocote.^  The  same  occurred  in  1806,  and  was,  in  many  instances,  attended  by 
an  affection  of  tlie  mucous  membrane  of  the  air-passages ;  a  complication  which 
I  have  repeatedly  observed  in  the  sporadic  cases  of  this  country.  The  same 
complaint  prevailed  in  1808,  at  Yicenza,  in  Italy.  It  has  been  mentioned  by 
some  authors  that  this  disease  is  more  common  in  summer  and  autumn. 
In  Glasgow  and  its  neighborhood,  it  is  common  at  all  seasons;  but  most 
abundant  during  cold  wet  weather,  or  when  the  east  or  northeast  wind 
prevails. 

The  whole  way  from  Orihuela  to  Alicant,  in  Spain,  Mr.  Inglis  observed 
that  almost  all  the  children,  and  very  many  grown-up  persons,  were  affected 
with  sore  eyes.  The  poeple  in  the  neighborhood  were  unable  to  assign  any 
cause  for  this,  though  he  was  informed  at  Alicant  that  it  was  to  be  attributed 
to  irrigation.* 

In  Egypt,  many  circumstances  favor  the  rise  and  continuance  of  puro- 
mucous  ophthalmia ;  such  as  her  low  plains,  sandy  deserts,  the  lakes,  as  in 
the  neighborhood  of  Alexandria,  and  the  dazzling  glare  reflected  from  the 
uniformly  white  surface  which  every  object  presents.  On  European  armies 
in  that  country,  the  high  temperature,  and  the  heavy  night-dews,  must  have 
operated  unfavorably,  as  well  as  the  minute  particles  of  hot  sand  which  float 
in  the  air,  and  are  raised  by  the  slightest  breeze.  Although  endemic,  or  epi- 
demic, and,  in  the  first  instance,  excited  by  atmospheric  and  other  general 
causes,  it  appears  afterwards  to  become  contagious,  and,  then  in  an  aggravated 
form  constitutes  the  Egyptian  or  contagious  ophthalmia. 

Prognosis. — If  catarrhal  ophthalmia  be  neglected,  or  treated  only  with 
general  remedies,  or  with  improper  local  ones,  it  will  continue  for  many 
weeks,  and  become  the  cause  of  much  febrile  excitement  and  constitutional 
illness,  as  well  as  local  distress  and  danger.  Amongst  other  bad  effects  of 
neglect,  the  conjunctiva,  particularly  where  it  lines  the  upper  eyelid,  becomes 
sarcomatous  and  rough,  and  by  rubbing  in  this  state  against  the  cornea, 
renders  it,  and  especially  the  upper  half  of  it,  vascular  and  nebulous,  or  even 
densely  opaque.  The  discharge  from  the  conjunctiva  is  apt,  also,  under 
neglect  or  improper  treatment,  to  become  thicker  and  more  opaque,  and  to 
show  a  power  of  propagating  the  disease  by  contact. 

Contagiousness.— 1  regard  it  as  scarcely  admitting  of  doubt,  that  the  dis- 
charge in  catarrhal  ophthalmia,  if  conveyed  from  the  eyes  of  the  patient  to 
those  of  others,  by  the  fingers,  or  by  the  use  of  towels  and  the  like  in  com- 
mon, is  apt  to  excite  a  conjunctivitis  still  more  severe,  more  distinctly  puri- 
form,  and  more  dangerous  in  its  effects  on  the  cornea,  than  was  the  original 
ophthalmia.  This  is  the  conclusion  to  which  I  have  arrived,  from  the  obser- 
vation of  many  instances,  in  which,  as  far  as  it  was  possible  to  come  to  the 
facts,  this  disease  having  arisen  in  one  member  of  a  family  from  atmospheric 
exposure,  several  others  of  the  family  have  become  affected  without  any  such 
exposure  that  could  be  ascertained ;  and  while,  in  the  first  affected,  the  disease 
was  comparatively  mild,  and  scarcely  puriform,  in  the  latter  the  symptoms 
were  more  violent,  and  the  discharge  thick,  abundant,  and  opaque. 

I  think  it  probable,  that  the  ophthalmia  which  attacked  the  British  and 
French  armies  in  Egypt  was  a  puro-mucous  conjunctivitis  excited  by  atmo- 
spheric causes,  but  that  it  afterwards  degenerated  into  a  contagious,  perhaps 
infectious,  disease ;  that  is  to  say,  that  it  was  propagated  by  actual  contact 
of  the  discharge,  and  perhaps  by  miasmata  from  the  eyes  floating  through  the 
air.  Nor  is  this  idea  inconsistent  with  what  is  generally  admitted  regarding 
contagious  and  infectious  diseases.  If  we  admit  such  a  thing  as  contagion  or 
infection  at  all,  we  must  also  admit,  I  should  apprehend,  that  diseases  originally 
excited  by  external  influences,  are  propagated  only  in  the  second  and  succeed- 
ing instances  by  their  contagious  or  infectious  power. 


CATARRHAL  OPHTHALMIA.  441 

I  know  of  no  experiments  in  which  the  discharge  from  an  eye  affected  with 
simple  catarrhal  ophthalmia,  or  puro-mucous  conjunctivitis  arising  from 
atmospheric  influence,  has  been  applied  to  a  sound  eye.  Dr.  Guillie's  experi- 
ments, indeed,  may  have  been  pei'formed  with  matter  of  this  description. 
He  took  the  puriform  mucus  from  the  eyelids  of  some  children  affected  with 
puro-mucous  conjunctivitis,  in  the  Hospital  for  Sick  Children  at  Paris,  and 
introduced  it  under  the  eyelids  of  four  children  belonging  to  the  Institution 
for  the  Blind.  These  children  were  amaurotic,  but  the  external  surface  of 
their  eyes  was  healthy  and  entire.  In  all  four  a  regular  pui'O-mucous  con- 
junctivitis was  produced.*  Mr.  Mackesy**  relates  some  experiments,  in  which 
he  applied  the  discharge,  taken  from  the  eyes  of  four  soldiers,  to  his  own, 
without  producing  any  inflammation.  The  men  from  whom  the  matter  was 
taken,  appear  to  have  been  laboring  under  catarrhal  ophthalmia,  but  the  ap- 
plication to  the  conjunctiva  was  probably  insufficiently  accomplished,  Mr. 
'Mackesy  satisfying  himself  principally  with  keeping  a  piece  of  linen,  imbued 
with  the  discharge,  laid  upon  his  eyelids. 

In  the  next  section,  I  shall  have  occasion  to  refer  to  one  or  more  striking 
instances  of  catarrhal  ophthalmia  spreading  apparently  by  contagion  or  in- 
fection. 

Treatment. — Catarrhal  ophthalmia  yields  readily  to  a  very  simple  treatment, 
chiefly  of  a  local  stimulating  kind.  I  was  first  struck  with  the  truth  of  this 
fact  iu  the  successful  management  of  this  disease  by  Professor  Beer,  at  Vienna, 
in  181 1 ;  and  I  was  confirmed  in  this  veiew  by  an  attentive  consideration  of 
the  cases  detailed  in  an  excellent  Report  by  Mr.  Melin,  published  in  the 
London  Medical  and  Physical  Journal,  for  September,  1824.  The  results  of 
my  own  practice,  both  in  private  and  at  the  Glasgow  Eye  Infirmary,  some 
account  of  which  I  submitted''  to  the  profession  in  1826,  have  amply  borne 
me  out  in  the  belief,  that  general  remedies  in  this  disease  are  inferior  in  im- 
portance to  local  ones  ;  that  violent  general  remedies  are  worse  than  useless; 
and  that  a  local  stimulant  treatment  may  generally  be  relied  on. 

1.  The  feeling  of  sand  in  the  eye  is  uniformly  relieved,  and  the  inflamma- 
tion abated,  by  the  use  of  a  solution  of  nitrate  of  silver,  a  remedy  of  sovereign 
utility  in  the  puro-mucous  inflammations  of  the  conjunctiva,  and  without  which 
these  diseases  would  often  prove  destructive  to  vision.  The  solution  which 
I  generally  employ  contains  4  grains  of  the  nitrate  in  1  ounce  of  distilled 
water.  A  large  drop  is  to  be  applied  to  the  eye  once,  twice  or  thrice  a-day, 
according  to  circumstances,  by  means  of  a  pretty  thick  camel-hair  pencil. 
For  a  minute  or  two  after  the  drop  is  applied,  nothing  particular  is  felt.  The 
eye  then  begins  to  be  affected  with  pricking  pain,  which,  when  the  inflamma- 
tion is  acute,  becomes  pretty  smart,  continues  for  perhaps  10  minutes,  and 
dies  away ;  after  which  the  eye  feels  much  easeir  than  it  did  before  the  drop 
was  applied.  In  particular,  the  feeling  of  sand  and  tendency  to  lachrymation 
are  much  relieved.  The  eye  continues  easy  for  perhaps  five  or  six  hours, 
when  the  symptoms  again  return,  and  ought  immediately  to  be  checked  by 
the  application  of  another  drop.  As  the  disease  subsides,  the  remedy  gives 
less  and  less  pain,  till  at  last  it  is  scarcely  felt.  I  have  sometimes  alarmed 
other  practitioners,  by  proposing  to  drop  upon  the  surface  of  an  eye  highly 
vascular,  affected  with  a  feeling  as  if  broken  pieces  of  glass  were  rolling  under 
the  eyelids,  and  evidently  secreting  puriform  matter,  a  solution  of  lunar  caus- 
tic ;  and  I  have  been  not  a  little  pleased  and  amused  at  their  surprise,  when, 
next  day,  they  have  found  all  the  symptoms  much  abated  by  the  use  of  this 
application.  If  the  patient  is  of  a  torpid  constitution,  and  the  discharge 
from  the  conjunctiva  copious,  a  solution  of  10  grains  to  the  ounce  may  be 
used.  Stronger  solutions  than  this,  or  even  a  saturated  one,  may  sometimes 
be  applied  with  advantage. 


442  CATARRHAL  OPHTHALMIA. 

2.  The  patient  experiences  much  relief  from  fomenting  the  eyes  with  warm 
water,  or  warm  poppy  decoction.  As  a  fomentation  or  collyrium,  I  am  in 
the  habit,  however,  of  employing  a  solution  of  1  grain  of  corrosive  sublimate, 
and  6  grains  of  muriate  of  ammonia,  in  6  ounces  of  water,  to  a  tablespoon- 
ful  of  which,  at  the  time  of  being  used,  is  to  be  added  an  equal  quantity  of 
boiling  water.  This  diluted  solution  is  to  be  used  twice  a-day  for  fomenting 
the  eyelids,  by  means  of  a  folded  piece  of  linen,  or  flat  soft  sponge.  In  mild 
cases,  a  few  drops  are  then  allowed  to  flow  in  upon  the  eye  ;  but,  in  severe 
cases,  in  which  the  discharge  is  copious  and  puriform,  the  collyrium  must  be 
injected  over  the  whole  surface  of  the  conjunctiva,  and  especially  into  the 
upper  fold  of  that  membrane,  by  means  of  a  syringe,  so  that  the  morbid  se- 
cretion may  be  entirely  removed,  and  the  diseased  membrane  touched  imme- 
diately by  the  solution.  Great  relief  is  obtained  in  all  the  puro-raucous 
ophthalmise  by  the  removal  of  the  discharge,  the  feeling  of  sand  in  the  eye , 
being  in  a  gi'eat  measure  caused  by  its  presence. 

3.  At  bedtime,  about  the  size  of  a  barley-corn  of  red  precipitate  ointment, 
melted  on  the  end  of  the  finger,  is  to  be  smeared  along  the  edges  of  the  eye- 
lids. The  ointment  must  be  prepared  in  the  manner  specified  at  page  17t, 
and  ought  generally  to  be  of  the  strength  of  20  grains  to  the  ounce. 

4.  I  rarely  find  it  necessary  to  take  away  blood  in  catarrhal  ophthalmia, 
either  from  a  vein  or  by  leeches.  When  there  is  more  than  ordinary  consti- 
tutional irritation,  the  taking  away  of  from  12  to  20  ounces  of  blood  from  the 
arm,  will  no  doubt  prove  useful ;  but  this  will  rarely  be  necessary  if  the  disease 
has  not  been  neglected  for  a  number  of  days  or  mistreated.  If  the  local 
symptoms  do  not  speedily  yield  to  the  remedies  already  mentioned,  from  6  to 
12  leeches  may  be  applied,  two  or  three  over  the  nasal  vein,  and  the  rest 
over  the  temple  or  eyelids. 

5."  Scarification  of  the  conjunctiva  of  the  eyelids  is  necessary  only  in  cases 
in  which  there  is  some  degree  of  chemosis,  and  a  distinctly  puriform  discharge. 
In  such  cases,  it  proves  a  valuable  means  of  cure,  if  performed  according  to 
the  directions  given  at  page  425. 

6.  A  brisk  dose  of  calomel  and  jalap  may  be  ordered  at  the  commencement, 
with  occasional  doses  of  neutral  salts  during  the  course  of  the  disease. 

1.  Determining  to  the  skin  is  useful.  This  may  be  done  by  the  warm 
pediluvium  at  bedtime,  small  doses  of  spiritus  Mindereri,  or  of  any  other 
mild  diaphoretic,  in  combination  with  diluent  drinks,  and  rest  in  bed. 

8.  In  severe  cases,  a  blister  to  the  back  of  the  neck  will  be  found  useful, 
or  blisters  behind  the  ears,  kept  open. 

9.  When  the  disease  has  been  long  neglected,  and  has  fallen  into  a  chronic 
state,  the  remedies  already  indicated  should  be  tried  in  the  first  instance. 
Should  they  fail  in  producing  the  amount  of  benefit  which  is  expected,  ad- 
vantage will  be  obtained  by  adding  two  drachms  of  vinum  opii  to  the  6  ounces 
of  the  colljTium.  Recourse  may  also  be  had  to  a  nitrate  of  silver  salve,  con- 
taining from  10  to  20  grains  of  the  salt  to  the  ounce  of  fatty  matter,  or  to 
red  precipitate  salve  of  the  strength  of  from  30  to  60  grains  to  the  ounce. 
The  method  of  using  these  salves  is  to  wipe  the  conjunctiva  of  both  lids  dry, 
and  then  having  about  the  bulk  of  a  split  pea  of  the  salve,  melted  on  the  point 
of  the  finger,  rub  it  into  the  diseased  surface.  The  salve  is  a  substitute  for 
the  nitrate  of  silver  solution,  and  is  to  be  applied  once  a-day. 

10.  Though  the  sclerotic  conjunctiva  has  become  free  from  redness,  it  is 
not  to  be  supposed  that  the  disease  is  completely  subdued.  It  is  probable  that 
the  palpebral  conjunctiva  still  remains  in  an  injected  state.  The  inside  of 
the  eyelids,  and  especially  of  the  upper  one,  ought  daily  to  be  inspected.  If 
there  is  any  tendency  to  a  rough  and  sarcomatous  state  of  the  conjunctiva,  it 
ought  to  be  alternately  scarified,  and  touched  with  solid  sulphate  of  copper 


CONTAGIOUS   OPHTHALMIA.  443 

or  nitrate  of  silver,  as  I  shall  explain  more  particularly  under  the  head  of 
Granular  Conjunctiva. 

Regimen. — The  patient  should  use  a  mild  diet,  without  fermented  liquors, 
avoid  reading  and  writing,  shade  the  eyes  from  bright  light,  and  go  early 
to  bed. 

I  have  treated  many  hundred  cases  of  catarrhal  ophthalmia  according  to  the 
plan  above  detailed,  and  generally  with  these  three  applications  only;  namely, 
the  solution  of  nitrate  of  silver,  the  bichloride  of  mercury  collyrium,  and 
the  red  precipitate  salve.  In  almost  no  case  (indeed,  I  may  say  in  no  case 
where  scrofula  did  not  modify  the  symptoms),  in  which  these  remedies  were 
had  recourse  to  previously  to  ulcer  or  opacity  of  the  cornea,  did  any  ulcer  or 
opacity  ever  occur ;  nor  did  the  symptoms  ever  fail  speedily  to  subside.  On 
the  other  hand,  I  have  repeatedly  had  occasion  to  see  cases  of  this  disease 
which  had  been  much  aggravated  by  trusting  altogether  to  general  ti-eatment, 
and  eF45ecially  to  bleeding ;  or  by  the  use  of  acetate  of  lead,  or  sulphate  of 
zinc,  as  local  applications. 

Modified  by  scrofula. — Catarrhal  ophthalmise  occurring  in  scrofulous  habits, 
and  especially  in  children  of  that  constitution,  is  very  liable  to  degenerate 
into  the  phlyctenular  ophthalmia,  hereafter  to  be  described.  The  scrofulo- 
catarrhal  is  one  of  the  compound  ophthalmise,  which  are  apt  to  prove  puz- 
zling to  the  inexperienced  practitioner.  The  treatment,  in  cases  of  this  sort, 
must  partake  of  the  remedies  above  mentioned,  and  of  those  hereafter  to  be 
recommended  for  scrofulous  conjunctivitis. 


'  VeJpeau,  Manael  pratique  des  Maladies  des  *  Bibliotheque    Ophthalmologique ;    Tome  i. 

Yeux,  p.  180 ;  Paris,  1840.  p.  81 ;  Paris,  1820. 

*  Manuale  di  Cbirurgia;  Parte  ii.  p.  117;  *  Edinburgh  Medical  and  Surgical  Journal; 
Milano,  1812.  Vol.  xii.  p.  411;   Edinburgh,  1816. 

*  Reveille-Parise,  Hygiene  Oculaire,  p.  19;  '  Medical  and  Pl)}-sical  Journal;    Vol.    IvL 
Paris,  1823.  p.  327 ;  London,  1826. 

'  Spain,  byHenrj  D.  Inglis;  Vol.  ii.  p.  223; 
London,  1S37. 


SECTION  VIL — CONTAGIOUS  OPHTHALMIA. 

Syn. — Conjunctivitis  puro-mucosa  contagiosa.  Epidemic  ophthalmia  Ophtbalmia  puni- 
lenta  gravior.  Ophthalmia  bellica.  Egyptian  ophthalmia.  Purulent  ophthalmia. 
Conjonctiyite  graauleuse.     Ophthalmie  militaire. 

Fig.  Grafe,  Tab.  L— IV.     Miiiler,  Taf.  1.  IL     Eble,  Taf.  IIL     Dalrymple,  PI.  IX.  Fig.  3,  X. 

and  XI. 

The  disease  now  to  be  considered  is  essentially  the  same  with  that  described 
in  the  last  section,  only  much  more  severe,  and  although  excited  in  the  first 
instance  in  a  similar  way — namely,  by  exposure  to  atmospheric  influences — 
propagated  in  the  second  and  succeeding  cases  by  contact,  and  perhaps  by  a 
volatile  matter  arising  from  the  diseased  eyes,  and  floating  through  the  air. 
It  is  a  common  and  most  afflictive  disease  in  warm  climates,  as  Egypt,  Persia, 
and  India.  Having  passed,  along  with  the  British  troops,  to  this  country, 
in  1800,  1801,  and  1802,  from  Egypt,  where  for  ages  it  has  been  endemic,  it 
is  commonly  known  by  the  name  of  the  Egyptian  ophthalmia.  Rarely  seen 
in  private  life,  it  is  mostly  met  with  in  armies,  on  board  ship,  in  poor-houses, 
or  in  large  public  schools.  It  may  arise  in  any  climate  or  region  of  the  earth, 
and  is  not  the  effect  of  any  specific  principle  or  virus  imported  from  Egypt. 

Symptoms. — These  succeed  each  other  with  different  degrees  of  rapidity, 
and  present  very  different  degrees  of  severity  in  different  individuals  who  are 
suffering  at  the  same  time,  in  the  same  place,  and  from  the  same  infection. 


444  CONTAGIOUS   OPHTHALMIA. 

These  differences  depend  on  the  constitutions  of  the  patients,  on  their  state 
of  health  when  they  become  affected,  and  upon  incidental  and  minute  cir- 
cumstances of  situation.  In  women,  for  instance,  the  disease  is  said  to  be 
milder  than  in  men.  It  has  also  been  remarked  that,  as  the  age  is  near  to 
puberty,  on  either  side,  the  disease  is  in  general  more  fatal  in  its  effects. 
In  scrofulous  persons,  it  is  always  tedious,  and  more  likely  to  destroy  the 
cornea. 

The  disease  is  also  much  more  severe  in  one  instance  of  its  occurrence 
than  in  another.  In  1806,  it  raged  with  greater  rapidity  and  severity  in  the 
54th  than  in  the  52d  regiment.  It  never  was  so  severe  in  the  Military  Asy- 
lum at  Chelsea,  as  in  the  latter  regiment.  It  appears  to  have  been  much 
more  severe  in  the  Military  Asylum  in  1809  than  in  1804.  These  differences 
appear  to  be  owing  to  the  climate  and  situation  where  the  disease  occurs,  the 
temperature,  the  season  of  the  year,  and  other  general  causes. 

The  purely  inflammatory  stage  of  this  disease,  though  often  shorter  in  its 
duration,  appears  never  to  surpass  thirty  hours.  At  the  end  of  that  time, 
purulent  matter  is  always  formed  by  some  portion  of  the  conjunctiva.  In 
most  cases,  the  purely  inflammatory  stage  is  so  slight  and  rapid  as  not  to 
come  under  the  observation  of  the  surgeon.  So  early  does  the  formation  of 
purulent  matter  take  place,  that  even  when  the  inflammation  has  extended 
no  farther  than  the  palpebral  conjunctiva,  pus  is  seen  on  everting  the  eyelids, 
although  its  quantity  is  not  yet  sufficient  to  be  observed  unless  this  mode  of 
examination  be  adopted. 

The  disease  appears  to  commence  soon  after  the  application  of  the  con- 
tagious or  infectious  matter  to  the  conjunctiva,  but  in  many  cases  it  advances 
to  the  secretion  of  purulent  matter,  before  the  patient  is  aware  that  he  is 
affected.  It  often  happens  that  he  makes  no  complaint  till  his  attention  is 
excited  by  finding  his  eyelids  adhering  in  the  morning,  or  till  the  feeling  as 
if  some  extraneous  body  were  in  the  eye  has  become  distressing.  A  sudden 
attack  of  darting  pain  through  the  eyeball  or  in  the  forehead,  is  sometimes 
the  first  thing  which  attracts  his  attention,  while  in  other  cases  the  disease 
advances  till  there  is  such  vascularity  of  the  conjunctiva  as  cannot  fail  to  be 
observed  by  others.  In  all  these  cases,  the  disease  has  unquestionably  existed 
for  some  time,  but  it  has  been  unobserved  by  the  patient  himself,  or  if  ob- 
served, concealed.  When  this  disease  breaks  out  in  a  family,  or  in  any  larger 
community  of  individuals,  those  first  attacked,  ignorant  of  the  previous  exist- 
ence of  the  disease  in  others  from  whom  they  might  have  received  it,  and 
ignorant  of  its  nature,  will  seldom  demand  advice  till  urged  by  the  violence 
of  the  symptoms.  When  once  the  plan  is  adopted,  as  it  should  always  be, 
of  daily  inspecting  the  healthy  individuals  of  any  community  in  which  the 
disease  is  likely  to  appear,  it  will  be  the  fault  of  the  surgeon  if  he  ever  meets 
with  a  new  case  in  which  the  disease  is  so  far  advanced  as  to  be  attended  with 
any  other  symptom  than  an  increased  vascularity  of  the  conjunctiva  of  the 
eyelids. 

The  right  eye  is  more  frequently  attacked  by  this  disease  than  the  left.  It 
is  also,  in  general,  more  severely  affected,  and  the  sight  of  it  is  more  frequently 
lost.  In  some  instances,  only  one  of  the  eyes  takes  the  disease ;  but,  com- 
monly, both  suffer  from  it,  although  there  is  often  an  interval  of  several  days 
before  the  second  becomes  inflamed. 

When  the  symptoms  succeed  each  other  with  moderate  rapidity,  the  follow- 
ing is  the  order  in  which  they  appear  : — 

A  considerable  degree  of  itching  is  first  felt  in  the  evening,  or  suddenly 
thei'e  arises  in  the  eye  the  feeling  as  if  particles  of  dust  were  between  the  lids 
and  the  eyeball.  This  is  succeeded  by  a  sticking  together  of  the  lids,  prin- 
cipally complained  of  by  the  patient  on  awakening  in  the  morning.     The 


CONTAGIOUS   OPHTHALMIA.  445 

eyelids  appear  fuller  externally  than  they  ought  to  do.  Their  internal  surface 
is  inflamed,  being  tumefied  and  highly  vascular ;  and  the  semilunar  membrane 
and  caruncula  lachrymalis  are  considerably  enlarged  and  redder  than  usual. 
The  swelling  of  these  parts  is  soft,  somewhat  elastic,  slippery,  and  easily 
excited  to  bleed. 

We  have  here  all  the  symptoms  of  the  purely  inflammatory  stage,  and  even 
the  symptoms  of  commencing  suppuration.  The  itching,  which  is  one  of  the 
earliest  symptoms,  indicates  a  suppression  of  the  natural  mucous  secretion  of 
the  conjunctiva  of  the  eyelids,  and  of  the  Meibomian  secretion.  Such  sup- 
pression appears  to  be  the  constant  and  earliest  eifect  of  inflammation  upon 
every  mucous  membrane,  and  secreting  organ  of  the  body.  In  the  course  of 
a  few  hours,  a  thin  acrid  secretion  takes  place  from  the  conjunctiva.  This 
gives  the  slipperiness  to  the  internal  surface  of  the  eyelids  ;  and  the  Meibo- 
mian secretion  being  now  increased  above  its  usual  quantity,  concretes  amono- 
the  eyelashes,  and  causes  the  eyelids  to  adhere  during  sleep.  The  sensation 
of  sand  in  the  eye  is  owing  chiefly  to  the  dilated  state  of  the  conjunctival 
vessels. 

In  about  24  hours  after  the  first  symptoms  make  their  appearance,  the 
mucous  discharge  from  the  internal  surface  of  each  eyelid  is  considerable  in 
quantity.  It  is  still  thin,  but  somewhat  viscid,  and  begins  to  be  opaque.  It 
lodges  at  the  inner  angle  of  the  eye.  On  everting  the  lids,  their  internal  sur- 
face is  observed  to  be  much  more  vascular  and  tumid.  The  patient  is  troubled 
with  epiphora,  especially  when  he  exposes  his  eye  to  a  current  of  air.  He 
complains  of  a  sensation  as  if  the  eye  were  full  of  sand,  but  seems  to  experience 
little  uneasiness  from  the  light,  unless  he  be  of  a  scrofulous  habit,  and  then 
the  intolerance  is  acute.  Not  unfrequently,  a  considerable  discharge  of  blood 
takes  place  from  the  conjunctiva,  after  which  the  swelling  of  the  membrane 
may  diminish  for  a  time.  This  is  sometimes  repeated  more  than  once  before 
the  profuse  puriform  discharge  sets  in.  The  hemorrhage  often  appears  to 
arise  not  so  much  from  actual  rupture  of  vessels,  as  to  be  a  mere  tinging 
of  the  inflammatory  product  of  the  conjunctiva,  through  oozing  of  dissolved 
coloring  matter  from  the  blood. 

The  inflammation  now  extends  to  the  whole  internal  surface  of  the  eyelids. 
The  secretion  from  the  palpebral  conjunctiva  is  much  augmented,  and  be- 
comes more  distinctly  purulent,  being  yellowish  and  thick.  In  many  cases  it 
is  so  abundant,  that  on  the  patient  opening  his  eyes,  the  matter  instantly 
flows  down  the  cheek.  It  irritates  the  skin  and  even  excoriates  it.  The 
swelling  of  the  conjunctiva  of  the  lids,  and  especially  of  the  upper,  increases 
with  the  discharge ;  partly  from  a  serous  effusion  immediately  under  the  mem- 
brane, partly  from  an  inflammatory  development  of  its  papillary  structure, 
giving  rise  to  a  sarcomatous  appearance  of  the  internal  surface  of  the  eyelids. 
The  disease  may  not  proceed  farther  over  the  conjunctiva,  but  remain  in 
the  state  described  for  weeks  or  even  months,  and  however  severe  it  may  ap- 
pear to  another  person,  give  but  little  uneasiness  to  the  patient.  The  puru- 
lent secretion  may  then  diminish,  and  recovery  gradually  take  place. 

In  other  cases,  the  inflammation  spreads  rapidly  to  the  conjunctiva  of  the 
eyeball.  Its  vessels  are  distended  with  red  blood,  forming  a  thick  network 
over  the  sclerotica,  interspersed,  in  some  instances,  with  small  spots,  from  ex- 
travasation. The  membrane  itself  becomes  speedily  thickened,  its  semilunar 
fold  is  enormously  enlarged,  and  a  serous  effusion  taking  place  into  the  areo- 
lar tissue  which  connects  the  conjunctiva  to  the  sclerotica,  the  former  is  raised 
so  as  to  form  a  soft  pale-red  elevation  or  chemosis.  In  some  cases,  this  in- 
flammatory oedema  exists  only  at  particular  spots.  It  commonly  happens 
that  the  chemosis  gradually  spreads  from  the  lids  over  the  surface  of  the  eye 
towards  the  cornea,  with  its  advancing  edge  accurately  defined,  leaving  for 


446  CONTAGIOUS   OPHTHALMIA. 

awhile  a  circle  round  the  cornea.  Gradually  the  swelling  intrudes  on  the 
cornea,  till  it  closely  surrounds  it,  and  at  last  completely  buries  and  overlaps 
it,  so  that  even  its  centre  can  scarcely  be  seen.  The  chemosis  is  sometimes 
so  great,  that  the  conjunctiva  of  the  eyeball  protrudes  from  between  the  lids. 

The  chemosis  is  accompanied  by  livid  redness  and  swelling  of  the  skin  of 
the  eyelids,  sometimes  extending  to  a  considerable  distance  from  the  eye,  and 
resembling  very  much  in  color  and  general  appearance  the  redness  and  swell- 
ing which  surround  the  cow-pox  pustule  between  the  9th  and  12th  days  after 
inoculation.  This  swelling  of  the  lids  is  often  as  sudden  in  its  occurrence, 
as  if  it  had  been  owing  to  the  stinging  of  an  insect,  or  some  other  immediate 
irritation.  It  is  sometimes  seen  to  advance  almost  by  sensible  degrees,  and 
attains  its  utmost  height  in  a  few  hours  ;  at  other  times,  it  increases  gradually 
during  several  days.  It  affects  chiefly  the  upper  lid,  which  often  reaches  a 
very  great  size,  completely  overhanging  the  lower,  so  as  to  render  it  difficult 
to  obtain  access  to  the  eye  for  examination. 

The  sudden  swelling  of  the  lids  render  them  almost  immovable.  It  also 
occasions  at  first  a  degree  of  inversion  from  the  cartilages  not  yielding  with 
facility ;  but  after  a  time,  the  lids  are  apt  to  become  everted,  as  has  been  ex- 
plained at  page  220.  This  happens  especially  to  the  lower,  but  occasionally 
to  the  upper  also.  The  sensations  produced  by  this  enlargement  of  the  ex- 
ternal parts  of  the  eye  are  by  no  means  severely  painful,  scarcely  surpassing 
a  sense  of  stiffness  and  weight,  along  with  a  feeling  of  uneasiness  occasioned 
by  the  accumulation  of  matter  seci'eted  by  the  conjunctiva,  which  flows  in 
great  abundance  on  raising  the  lids.  The  sensation  of  gravel  in  the  eye  is 
now  less  troublesome.  If  light  be  excluded,  and  the  eyes  kept  at  rest,  the 
f»atient  does  not  complain  much  of  pain. 

After  the  conjunctiva  of  the  eyeball  takes  part  in  the  disease,  the  secretion 
©f  puriform  fluid  is  greatly  increased,  varying,  however,  from  time  to  time, 
in  quantity,  color,  and  consistence,  as  does  the  discharge  in  gonorrhoea.  Dr. 
■Fetch  estimates  its  quantity  as  exceeding  several  ounces  in  the  day.  It 
partly  escapes  from  between  the  lids,  partly  lodges  in  their  folds,  and  in  the 
pit  ferraed  over  the  cornea  by  the  chemosed  conjunctiva.  In  this  last  situa- 
tion, the  purulent  discharge  is  sometimes  allowed,  from  carelessness,  to  re- 
main £0  long,  that  it  assumes  the  appearance  of  a  thick  membrane,  so  that 
one  unacquainted  with  the  symptoms,  on  seeing  this  piece  of  matter  drop 
from  the  eye,  is  apt  to  suppose  that  the  organ  is  destroyed,  and  that  it  is  the 
cornea  in  the  state  of  a  slough  which  has  separated. 

The  puriform  secretion  may  continue  without  much  change  for  12  or  14 
days,  or  even  a  longer  period.  At  length  the  chemosis,  which  for  a  time 
filled  up  completely  the  space  which  exists  in  the  healthy  state  between  the 
eyeball  and  the  eyelids,  begins  to  shrink,  and  the  fluid  secreted  to  diminish 
in  quantity,  and  gradually  to  lose  the  characters  of  pus,  becoming  thin  and 
gleety.  The  internal  surface  of  the  eyelids,  the  semilunar  membrane,  and 
caruncula  lachrymalis,  which  were  the  parts  first  afi"ected,  are  the  last  in  which 
the  disease  disappears.  The  internal  surface  of  the  lids  generally  remains  in 
a  sarcomatous  state,  from  the  morbid  condition  of  the  papillary  structure  of 
the  conjunctiva.  The  papillae,  instead  of  subsiding  to  their  natural  size,  be- 
come indurated,  and  form  a  granular,  scabrous,  or  mulberry  surface  ;  and  this, 
constantly  rubbing  against  the  cornea,  keeps  up  a  chronic  inflammation  in  its 
investing  membrane,  which  becomes  covered  with  red  vessels,  and  loses  in  a 
igreat  measure  its  transparency. 

Such  may  be  looked  on  as  a  favorable  case  of  the  disease.  We  must  be 
prepared  to  meet  with  much  more  destructive  terminations  of  it.  It  often 
happens,  indeed,  that  the  tumefaction  of  the  conjunctiva  and  whole  substance 
of  the  lids  is  so  great,  that  we  cannot  ascertain  the  morbid  changes  which 


CONTAGIOUS  OPHTHALMIA.  44T 

are  going  on  in  the  eye.  When  this  tumefaction  declines,  so  as  to  admit  of 
the  eyeball  being  exposed,  we  sometimes  find  it  disorganized.  The  cornea 
presents  itself  in  various  states;  for  example,  turbid,  but  entire;  of  a  fleshy 
appearance,  being  covered  with  fungous  excrescences ;  penetrated  by  one  or 
by  several  ulcerations,  through  which  portions  of  the  iris  protrude ;  or  almost 
entirely  destroyed  by  suppuration. 

We  have  reason  to  conclude,  that,  in  some  cases,  the  primary  inflammation 
extends  to  the  cornea.  Its  conjunctival  covering  becomes  thickened,  and 
more  or  less  opaque.  Not  unfrequently  the  lower  half  of  the  cornea  is  turbid 
or  nebulous,  the  upper  half  clear,  with  the  line  of  division  between  them 
well  marked.  The  patient's  vision  is  much  affected  by  these  changes ;  and 
very  frequently  the  opacity  and  consequent  impairment  of  vision  continue 
after  all  the  acute  symptoms  of  the  disease  have  disappeared.  Superficial 
ulceration  may  attack  the  cornea,  the  ulcer  being  sometimes  clear,  as  if  a 
piece  of  the  cornea  were  chipped  off.  This  is  apt  to  leave  the  cornea  partially 
flattened,  or  irregular  on  its  surface,  so  as  thereby  permanently  to  unfit  the 
eye  for  distinct  vision.  In  other  cases,  the  ulcers,  though  superficial,  are 
flocculent  and  whitish,  and  these  are  likely  to  end  in  opaque  cicatrices  of 
various  sizes.  Even  when  the  ulceration  has  not  penetrated  through  the 
cornea,  the  iris  sometimes  advances  and  adheres  to  its  internal  surface,  op- 
posite to  the  ulcerated  part. 

It  often  happens  that  the  inflammatory  process  is  still  more  severe,  attacking 
the  whole  substance  of  the  cornea,  and  even  extending  to  the  internal  textures 
of  the  eye.  The  patient  is  now  subject  to  sharp  lancinating  pain  deep  in  the 
orbit,  aggravated  during  the  night,  and  declining  towards  morning.  There 
is  also  pulsatory  pain  in  the  eye  coming  on  sometimes  in  paroxysms,  in  other 
instances  continuing  with  scarcely  any  remission  in  its  violence  till  the  cornea 
gives  way.  The  varieties,  indeed,  in  regard  to  the  pain,  are  exceedingly  re- 
markable, depending,  no  doubt,  in  a  considerable  measure  on  the  part  which 
the  several  textures  of  the  eye  take  in  the  disease.  For  the  most  part,  the 
attacks  of  pain  are  sudden.  Occasionally  they  are  preceded  by  chilliness  and 
slight  nausea,  or  by  a  peculiar  sensation  about  the  head.  Frequently  the 
pain,  with  a  remarkable  increase  of  heat,  occurs  around  the  orbit,  in  a  degree 
no  less  excruciating  than  in  the  eye  itself.  The  space  over  the  frontal  sinuses, 
the  temples,  and  the  face,  are  its  frequent,  seats,  or  to  speak  more  exactly,  it 
affects  the  branches  of  the  fifth  nerve,  distributed  to  those  parts.  Sometimes 
it  occurs  immediately  above  the  eye,  commencing  about  the  supra- orbitary 
foramen.  This  supra-orbital,  or  circum-orbital  pain  is  indicative  of  the  in- 
flammation extending  to  the  sclerotica,  cornea,  choroid,  and  iris.  Inflam- 
mation of  these  textures  always  excites  sympathetic  pain  in  the  fifth  nerve. 
The  pain  round  the  eye  is  aggravated  by  pressure,  and  occasionally  a  circum- 
scribed swelling  suddenly  takes  place  over  the  part  affected.  When  such  a 
swelling  appears  in  the  face,  it  partakes  of  an  oedematous  nature ;  and  though 
equally  sudden  in  its  accession,  does  not  subside  so  rapidly  during  an  inter- 
mission, as  the  swellings  which  rise  under  the  same  circumstances  on  the  fore- 
head and  temple.  At  all  times,  the  eye  is  the  most  frequent  seat  of  the  pain, 
which  is  generally  described  to  be  of  a  darting  or  shooting  kind.  Sometimes 
it  is  compared  by  the  patient  to  what  might  be  felt  if  the  eye  were  stuck  full 
of  needles,  and  always  appears  to  be  exceedingly  severe.  It  is  generally 
confined  to  one  eye  at  a  time,  though  it  frequently  shifts  from  the  one  to  the 
other. 

The  apparent  absence  of  all  uneasiness  from  the  presence  of  light,  during 
the  paroxysms,  is  probably  owing  to  the  patient's  attention  being  engrossed 
by  the  violence  of  the  pain.  The  duration  of  the  paroxysms,  and  their  recur- 
rence, do  not  observe  any  great  regularity.     The  more  common  duration  ap- 


448  CONTAGIOUS   OPHTHALMIA. 

pears  to  be  from  three  to  four  hours.  Sometimes  they  do  not  continue  longer 
than  two  hours,  and  sometimes  they  extend  to  six.  They  appear  to  come  on 
most  frequently  from  10  to  12  in  the  evening.  During  the  pain,  the  secretion 
of  tears  is  more  copious,  and  the  purulent  discharge,  on  the  contrary,  almost 
uniformly  diminished. 

This  intermittent  type  of  the  pain  is  a  remarkable  circumstance,  and  might 
appear  inexplicable,  were  we  not  acquainted  with  the  fact,  that  pain  in  and 
round  the  eye,  aggravated  during  certain  hours  of  the  night,  is  an  invariable 
attendant  on  sclerotitis.  It  has  already  been  mentioned,  that  in  many  cases 
there  is  no  entire  intermission,  and  scarcely  any  remission  in  the  violence  of 
the  pain.  Dr.  Vetch  (to  whose  excellent  account  of  the  disease  I  am  indebted 
for  many  of  the  facts  stated  in  this  section)  tells  us,  that  in  those  patients  who 
were  of  a  habit  particularly  robust,  or  who  had  been  exposed  to  some  strongly 
exciting  cause,  or  who  were  of  a  shape  favorable  to  a  determination  to  the 
head,  there  was  no  entire  intermission,  and  scarcely  ever  any  remission  in  the 
violence  of  the  pain.* 

It  is  only  when  the  disease  assumes  its  most  violent  form  that  it  is  accom- 
panied by  the  frequent  occurrence  of  the  paroxysms  of  pain  above  described, 
and  under  these  circumstances  the  rupture  of  the  cornea  frequently  takes 
place,  an  event  which  is  almost  always  followed  by  staphyloma  and  loss  of 
sight.  The  period  at  which  this  happens  varies  exceedingly  in  different  pa- 
tients. About  the  eighth  day  of  the  disease  is  a  common  period  for  the  cornea 
to  give  way ;  but  this  event  may  happen  as  early  as  the  third  or  fourth  day. 
In  some  instances,  the  paroxysms  of  pain  have  occurred  daily,  during  a 
number  of  weeks  before  rupture  of  the  cornea  is  produced.  In  others  this 
is  effected  under  the  second  or  third  attack,  and  gives  a  temporary  relief. 
I  say  temporary;  for  even  the  rupture  of  the  cornea  does  not  afford  a  termina- 
tion to  the  disease,  and  often  scarcely  checks  its  progress.  The  severe  pain 
is  seldom  present  in  both  eyes  at  the  same  time,  and  although  it  occasionally 
happens  that  the  attacks  of  pain  alternate  from  the  one  eye  to  the  other,  the 
rupture  of  the  one  is  generally  produced  before  the  severe  pain  affects  the 
other.  In  some  cases,  where  both  eyes  are  destroyed  by  rupture  of  the  cornea, 
the  patient  has  no  recurrence  of  the  pain  for  some  time  after  the  rupture  of 
the  first ;  while  in  other  cases,  the  pain  almost  instantly  shifts  to  the  other 
eye.  It  has  been  known  that,  while  the  second  eye  was  suffering  rupture  of 
the  cornea,  the  first  eye  by  cicatrizing,  was  only  becoming  liable  to  the  same 
accident  again,  and  this  second  rupture  of  the  cornea  has  been  preceded  by 
as  much  pain  as  was  the  first. 

Rupture  of  the  cornea  generally  happens  when  the  disease  is  at  the  height 
of  its  violence,  and  when  the  swelling  of  the  external  parts  is  so  great,  as  to 
prevent  an  examination  of  those  immediately  concerned  in  the  event.  From 
the  distinct  sensation,  however,  which  the  accident  uniformly  communicates 
to  the  patient,  accompanied  by  a  copious  discharge  of  hot  fluid,  we  seldom 
remain  ignorant  of  its  having  taken  place.  In  other  instances,  the  swelling 
of  the  conjunctiva  and  of  the  eyelids  is  not  so  great  as  to  prevent  the  inspection 
of  the  eye  at  the  time  of  its  rupture.  The  progress  of  disorganization  may 
then  be  observed.  The  cornea  is  first  dull  and  hazy,  then  whitish,  and  at 
last,  from  matter  infiltrated  more  or  less  extensively  into  its  substance,  it 
becomes  yellow.  Its  lamella  are,  no  doubt,  softened  by  the  disease,  and  by 
this  infiltration  detached  from  one  another.  The  cornea  swells,  and  advances 
gradually  out  of  the  pit  formed  around  it  by  the  chemosed  conjunctiva.  Its 
surface  becomes  ulcerated  in  one  or  more  points.  The  ulcers  rapidly  deepen 
and  spread,  and  at  last  the  cornea  gives  way.  Through  the  opening,  or 
openings,  thus  formed,  we  may  sometimes  see  the  clear  lens  lying  in  its  cap- 
sule.    It  rarely  happens  that  there  is  any  formation  of  pus,  or  deposition  of 


CONTAGIOUS  OPHTHALMIA.  449 

coagulable  lymph  in  the  chambers  of  the  eye  in  this  disease;  and  hence,  when 
the  cornea  is  destroyed,  the  internal  parts  of  the  eye  appear  natural.  The 
patient  is  sometimes  able  even  to  see  objects  pretty  distinctly  after  the  cornea 
has  given  way,  or  is  almost  quite  destroyed  by  ulceration,  and  is  apt  to  believe 
his  eye  to  be  nearly  cured,  or  at  least  out  of  danger.  The  iris  is  pushed  into 
the  opening  or  openings  of  the  cornea  ;  assuming  a  reddish  fungous  appear- 
ance, it  swells  and  protrudes ;  union  takes  place  between  the  iris  and  the  remains 
of  the  cornea,  lymph  is  deposited  over  the  front  of  the  eye,  a  dense  cicatrice 
forms  over  the  protruded  iris,  and  partial  or  total  staphyloma  is  the  result. 
In  some  cases,  the  iris  remains  protruding  at  different  points,  scarcely  covered 
by  any  cicatrice  or  pseudo-cornea,  but  presenting  a  number  of  dark-colored 
prominences,  like  the  grains  of  a  bramble-berry,  a  state  of  parts  which  is 
styled  staphyloma  racemosum. 

The  cornea  may  give  way  under  one  of  the  violent  paroxysms  of  pain  of 
which  I  have  spoken,  before  it  has  undergone  much  disorganization.  Dr. 
Vetch  minutely  describes  a  case,  in  which,  on  examining  the  eye  after  the 
patient  had  felt  the  peculiar  sensation  indicating  rupture  of  the  cornea,  and 
the  discharge  of  scalding  fluid  had  taken  place  which  attends  this  accident, 
he  found  merely  a  small  line  extending  across  the  lower  segment  of  the 
cornea,  and  which  remained  without  any  alteration  after  the  eye  w^as  washed 
with  tepid  water.  As  any  attempts  to  ascertain  the  nature  of  this  line,  gave 
uneasiness,  its  examination  was  left  to  next  day.  In  the  meantime,  the  patient 
saw  better  than  he  had  done  before  the  rupture  took  place.  Next  day,  the 
line  was  more  visible  along  its  whole  extent,  from  a  slight  opacity  which 
accompanied  it,  and  which  daily  increased,  till  the  greater  part  of  the  cornea 
was  not  only  opaque,  but  projected  in  an  irregular  cone,  and  as  this  altera- 
tion went  on,  vision,  which  for  some  time  after  the  rupture  continued  more 
correct  than  before,  became  totally  obstructed. 

It  would  thus  appear  that  in  certain  cases,  the  aqueous  humor  escapes  by 
a  division  of  the  cornea,  nearly  as  clean  as  if  made  with  a  knife.  Were  the 
disease  to  subside  immediately  after  such  a  rupture  of  the  cornea,  this  accident 
would  in  all  likelihood  be  attended  with  little  permanent  injury  to  the  sight. 
But,  besides  the  obstacles  which  the  presence  of  the  disease  offers  to  repara- 
tion of  the  cornea,  the  same  causes  which  produced  the  first  rupture  continue 
to  operate,  so  as  to  produce  a  second  or  a  third,  the  disorganization  and  de- 
formity increase,  and  the  termination  with  respect  to  vision  is  proportiouably 
unfavorable. 

As  Dr.  Yetch  relates  one  case  of  this  kind  of  rupture  of  the  cornea  with 
much  minuteness,  and  tells  us  that  he  has  seen  several  others  of  the  same 
kind,  I  cannot  think  that  he  has  been  mistaken  concerning  the  fact.  Yet  I 
am  convinced  that,  far  from  being  the  manner  in  which  the  cornea  generally 
gives  way,  this  sort  of  rupture  occurs  very  rarely.  One  mode  in  which  the 
corneals  destroyed  is  by  ulceration,  commencing  on  the  surface  and  gradually 
penetrating  into  the  cornea.  An  ulcerated  trench  is  seen  at  some  part  of  the 
edge  of  the  cornea,  where  it  is  overlapped  by  the  chemosed  conjunctiva. 
This  trench  or  groove  gradually  increases  so  as  to  embrace  a  fourth  or  a  third 
of  the  circumference  of  the  cornea,  becomes  deeper,  and  at  length  opens  into 
the  anterior  chamber.  Infiltration  of  matter  into  the  substance  of  the  cornea, 
presenting  at  first  the  appearance  denominated  onyx,  and  at  length  forming 
complete  abscess  of  the  cornea,  followed  by  rupture  and  ulceration,  is  another 
mode  of  destruction.  In  some  instances,  but  by  no  means  frequently,  the 
exteroir  lamellae  slough  off  in  the  form  of  loose  leathery  scales.  Rarely,  if 
ever,  does  the  whole  thickness  of  the  cornea  come  away  in  this  state. 

This  disease  is  a  very  deceptive  one.     The  cornea  may  look  pretty  clear, 
actually  clearer  than  it  had  done  for  some  days  before,  although  the  edge, 
29 


450  CONTAGIOUS  OPHTHALMIA. 

overlapped  by  the  chemosed  conjuuctiva,  and  especially  the  lower  edge,  may 
be  falling  into  ulceration,  unobserved.  In  the  morning,  expecting  farther 
improvement,  we  find  the  cornea  given  way  and  the  iris  protruding.  Next 
day,  the  protrusion  and  the  cornea  are  flat.  The  pain  of  the  eye  and  head  is 
much  less,  from  the  tension  being  rather  off.  For  some  days,  the  symptoms 
may  go  on  subsiding.  Then,  another  ulcer  forms  and  bursts  in  the  middle  of 
the  cornea,  or  towards  its  upper  edge,  so  that  we  have  two  protrusions  of  the 
iris,  the  case  ending  in  staphyloma. 

In  many  instances,  the  progress  of  the  disease  is  not  terminated  by  the 
bursting  of  the  cornea.  In  a  few  hours,  the  capsule  gives  way,  the  lens 
escapes  through  the  ruptured  capsule  and  cornea,  more  or  less  of  the  vitre- 
ous humor  generally  follows,  and  sometimes  almost  the  whole  contents  of  the 
eyeball  are  evacuated.  In  this  case,  no  staphyloma  takes  place,  but  a  small 
deformed  eyeball  is  left  deep  sunk  in  the  orbit,  over  which  the  lids  fall  in, 
become  concave  externally,  and  remain  ever  afterwards  closed. 

Although  this  ophthalmia  proves  most  contagious  in  warm  weather,  the 
symptoms  are  greatly  aggravated  by  the  patient's  exposure  to  cold  and 
moisture.  The  symptoms  are  also  more  severe  in  females  for  some  days 
previous  to  menstruation,  and  on  this  evacuation  taking  place  they  as  con- 
stantly become  mitigated. 

It  is  always  found,  when  contagious  ophthalmia  affects  any  considei'able 
number  of  persons  congregated  together,  such  as  a  regiment  or  school,  that 
many  relapses  take  place,  whereby  the  cure  is  not  merely  retarded,  but  the 
symptoms  often  become  much  more  severe,  and  more  difficult  to  overcome, 
than  were  those  of  the  original  attack.  By  some  imprudent  exposure,  or 
some  error  in  diet,  more  ground  is  often  lost  in  the  course  of  a  few  hours, 
than  had  been  gained  by  the  most  assiduous  attention  and  best-directed 
treatment  during  perhaps  several  previous  weeks.^ 

The  external  symptoms  of  the  disease  and  the  pain  cease  at  very  uncertain 
periods.  After  the  severe  pain  has  subsided,  the  vascularity  and  sarcoma- 
tous tumefaction  of  the  conjunctiva  generally  remain  stationary  for  a  con- 
siderable time,  and  then  rapidly  diminish.  In  other  cases,  this  process  goes 
on  slowly  and  gradually.  The  external  tumefaction  of  the  eyelids  commonly 
disappears  first,  and  then  the  chemosis  gradually  subsides ;  that  part  of  the 
conjunctiva  which  immediately  surrounds  the  cornea  first  assuming  its  na- 
tural appearance,  and  presenting  a  ring  of  white  similar  to  what  was  for- 
merly seen  in  the  advancement  of  the  disease.  The  white  space  gradually 
enlarges  till  the  swelling  and  vascularity  are  confined  to  the  semilunar  mem- 
brane and  its  neighborhood,  and  to  the  bottom  of  the  folds  between  the  eye- 
ball and  eyelids.  The  eyelids  have  now  a  gaping  and  relaxed  appearance 
from  the  subsidence  of  the  tumefaction,  and  a  little  matter  still  forms  on  their 
internal  surface.  In  this  state,  which  may  continue  for  months,  any  irrita- 
tion of  the  eye  or  of  the  system  is  sufficient  to  cause  a  violent  relapse,  and 
the  patient  still  continues  capable  of  infecting  others. 

The  rapidity  with  which  the  opacities  of  the  cornea  caused  by  this  disease 
frequently  disappear,  when  their  removal  once  begins  to  take  place,  is  a 
remarkable  circumstance.  In  many  cases  of  opacity  of  the  cornea,  supposed 
to  be  perfectly  hopeless,  the  patients  have  speedily  recovered  such  a  degree 
of  vision  as  to  be  of  considerable  use  to  them.  Dr.  Vetch  mentions  the  fol- 
lowing remarkable  illustration  of  this  fact : — 

Case  265. — During  tbe  convalescence  of  a  man  from  this  disease,  some  pectoral  symp- 
toms, to  which  he  had  long  been  subject,  suddenly  assumed  the  appearance  of  pulmonary 
consumption,  which  proceeded  rapidly  towards  its  last  stage.  Five  days  before  his 
death,  he  was  seized  with  a  violent  aggravation  of  the  hectic  fever  and  other  symptoms, 
BO  that  his  death  was  hourly  expected.  At  this  time,  to  the  surprise  of  his  attendants, 
the  opacities,  by  which  the  vision  of  both  eyes  had  long  been  obstructed,  disappeared 


CONTAGIOUS   OPHTHALMIA.  451 

with  amazing  rapiditj',  so  that  a  short  time  before  his  death,  his  sight  became  nearly  as 
distinct  as  ever.  On  examining  his  eyes  after  death,  the  remains  of  the  opacity  were 
found  to  extend  to  the  internal  surface  of  the  cornea,  which  was  at  the  opaque  part 
slightly  corrugated.  There  was  also  a  very  partial  adhesion  of  the  iris  to  the  cornea  in 
both  eyes,  which  had  not  been  discerned  during  life. 

Especially  after  repeated  relapses,  the  symptoms  which  are  the  latest  to 
disappear  are  the  indurated  and  hypertrophied  state  of  the  papillary  struc- 
ture of  the  conjunctiva,  and  the  vascularity  and  opacity  of  the  cornea  depend- 
ing on  the  irritation  produced  by  the  friction  of  the  diseased  eyelids.  The 
state  of  the  conjunctiva  of  which  I  am  speaking  has  generally  received  the 
name  of  gramdar  conjunctiva.  If  by  granular,  those  who  employed  this 
term  meant  merely  that  the  conjunctiva  was  extremely  irregular  on  its  sur- 
face, the  name  would  not  be  unexpressive  nor  very  improper.  It  has  evi- 
dently been  used,  however,  to  signify  a  state  of  granulation.  We  have  even 
heard  of  removing  the  granulations  of  the  conjunctiva.  That  the  promi- 
nences in  question  are  not  granulations  is  proved  both  from  the  nature  of 
the  conjunctiva  and  from  the  history  of  the  symptom  itself  No  mucous 
membrane  is  known  to  throw  out  granulations,  without  having  been  pre- 
viously ulcerated  upon  its  surface.  But  in  this  disease,  no  ulceration  of 
those  parts  of  the  conjunctiva  which  are  affected  with  this  granular  appear- 
ance has  ever  existed.  If  these  prominences  were  really  granulations,  adhe- 
sion between  the  eyelids  and  the  eyeball  would  be  extremely  frequent,  whereas 
this  is  a  very  rare  occurrence.  The  granular  prominences  in  question  are 
nothing  more  than  the  papillae  of  the  palpebral  conjunctiva,  hypertrophied 
by  inflammation. 

A  principal  difference  between  catarrhal  and  contagious  ophthalmia  is, 
that  the  latter  affects  the  papillary  structure  of  the  conjunctiva  with  more 
rapidity  and  intensity,  and  is  thereby  apt  to  become  inveterate.  A  patient 
may  remain  for  many  months  with  the  conjunctiva  of  the  eyelids  in  the  gra- 
nular state,  his  cornea  probably  vascular  and  nebulous,  but  without  any 
puriform  discharge,  when,  after  a  fit  of  intoxication,  or  some  other  irregu- 
larity, the  inflammation  shall  suddenly  return  in  its  original  form,  and  with 
Its  original  propagative  power.  Hence  it  may  happen  that  a  soldier,  dis- 
charged in  the  state  described,  returning  home  into  the  country,  and  there 
relapsing,  may  give  rise  to  an  ophthalmia  which  shall  spread  through 
many  families,  with  all  the  symptoms  and  severity  of  the  original  disease. 

Constitutional  symptoms. — The  system  does  not  appear  to  be  in  the  small- 
est degree  primarily  affected ;  the  early  stage  is  entirely  local.  The  pulse 
commonly  continues  soft.  The  skin  is  seldom  hot.  Thirst  is  seldom  re- 
marked. The  appetite  for  food  is  rather  keen  than  otherwise.  The  blood 
drawn  is  not,  in  general,  buflfy.  All  these  circumstances  denote  how  little 
the  constitution  is  affected  in  the  early  stage  of  the  disease.  Varieties,  no 
doubt,  must  occur  in  this  respect.  Judging  from  the  accounts  given  by  Dr. 
Vetch  and  Sir  Patrick  Macgregor,  we  should  conclude,  that  children  labor- 
ing under  this  disease  are  subject  to  more  constitutional  irritation  than 
adults.  As  the  local  symptoms  grow  in  severity,  the  constitution  begins  to 
suffer.  The  pulse  becomes  frequent  and  sharp.  At  last,  there  is  always 
much  general  uneasiness,  and  sleep  is  prevented  by  the  paroxysms  of  noc- 
turnal pain.  The  blood,  now  taken  from  a  vein,  is  highly  inflamed.  Great 
debility  comes  on,  especially  when  the  patient  has  suffered  repeated  relapses. 
Sir  James  Macgregor  states  that  in  Egypt  the  disease  very  often  continued 
two  or  three  months,  that  it  much  impaired  the  general  health,  often  ter- 
minated in  diarrhoea  or  dysentery,  and  that  sometimes  the  patient  became 
hectic.^ 

Those  patients  who  are  of  a  scrofulous  constitution  are  more  liable  than 


452  CONTAGIOUS   OPHTHALMIA. 

others,  to  disorganization  of  the  cornea  in  the  course  of  contagious  oph- 
thahnia. 

Predisposing  causes The  military  life  appears  to  be  one  of  the  strongest 

predisposing  causes.  This  includes  the  hard  exercise  of  soldiers,  their 
exposure  while  on  guard  during  the  night,  their  exposure  to  changes  of 
temperature,  their  residence  in  cold,  dirty,  crowded  barracks,  bad  diet,  the 
excessive  use  of  alcoholic  drinks,  improper  clothing,  and  various  other  detri- 
mental influences.*  Dr.  Yleminckx  thinks  the  great  predisposing  cause  is 
the  inconvenient  clothing  of  soldiers,  especially  their  tight  collars  and  heavy 
caps.  Since  these  have  been  rectified  in  the  Belgian  army,  the  disease  has 
become  less  and  less. 

Propagation  of  the  disease — Contagion — Infection — Epidemic  character. — 
I  have  already  explained  my  views  regarding  the  propagative  power  assumed 
by  the  common  catarrhal  conjunctivitis  of  this  country  ;  and  have  hinted  that 
probably  the  ophthalmia  which  arose  in  the  British  and  French  armies  in 
Egypt,  and  with  which  they  returned  to  Europe,  had  a  similar  origin. 
Assalini  attributes  the  disease  as  it  occurred  among  the  French,  to  the  vivid 
light  and  excessive  heat  of  the  country  as  predisposing  causes,  and  suppressed 
perspiration  as  the  occasional  cause  ;  or,  in  other  words,  considers  it  as  a 
catarrhal  ophthalmia.  Catarrhal  inflammation  of  the  conjunctiva,  arising 
where  or  how  it  may,  appears  speedily  to  acquire,  if  it  does  not  from  the 
first  process,  the  power  of  producing  by  contagion  a  disease  similar  in  nature 
to  itself,  but  much  more  severe. 

It  is  undeniable,  that  the  return  of  the  Egyptian  expedition  introduced  a 
sevtgre  contagious  ophthalmia  into  this  country,  which  afterwards  prevailed 
extensively  in  regiments  which  had  never  served  in  Egypt,  and  which  accom- 
panied the  British  troops  to  almost  every  foreign  station  to  which  they  were 
sent.  For  many  ages  this  ophthalmia  has  prevailed  in  Egypt.  It  is  more 
frequent  among  the  natives  of  the  country  than  among  strangers,  owing  to 
the  freer  intercourse  of  the  former  with  each  other ;  and  for  the  same  reason, 
more  among  the  lower  than  the  higher  classes  of  society,  and  more  in  cities 
than  in  the  country.^  But  it  is  not  confined  in  its  origin  to  Egypt,  nor  to 
warm  countries.  It  has  been  known  to  arise  among  a  ship's  crew  far  from 
land.  It  is  probably  in  a  great  measure  the  coldness  of  this  climate,  and 
our  attention  to  cleanliness,  which  prevent  the  common  catarrhal  ophthalmia, 
which  we  see  every  day,  from  degenerating  into  the  contagious  disease. 

Whether  this  disease  be  capable  of  propagating  itself  by  infection — that  is 
to  say,  whether  the  mere  miasmata  arising  from  the  eyes  of  those  affected 
with  it,  floating  through  the  air,  be  capa])le  of  exciting  the  same  disease  in 
the  eyes  of  others — is  a  point  which  still  remains  in  doubt ;  for  in  every  case 
in  which  this  ophthalmia  has  spread  through  a  regiment,  school,  or  family, 
there  has  been  a  suspicion,  of  actual  contact,  by  means  either  of  the  fingers 
of  the  patients,  or  of  the  towels  or  other  utensils  which  they  were  in  the 
habit  of  using  in  common.  Speaking  of  soldiers,  Dr.  Vetch  says:  "Each 
company  has  a  separate  room,  in  which  the  intercourse  among  the  men  is 
necessarily  great.  Many  things  are  used  in  common  ;  nor  are  they  even  over- 
scrupulous in  washing  their  faces  in  the  same  water ;  and  however  attentively 
some  may  avoid  this,  they  are  all  under  the  necessity  of  having  recourse  to 
the  same  towel."  The  same  author  observes,  that  "all  the  attendants  on 
the  sick,  who  were  particularly  careful  in  avoiding  such  intercourse  as  might 
communicate  a  local  disease,  escaped  without  exception." 

The  experiments  of  Guillie,  to  which  I  have  referred  at  page  441,  fully 
demonstrate  that  puro-mucous  conjunctivitis  is,  in  the  strict  sense  of  the 
term,  contagious ;  in  other  words,  that  the  matter  taken  from  an  eye  affected 


CONTAGIOUS   OPHTHALMIA.  453 

with  this  ophthalmia,  and  applied  to  the  healthy  conjunctiva  of  another  eye, 
will  produce  the  same  disease. 

Sir  Patrick  Macgregor  has  recorded  several  cases  of  accidental  inoculation 
with  the  matter  from  the  conjunctiva  in  this  disease. 

Case  266. — A  nurse  of  the  Military  Asylum  Hospital,  about  9  o'clock  A.  M.,  -when 
occupied  in  syringing  the  eyes  of  a  patient,  who  had  much  swelling  of  both  eyelids,  with 
a  profuse  purulent  discharge,  found  that  some  of  the  matter  mixed  with  the  injection 
had  spirted  into  her  left  eye.  She  was  directed  to  bathe  her  eye  immediately  with  luke- 
warm water.  Notwithstanding  this  precaution,  about  7  o'clock  in  the  evening,  the  left 
eye  began  to  itch  to  such  a  degree  that  she  could  not  refrain  from  rubbing  it.  When  she 
awoke  next  morning,  the  eye  was  considerably  inflamed,  the  lids  were  swollen,  and  when 
she  moved  the  eyeball,  she  had  a  sensation  as  if  sand  were  lodged  between  it  and  the  eye- 
lids. In  the  course  of  the  day,  purulent  matter  issued  from  the  eye,  and  other  symp- 
toms followed,  which  were  similar  to  those  in  the  children  under  her  care.  The  disorder, 
however,  subsided  vinder  the  usual  treatment  in  14  days,  the  right  eye  remaining  sound 
during  the  progress  of  the  disease  in  the  left. 

Case  267. — Another  nurse,  about  8  o'clock  A.  M.,  while  washing  with  warm  water  the 
eyes  of  a  boy  suffering  severely  from  purulent  ophthalmia,  inadvertently  applied  the 
sponge  which  she  had  used  to  her  right  eye.  She  immediately  mentioned  this  circum- 
stance to  the  other  nurses,  but  took  no  means  to  prevent  infection.  Between  3  and  4  P.  M. 
of  the  same  day,  great  itching  of  the  right  eye  took  place,  and  before  she  went  to  bed  it 
was  considerably  inflamed.  Next  morning  her  eyelids  were  swollen,  she  complained  of 
pain  on  moving  them,  and  the  whole  anterior  surface  of  the  eyeball  was  much  inflamed. 
A  purulent  discharge  also  began  to  trickle  down  the  cheeks  from  the  inner  canthus.  The 
symptoms  increased  in  severity,  and,  notwithstanding  the  means  that  were  used  for  her 
relief,  the  eyeball  burst  in  front  of  the  pupil,  on  the  4th  day  after  the  application  of  the 
purulent  matter.  The  sight  of  the  eye  was  irrecoverably  lost,  and  the  inflammation  con- 
tined  for  upwards  of  three  months  ;  l)ut  the  left  eye  did  not  become  afi'ected.^ 

The  following  is  a  striking,  and  indeed  fearful  instance  of  puro-mucous 
conjunctivitis,  excited  by  atmospheric  influence,  spreading  by  contagion  or 
infection. 

The  French  slave  ship,  Le  Rodeur,  Captain  B.,  of  200  tons  burden,  left  Havre  on  the 
24th  of  January,  1819,  for  the  coast  of  Africa,  reached  her  destination  on  the  14th  of 
March,  and  cast  anchor  off  Bonny.  The  crew,  of  22  men,  enjoyed  good  health  the  whole 
voyage,  and  during  their  stay  at  Bonny  till  the  6th  of  April.  No  trace  of  ophthalmia 
had  been  observed  among  the  inhabitants  of  the  coast;  and  it  was  not  till  15  days  after 
the  Rodeur  had  put  to  sea,  and  was  nearly  on  the  equator,  that  the  first  symptoms  of 
disease  were  perceived. 

It  was  observed  that  the  negroes,  160  in  number,  crowded  together  in  the  hold  and 
between  decks,  had  contracted  a  considerable  redness  of  the  eyes,  which  spread  with 
rapidity  from  one  to  another.  At  first,  however,  the  crew  paid  no  great  attention  to 
this  appearance,  imagining  that  it  was  occasioned  merely  by  want  of  fresh  air  in  the  hold, 
and  by  scarcity  of  water  ;  for  they  had  already  limited  the  allowance  of  water  to  8  ounces 
a-day,  and  some  time  after  they  could  allow  only  half  a  glass  a-day.  It  was  thought 
suflicient  to  make  use  of  an  eye-water  made  from  an  infusion  of  elder-flowers,  and,  fol- 
lowing the  advice  of  the  person  who  acted  as  ship- surgeon,  to  bring  up  the  negroes  in 
turns  upon  deck.  This  salutary  measure,  however,  they  were  obliged  to  abandon ;  for 
the  poor  Africans,  torn  from  their  native  home,  and  heart-wrung  by  the  horrors  of  their 
situation,  embracing  each  other,  threw  themselves  into  the  sea. 

The  disease  which  had  spread  among  the  negroes  in  a  frightful  and  rapid  manner,  now 
began  to  threaten  the  crew.  The  first  man  of  the  crew  attacked  was  a  sailor  who  slept 
under  deck,  close  to  the  grated  partition  which  communicated  with  the  hold.  Next  day, 
a  lad  was  affected  with  the  ophthalmia  ;  and  in  the  course  of  the  next  three  days,  the 
captain  and  almost  all  the  crew  were  seized. 

In  the  morning,  on  awakening,  the  patients  experienced  a  slight  pricking  and  itching 
in  the  edges  of  the  eyelids,  which  became  red  and  swollen.  Next  day  the  swelling  of  the 
eyelids  was  increased,  and  attended  with  sharp  pain  ;  in  order  to  lessen  which,  they  ap- 
plied to  the  eyes  poultices  of  rice,  as  hot  as  they  could  bear  them.  On  the  third  day  of 
the  disease  a  discharge  of  yellowish  matter  took  place,  rather  thin  at  first,  but  which 
afterwards  became  viscid  and  greenish,  and  was  so  abundant,  that  the  patients  had  only  to 
open  their  eyes  every  quarter  of  an  hour,  when  the  matter  fell  in  drops.  From  the  com- 
mencement of  the  disease  there  were  considerable  intolerance  of  light,  and  discharge  of 
tears.  AVhen  the  rice  failed,  boiled  vermicelli  were  used  for  poultices.  On  the  fifth  day 
blisters  were  applied  to  the  nape  of  the  neck  of  some  of  the  patients  ;  but  as  the  cautha- 


454  CONTAGIOUS   OPHTHALMIA. 

rides  were  soon  exhausted,  they  endeavored  to  supply  their  place  by  the  use  of  pediluyia 
containing  mustard,  and  by  exposing  the  swollen  eyelids  to  the  steam  of  hot  water. 

Far  from  diminishing  under  this  treatment,  the  pain  increased  from  day  to  day,  as  well 
as  the  number  of  those  who  lost  their  sight ;  so  that  the  crew,  besides  fearing  a  revolt 
among  the  negroes,  were  struck  with  terror  lest  they  should  not  be  able  to  manage  the 
vessel  till  they  should  reach  the  West  Indies.  One  sailor  only  had  escaped  the  contagion,  ^ 
and  upon  him  their  whole  hopes  depended.  The  Rddeur  had  already  fallen  in  with  a 
Spanish  ship,  the  Leon,  whose  whole  crew  were  so  affected  with  the  same  disease  that 
they  could  no  longer  manage  their  ship,  but  begged  the  aid  of  the  Rodeur,  already  almost 
as  helpless  as  themselves.  The  seamen  of  the  Rddeur,  however,  could  not  abandon  their 
own  ship,  on  account  of  the  negroes  ;  nor  had  they  room  to  receive  the  crew  of  the  Leon. 
The  difficulty  of  nursing  so  many  patients  in  so  narrow  a  space,  and  the  want  of  fresh 
provisions  and  of  medicines,  made  the  survivors  envious  of  those  who  died ;  a  fate  which 
seemed  to  be  fast  coming  upon  all,  and  the  thought  of  which  caused  general  consternation. 

Some  of  the  sailors  made  use  of  brandy,  which  they  dropped  between  their  eyelids,  and 
from  which  they  experienced  some  relief;  which  might  have  suggested  to  the  surgeon  the 
propriety  of  a  local  stimulating  treatment. 

On  the  twelfth  day,  the  sailors  who  had  experienced  some  relief  came  upon  deck  to  re- 
lieve the  others.     Some  were  thrice  attacked  with  the  disease. 

The  tumefaction  of  the  eyelids  having  subsided,  some  phlyctenulse  were  observed 
on  the  conjunctiva  of  the  eyeball.  These  the  surgeon  had  the  imprudence  to  open ;  a 
step  which  proved  hurtful  in  his  own  case,  for  he  remained  blind,  without  any  possibility 
of  recovering  his  sight. 

On  reaching  Guadaloupe,  on  the  21st  June,  the  crew  were  in  a  deplorable  state;  but 
very  soon  aftei",  from  the  use  of  fresh  provisions,  and  by  simple  lotions  of  spring  water 
and  lemon  juice,  recommended  by  a  negress,  they  became  sensibly  better.  Three  days 
after  coming  ashore,  the  onlj*  man  who,  during  the  voyage,  had  escaped  the  contagion, 
was  in  his  turn  seized  with  the  same  symptoms  ;  the  ophthalmia  running  its  course  as  it 
had  done  in  the  others  on  board  ship. 

Of  the  negroes,  39  remained  totally  blind,  12  lost  each  one  eye,  and  14  had  specks, 
more  or  less  considerable  of  the  cornea. 

Of  the  crew,  12  men  lost  their  sight;  one  of  these  was  the  surgeon.  Five  lost  each  one 
eye,  and  amongst  these  was  the  captain.  Four  had  considerable  specks,  and  adhesions 
of  the  iris  to  the  cornea.'' 

The  history  given  by  Sir  Patrick  Macgregor  of  the  spread  of  puro-mucons 
ophthalmia  in  the  Military  Asylum  at  Chelsea,  an  extensive  institution  for 
the  education  of  soldiers'  children,  in  1804,  appears  sufficiently  demonstrative 
of  its  being  propagated  from  person  to  person. 

"In  the  beginning  of  the  month  of  April,  1804,"  says  he,  "two  boys,  brothers,  were 
brought  to  the  Infirmary  with  their  eyes  inflamed,  but  in  so  slight  a  degree,  as  not  to 
require  their  being  admitted.  They  were  made  out-patients,  and  by  using  the  common 
remedies,  got  well  in  eight  or  ten  days.  In  the  end  of  this  month,  six  boys  with  ophthal- 
mia were  brought  to  me ;  three  of  them  had  it  in  a  violent  degree,  and  were  admitted  into 
the  Infirmary ;  the  other  three  were  ordered  to  attend  daily  for  advice. 

"In  the  month  of  i\Iay,  no  less  than  forty-four  boys,  and  five  girls,  affected  with  oph- 
thalmia, were  brought  to  the  Infirmary.  The  worst  cases  were  admitted  ;  but  there  was 
not  room  for  all,  and  even  some  of  those  that  were  admitted,  were  necessarily  mixed 
with  other  sick. 

"On  the  morning  of  the  fourth  day  after  their  admission,  two  boys  who  were  in  the 
same  ward  laboring  under  other  complaints  were  attacked  with  inflammation  of  the  eyes, 
and  in  the  course  of  that  week  the  nurse  took  the  disease.  She  had  it  so  violently  as  to 
be  deprived  of  sight  for  several  days,  and  rendered  unable  to  do  the  duty  of  her  situation 
for  about  three  weeks.  About  the  same  time,  her  son,  a  boy  twelve  years  old,  who  had 
been  in  attendance  on  the  sick,  and  a  few  days  after,  her  two  younger  children,  were  at- 
tacked, as  were  several  of  the  sick  in  the  same  ward. 

"In  June,  fifty-eight  boys  and  thirty-two  girls  were  attacked.  It  was  in  general 
observed,  that  they  had  the  disease  in  a  more  violent  degree  than  those  attacked  in  May. 
In  the  course  of  this  month,  the  nurse  of  the  Girl's  Hospital  caught  it,  and  her  husband, 
an  in-pensioner  of  Chelsea  Hospital,  who  came  daily  to  see  her,  was  also  seized  with  it, 
as  likewise  were  two  occasional  nurses.  Upon  inquiry,  I  found,  that  the  above-mentioned 
pensioner  was  the  only  person  at  this  time  afl'ected  with  ophthalmia  in  Chelsea  Hospital. 

"The  wife  of  a  field-oflScer  was  at  this  time  on  a  visit  at  the  Military  Asylum.  She 
had  a  son  between  five  and  six  years  of  age,  who  used  to  play  with  the  other  boys.  He 
caught  the  ophthalmia,  and  on  the  fourth  or  fifth  d.ay  after  it  appeared,  his  sister,  a  child 
two  years  old,  was  seized,  and  some  days  after  this  the  lady  herself  took  it. 


CONTAGIOUS   OPHTHALMIA.  455 

"  These  circumstances  gave  alarm,  and  particular  attention  was  paid  to  the  immediate 
separation  of  those  who  had  any  symptoms  of  the  disease  from  the  other  sick,  and  the 
other  means  usually  adopted  for  checking  the  progress  of  contagion  were  had  recourse  to. 

"  In  July,  the  ophthalmia  continued  to  spread,  and  several  of  those  children  who  had 
already  had  it,  and  were  recovered,  took  it  a  second  time.  Sixty-five  boys  and  thirty 
girls  were  attacked  this  month.  They  appeared  to  have  the  disease  more  severelj%  and 
did  not  so  readily  get  well,  as  those  affected  in  the  preceding  months,  although  treated  in 
the  same  manner.     The  weather  was  much  hotter  than  it  had  been  the  month  before. 

"In  August,  sixty-nine  boys  and  twenty-one  girls  caught  the  disease;  a  boy  and  a 
girl,  brought  by  their  mother  from  Scotland,  arrived  at  the  Asylum  one  evening  in  the 
end  of  this  month,  and  were  immediately  admitted.  The  children  were  put  by  the  nurse, 
without  my  knowledge,  into  a  ward  occupied  by  patients  affected  with  ophthalmia ;  on 
visiting  the  Infirmary  the  next  forenoon,  I  directed  the  children  to  be  immediately  re- 
moved into  another  ward.  This  was  accordingly  done ;  yet  on  the  third  morning  after 
their  arrival,  both  the  children  had  symptoms  of  ophthalmia,  which  in  no  respect  differed 
from  what  were  observed  in  the  others. 

"All  the  boys  from  five  to  six  and  a  half  years  of  age  are  formed  into  one  company. 
It  was  observed  that  in  the  course  of  the  last  and  present  month,  almost  the  whole  of  this 
company  took  the  ophthalmia.  Its  progress  could  in  their  dormitories  be  traced  from 
one  bed  to  another,  in  the  order  in  which  they  were  placed,  until  nearly  the  whole  were 
affected.  The  two  nurses  attached  to  this  company  alwaj's  slept  in  their  wards,  and  were 
the  only  nurses  belonging  to  the  institution  (those  connected  with  the  Infirmary  excepted) 
that  suffered  from  the  disease.  About  the  middle  of  this  month,  I  caught  it  myself;  and 
though  the  inflammatory  symptoms  subsided  in  ten  days,  I  did  not  recover  from  its  effects 
in  five  or  six  weeks. 

"In  September,  sixteen  boys  and  four  girls  took  the  disease;  in  October,  sixteen  boys 
and  seven  girls ;  in  November,  nine  boys  and  six  girls ;  and  from  the  twenty-second  of 
this  month  to  the  end  of  December,  only  two  instances  of  it  occurred,  and  these  were  in 
two  boys,  brothers,  who  had  slept  together,  and  had  labored  under  the  disease  in  the 
month  of  August  in  a  violent  degree. 

"From  the  above  statement  of  the  progress  of  this  ophthalmia,  there  is  much  reason 
to  suppose  that  it  was  contagious.  For  if  the  disease  had  been  first  produced,  and  after- 
wards kept  up,  by  anj'  general  cause  (as  a  peculiar  state  of  the  atmosphere),  the  girls 
would  have  been  as  subject  to  it,  in  the  first  instance,  as  the  boys,  and  the  officers,  Ser- 
jeants, and  nurses  of  the  institution,  generally,  would  have  been  as  liable  to  it  as  the  per- 
sons of  the  same  description  that  were  immediately  about  the  sick.  But  this  was  not  the 
case ;  it  had  prevailed  among  the  boys  for  near  a  month  before  the  girls  were  attacked, 
and,  as  appears  by  the  preceding  statement,  all  the  adults  who  did  not  mix  with  the  sick 
escaped  the  disease  while  those  who  were  connected  with  them  all  suffered  from  it,  the 
assistant-surgeon  excepted. 

"  The  disease  sometimes  showed  itself  as  early  as  the  third  day  after  exposure  to  infec- 
tion.    This  was  clearly  proved  in  the  cases  of  the  two  children  from  Scotland. 

"It  would  appear  also,  that  closer  connection  with  the  affected  person  was  necessary 
to  produce  it,  than  what  is  requisite  in  most  other  contagious  diseases.  This  may  be 
inferred,  from  the  servants  of  the  Infirmary,  and  the  two  nurses  that  attended  the  little 
boys,  taking  it  so  readily,  while  the  other  servants  of  the  institution  escaped  it. 

"  It  was  influenced  by  the  state  of  the  atmosphere,  being  much  more  severe  in  its  at- 
tacks, and  of  longer  duration,  in  hot  sultry  weather,  than  during  cold  or  moderate  weather. 
This  was  cleai-ly  seen  in  July,  August,  and  September,  when  the  disease  was  unusually 
severe,  and  of  longer  duration  than  before  or  after  those  months. 

"  There  is  reason  to  think,  that  it  was  most  contagious  in  its  early  stage,  when  the  in- 
flammation was  active,  and  there  was  a  considerable  purulent  discharge."^ 

While  the  generally  received  opinion,  and  one  upon  which  it  is  wise  to  act, 
is,  that  this  ophthalmia  is  contagious,  some  have  inclined  to  the  opposite  way 
of  thinking.  Mr.  Lawrence,  for  instance,  expresses^  a  doubt,  whether  the 
spread  of  this  complaint,  especially  among  soldiers,  is  owing  to  the  applica- 
tion of  a  contagious  matter,  or  to  those  unfavorable  effects  upon  health  which 
arise  when  many  individuals  are  crowded  together.  Dr.  Eble,  while  he  ac- 
knowledges the  possibility  of  the  disease  being  propagated  per  contactum, 
thinks  that  it  spreads  much  oftener  by  infection  in  distans^^  Mr.  Roberts, 
after  a  careful  investigation  of  the  disease  as  it  occurred  in  Malta,  adopts  the 
view  of  its  being  propagated  by  contagion.  He  mentions  that  in  the  59th 
Regiment,  to  which  he  was  attached,  it  commenced  among  the  children,  ex- 


456  CONTAGIOUS   OPHTHALMIA. 

tended  itself  to  the  -o-omen,  then  to  the  married  men,  and  lastly  to  the  single 
men  of  the  regiment." 

This  ophthalmia  resembles  other  epidemic  contagious  diseases.  The  epi- 
demic constitution,  as  it  is  termed,  operates  in  its  production,  and  modifies 
its  phenomena,  as  it  does  in  influenza,  typhus,  plague,  dysentery,  cholera,  &c., 
all  of  which  seem  to  become  contagious.  Like  these  diseases,  this  ophthalmia 
often  follows  an  irregular  and  inexplicable  course,  attacking  one  place  and 
sparing  the  neighboring  places,  manifesting  remissions  which  we  cannot  ac- 
count for,  and  as  unaccountable  exacerbations.  At  one  time,  the  inflamma- 
tion is  so  severe  that  all  attempts  to  subdue  it  fail ;  at  another,  the  disease 
shows  a  general  tendency  to  yield,  and  every  eff"ort  proves  successful  in  accel- 
erating the  cure.  A  series  of  causes,  probably,  and  not  one  alone,  operates 
in  producing  this  ophthalmia,  snch  as  it  formerly  occurred  in  the  British  army, 
and  has  recently  proven  so  destructive  in  the  Belgian  and  other  continental 
armies.  An  altered  condition  of  the  atmosphere  in  the  first  instance,  produces 
an  epidemic  catarrhal  ophthalmia,  which  afterwards  spreads  from  person  to 
person  in  consequence  of  the  transmission  of  a  morbific  principle  through  the 
air ;  while,  in  some  cases,  the  disease  is  propagated  by  the  immediate  appli- 
cation of  the  purulent  discharge  from  the  conjunctiva. 

Treatment. — The  treatment  by  which  the  cure  of  contagious  ophthalmia  is 
best  promoted  consists,  on  the  one  hand,  of  antiphlogistic  means,  and,  on  the 
other,  of  astringents.  Let  no  man  who  feels  anxious  for  the  Avelfare  of  his 
patient  neglect  either  the  one  or  the  other  ;  but  carefully  employ  both. 

Constitutional  treatment. — \.  Bloodletting.  When  we  have  the  charge  of 
the  patient  from  the  beginning  of  the  disease,  and  the  symptoms  are  moderate, 
the  treatment  already  recommended  for  catarrhal  ophthalmia  will  generally  be 
successful.  Should  we  be  later  of  being  called  in,  and  chemosis  be  already 
present,  bleeding  from  the  arm  or  temporal  artery,  to  the  extent  of  from  10 
to  20  or  30  ounces,  according  to  the  age  and  constitution  of  the  patient,  fol- 
lowed by  leeches  round  the  eye,  will  be  necessary,  and  may  be  repeated  ac- 
cording to  circumstances.  The  blood  from  the  arm  should  be  taken  from  a 
large  orifice.  The  leeches,  in  number  from  six  to  twenty-four,  should  be  ap- 
plied within  two  hours  after  the  bleeding  from  the  arm.  Leeches  en  perma- 
nence behind  the  ears  are  likely  to  do  good. 

We  ought  neither  to  delay  the  abstraction  of  blood,  if  the  symptoms  are 
acute,  and  the  case  of  some  days'  standing;  nor  ought  we,  on  the  other  hand, 
to  indulge  in  the  expectation  that  profuse  bloodletting  is  to  check  the  disease 
completely,  without  the  use  of  local  applications.  I  hold  any  notions  of  this 
kind,  which  some  may  have  entertained,  as  crude  and  irrational,  and  their 
practice  as  perhaps  the  most  destructive  which  could  be  followed.  By  very 
profuse  bloodletting,  the  patient  is  too  much  reduced,  and  the  eye  rendered 
more  susceptible  of  disorganization.  We  must  not  for  a  moment  indulge  in 
the  fancy  that  the  stream  of  blood  is  to  be  allowed  to  flow,  till  the  redness  of 
the  eye  fades  under  our  view,  nor  are  we  even  to  make  the  cessation  of  pain 
the  condition  for  stopping  the  bleeding.  These  effects  might  not  be  obtained 
by  extracting  50  or  60  ounces  of  blood,  whereas  the  same  real  benefit  will 
follow  in  the  course  of  an  hour  or  two,  although  not  more  than  20  or  30 
ounces  be  taken,  the  patient  will  be  less  debilitated,  and  the  course  of  the 
disease  with  greater  certainty  abridged. 

Yemesection  may  with  propriety  be  repeated,  or  blood  may  be  taken  from 
the  temple  by  cupping,  if  in  the  course  of  24  hours,  the  symptoms  have  not 
abated,  or  have  increased  in  severity.  Afterwards,  also,  should  there  be  any 
signs  of  a  renewal  of  inflammatory  action,  more  blood  is  to  be  taken  away. 
It  is  chiefly  in  cases  where  there  is  pulsative  pain  in  the  eye,  and  circum-orbital 


CONTAGIOUS   OPHTHALMIA.  45t 

pain,  coming  on  in  nocturnal  paroxysms,  that  repeated  general  bloodletting 
is  necessary. 

Besides  venesection,  cupping,  and  the  application  of  leeches,  scarification 
of  the  conjunctiva  of  the  eyelids,  and  even  of  the  eyeball,  is  to  be  employed. 
This  may  be  repeated  every  second  or  third  day,  or  even  every  day.  In  the 
swollen  and  fleshy  state  of  the  conjunctiva  which  attends  this  disease,  an 
incision  may  be  made,  first  along  the  inside  of  the  lower  eyelid,  and  then  along 
that  of  the  upper;  they  will  bleed  very  copiously;  and  greatly  allay  the 
symptoms.  If  the  state  of  the  lids  permit  the  eyeball  to  be  sufficiently 
exposed,  the  conjunctiva  should  be  divided  by  several  radiating  incisions, 
proceeding  from  the  edge  of  the  cornea  towards  the  periphery  of  the  eyeball. 
This  will  be  best  eff"ected  by  a  small  scythe-shaped  knife,  such  as  is  recom- 
mended and  figured  by  Mr.  Haynes  Walton.*^  It  is  also  a  useful  practice  to 
snip  away  one  or  two  of  the  folds  of  swollen  conjunctiva,  which  project  from 
between  the  eyelids.  This  causes  a  profuse  discharge  of  blood.  I  am  dis- 
posed to  place  scarification  of  the  conjunctiva,  and  the  snipping  away  of 
one  or  two  of  its  folds,  among  the  most  effectual  means  of  combating  the 
disease. 

2.  Regimen. — The  patient  is  to  remain  at  rest,  in  a  well-ventilated  apart- 
ment, his  eyes  shaded  from  the  light,  and  to  adhere  strictly  to  the  antiphlo- 
gistic regimen. 

3.  Purgatives. — In  mild  cases,  bloodletting,  at  least  general  bloodletting, 
will  not  be  necessary  ;  but  in  all  cases  purgatives  are  to  be  used.  A  dose  of 
calomel  and  jalap  may  be  given  at  first,  and  either  repeated  from  time  to  time 
during  the  course  of  the  treatment,  or  changed  for  some  of  the  neutral  salts. 
Purgatives  operate  not  merely  by  depleting,  but  have  a  strong  sympathetic 
effect  upon  the  conjunctiva.  Emeto-purgatives,  as  tartar  emetic  with  sulphate 
of  magnesia,  will  be  found  highly  useful. 

4.  Diaphoretics. — As  soon  as  the  active  inflammation  is  subdued,  much 
advantage  will  be  derived  from  promoting  the  action  of  the  skin.  For  this 
purpose  the  warm  pediluvium  is  to  be  used  at  bed-time ;  after  which  the 
patient  may  take  from  10  to  20  grains  of  Dover's  powder.  The  action  of 
these  remedies  may  be  assisted  by  draughts  of  tepid  diluents,  and  during  the 
day  by  small  doses  of  antimony  or  acetate  of  ammonia. 

5.  Alteratives. — Next  to  copious  venesection,  no  remedy  will  be  found 
more  useful  in  severe  cases,  attended  by  nocturnal  circum-orbital  pain,  than 
calomel  with  opium.  Two  grains  of  calomel,  with  from  one  quarter  of  a 
grain  to  a  whole  grain  of  opium,  may  be  given  in  the  form  of  pill,  every 
second  hour,  or  thrice  a-day,  or  only  at  bed-time,  according  to  circumstances, 
till  the  mouth  is  sore.  This  combination  may  be  used,  from  the  first,  with 
advantage,  even  although  severe  nocturnal  pain  is  not  yet  present. 

Should  any  cause  prevent  our  using  mercury,  iodide  of  potassium  may  be 
substituted  in  its  place. 

6.  Bark  and  other  tonics  are  to  be  given  only  in  the  chronic  stage.  They 
are  then  highly  useful. 

Local  treatment. — If  no  local  remedies  are  employed,  or  only  improper 
ones,  the  eyes  may  be  lost,  notwithstanding  the  ))est  directed  general  treat- 
ment. It  may  to  some  appear  paradoxical  that  the  local  applications  in  this 
disease  ought  to  be  alternately  soothing  and  stimulating.  Were  we  to  trust 
to  either  sort  alone,  we  should  endanger  the  eyes.  Soaking  them  conslMntly 
with  tepid  water,  or  laying  emollient  cataplasms  over  them,  would  be  almost 
certain  destruction;  and,  on  the  other  hand,  a  perpetual  succession  of  stimu- 
lating solutions  and  salves  would  be  not  less  detrimental.  The  bad  eft'ects 
of  a  continued  soothing  or  emollient  local  treatment,  are  well  illustrated  in 
the  history  already  quoted  of  the  French  slave-ship  at  sea,  while  the  good 


458  CONTAGIOUS   OPHTHALMIA, 

eifects  of  stimulants  are  shown  by  the  rapid  improvement  which  followed  the 
negress's  prescription  of  lemon-juice,  on  the  patients  going  on  shore  at  Guada- 
loupe.  Applications  which  smart  the  eye  are  also  employed  by  the  native 
Africans  in  their  own  country  for  the  cure  of  this  ophthalmia. ^^  The  Arrow- 
awk  Indians  in  South  America  employ  the  expressed  juice  of  the  root  of  the 
bignonia  ophthalmica  with  great  success.^*  Urine,  sea  water,  solution  of 
common  salt,  solution  of  alum,  and  many  similar  substances,  have  been  found 
useful  for  the  same  purpose. 

1.  Cleaning  the  eyes. — The  first  point  in  the  local  treatment  is  to  clean  away 
completely  and  frequently,  in  the  course  of  the  day  and  night,  the  puriform 
discharge.  This  is  to  be  done  with  a  small  piece  of  soft  clean  sponge,  while 
the  patient  lies  on  his  back.  The  fluid  which  I  recommend  is  a  tepid  solu- 
tion of  1  grain  of  corrosive  sublimate,  with  6  grains  of  sal  ammoniac,  in  8 
ounces  of  water,  to  which  are  occasionally  added  2  drachms  of  vinum  opii. 
This  not  only  cleans  the  eye,  but  acts  as  a  gentle  astringent.  It  is  still  more 
efficient,  to  inject  the  same  collyriura  into  the  sinuses  of  the  conjunctiva  with 
a  small  syringe,  the  fluid  being  sent  over  the  whole  surface  of  the  diseased 
membrane  with  considerable  force  ;  and  especially  into  the  fold  between  the 
eyeball  and  the  upper  lid.  The  use  of  the  syringe,  however,  in  no  small 
degree  endangers  the  eyes  of  the  operator,  as  is  shown  in  Case  266. 

2.  Astringents — JEscharotics. — With  regard  to  other  astringents,  my  expe- 
rience leads  me  decidedly  to  condemn  sugar  of  lead,  in  whatever  form  :  nor 
can  I  speak  favorably  of  sulphate  or  acetate  of  zinc.  Some  highly  recom- 
mend a  solution  of  alum,  while  others  trust  to  solid  sulphate  of  copper,  rubbed 
over  the  internal  surface  of  the  eyelids. ^^  I  consider  a  solution  of  nitras 
argenti  as  the  best  remedy  for  constringing  the  inflamed  vessels,  allaying  the 
painful  feeling  of  sand  in  the  eye,  and  lessening  the  discharge.  I  have  tried 
this  solution  in  various  degrees  of  strength,  and  consider  10  grains  to  the 
ounce  of  simple  distilled  water,  as  recommended  by  Dr.  Ridgway,*^  to  be, 
in  general,  the  most  suitable.  The  solution  may  be  applied  every  five  or  six 
hours,  or  as  soon  as  the  raw,  painful  feeling  in  the  eye  is  renewed.  It  is  to 
be  taken  up  with  a  pretty  large  camel-hair  pencil,  with  which  first  the  inside 
of  the  upper  eyelid  is  to  be  well  brushed,  and  then  that  of  the  lower,  not 
omitting  any  of  the  folds  formed  by  the  chemosed  conjunctiva.  We  generally 
find  a  very  marked  improvement  in  the  course  of  24  hours  under  the  use  of 
this  application.  Circumstances  may  lead  the  practitioner  to  vary  the  strength 
from  2  to  10  grains.  It  may  be  well  to  begin  with  it  weak,  and  see  how  it 
agrees  :  if  weak,  it  may  be  used  oftener.  Should  it  disappoint  our  expecta- 
tions, and  the  purulent  discharge  run  on  unabated,  recourse  may  be  had  to  a 
salve  containing  from  10  to  20  grains  of  the  nitrate  of  silver  in  an  ounce  of 
axunge,  or  the  inside  of  the  lids  may  be  touched  rapidly  with  the  lunar  caustic 
pencil.  Some  practitioners  trust  almost  entirely  to  this  last  means,  to  the 
exclusion  even  of  depletion  of  any  kind.^^  They  apply  it  once  or  twice  a-day, 
chiefly  or  only  to  the  inside  of  the  lower  eyelid.  I  conceive  that  if  only  caustic 
is  employed,  without  depletion,  the  eye  is  very  likely  to  be  lost.  Depletion 
enables  us  to  use  astringents  and  escharotics  with  more  effect  and  less  danger. 
Red  precipitate  salve,  of  the  strength  of  30  grains  to  the  ounce  of  axunge, 
has  been  found  useful  as  an  application  to  the  conjunctiva,  and  may  be  sub- 
stituted for  the  preparations  of  lunar  caustic. 

These  two  local  applications,  the  nitrate  of  silver  solution,  and  the  corro- 
sive sublimate  wash,  cannot  be  managed  by  the  patient  himself,  and  can  rarely 
be  trusted  to  a  nurse ;  they  should  be  used  by  the  practitioner. 

3.  To  prevent  the  lids  from  adhering,  recourse  is  to  be  had  to  the  red  pre- 
cipitate, or  the  citrine  ointment,  melted  on  the  end  of  the  finger,  and  rubbed 
along  the  edges  of  the  lids  at  bedtime.     I  generally  anoint  the  edges  of 


CONTAGIOUS  OPHTHALMIA.  459 

the  lids  each  time  I  apply  the  solution  of  the  nitras  argenti.  One  or  other 
of  these  applications  fulfils  not  only  the  intention  here  stated,  but  operates  in 
subduing  the  inflammation.  Indeed,  Sir  Patrick  Macgregor  states"*  in  his 
first  paper,  that  of  all  the  remedies  that  were  employed  in  the  Military  Asylum, 
the  citrine  ointment  was  found  the  most  frequently  successful. 

4.  Counter-irritants  are  highly  serviceable  in  this  disease,  and  ought  always 
to  be  employed.  There  is  generally  a  marked  change  in  the  quantity  and 
appearance  of  the  discharge  from  the  eye  as  soon  as  a  counter-discharge  is 
established  by  blisters  on  the  temples,  on  the  nape  of  the  neck,  or  behind  the 
ears. 

5.  Opiate  fomentations,  and  friction. — Considerable  relief  to  the  pain  of 
the  eye  is  sometimes  obtained  from  allowing  the  steam  of  hot  water  with 
laudanum,  to  rise  into  the  eyes  from  a  teacup  ;  or  from  fomenting  the  eyes 
with  warm  decoction  of  poppy-heads.  Rubbing  the  head  with  warm  lauda- 
num when  the  circum-orbital  pain  threatens  to  commence,  is  also  highly 
useful. 

6.  Dilatation  of  the  pupil. — Although  it  is  rarely  the  case  that  adhesions 
of  the  iris  form  in  any  of  the  puro-mucous  ophthalmias,  unless  to  the  cornea 
in  consequence  of  penetrating  ulcers,  still  in  case  adhesions  should  occur,  it 
is  proper  to  paint  the  eyebrow  and  eyelids  with  the  extract  of  belladonna,  so 
as  to  dilate  the  pupil.  This  ought  always  to  be  done  when  ulcer  of  the  cornea 
occurs. 

Y.  Evacuation  of  the  aqueous  humor  has  been  adopted  as  a  means  of  reliev- 
ing the  severe  pain  of  the  eye  and  head,  and  of  preventing  bursting  of  the 
cornea.  This  is  a  practice  of  the  utility  of  which  in  contagious  ophthalmia 
I  can  say  nothing  from  ray  own  experience  ;  nor  do  I  conceive  it  will  often 
be  required  if  the  remedies  already  recommended  be  had  recourse  to.  Sir 
Patrick  Macgregor  expresses  his  conviction,  that  many  have  lost  their  sight 
from  rupture  of  the  cornea,  whose  eyes  might  have  been  saved  by  a  timely 
and  judicious  performance  of  this  operation.  Within  two  years  he  had  per- 
formed it  in  twenty-three  instances,  with  a  degree  of  success  which  strongly 
induced  him  to  recommend  it. 

8.  Solid  caustic  to  ulcers  of  the  cornea. — In  cases  of  ulcers  of  the  cornea, 
much  advantage  is  derived  from  the  use  of  the  lunar  caustic  pencil,  sharpened 
to  a  point,  and  applied  for  an  instant  to  the  spot.  The  good  effects  of  this 
application  are  often  very  striking,  where  a  small  portion  of  the  iris  protrudes 
through  an  ulcer.  Yet  this  is  a  practice  not  altogether  exempt  from  danger; 
for  if  a  myocephalon  is  touched  with  caustic,  the  aqueous  humor  is  apt  to  be 
discharged ;  the  cornea,  consequently,  becoming  flattened,  may  not  again 
become  plump,  and  hence  vision  will  be  permanently  impaired. 

9.  Vinum  opii. — When  the  purulent  discharge  is  gone,  or  nearly  so,  the 
vinum  opii,  pure  or  diluted,  proves  an  excellent  application  to  the  relaxed 
conjunctiva.  It  is  sometimes  advantageously  combined,  in  this  stage  of  the 
disease,  with  a  solution  of  the  lapis  divinus. 

Granular  conjunctiva  and  nebulous  cornea,  two  important  sequelce  of  con- 
tagious ophthalmia,  I  shall  consider  in  a  separate  section.  Of  the  eversion 
of  the  lids,  which  occasionally  proves  a  troublesome  attendant  on  this  ophthal- 
mia, I  have  already  treated  at  p.  219. 

Prevention. — To  military  surgeons  especially,  the  means  of  preventing  this 
destructive  disease  are  of  high  importance.  Some  of  the  following  rules  they 
will  at  all  times  be  able  to  follow ;  the  others  must  depend  on  the  higher 
military  authorities : — 

1.  Supposing  troops  to  be  sent  to  any  of  the  countries  where  this  disease 
prevails,  it  would  be  necessary  to  guard  them  as  much  as  possible  against  the 
exciting  causes  of  catarrhal  ophthalmia,  in  which  it  appears  that  the  conta- 


460  CONTAGIOUS   OPHTHALMIA. 

gious  disease  originates.  It  is  found  in  Egypt  that  exposure  to  the  night  air 
is  extremely  apt  to  bring  on  the  ophthalmia  of  the  country.  Soldiers  on 
guard,  then,  oi-  at  bivouac,  should,  during  the  night,  cover  their  heads  well  ; 
and,  if  in  moist  and  cold  situations,  avoid  currents  of  air  as  much  as  possible. 
Dr.  Vetch  mentions  that  of  four  officers  who  slept  in  the  same  tent,  in  Egypt, 
two  took  the  precaution  to  bind  their  eyes  up  every  night  when  going  to  rest, 
and  the  two  others  did  not ;  the  latter  were  in  a  very  short  time  attacked  by 
the  disease,  while  the  other  two  escaped. 

2.  Heavy  caps  and  tight  stiff  collars  ought  to  be  laid  aside. 

3.  As  soon  as  there  are  any  appearances  of  puro-mucous  ophthalmia  in  a 
regiment,  a  daily  and  minute  inspection  by  the  medical  officers  of  every  indi- 
vidual belonging  to  it,  becomes  a  duty  of  the  first  moment,  both  for  the  sake 
of  those  who  may  have  caught  the  disease,  and  for  the  sake  of  their  com- 
rades. 

4.  Those  in  whom  the  disease  is  detected  should  instantly  be  separated 
from  the  rest,  and  not  join  their  companies  till  they  are  perfectly  cured,  and 
have  passed  several  weeks  in  an  establishment  removed  some  miles  from  the 
place  where  they  were  attacked. 

5.  Those  patients  who  are  found  to  be  liable  to  frequent  relapses,  or  who 
are  affected  with  obstinate  granular  conjunctiva,  should  be  invalided  or  sent 
to  a  distance. 

6.  Excessive  crowding  of  the  men  together,  especially  in  their  dormitories, 
must  be  carefully  avoided,  as  this  of  itself  appears  very  much  to  promote  the 
contagious  power  and  spread  of  the  disease,  and  to  prevent  its  cure.  A  well 
ventilated  hospital,  in  a  wholesome  open  situation,  is  to  be  chosen.  The  beds 
are  to  be  placed  asunder.  Proper  means  for  disinfecting  the  air,  clothing, 
utensils,  &c.,  are  to  be  adopted. 

Y.  Those  exposed  to  the  disease  ought  to  be  made  acquainted  with  the  fact 
of  its  contagious  nature,  and  warned  against  the  modes  in  which  it  is  likely 
to  be  communicated ;  as,  touching  the  eyes  of  the  diseased  person  and  then 
touching  inadvertently  their  own,  using  the  same  towel  as  those  affected  with 
the  ophthalmia,  and  the  like.  Barrack-towels  must  afford  a  constant  medium 
for  the  communication  of  this  disease ;  they  ought,  therefore,  to  be  discarded, 
and  every  man  furnished  with  a  towel  for  himself. 

8.  It  will  be  found  a  salutary  practice  frequently  to  parade  the  men,  in 
their  respective  companies,  with  separate  vessels  of  water,  while  an  officer 
attends  to  see  their  faces  and  eyes  carefully  washed. 

9.  A  regiment  attacked  by  the  ophthalmia  should  move  from  the  station 
where  the  disease  seems  to  be  epidemic. 

10.  If  the  number  be  great  who  have  suffered  from  the  ophthalmia,  they 
should  be  formed  into  a  battalion,  into  which  no  fresh  recruits  are  to  enter, 
and  which  should  be  removed  to  a  wholesome  locality,  and  not  readmitted 
into  the  service  till  after  several  months'  separation. 


'Account  of  the  Ophthalmia  which  has  ap-  night-time,Tnounting  guard  on  those  cold,  bleak, 

peared  in  England  since  the  Return  of  the  Brit-  unprotected  positions  upon  the  batteries  and  lines 

ish  Army  from  Egypt,  p.  117;  London,  1S07.  adjoining  the  bank  of  the  River  Shannon.     The 

"  See  Sketch  of  the  Medical  History  of  the  atmosphere  is  the  dampest  that  I  ever  experi- 

47th  Regiment,  by  George  Saunders.     Medical  enced,  except  perhaps  in  India,  during  the  rains. 

Times,  August  30,  1851 ;  p.  227.  The  cold  damp  wind,  coming  down  off  the  lake 

"  Medical  Sketches  of  the  Expedition  to  Egypt  and  the  bogs  at  night,  used  to  give  the  men  the 

from  India,  p.  151;  London,  1804.  ophthalmia  as  if  struck  by  the  disease.     I  have 

'  "  Athlone  is  well  known  as  a  locality  where  seen  four, and  sometimes  six  men  come  oft  guard 

ophthalmia  constantly  prevails.     Nearly  every  into  hospital,  with  severe  conjunctivitis,  who  had 

regiment  quartered  there  for  many  years  past  mounted  guard  perfectly  well.     I  know  not  if 

appears  to  have  been  afi"ected  with  the  disease,  you  are  aware  that  soldiers'  guard-rooms  are 

I  believe  the  main  cause  of  its  prevalence  there  about  as  small  as  they  well  can  be;  and  that, 

depends  upon  the  great  exposure  of  soldiers  at  when  a  sentry  is  relieved,  he  goes  into  the  guard- 


OPHTHALMIA   OF  NEW-BORN  CHILDREN. 


461 


room,  wliere  he  and  his  comrades  lie  down,  in 
their  great  coats,  all  together,  huddled  as  close 
as  possible.  They  shut  the  doors  and  windows, 
and  light  a  large  fire,  and  are  consequently  al- 
most stewed.  Then,  when  it  comes  again  to 
their  turn  to  go  on  sentry,  they  change  at  once 
from  this  great  heat  to  a  two  hours'  watch  on 
the  lines,  exposed  to  the  cold  damp  wind  I  have 
described.  I  am  satisfied  that  it  is  this  atmos- 
pheric influence,  and  this  sudden  transition,  that 
produces  ophthalmia  at  Athlone."  Letter  from 
Dr.  Masse}^,  of  the  31st  Regiment,  in  Mr.  Wilde's 
valuable  Report  on  the  Epidemic  Ophthalmia  in 
the  Work-houses  and  Schools  of  the  Tipperary 
and  Athlone  Unions;  London  Journal  of  Medi- 
cine for  January,  1851,  p.  17. 

'  In  Egypt  many  causes  occur  to  produce  oph- 
thalmia; such  as,  the  exhalations  from  the  soil 
after  subsidence  of  the  Nile,  sleeping  upon  the 
house-top,  or  in  an  uncovered  apartment;  the 
dust  during  the  sirocco,  or  hot  wind  from  the 
desert;  the  flies,  which  are  allowed  unmolested 
to  stick  on  the  eyes  of  the  children,  and  suck  the 
diseased  secretions;  filthiness,  and  a  notion  that 
loss  of  sight  would  result  from  washing  the  eyes, 
when  inflamed,  Ac.  See  Lane's  Modern  Egyp- 
tians, and  other  works  on  Egj'pt. 

^  Transactions  of  a  Society  for  the  Improve- 


ment of  Medical  and  Chirurgical  Knowledge; 
Vol.  iii.  p.  52 ;  London,  1812.  Similar  cases  are 
recorded  by  Deconde,  Bulletin  Medical  Beige, 
Avril,  1837,  p.  54. 

''  Bibliotheque  Ophthalmologique,  par  M. 
Guillie;  Tome  i.  p.  74;  Paris,  1820. 

'  Op.  cit.  p.  31. 

'  Lectures  on  Surgery,  London  Medical  Ga- 
zette; Vol.  vi.  p.  745;  London,  1830. 

'°  Eble,  Ueber  die  in  der  belgischen  Armee 
herrschende  Augenkrankheit ;  p.  10;  Wien, 
1836. 

"  MedicalGazette;  Vol.  xxvi.  p.  23;  London, 
1840. 

'^  Operative  Ophthalmic  Surgery;  fig.  80,  p. 
260; London,  1853. 

'^  AVinterbottom's  Account  of  the  Native 
Africans  in  the  neighborhood  of  Sierra  Leone  ; 
Vol.  ii.  p.  129;  London,  1803. 

' '  Duncan's  Medical  Commentaries ;  Vol.  xix. 
p.  368;  Edinburgh,  1795. 

"  O'llalloran's  Practical  Remarks,  p.  12; 
London,  1824. 

"  London  Medical  and  Physical  Journal; 
Vol.  liii.  p.  122;  London  1825. 

'■'  Walker's  Oculist's  Vade-mecum,  p.  40; 
London,  1843. 

'^  Op.  cit.  p.  42. 


SECTION  VIII. — OPHTHALMIA  OP   NEW-BORN  CHILDREN. 
Syn. — Blepharitis  puriformis  neonatorum.     Lippitudo  neonatorum. 
Fig.  Ammon,  Thl.  I.  Tab.  I.  Figs.  1-6.     Dalrymple,  PI.  IX.  Figs.  1,  2. 

Infants  are  subject  to  a  puro-mucous  inflammation  of  the  conjunctiva,  com- 
mouly  denominated  ophthalmia  neonatorum  or  the  purulent  ophthalmia  of  in- 
fants. This  affection  generally  occurs  within  a  week  after  birth ;  sometimes 
not  for  three  or  four  weeks. 

Causes. — The  cause  is  not  uniform  : — 

1.  There  is  reason  to  believe  that  this  disease  is,  not  unfrequently,  an  in- 
oculation of  the  conjunctiva  by  leucorrhoeal  fluid,  during  parturition;  and 
that,  therefoi'e,  it  might  often  be  prevented,  by  repeated  injections  of  tepid 
water,  or  a  weak  alkaline  solution,  into  the  vagina  in  the  first  and  second 
stages  of  parturition,  and  by  carefully  washing  the  eyes  of  the  infant,  as  soon 
as  it  is  removed  from  the  mother.  The  former  precaution  is  scarcely  ever, 
and  the  latter  too  seldom  attended  to.  The  practitioner  ought  to  acquaint 
himself  beforehand  with  the  fact,  whether  the  mother  is  affected  with  any 
vaginal  discharge,  and  be  prepared  to  use  the  means  proper  for  averting  the 
danger  thereby  arising  to  the  child.  If  the  vaginal  discharge  is  not  removed, 
or  if,  on  the  child  being  born,  nothing  is  done  to  it  for  perhaps  half  an  hour 
or  longer,  every  chance  is  given  for  inoculation  of  the  eyes.  It  will,  in  general, 
be  found  that,  when  the  child  becomes  aifected  with  this  ophthalmia,  the 
mother  had  leucorrhoea,  and  that  the  eyes  were  not  cleaned  for  some  time  after 
birth.  Like  a  disease  communicated  by  contagion,  this  ophthalmia  is  sudden 
in  its  attack,  and  much  more  violent  than  we  almost  ever  see  catarrhal  oph- 
thalmia, so  that  it  resembles  in  this  respect  the  Egyptian,  or  the  gonorrhoeal 
inflammation  of  the  conjunctiva.^ 

2.  That  the  purulent  ophthalmia  of  infants,  in  its  worst  form,  is  the  result 
of  the  application  of  gonorrhoeal  matter,  during  the  passage  of  the  head 
through  the  vagina,  is  generally  admitted.     The  same  precautious,  during 


462  OPHTHALMIA  OF   NEW-BORN   CHILDREN. 

parturition,  ought  to  be  used  when  the  mother  is  known  to  have  gonorrhoea, 
as  when  she  is  affected  with  leucorrhoea.*^ 

3.  Exposure  to  the  light,  to  the  heat  of  the  fire,  or  to  the  cold  draught 
from  the  door,  are  all  likely  enough  to  have  an  injurious  influence  on  the  eyes 
of  the  new-born  infant ;  and,  accordingly,  some  have  been  led  to  attribute 
the  purulent  ophthalmia  which  so  frequently  shows  itself  after  birth,  to  these 
causes.     That  some  of  the  milder  cases  are  catarrhal,  is  by  no  means  unlikely. 

4.  I  have  little  doubt  that  this  ophthalmia  is  frequently  traumatic,  being 
occasioned  by  intrusion  into  the  eyes  of  the  soap  with  which  the  child  is 
washed,  or  the  whisky  or  gin  which  is  absurdly  rubbed  over  its  head.  Such 
intrusion  may  happen  immediately  after  birth,  or  in  the  course  of  the  first 
two  or  three  weeks.  Even  when  the  spirits  do  not  touch  the  eyes,  but  are 
merely  rubbed  over  the  head,  they  are  likely  to  excite  inflammation  of  the 
conjunctiva.     If  they  go  into  the  eyes,  this  effect  is  almost  certain. 

Symptoms. — It  is  commonly  on  the  morning  of  the  third  day  after  birth, 
that  the  upper  eyelid  is  observed  to  be  somewhat  swollen,  its  edge  red,  and 
the  eyelashes  glued  together  by  concrete  purulent  matter.  On  opening  them, 
a  drop  of  thick  white  fluid  is  discharged  ;  and  on  examining  the  inside  of  the 
lids,  they  are  found  extremely  vascular  and  considerably  swollen.  I  am  per- 
fectly convinced  of  the  purulent  appearane  of  the  discharge,  as  early  as  the 
third  day  after  birth,  and  first  morning  of  the  disease  being  noticed.  But  it 
is  not  always  distinctly  purulent  at  this  early  stage;  for  some  days  it  may 
continue  thin,  like  mucus  or  serum  and  without  almost  any  opacity.  It  after- 
wards presents  a  diversity  of  color  in  different  cases,  being  whitish  yellow, 
greenish  yellow,  and  sometimes  mixed  with  blood.  The  discharge  is  apt  to 
lie,  as  if  coagulated,  between  the  folds  of  the  conjunctiva,  unless  carefully 
removed. 

First  one  eye  is  affected,  and  in  a  few  days  the  other  also.  If  neglected, 
as  this  disease  but  too  often  is,  or  treated  with  some  such  useless  application 
as  a  little  of  the  mother's  milk,  the  lids  swell  externally  and  assume  a  dark 
red  color,  the  inflammation  of  the  palpebral  conjunctiva  rapidly  increases, 
and  the  purulent  discharge  becomes  very  copious.  The  infant  keeps  the  eyes 
constantly  shut.  It  is  the  palpebral  portion  of  the  conjunctiva,  and  the  fold 
formed  by  its  reflexion  to  the  eyeball,  which  are  chiefly  inflamed.  The  ocular 
portion  is  much  less  affected,  and  hence  chemosis,  so  as  to  overlap  the  cornea, 
is  rarely  seen  in  ophthalmia  neonatorum. 

In  this  state  the  eyes  may  continue  for  eight  days,  or  a  few  days  longer, 
without  any  affection  of  the  transparent  parts,  except  perhaps  slight  haziness 
of  the  cornea,  and  redness  of  its  edge.  About  the  12th  day,  however,  the 
cornea  is  apt  to  assume  an  opaline  tint,  indicative  of  approaching  ramollisse- 
ment,  or  it  becomes  partially  infiltrated  with  pus.  This  infiltration  extends, 
the  texture  of  the  cornea  is  thereby  speedily  destroyed,  it  gives  way  by  ulcera- 
tion, first  of  all  exteriorly  to  the  pus  effused  between  its  lamellae,  and  then 
through  its  whole  thickness,  and  this  either  in  a  small  spot  only,  or  over  almost 
its  whole  extent ;  so  that  sometimes  we  find  only  a  small  penetrating  ulcer,  with 
the  lower  part  of  the  iris  pressing  through  it ;  in  other  cases  the  whole  cornea 
gone,  the  iris  exposed,  and  the  humors  bulging  through  the  pupil. 

The  lens  often  comes  away.  A  poor  woman  from  Paisley,  who  had  trusted 
to  the  opinion  of  her  midwife,  that  the  disease  was  common  and  not  at  all 
dangerous,  brought  me  her  child,  aged  five  weeks.  She  had  with  her,  wrapped 
up  in  a  bit  of  rag,  the  left  lens,  dry  and  shrivelled,  it  having  that  morning 
been  discharged  through  the  ulcerated  cornea.  I  put  it  in  water  for  a  few 
hours,  when  it  became  plump  and  transparent.  It  was  inclosed  in  its  capsule. 
On  submitting  some  shreds  of  the  lens  to  the  microscope,  the  fibrous  texture 
was  quite  evident.     The  right  cornea  was  opaque,  and  partly  ulcerated. 


OPHTHALMIA   OF   NEW-BORN   CHILDREN.  463 

It  is  melancholy  to  reflect  on  the  frequency  of  destroyed  vision  from  this 
disease,  especially  as  the  complaint  is,  in  general,  completely  within  control, 
if  taken  in  time  and  properly  treated.  The  attendants  are  not  alarmed  suffi- 
ciently early,  by  merely  a  little  matter  running  from  the  eye  ;  and  but  too 
often  it  happens  that  medical  practitioners  are  betrayed  into  the  false  supposi- 
tion, that  there  is  nothing  dangerous  in  the  complaint,  till  the  cornese  burst, 
and  the  eyes  are  destroyed.  Many  children  have  been  brought  to  me  in  this 
state ;  but  the  most  deplorable  instance  of  the  disease  which  I  have  witnessed, 
was  that  of  twin  infants  from  Perthshire,  for  whom  I  was  consulted  some 
time  ago.  One  of  the  children  had  totally  lost  the  sight  of  both  eyes,  while 
the  other  retained  but  very  partial  vision  with  one  eye. 

Infants  laboring  under  this  ophthalmia  are  fretful  and  uneasy,  and  rest  ill 
during  the  night.  The  tongue  is  white,  and  the  bowels  deranged.  If  the 
disease  is  neglected,  the  flesh  wastes  away  and  the  integuments  become  loose 
and  ill-colored. 

Epidemic. — I  have  frequently  remarked,  that  ophthalmia  neonatorum  was 
much  more  frequent  at  certain  seasons  than  at  others.  This  epidemic  char- 
acter has  also  been  observed  by  M.  Dequevauviller,  in  the  Hospice  des  En- 
fans  Trouves,  at  Paris.  On  one  occasion,  the  epidemic  in  that  institution 
was  attended  by  a  scaly  eruption  on  the  eyelids  and  forehead,  and,  on  another, 
was  characterized  by  the  rapid  course  of  the  ophthalmic  symptoms.^  It  is 
stated,  on  the  authority  of  M.  Trousseau,  that  when  puerperal  diseases  pre- 
vail in  hospitals,  such  as  peritonitis,  suppurative  fever,  gangrene  of  the  vulva, 
&c.,  new-born  infants  become  subject  to  an  ophthalmia,  which  at  first  seems 
simply  catarrhal,  but  which,  in  three  or  four  days,  ends  in  perforation  of  the 
cornea.* 

Prognosis. — If  the  disease  is  recent,  and  the  corneas  are  only  free  from  ul- 
ceration, and  from  purulent  infiltration,  how  violent  so  ever  the  inflammation 
and  profuse  the  discharge,  our  prognosis  is  favorable — the  sight,  in  general, 
is  safe.  If  the  disease  has  been  allowed  fairly  to  establish  itself,  and  its  pro- 
gress not  interfered  with  for  eight  days  or  longer,  it  often  proves  tedious ; 
six,  eight,  or  ten  weeks  clasping  before  it  is  perfectly  cured.  It  is  always 
more  difficult  to  overcome,  when  the  child  is  exposed  to  cold  damp  air,  ill 
nourished,  improperly  fed,  or  when  the  nurse  drinks  spirits  or  porter.  If 
there  is  superficial  ulceration,  without  onyx,  probably  a  slight  speck  may  re- 
main. If  the  ulceration  is  deep,  an  indelible  opacity  may  be  the  consequence. 
If  the  iris  is  protruding  through  a  small  penetrating  ulcer,  the  pupil  will  be 
permanently  disfigured,  and  vision  more  or  less  impeded.  If  the  ulcer  is  di- 
rectly over  the  pupil,  the  probability  is  that  the  pupillary  edge  of  the  iris 
will  adhere  to  the  cicatrice,  and  vision  be  lost  until  an  artificial  pupil  be  formed 
in  after-life  by  an  operation.  If  there  is  a  considerable  onyx,  we  can  promise 
nothing  ;  for  although,  under  proper  treatment,  the  matter  may  be  absorbed, 
this  is  by  no  means  a  certain  result ;  the  laraellaj  exterior  to  the  onyx  are 
much  more  likely  to  ulcerate  ;  and  the  purulent  exudation  may  even  increase 
to  such  an  extent  that  the  cornea  shall  give  way,  and  the  eye  become  par- 
tially or  totally  staphylomatous.  Whenever  the  person  who  brings  the  child  to 
me,  announces  that  the  disease  has  continued  for  three  weeks  or  longer,  with- 
out anything  having  been  done  for  its  relief,  I  open  the  lids  of  the  infant  with 
the  fearful  presentiment  that  vision  is  lost,  and  but  too  often  I  find  one  or 
both  of  the  corneas  gone,  and  the  iris  and  humors  protruding.  In  this  case, 
it  is  our  painful  duty  to  say  that  there  is  no  hope  of  sight. 

The  most  dangerous  variety  of  ophthalmia  neonatorum  is  that  which  arises 
from  gonorrhoeal  inoculation.  In  this  case,  unless  the  disease  is  taken  early 
and  treated  energetically,  one  or  both  eyes  are  likely  to  be  lost.     In  gonor- 


464  OPHTHALMIA   OF   NEW-BORN   CHILDREN. 

rboeal  cases,  there  is  much  swelling  of  the  lids  and  conjunctiva,  the  pain  is 
severe,  and  the  yellowish  or  greenish  discharge  very  copious. 

Like  all  the  other  violent  puro-mucous  inflammations  of  the  conjunctiva, 
ophthalmia  neonatorum  is  much  more  destructive  in  cases  where  the  eyelids 
are  small,  and  press  more  than  ordinarily  on  the  eyeballs,  than  when  the 
fissure  between  them  is  long,  and  their  sinuses  ample. 

Central  capsular  or  capsulo-lenticular  cataract  is  by  no  means  an  uncom- 
mon result  of  ophthalmia  neonatorum.  It  is  met  with  in  cases  where  there 
has  been  no  penetrating  ulcer  of  the  cornea.  The  capsule  appears  to  have 
partaken  in  the  inflammatory  action,  and  become  partially  albugineous.  In 
other  cases,  from  the  coexistence  of  a  small  central  opacity  of  the  cornea, 
there  is  a  suspicion  that  the  cornea  had  given  way  from  ulceration,  and 
allowed  the  capsule  to  advance  into  contact  with  the  ulcerated  point,  after 
which  the  ulcer  had  healed,  and  the  aqueous  chambers  again  become  plump. 
The  opacity  of  the  cornea,  when  such  exists,  does  not  always  exactly  corre- 
spond to  that  of  the  lenticular  body.  The  opacity  is  often  no  bigger  than  a 
pin-point ;  in  other  cases  it  is  more  extensive ;  but  is  seldom,  if  ever,  so 
large  as  the  pupil.  Whether  it  occupies  the  anterior  capsule  only,  or  partly 
also  the  lens,  it  is  accurately  circumscribed,  the  capsular  part  being  more 
densely  opaque  than  the  lenticular,  while  the  circumference  of  the  lens  is 
perfectly  transparent.  I  have  not  observed  this  opacity  to  be  in  any  case 
totally  removed,  and  have  scarcely  seen  it  diminish  in  any  degree.  As  the 
child  grows,  vision  improves,  in  consequence  of  the  expansion  which  the  pupil 
undergoes;  the  cataract  remaining  of  its  original  size.  Short-sightedness  is 
one  of  the  results  of  the  central  cataract. 

Oscillation  of  the  eyes,  strabismus,  asthenopia,  and  incomplete  amaurosis, 
are  occasional  sequelae  of  ophthalmia  neonatorum. 

The  purulent  discharge  in  ophthalmia  neonatorum  is  highly  contagious ;  a 
melancholy  example  of  which  I  witnessed  at  the  Glasgow  Eye  Infirmary,  in 
an  infant  and  its  grandfather,  the  latter  inoculated  from  the  former.  Both 
were  so  severely  affected,  that  the  infant  had  the  one  eye  left  in  a  state  of 
total,  and  the  other  of  partial  staphyloma;  while  in  each  eye  of  the  old  man, 
the  greater  part  of  the  cornea  remained  opaque  and  adherent  to  the  iris.* 

Treatment. — 1.  As  it  is  of  the  utmost  importance  to  remove  the  purulent 
discharge,  from  time  to  time  in  the  course  of  the  day,  I  may  be  excused  for 
explaining  minutely  how  the  eyes  are  to  be  cleaned.  Unless  the  discharge 
is  removexl  with  regularity  and  care,  other  means  will  fail  in  curing  the  dis- 
ease. The  surgeon  lays  a  towel  over  his  knees,  on  which  to  receive  the  head 
of  the  child,  which  the  nurse  sitting  before  him,  lays  across  her  lap.  Every 
person  bringing  a  child  with  ophthalmia  neonatorum  to  an  Eye  Infirmary, 
should  be  supplied  with  a  separate  bit  of  sponge  for  cleaning  the  eyes,  lest 
by  using  the  same  sponge  for  different  children,  we  may  reinfect  the  eyes 
when  they  are  beginning  to  get  better.  The  fluid  which  I  commonly  use  for 
washing  the  eyes,  is  a  tepid  solution  of  1  grain  of  corrosive  sublimate,  with 
6  of  sal  ammoniac,  in  from  8  to  12  ounces  of  water.  The  lids  are  opened 
gently,  and,  with  the  bit  of  sponge,  the  purulent  discharge  which  gushes  out 
is  removed.  The  lower  lid,  and  then  the  upper,  are  next  everted,  and  wiped 
clean  with  the  sponge.  The  upper  lid  has  a  tendency  to  remain  everted, 
especially  if  the  child  cries.  This  is  overcome  by  pushing  the  swollen  con- 
junctiva into  its  place,  and  bringing  down  the  edge  of  the  lid.  All  this 
ought  to  be  repeated  three  or  four  times,  or  oftener,  in  the  24  hours,  by  the 
nurse,  or  by  the  surgeon.  Washing  out  the  discharge  with  a  syringe  is  more 
effectual ;  but  the  surgeon  only  should  attempt  this,  and  if  he  does  so,  should 
guard  against  the  fluid  injected  spirting,  along  with  the  discharge,  into  his 
own  eyes.     The  impetus,  however,  with  which  a  fluid  is  sent  over  the  cornea 


OPHTHALMIA   OP   NEW-BORN   CHILDREN.  465 

by  a  syringe  is  not  altogether  free  from  clanger,  but  is  apt  to  bring  on  or  to 
increase  ulceration.     The  use  of  the  sponge  is  sufficient  and  safe.^ 

2.  The  corrosive  sublimate  collyrium,  used  in  cleaning  the  eyes,  tends 
gently  to  repress  the  discharge.  Alone,  however,  it  is  not  sufficient  for  that 
purpose,  and  we  have  recourse,  therefore,  to  astringent  applications  of  more 
power.  The  solution  of  nitras  argenti  is  what  I  have  found  most  useful. 
The  strength  of  the  solution  should  vary,  according  to  the  state  of  the  con- 
junctiva and  the  duration  of  the  disease,  from  2  to  10  grains  to  the  ounce  of 
distilled  water.  In  recent  cases,  where  there  is  little  thickening  of  the  con- 
junctiva, a  weak  solution  is  to  be  used ;  when  the  disease  has  gone  on  for  a 
week  or  more,  and  the  membrane  has  already  become  hypertrophied,  a  stronger 
solution  will  be  required.  With  a  large  camel-hair  pencil,  the  solution  is  to 
be  applied  to  the  whole  surface  of  the  inflamed  conjunctiva,  immediately  after 
it  has  been  cleaned  as  above  described.  This  application  ought  to  be  repeated 
every  six  or  eight  hours.  Not  only  the  local,  but  even  the  constitutional 
good  effects  of  removing  and  restraining  the  purulent  discharge  are  very  re- 
markable. The  first  night  after  the  use  of  the  collyrium  and  drops,  we 
generally  find  that  the  infant  has  been  much  quieter  than  it  had  been  when 
the  disease  was  neglected.  In  two  or  three  days  the  eyes  begin  to  open  ; 
and  in  ten  or  twelve  days  the  acute  symptoms  are  overcome. 

3.  To  prevent  the  eyelids  from  adhering  together,  the  red  precipitate  oint- 
ment melted  on  the  end  of  the  finger,  is  to  be  applied  along  their  edges, 
whenever  the  child  goes  to  sleep. 

4.  The  above  remedies  are  perfectly  sufficient  to  remove  this  disease,  if  had 
recourse  to  within  two  or  three  days  after  the  first  symptoms  have  shown 
themselves.  I  have  seen  two  applications  of  the  nitras  argenti  solution,  viz : 
on  the  third  and  fourth  days  after  birth,  on  the  first  and  second  days  of  the 
disease  showing  itself,  remove  the  complaint  completely,  although  thick  white 
matter  was  flowing  from  the  conjunctiva.  In  cases  attended  by  a  discharge 
less  distinctly  puriform,  the  use  of  the  red  precipitate  salve  at  bedtime  has 
sometimes  been  sufficient.  In  cases,  again,  which  have  been  neglected  for 
perhaps  eight  or  ten  days,  it  is  necessary  to  take  away  blood  from  the  external 
surface  of  the  upper  eyelid  by  the  application  of  a  leech,  or  from  the  inflamed 
conjunctiva  by  scarification.  The  former  may  be  tried  in  the  first  instance  ; 
and  unless  followed  by  marked  abatement  of  the  redness  and  swelling  on  the 
inside  of  the  lids,  the  conjunctiva  may  next  day  be  divided  with  a  lancet. 
The  taking  away  of  blood  in  either  of  these  ways  is  productive  of  much  ben- 
efit, and  ought  by  no  means  to  be  omitted,  if  there  be  much  swelling  of  the 
lids,  any  tendency  to  chemosis,  or  haziness  of  the  cornea.  A  more  profuse 
loss  of  blood  than  can  be  obtained  by  the  methods  here  recommended,  I 
do  not  consider  necessary.  It  may  be  proper,  however,  to  leech  or  to  scarify 
repeatedly. 

5.  Should  the  conjunctiva  threaten  to  assume  the  sarcomatous  or  granular 
state,  scarification  should  be  used,  after  which,  if  there  is  no  ulceration  of 
the  cornea  present,  the  inside  of  the  lids  may  be  rubbed  with  a  smooth  bit  of 
sulphas  cupri.  For  the  same  purpose,  a  salve  containing  10  grains  of  nitrate 
of  silver  in  1  ounce  of  axunge  may  be  applied  to  the  palpebral  conjunctiva ; 
or  the  membrane,  being  wiped  dry,  may  be  rapidly  touched  with  the  lunar 
caustic  pencil.  The  latter  application  generally  produces  considerable  pain 
and  swelling  of  the  lids,  which  subside  under  the  use  of  cold  wet  compresses. 
Strong  red  precipitate  salve  is  also  a  valuable  application  in  granular  con- 
junctiva. 

6.  None  of  these  strong  applications  are  to  be  used,  if  the  cornea  is  affected 
with  ulceration.  In  this  case,  the  solution  of  nitrate  of  silver  should  be 
omitted,  and  the  eye  brought  under  the  influence  of  belladonna,  by  painting 

30 


466  OPHTHALMIA   OF   NEW-BORN   CHILDREN, 

the  lids  with  the  moistened  extract.  We  may  further  the  same  object,  by 
infusing  1  drachm  of  the  extract  of  belladonna,  or  dissolving  2  grains  of  the 
sulphate  of  atropia,  in  every  8  ounces  of  the  corrosive  sublimate  collyrium. 
It  is  not  for  the  mere  dilatation  of  the  pupil  that  the  belladonna  or  atropia  is 
to  be  used,  but  to  obtain  the  influence  of  this  anodyne  over  the  ulcerated 
cornea.  Much  experience  has  convinced  me  of  its  efficacy,  in  inducing  a 
healing  action  in  the  cornea  when  affected  with  ulceration.  Many  eyes,  which 
seemed,  from  the  extent  and  depth  of  the  ulcers  present,  to  be  doomed  to 
destruction,  have  to  all  appearance  been  saved  by  its  careful  employment. 
Even  in  cases  of  perforated  cornea,  I  have  seen  the  ulcer  begin  to  fill  up, 
and  ultimately  heal,  without  any  adhesion  of  the  iris,  under  the  influence  of 
belladonna. 

I.  A  remedy  of  considerable  service  in  this  disease  is  the  application  of 
blisters  behind  the  ears,  or  to  the  back  of  the  head.  A  bit  of  candlewick, 
covered  with  cantharides  plaster,  and  laid  into  the  angle  between  the  head 
and  the  external  ear,  is  a  convenient  mode  of  breaking  the  skin ;  and  by  con- 
tinuing this  application  either  constantly,  or  several  hours  daily,  a  continued 
discharge  will  be  procured.  As  soon  as  there  is  a  discharge  of  matter  from 
the  blistered  parts  we  perceive  an  amendment  in  the  state  of  the  eyes.  If, 
however,  the  ears  are  allowed  to  get  well,  we  often  observe  a  renewal  of  the 
inflammation,  and  a  more  copious  flow  of  matter;  but  the  symptoms  again 
subside  if  the  blisters  are  reapplied. 

8.  A  dose  of  castor  oil  occasionally  will  be  found  useful. 

9.  Small  doses  of  calomel  are  highly  beneficial.  From  half  a  grain  to  a 
grain  daily  will  be  sufficient.  Besides  acting  favorably  on  the  conjunctiva, 
this  remedy  is  likely  to  counteract  the  tendency  to  capsular  cataract. 

10.  In  threatened  disorganization  of  the  cornea,  Mr.  Saunders  strongly 
recommended  the  extract  of  cinchona.  The  sulphate  of  quina  answers  better, 
and  is  more  easily  administered.  From  half  a  grain  to  a  grain  may  be  given 
thrice  daily. 

II.  The  relaxed  conjunctiva,  after  the  purulent  discharge  has  entirely  sub- 
sided may  be  advantageously  touched,  once  a  day,  with  vinum  opii.  I  have 
sometimes  treated  cases  with  the  vinum  opii  throughout,  but  \  consider  this 
remedy  as  more  applicable  for  the  chronic  stage  of  the  complaint  than  for 
the  acute.  It  serves  to  clear  the  cornea  from  the  opacities  so  apt  to  be  pro- 
duced by  this  disease. 

12.  The  child  should  be  nourished  by  the  breast  alone.  Giving  it  food 
often  seems  to  keep  up  the  disease.  The  mother's  or  nurse's  diet  should  be 
carefully  regulated.  During  the  acute  stage  of  the  ophthalmia,  she  should 
take  little  or  no  animal  food,  and  should  taste  neither  wine,  spirits,  nor  ale. 
After  the  acute  stage  is  over,  should  the  conjunctiva  continue  relaxed,  tincture 
of  iron  may  be  given  to  the  nurse  with  advantage  to  the  child. 

In  several  instances,  I  have  known  ophthalmia  neonatorum  attack  one 
child  after  another  of  the  same  parents.  Such  cases  I  suspect  to  be  generally 
leucorrhceal. 


'  To  ascertain  whether  the  purulent  ophthal-  and  ISl  had  not.     Thirty  infants  had  purulent 

mia  of  infants  is  caused  by  a  discharge  from  ophthalmia;  namely,  20  whose  mothers  had  a 

the  genitals  of  the  mother,  affecting  the  eyes  discharge,  and  10  whose    mothers    had    none, 

of  the  child  during  birth,  Dr.  Cederschjold  had  Hence  it  appears  that  discharges  from  the  geui- 

the    question   put   to    every  woman    delivered  tals   are  extremely  common   among   pregnant 

during  the  year  1832,  in  the  gener.al  lying-in  women,  that  women  may  be  afflicted  with  them 

hospital  of  Stockholm,  whether  or  not  she  had  without  giving  their  offspring  ophthalmia  puru- 

such   a  discharge.     Three  hundred   and  sixty  lenta,  and  that  children  may  have  the  disease, 

women  were  delivered  ;  and,  subtracting  those  though  the  mothers  have  no  discharge;  a  proof 

who  bore  dead  children,  or  whose  children  died  that  the  malady  may  arise  from  other  causes, 

a  few  days  after  birth,  there  remained  328.     Of  But  when  we  consider  that  of  the  children  born 

ihcse,  137  had  a  discharge  from  the  genitals,  of  mothers  affected  with  a  discharge,  20  in  137, 


GONORRHCEAL  OPHTHALMIA.                                         46t 

or  about  1  in  7,  suffered  from  the  ophthalmia,  folds  were  much  enlarged  before  I  saw  the 
while  only  10  in  181,  or  about  1  in  18,  of  those  child,  the  case  puzzled  me  a  good  deal.  I  saw 
whose  mothers  were  unaffected,  had  the  oph-  what  I  thought  was  part  only  of  the  cornea 
thalmia;  and  that,  therefore,  the  proportion  of  tolerably  clear,  till  the  swelling  of  the  conjunc- 
tho  former  was  nearly  three  times  as  great  as  tiva  fell,  when  the  real  nature  of  the  case  ap- 
that  of  the  latter,  we  may  assume  that  a  dis-  peared.  Gonorrhoea  had  existed  in  both  pa- 
charge  from  the  genitals  of  the  mother,  though  rents. 

not  the  sole  cause  of  this  disease,  is  a  very  fre-  '  Archives  Generales  de  Mcdecine,  4^  Serie  ; 

quent   one.     Medical    Gazette;   Vol.  xxvii.  p.  Tome  i.  p.  397  ;  Tome  ii.  p.  9 ;  Paris,  1843. 

382;  London,  1840.  *  Gazette   MIdicale   de   Paris,   Janvier  24, 

Dr.  Tyler  Smith  is  of  opinion  that  it  is  the  1852,  p.  52. 

acid   or  epithelial  secretion   of  the  vagina  in  '  A  similar  case  is  related  by  Jiingken  in  his 

leucorrhcea,  and  not  puriform  matter,  which  is  work  LTeber  die  Augenkrankheit  welche  in  der 

the  cause  of  ophthalmia  neonatorum.     Lancet,  belgischen  Armee  herrscht;  p.  8  ;  Berlin,  1834. 

August  20,  1853,  p.  158.  '^  M.    Chassaignac    announced,    some    years 

2  I  think  there  is  reason  to  believe  thatgonor-  ago,  that  the  conjunctiva  was  covered  in  oph- 
rhoea  in  either  parent,  or  in  both,  may  affect  thalmia  neonatorum  by  a  pseudo-membrane, 
the  offspriqg  in  various  ways;  for  example,  and  that  a  great  improvement  in  the  treatment 
with  malformations,  as  coloboma  palpebrse,  consisted  in  the  employment  of  a  cold  water 
microphthalmos,  &c.  It  has  often  struck  me,  douche  to  the  eyes.  There  is  some  reason  to 
that  gonorrhoea  in  the  parents  may  perhaps  so  suspect,  that  what  he  considered  a  fase  mem- 
affect  the  child  in  vtero,  that  it  is  born  with  a  brane  was  the  epithelium,  so  thickened  and 
predisposition  to  this  ophthalmia.  On  one  changed  by  the  action  of  the  douche,  that  it 
occasion  I  met  with  the  ej'es  in  the  state  of  could  be  removed  with  the  forceps.  See  An- 
mierophthalmus,  and  affected  with  gonnrrha?al  nales  d'Oculistique  ;  Tome  xviii.  pp.  138,  140, 
ophthalmia  neonatorum.     As  the  conjunctival  273,  279  ;  Bruxelles,  1847. 


SECTION   IX. — GONORRHCEAL   OPHTHALMIA. 

Syn. — Conjunctivitis  puro-mucosa  gonorrhoica.     Gonorrhoea  oculi.     Der  Augentripper, 

Ger. 

Firj.  Dalrymple,  PI.  X.  Figs.  3-6. 

Different  views  have  been  entertained  of  the  purulent  inflammation  of  the 
conjunctiva,  which  is  frequently  found  to  attend,  or  succeed  to  gonorrhoea. 
1st.  This  ophthalmia  has  been  ascribed  to  inoculation  with  matter  from  the 
urethra  ;  2dly.  It  has  been  supposed  to  be  metastatic  ;  and  3dly.  It  has 
been  considered,  at  least  in  certain  cases,  as  an  efiTect  owing  to  irritation 
merely,  without  either  inoculation  or  metastasis.  It  is  quite  possible  that 
there  may  be  three  such  varieties  of  this  ophthalmia.  The  existence  of  the 
first  I  consider  beyond  all  doubt ;  but  the  second  and  third  are  somewhat 
problematical. 

Some,  while  they  have  admitted  that  facts  fully  demonstrate  that  gonor- 
rhoeal  ophthalmia  occasionally  owes  its  origin  to  inoculation,  have  expressed 
their  surprise  that  it  is  not  more  frequently  produced  in  this  way,  considering 
how  common  gonorrhoea  is,  and  how  careless  many  of  those  of  the  lower 
ranks  are  of  cleanliness.  We  should  expect,  say  they,  the  finger  to  be  in 
many  more  cases  the  conveyer  of  the  matter  of  the  gonorrhoea  to  the  con- 
junctiva, than  it  actually  appears  to  be.  The  instinctive  closure  of  the  eye- 
lids when  the  finger  approaches  the  eye,  making  it  actually  difiicult  for  a 
person  to  touch  his  own  conjunctiva,  unless  with  one  finger  he  draws  down 
the  lower  lid,  and  intentionally  applies  another  finger  to  the  eye,  will  serve  in 
some  measure  to  explain  the  rarity  of  this  kind  of  inoculation. 

Women  are  much  less  frequently  the  subjects  of  gonorrhoeal  ophthalmia 
than  men.  [This  fact  is  to  be  accounted  for  by  the  conformation  of  the 
male,  and  the  character  of  his  clothing,  and  is  a  strong  argument  in  favor  of 
the  contagious  origin  of  the  disease,  the  hand  serving  most  frequently,  as  the 
means  of  its  communication. — H.] 

In  general,  it  is  only  one  eye  which  is  affected  with  this  disease.  When- 
ever we  see   one  eye  affected  with  severe  puro-mucous  inflammation,  the 


468  GONORRHEAL   OPHTHALMIA. 

lids  much  swollen,  and  of  a  livid  color,  and  the  discharge  copious,  without 
any  affection  of  the  other  eye,  we  may  suspect  the  case  to  be  gonorrhoeal. 
Dr.  Vetch,  speaking  of  the  Egyptian  ophthalmia,  says,  "There  is  not  one 
case  in  a  thousand  in  which  one  eye  only  becomes  affected."^ 

§  1.    Gonorrhoeal  Ophthalmia  from  Inoculation. 

Case  268. — A  patient  was  brought  to  me  from  the  country  by  a  gentleman  under  whose 
care  he  was,  and  who  had  formerly  been  one  of  my  pupils.  The  left  eye  was  violently 
inflamed  and  chemosed,  the  chemosis  of  a  pale  red  color,  the  conjunctiva  discharging  a 
large  quantity  of  purulent  fluid,  the  lower  lid  greatly  everted,  and  the  cornea,  from  lymph, 
and  probably  pus,  efi"used  between  its  lamella?,  totally  opaque.  The  patient  was  affected 
with  gonorrhoea,  and,  13  days  before  I  saw  him,  while  engaged  in  removing  the  discharge 
from  the  urethra,  a  drop  of  the  gonorrhoeal  matter  was  by  mischance  thrown  fairly  in 
upon  his  left  eye,  and  excited  the  severe  puro-mucous  ophthalmia  under  which  he  was 
laboring.  The  gonorrhoea  still  continued  when  I  saw  him.  The  inflammation  of  the  eye 
subsided  under  appropriate  means,  the  cornea  cleared  to  a  degree  far  beyond  my  expecta- 
tions, and  a  considerable  share  of  vision  was  preserved.  The  right  eye  was  not  at  all 
affected. 

Case  2G9. — In  a  patient  who  came  under  my  care  25th  April,  1851,  a  drop  of  urine 
only,  as  he  thought,  had  been  projected  into  the  right  eye.  lie  had  had  gonorrhoea,  but 
it  seemed  to  have  ceased  before  the  accident  happened,  four  or  five  days  after  which  he 
felt  as  if  a  mote  had  got  into  the  eye.  This  was  followed  by  violent  purulent  ophthalmia. 
The  eye  was  saved. 

Case  270. — Mr.  AU.an  relates  the  following  interesting  case  of  contagious  gonorrhoeal 
ophthalmia:  "I  was  consulted,"  says  he,  "  by  a  young  gentleman  of  17  years  of  age,  on 
account  of  a  gonorrhoea  recently  contracted,  but  by  no  means  severe.  In  a  few  days 
after  his  application  to  me,  the  ej-es  became  violently  and  suddenly  inflamed,  the  eyelids 
much  tumefied,  and  there  took  place  a  profuse  discharge,  similar  to  that  of  gonorrhoea, 
excoriating  the  cheeks,  and  accompanied  by  great  pain,  considerable  fever,  and  general 
restlessness  ;  the  discharge  from  the  urethra  did  not  at  once  disappear,  notwithstanding 
the  violence  of  the  ophthalmia.  In  a  few  days,  his  younger  brother,  a  boy  of  14  years  of 
age,  who  had  never  been  exposed  to  any  venereal  complaint  contracted  by  sexual  inter- 
course, and  who  slept  in  the  same  room,  was  similarly  affected  ;  and  the  disease  in  both 
eyes  was  equally  severe  as  in  those  of  the  elder  brother.  I  called  Dr.  Monro  and  Mr.  J. 
Bell  into  attendance  ;  but  notwithstanding  every  means  that  could  be  devised,  the  elder 
brother  lost  the  sight  of  both  his  ej^es,  and  the  younger  brother  of  one  eye.  If  it  be  said," 
adds  Mr.  Allan,  "that  in  the  elder  brother  the  ophthalmia  might  arise  from  a  consenta- 
neous connection  or  sj-rapathy  betwixt  the  urethra  and  the  conjunctiva,  and  not  from  the 
direct  application  of  the  virus,  still  this  explanation  will  not  at  all  apply  to  the  younger 
brother,  who  had  no  gonorrhoea,  but  who  must  have  contracted  the  disease  from  actual 
contact;  as  by  using  the  same  towel  or  wash-hand  basin  with  his  brother,  wiping  his  face 
with  the  same  handkerchief,  or  in  some  less  obvious  manner,  and  in  whom  it  was  equally 
severe."^ 

Case  271. — Astruc  relates,  that  a  young  man  had  been  in  the  habit  of  bathing  his  eyes 
every  morning  with  his  urine  while  it  was  yet  warm,  in  order  to  strengthen  his  sight. 
Although  he  had  contracted  a  gonoi'rhoea,  he  did  not  abstain  from  this  custom,  appre- 
hending no  harm  from  it ;  but  the  urine  partaking  of  the  infectious  matter,  quickly  com- 
municated the  same  disease  to  the  tunica  conjunctiva  of  the  eye  and  eyelids.  The  conse- 
quence was  a  severe  ophthalmia,  attended  with  an  acrid  and  involuntary  discharge  of 
tears  and  purulent  matter,  but  which  yielded  to  the  same  remedies  which  removed  the 
gonorrhoea.'' 

Case  272. — A  healthy  young  woman  happened  to  wash  her  eyes  with  some  sugar  of 
lead  water  and  a  sponge,  which  had  previously  been  used  by  a  young  man  affected  with 
gonorrhoea  ;  the  consequence  was,  that  she  immediately  contracted  a  severe  ophthalmia, 
which  rapidly  destroyed  one  eye,  and  brought  on  swelling  of  the  lymphatic  glands  about 
the  neck,  for  which  she  underwent  a  course  of  mercury.* 

Case  273. — I  saw  a  mother  infected  in  the  right  eye  with  gonorrhoeal  ophthalmia,  from 
the  left  eye  of  her  son,  who  was  similarly  affected.  He  was  laboring  under  preputial 
gonorrhoea,  without  being  able  to  tell  how  he  had  got  it.  Both  the  inflamed  eyes  were 
lost. 

So  similar  is  the  discharge  from  the  eye  in  gonorrhoeal  and  in  Egyptian 
ophthalmia,  to  that  which  runs  from  the  urethra  in  gonorrhoea,  that  some 
have  gone  the  length  of  concluding  that  gonorrhoea  has  been  originally  an 
inoculation  of  the  urethra  by  the  matter  derived  from  the  eye  in  Egyptian 


GONORRHCEAL   OPHTHALMIA.  469 

ophtlialmia ;  while  others  are  of  opinion  that  this  last  disease  is  nothing  else 
than  the  eiiorts  of  an  inoculation  of  the  conjunctiva  with  matter  from  the 
urethra  in  gonorrhoea.  Both  parties  have  referred  to  experiments  in  favor  of 
their  own  opinion.  Little  can  be  drawn  from  negative  experiments  on  this 
subject.  It  is  demonstrated  beyond  all  doubt  that  the  matter  from  the  urethra 
in  gonorrhoja,  applied  to  the  conjunctiva,  excites  a  severe  puro-mucous  oph- 
thalmia, and  a  similar  inflammation  of  the  urethra  has  unquestionably  been 
brought  on  by  inoculation  with  the  matter  coming  from  the  conjunctiva  in 
the  Egyptian  ophthalmia  ;  but  experiments  of  this  kind  have  also  sometimes 
failed,  and  from  such  failures  conclusions  have  been  drawn  that  are  altogether 
unwarrantable.  For  example.  Dr.  Yetch  tells  us  that,  in  a  soldier  in  a  very 
advanced  stage  of  the  Egyptian  ophthalmia,  he  attempted  to  divert  the  dis- 
ease from  the  eyes  to  the  urethra,  by  applying  some  of  the  matter  taken  from 
the  eyes  to  the  orifice  of  the  urethra.  No  effect  followed  this  trial.  It  was 
repeated  in  some  other  patients,  all  laboring  under  the  most  virulent  state  of 
the  Egyptian  disease;  and  in  all,  the  application  was  perfectly  innocuous. 
But,  iu  another  case,  where  the  matter  was  taken  from  the  eye  of  one  man 
laboring  under  purulent  ophthalmia,  and  applied  to  the  urethra  of  another, 
the  purulent  inflammation  commenced  in  36  hours  afterwards,  and  became  a 
very  severe  attack  of  gonorrhoea.  From  the  result  of  these  experiments,  Dr. 
Yetch,  while  he  admits  that  gonorrhoeal  matter  taken  from  one  person  and 
applied  to  the  conjunctiva  of  another,  will  excite  a  highly  purulent  ophthal- 
mia, regards  himself  justified  in  no  longer  admitting  the  possibility  of  infec- 
tion being  conveyed  to  the  eyes  from  the  gonorrhoeal  discharge  of  the  same 
person.  He  adds  that  the  impossibility  of  this  effect  was  rendered  decisive 
by  an  hospital-assistant,  who,  with  more  faith  than  prudence,  conveyed  the 
matter  of  a  gonorrhoea  to  his  eyes  without  any  affection  of  the  conjunctiva 
being  the  consequence.^  It  is  remarkable,  that  Dr.  Guillie  has  fallen  into  the 
same  error  of  reasoning  as  Dr.  Yetch,  only  that  his  negative  experiments 
have  led  him  to  the  very  opposite  conclusion.  He  applied  the  matter  taken 
from  the  conjunctiva  of  one  patient,  to  the  urethra  of  another  ;  no  effect  fol- 
lowed, and  hence  he  concludes  that  the  notion  of  some,  regarding  the  propa- 
gation of  puro-mucous  inflammation  from  one  mucous  membrane  to  another 
in  different  individuals,  is  unfounded.^ 

Case  268  would  have  been  sufficiently  convincing  to  me  of  the  reality  of 
gonorrhoeal  ophthalmia  by  inoculation,  had  I  entertained  any  doubt  on  the 
subject.  The  patient  had  a  profuse  gonorrhoea,  but  his  eyes  were  perfectly 
well ;  shaking  away  the  discharge  from  the  penis,  and  stooping  at  the  time, 
a  drop  went  fairly  in  on  the  left  eye  ;  a  violent  inflammation  immediately  set 
in,  was  all  along  confined  to  the  eye  which  had  been  inoculated,  and  pro- 
duced the  results  already  stated,  while  the  gonorrhoea  continued  to  run  its 
course. 

Diagnosis. — There  are  no  marks  which  can  be  absolutely  depended  on,  by 
which  to  distinguish  gonorrhoeal  ophthalmia,  produced  by  inoculation,  from 
the  Egyptian  or  contagious  ophthalmia.  The  symptoms  of  the  former  are 
not  less  rapid  and  severe  than  those  of  the  latter  ;  and  the  danger  of  losing 
the  eye,  by  destruction  of  the  cornea,  greater  perhaps  than  in  any  other  oph- 
thalmia. There  is  a  greater  degree  of  chemosis,  and  a  profuse  discharge  of 
matter,  varying  in  color,  like  the  discharge  in  gonorrhoea.  The  external  sur- 
face of  the  lids  is  perhaps  not  so  much  swollen,  nor  of  so  dark  a  red  color, 
as  in  the  Egyptian  ophthalmia.  In  the  early  stage,  it  will  also  be  observed, 
that  in  the  latter  disease  the  inflammation  commences  on  the  inside  of  the 
lids ;  whereas  in  gonorrhoeal  ophthalmia,  it  attacks  the  conjunctiva  more 
generally.  The  history  of  the  two  diseases  will  perhaps  afford  the  best 
ground  for  diagnosis.^ 


410  GONORRHCEAL   OPHTHALMIA. 

Prognosis. — In  48  hours,  this  disease  may  have  proceeded  so  far  that  sight 
shall  be  irretrievably  gone.  Thus,  out  of  14  cases  related  by  Mr.  Lawrence,^ 
9  having  only  one  eye  affected,  and  5  both  eyes,  6  of  the  former  suffered 
tatal  loss  of  vision  of  the  eye  affected,  while  3  retained  pei'fect  sight,  though 
one  had  anterior  synechia,  and  another  a  leucoma.  Of  the  other  5,  who  had 
both  eyes  affected,  4  lost  each  one  eye,  and  saved  one ;  the  5th  losing  both 
eyes. 

Like  gonorrhoea,  this  ophthalmia  varies  much  in  severity  ;  and  from  dif- 
ferences of  constitution  and  other  causes  its  effects  are  very  different  in  dif- 
ferent individuals,  some  eyes  resisting  the  tendency  to  disorganization  and 
getting  well,  others  being  rapidly  destroyed.  The  previous  habits  of  the 
patient,  such  as  his  addiction  to  the  use  of  spirits,  often  diminish  greatly  the 
chance  of  recovery. 

Symptoms. — The  symptoms  of  gonorrhoeal  ophthalmia  by  inoculation  bear 
so  close  a  resemblance  to  those  of  the  Egyptian  ophthalmia,  that  it  is  un- 
necessary to  detail  them. 

The  chemosis  and  swelling  of  lids  are  often  rather  pale.  The  discharge 
from  the  eye  is  generally  profuse  and  purulent. 

The  cornea  is  often  destroyed  by  an  ulcerated  groove  forming  at  its  edge, 
where  it  is  covered  and  pressed  upon  by  the  chemosed  conjunctiva.  This 
groove  goes  round  a  considerable  portion  of  the  edge  of  the  cornea ;  and 
about  the  twelfth  or  fourteenth  day  of  the  disease  is  very  apt  to  give  way, 
allowing  the  iris  to  protrude  in  one  or  several  points.  The  eye  may  be  quite 
entire  and  clear  to-day,  and  to-morrow  we  find  the  cornea  burst,  generally 
near  its  lower  edge.  This  event  is  very  apt  to  happen  about  midnight,  and 
is  attended  by  the  sensation  of  something  having  giving  way  in  the  eye.  I 
have  known  this  event  to  happen  when  the  patient  was  straining  at  stool. 
After  this  happens,  the  cornea  appears  small  and  flat,  its  centre  continues 
pretty  clear  for  a  while,  but  vision  is  lost.  In  other  cases,  I  have  seen  ulcera- 
tion spread  over  a  great  part  of  the  surface  of  the  cornea,  without  penetrat- 
ing, at  least  for  a  time,  through  its  whole  thickness.  The  cornea  seems,  in 
this  case,  to  melt,  as  it  were,  away ;  it  becomes  so  thin  as  to  bulge  forwards, 
and  some  part  of  it  may  look  clear,  from  being  so  much  thinned.  In  a  day 
or  two  it  gives  way,  and  the  case  ends  in  staphyloma.  All  this  may  happen 
without  any  great  chemosis  and  without  any  overlapping  of  the  cornea  by  the 
conjunctiva. 

Treatment. — This  ought  to  be  exactly  the  same  as  in  the  Egyptian  oph- 
thalmia. Rest  is  of  great  importance.  The  patient  ought  not  to  travel  to 
and  from  an  hospital,  but  should  be  admitted  into  the  house.  There  should 
be  an  abstinence  from  all  stimulants.  Bloodletting,  both  general  and  local, 
by  venesection,  cupping,  leeches,  and  scarifying  the  conjunctiva,  should  be 
promptly  used,  as  delay  for  a  day,  or  even  for  an  hour,  may  prove  fatal  to 
the  eye.  The  exhibition  of  purgatives,  or  emeto-purgatives,  and  diaphoretics, 
is  to  be  had  recourse  to  in  the  early  stage.  The  discharge  is  to  be  frequently 
and  carefully  removed  with  the  muriate  of  mercury  collyrium,  the  conjunctiva 
is  to  be  brushed  repeatedly  in  the  course  of  the  day  with  the  nitras  argenti  so- 
lution, and  the  lids  are  to  be  prevented  from  adhering  by  the  use  of  the  red 
precipitate  salve.  Belladonna  is  to  be  applied,  even  before  any  ulceration  of 
the  cornea  makes  its  appearance.  Counter  irritation  ought  to  be  employed 
from  the  very  first,  by  means  of  sinapisms  and  blisters  to  the  neck,  between 
the  shoulders,  or  behind  the  ears.  If  the  pain  of  the  eye  be  pulsative,  or  the 
circumorbital  region  affected  with  nocturnal  paroxysms  of  pain,  calomel  and 
opium  are  to  be  given  till  the  mouth  is  sore.  Aloes  and  blue  pill,  given  in 
combination,  I  have  found  useful,  when  it  is  desirable  to  act  on  the  system 
by  a  mercurial,  and  at  the  same  time  to  move  the  bowels.     Warm  fomenta- 


GONORRIICEAL   OPHTHALMIA.  411 

tions,  the  vapor  of  laudanum,  opiate  friction  of  the  head,  and  the  like,  will 
serve  to  moderate  the  pain  ;  but  our  chief  reliance  must  be  placed  on  deple- 
tion, counter-irritation,  scarification,  and  smarting  applications  to  the  conjunc- 
tiva. Snipping  out  a  fold  of  the  chemosed  membrane,  so  as  to  procure  a  con- 
siderable flow  of  blood,  is  highly  serviceable. 

Bleeding  alone  must  not  be  depended  on.  "  The  inflammation  produced," 
says  Mr.  Bacot,  "in  the  few  instances  that  have  come  under  my  observation, 
is  of  the  most  violent  and  intractable  description,  and  has  produced  the  total 
destruction  of  the  organ  of  vision  in  the  space  of  two  or  three  days,  notwith- 
standing the  most  vigorous  employment  of  general  and  topical  bloodletting, 
and  other  antiphlogistic  means.  "^  ^N'either  are  local  stimulants  to  be  trusted 
to  alone ;  but  a  combination  of  antiphlogistics  and  astringents  is  at  once  to 
be  employed. 

The  acetate  of  lead,  and  the  sulphates  of  zinc  and  copper,  at  least  in  the 
early  stage,  will  be  found  to  aggravate  the  symptoms.  These  are  the  local 
remedies  recommended  by  Mr.  Allan  ;  and  the  case  already  quoted,  the  pub- 
lication of  which  does  great  credit  to  his  candor,  shows  how  little  adapted 
these  applications  are  to  this  disease. 

§  2.    Gonorrhcecd  Ophthalmia  from  Metastasis. 

Saint- Yves  appears  to  have  been  the  first  to  speak  of  gonorrhoeal  ophthal- 
mia from  metastasis.  His  account  of  it  is  very  short.  He  describes  the  con- 
junctiva as  becoming  hard  and  fleshy,  the  disease  having  commenced  by  an 
abundant  discharge  of  white  or  yellowish  matter.  He  states  that,  in  most 
cases,  the  ophthalmia  began  two  days  after  the  commencement  of  the  gonor- 
rhoea, the  latter  discharge  having  at  that  period  suddenly  ceased,  and  thus 
caused  a  metastasis  to  the  eye.  He  recommends  bloodletting  from  the  first, 
mercury,  purgatives,  and  the  warm  bath.  As  local  applications,  he  advises 
brandy  and  water,  and  a  decoction  of  rosemary,  sage,  hyssop,  and  roses  in 
red  wine.*" 

Succeeding  writers  have  adopted  Saint-Yves'  views  of  the  subject  with  too 
little  hesitation,  and  appear  not  to  have  sufficiently  investigated  the  proba- 
bility of  the  ophthalmia  arising  rather  from  inoculation  than  from  metastasis. 

The  causes  of  the  suppression  of  the  gonorrhoea,  to  which  the  rise  of  me- 
tastatic gonorrhoeal  ophthalmia  is  attributed,  are  exposure  to  cold,  violent 
exertions  of  the  body,  the  abuse  of  spirituous  liquors,  and  the  employment  of 
astringent  injections  into  the  urethra. 

The  following  may  serve  as  a  specimen  of  alleged  metastatic  gonorrhoeal 
ophthalmia. 

Case  274. — A  captain  in  the  army,  aged  29,  was  ordered  to  mount  guard  at  court,  in 
the  month  of  January,  when  he  had  a  violent  gonorrhoea.  The  day  was  excessively  cold, 
and  he  was  forced  by  his  duty  to  remain  a  long  time  exposed  to  the  air  during  the  day 
and  night.  Towards  midnight  he  began  to  feel  the  most  violent  pain  in  both  eyes  at  once, 
which  was  very  soon  increased  to  such  a  degree  that  he  could  not  endure  any  kind  of 
light.  Next  day  these  symptoms  were  attended  by  a  discharge  of  puriform  matter  from 
both  eyes,  and  the  albuginea  appeared  very  much  inflamed  and  swollen.  A  physician 
was  sent  for,  unfortunately  verj-  ignorant,  who  ordered  general  remedies,  as  bleeding, 
purgatives,  &c.,  with  a  fomentation  of  hemlock.  The  third  day,  on  examining  things 
more  closely,  the  cornea  was  found  completelj'  opaque,  and  a  hypopion  formed  ;  there  ap- 
peared to  be  no  ulceration.  The  hemlock  was  continued  without  any  effect.  Ten  or 
twelve  days  after,  the  inflammation  began  to  abate,  and  the  discharge  from  the  eyes 
stopped ;  but  the  cornea  did  not  recover  its  transparency ;  on  the  contrary,  it  was  ex- 
tremely thickened,  and  the  patient  remained  entirely  blind  for  life." 

Treatment. — The  only  point  of  treatment  in  cases  of  metastatic  gonorrhoeal 
ophthalmia,  diS"erent  from  that  which  is  followed  when  the  disease  is  brought 
on  by  inoculation,  is  the  attempt,  so  much  recommended  by  some  authors,  to 


472  GONORRHCEAL   OPHTHALMIA. 

restore  tlie  suppressed  discharge  from  the  urethra.  This  is  done  by  introduc- 
ino-  a  bougie  into  the  urethra,  covered  with  some  of  the  purulent  discharge 
from  the  eye,  or  with  gouorrhoeal  matter  from  another  subject.  Even  the 
simple  introduction  of  a  bougie  might  perhaps  produce  the  effect  desired  ;  for 
any  stimulus  applied  to  the  lining  membrane  of  the  urethra,  of  sufficient  ac- 
tivity to  determine  an  irritation  and  an  abundant  secretion  of  mucus,  may 
produce  a  running  similar  to  gonorrhoea.  If  this  plan  is  adopted,  the  bougie 
must  be  retained  in  the  urethra  for  several  hours  at  a  time,  till  the  desired 
effect  is  produced. 

§  3.    Gonorrhceal  Ophthalmia  without  Inoculation  or  Metastasis. 

Various  authors  have  related  cases  of  puro-mucous  ophthalmia  occurring 
in  individuals,  who,  either  at  the  time  when  the  ophthalmia  attacked  them, 
or  a  short  time  before  its  attack,  had  been  affected  with  gonorrhoea.  An  al- 
ternation also  has  been  observed  by  these  authors  between  the  two  diseases ; 
that  is  to  say,  when  the  gonorrhoea  came,  the  ophthalmia  went,  and  vice 
versa.  The  conclusion  drawn  from  such  cases  has  been,  that  a  relation  exists 
between  the  two  diseases,  and  that  they  are  convertible  the  one  into  the  other 
without  being  metastatic.  None  of  the  authors  who  have  described  the  cases 
to  which  I  now  refer,  have  explicitly  attributed  the  production  of  the  oph- 
thalmia in  question  to  the  influence  of  nervous  sympathy ;  and  yet  if  we  throw 
inoculation  and  metastasis  aside,  there  appears  to  be  no  other  means  by  which 
the  diseases  of  remote  organs  can  be  connected,  except  by  nervous  communi- 
cation. The  facts  recorded  upon  the  subject  are  valuable,  whatever  opinion 
we  may  form  of  the  reasonings  of  those  by  whom  they  are  narrated. 

Case  275. — Swediaur  states  that  a  young  man  in  London  came  to  consult  him  for  an 
ophthalmia.  After  he  had  tried  the  best  remedies,  internal  and  external,  that  he  knew 
for  an  ophthalmia,  -without  effect,  the  patient  left  him.  He  heard  nothing  more  of  him 
for  two  months,  when  he  returned  to  him  with  gonorrhoea.  During  his  absence  he  con- 
sulted several  practitioners  on  account  of  his  ophthalmia,  but  with  no  better  success  than 
before  ;  but  having  caught  a  gonorrhoea  eight  days  before  returning  to  Swediaur,  he 
began  to  feel  his  eyes  better  from  the  third  day  of  the  discharge.  The  ophthalmia  con- 
tinued to  diminish  from  day  to  day,  and  he  was  quite  cured  of  it.  Swediaur  asked  him 
if  he  ever  had  gonorrhoea  previously  to  the  attack  of  ophthalmia.  He  said  he  had  it  some 
time  before  he  came  to  consult  him  first  about  his  eyes  ;  that  he  suffered  much,  and  for  a 
long  time,  with  it,  but  that  at  last  the  discharge  disappeared  ;  and  that  he  had  not  men- 
tioned it,  as  he  had  not  supposed  there  was  any  connection  between  the  gonorrhoea  and 
the  complaint  in  his  eyes,  which  had  come  on  several  weeks  after. 

Swediaur  tells  us,  that  this  fact  was  too  striking  a  lesson  for  him  ever  to 
forget  it ;  and  that  he  never  afterwards  failed,  in  similar  cases  of  ophthalmia, 
to  ask  the  patient  if  he  had  not  previously  had  a  gonorrhoea,  and  if  it  was 
properly  treated  and  cured.  He  describes  the  ophthalmia  in  cases  of  this 
sort,  as  a  chronic  inflammation  of  the  eyes,  and  especially  of  the  eyelids,  at- 
tended very  often  with  little  ulcers  of  the  sebaceous  glands,  and  with  oozing 
of  thick  yellowish  matter.  In  all  such  cases,  especially  when  the  patients 
told  him  that  they  had  tried  many  internal  and  external  remedies  for  the 
ophthalmia,  he  did  not  hesitate  to  advise  the  use  of  bougies  for  a  couple  of 
hours  a-day,  as  the  surest  and  speediest  way  of  curing  the  ophthalmia  ;  and 
he  tells  us,  that  he  had  the  satisfaction  of  seeing  most  of  such  cases  cured, 
even  without  any  other  external  application." 

Case  276. — A  sailor  used  all  his  influence  to  get  appointed  to  the  command  of  a  frigate. 
He  waited  on  the  Admiralty  frequently,  and  was  promised  a  ship  ;  and  in  the  mean  time 
went  into  Scotland  grouse-shooting.  Whilst  there,  he  received  instructions  from  the 
Admiralty  to  take  the  command  of  a  frigate  then  lying  at  Falmouth;  he  lost  no  time  in 
setting  out,  and  placed  himself  in  the  mail-coach  for  London.  Just  before  he  left  Edin- 
burgh, he  caught  a  gonorrhoea.  On  the  journey  his  eyes  became  inflamed ;  and  when  he 
reached  London,  he  had  a  violent  ophthalmia,  with  purulent  discharge.     He  was  in  a 


GONORRHCEAL   OPHTHALMIA.  413 

dreadful  state  both  of  body  and  mind,  could  not  bear  the  light,  and  had  great  pain  in  the 
eyes. 

Mr.  Abernethy,  whom  he  consulted,  asked  him  if  ever  he  had  gonorrhoea  or  inflamed 
eyes  before.  He  answered  that  he  had  had  both  the  one  and  the  other ;  and  that  when  the 
discharge  from  his  urethra  was  stopped,  the  eyes  became  bad,  and  when  his  eyes  got  well, 
the  gonoi'rhoea  returned. 

Mr.  A.  directed  him  to  remain  quiet  in  a  darkened  room,  to  wash  his  eyes  frequently, 
in  the  course  of  the  day,  with  tepid  poppy  water,  to  take  five  grains  of  the  blue  pill  every 
night,  with  some  castor  oil  to  open  the  bowels,  and  to  keep  himself  upon  a  strictly  spare 
diet.  During  the  first  six  days  he  mended  very  slowly  and  not  considerably.  But  on  the 
7th  day,  when  Mr.  A.  called,  he  found  the  patient  sitting  up  in  his  room,  the  window 
uncovered,  and  his  eyes  almost  well.  Mr.  A.  expressed  his  surprise,  and  asked  how  this 
change  had  so  suddenly  happened,  to  which  he  answered  that  he  had  had  a  number  of  very 
copious  fetid  stools  in  the  night,  and  that  his  complaints  had  left  him.  It  seemed  to  be  a 
sort  of  critical  secretion  from  the  liver  and  the  wliole  of  the  alimentary  canal,  followed 
by  an  almost  immediate  removal  of  the  irritable  inflammation  of  the  eyes. 

Mr.  Abernethy,  in  his  surgical  lectures,  spoke  of  such  cases  as  the  above 
as  examples  of  an  irritahle  ophthalmia,  attendant  on  gonorrhcEa,  very  different 
from  the  purulent  ophthalmia  excited  by  touching  the  eye  with  the  matter 
from  the  urethra,  and  in  fact  a  constitutional  malady.  He  stated  that  he  had 
seen  many  cases  of  both  diseases  ;  that  he  had  known  many  people  who  were 
liable  to  rheumatism  of  the  joints,  to  puriform  discharges  from  the  urethra,  and 
to  this  irritable  ophthalmia ;  and  that  these  diseases  used  to  alternate  the 
one  with  the  other.  When  the  rheumatism  ceased,  the  discharge  returned 
from  the  urethra,  and  when  the  discharge  from  the  urethra  ceased,  the  affec- 
tion of  the  eye  returned,  and  thus  one  disease  supervened  upon  another.  He 
stated  that  if  the  surgeon  is  frightened  at  this  irritable  ophthalmia,  supposing 
it  to  be  one  of  the  dreadful  cases  in  which  the  eye  is  clapped,  and  proceeds 
to  bleed  and  purge  the  patient  severely,  he  will  only  make  the  matter  worse. 
Moderate  bleeding,  he  said,  may  be  useful ;  but  the  chief  object  is  to  attend 
to  the  patient's  general  health.  No  means  are  so  likely  to  be  useful  as  setting 
the  digestive  organs  to  rights,  and  sending  the  patient  to  the  country. ^^ 

The  two  cases  above  quoted,  with  the  remarks  subjoined  to  them  by  their 
narrators,  will  serve  in  some  measure  to  show  the  diversity  which  exists  in 
the  opinions  entertained  regarding  the  ophthalmia?  which  in  some  individuals 
are  found  to  attend  gonorrhcea,  or  to  alternate  with  this  disease.  It  is  quite 
evident  that  the  ophthalmia?  which  have  been  observed  to  do  so,  are  far  from 
being  uniform.  That  observed  by  Swediaur  appears  to  have  been  little  more 
than  ophthalmia  tarsi ;  that  which  occurred  in  Mr.  Abernethy's  case  bears  a 
strong  resemblance  to  catarrhal  ophthalmia,  and  probably  was  nothing  more. 
As  it  is  acknowledged  that  in  neither  of  these  cases  was  there  either  inocula- 
tion or  metastasis,  it  may  fairly  be  doubted  whether  there  was  any  connection 
between  the  disease  of  the  urethra  and  that  of  the  eye,  farther  than  that 
they  occurred  in  the  same  individuals,  while  the  occurrence  of  both  might  be 
attributed  to  a  susceptibility  for  disease  arising  from  peculiar  or  debilitated 
constitutions. 

Swediaur's  hint  to  employ  the  bougie,  in  cases  of  ophthalmia  alternating 
with  gonorrhoea,  may  probably  be  found  of  use ;  it  is  evident,  however,  that 
this  remedy  cannot  be  trusted  to  alone,  but  that  the  ophthalmia  must  be 
treated  according  to  the  particular  symptoms  it  presents,  not  accordino-  to  the 
conjectural  notions  entertained  regarding  its  origin. 

[Notwithstanding  the  facts  that  the  theoi'y  of  sympathy  in  this  disease 
should  be  advocated  by  Sanson,  or  that  of  infection  should  find  a  champion  in 
Desruelles,  or  even  that  so  high  an  authority  in  ophthalmology  as  Mr.  Mac- 
kenzie, should  be  a  believer  in  the  metastasis  of  the  disease  from  the  urethral 
to  the  conjunctival  raucous  membrane,  we  can  hardly  admit  at  the  present 
day,  the  possibility  of  gonorrhoeal  conjunctivitis,  being   produced  by  any 


4T4  GONORRHCEAL   OPHTHALMIA. 

other  means  than  that  of  contagion  or  direct  contact  of  gonorrhoea!  matter 
with  the  conjunctira.  Our  author  seems  even  inclined  to  advocate  the  theory 
of  sympathy  to  account  for  the  cases  of  gonorrhoea!  ophthalmia,  which  he 
has  cited  from  Swediaur  and  Abernethy,  and  whicli  he  could  not  attribute  to 
inoculation  or  metastasis,  although  he  seems  to  have  misgivings  as  to  the 
really  specific  origin  of  either — admitting  that  one  was  only  probably  a  case 
of  ophthalmia  tarsi,  and  the  other,  a  case  of  catarrhal  ophthalmia  occurring 
after  the  subsidence  of  the  urethral  discharge. 

In  reference  to  the  cases  of  the  disease  attributed  to  metastasis,  we  may 
observe  that  many  of  such  cases  (as  for  instance  that  cited  by  the  author), 
bear  no  evidence  whatever,  of  any  such  change  having  taken  place  in  the 
location  of  the  disease,  and  in  their  recorded  history  we  can  find  sufficient 
causes  for  the  occurrence  of  the  disease,  without  invoking  the  theory  of  me- 
tastasis. As  in  the  very  case  of  the  young  captain,  was  not  the  exposure  to 
the  excessive  cold  in  the  month  of  January,  for  twenty-four  hours  continuously, 
and  that  on  mounted  duty,  sufficient  of  itself,  to  induce  a  violent  ophthalmia 
purely  catarrhal  in  its  character,  which  could  give  rise  to  all  the  symptoms  he 
endured,  and  which  by  the  treatment  resorted  to  in  the  case,  would  have  ter- 
minated as  it  did  ? 

Then  again,  in  the  cases  reputed  metastatic  in  their  origin,  and  of  which 
we  have  full  details,  it  is  not  evident  that  the  discharge  had  entirely  disap- 
peared from  the  urethra  before  or  coincident  with  the  appearance  of  the 
conjunctivitis,  an  occurrence  which  it  seems  to  us  essential  to  the  metastasis 
of  the  disease,  or  had  even  diminished  in  quantity,  as  for  instance,  Delpech, 
who  seems  to  be  no  enemy  to  the  theory  in  question,  says,  in  speaking  of  the 
subject,  "  II  est  bien  reconnue  que  I'ecoulement  ne  cesse  pas  toujours  en  pareil 
cas  ;  que  quelquefois  et  mOme  assez  souvent,  il  subsiste  dans  toute  sa  force." 
(Chirurgie  Clinique,  t.  i.  p.  319).  Such  cases,  however,  the  sympathists  or 
infectionists  may  claim  as  their  own  and  vaunt  in  confirmation  of  their  views, 
but  have  not  the  pure  contagionist  or  the  believer  in  the  non-specific 
character  of  the  disease,  an  equal  right  to  cite  them  in  support  of  their 
individual  doctrines?  and  why  should  we  envelop  the  thing  in  mystery,  by 
invoking  the  aid  of  a  cause  whose  mode  of  action  can  never  be  understood, 
even  admitting  its  existence,  when  we  can  explain  the  occurrence  by  one 
whose  mode  of  action  we  can  appreciate. 

The  coincidence  of  two  diseases,  or  their  occurrence  in  succession  to  each 
other,  is  no  positive  proof  of  their  relation  to  each  other  as  cause  and 
effect.  If  purulent  ophthalmia  following  the  existence  of  urethral  blennorrhoea, 
is  to  be  attributed  to  metastasis  of  the  disease,  ought  we  not  to  see  it  more 
frequently  than  we  do  ? 

Finally,  the  very  character  of  the  patients,  goes  very  strongly  to  confirm 
the  contagious  or  catarrhal  origin  of  the  disease,  as  for  instance  Beer,  one  of 
the  advocates  for  metastasis,  says:  "In  all  the  instances  which  I  have  seen, 
this  ophthalmia  has  occurred  in  young,  plethoric,  robust,  and  truly  athletic 
?new."  The  very  persons  who,  by  their  carelessness,  would  be  most  likely  to 
unconsciously  inoculate  themselves,  or  who,  by  their  mode  of  life  and  occupa- 
tions, would  be  most  exposed  to  the  causes  of  catarrhal  conjunctivitis. 

For  these  reasons  we  would  not  even  suggest  the  use  of  a  bougie  in  cases  of 
purulent  ophthalmia  following  or  coincident  with  gonorrhoea  or  its  suppres- 
sion, but  would  resort  to  the  ordinary  treatment  of  such  cases,  feeling  satis- 
fied that  the  counter  irritation  of  a  blister  at  the  nape  of  the  neck  would  be 
as  serviceable  in  the  cure  of  the  disease,  as  the  reproduction  of  the  gonor- 
rhoea.— H.] 

In  a  subsequent  section,  I  shall  give  some  account  of  an  internal  ophthal- 
mia, which  depends  upon  gonorrhoea,  under  the  head  of  Gonorrhceal  Iritis. 


APHTHOUS   OPHTHALMIA.  4t5 

*  Practical  Treatise  on  the   Diseases  of  the  tique  ;  Tome  xv.  p.  159  ;  Eruxelles,  1846.     On 
E_ve,  p.  195;   London,  1S20.  the  diagnosis  of  gonorrhoea!  and  Egyptian  oph- 

*  System  of  Pathological  and  Operative  Sur-  thalmia,  see  Henrotay,  Annales  d'Oculistique  ; 
gery  ;  Vol.  i.  p.  153  ;  Edinburgh,  1819.  Tome  xxiv.  pp.  179,  229,  254  ;  Bruxelles,  1850. 

"  De  Morbis  Venereis,  p.  192;  Lutetiae  Pa-  '  Treatise  on  the  Venereal  Diseases  of  the 

risiorum,  1736.  Eye,  p.  25;  London,  1830. 

■*  Chirurgie  Clinique  de  Montpellier,  par  le  '  Observations  on  Syphilis,  p.  46 ;  London, 

Professeur  Delpech;  Tome  i.  p.  318  ;  Montpel-  1821. 

lier,  1823.  '"  Nouveau  Traite  des  Maladies  des  Yeux. 

'  Op.  cit.  p.  242.  pp.  187,  209 ;  Paris,  1722. 

°  Bibliotheque  Ophthalmologique ;    Tome  i.  "  Swediaur's  Treatise  upon  the  symptoms, 

p.  83;  Paris,  1820.  Consequences,  Nature,  and  Treatment  of  Ve- 

''  Dr.  Hairion   insists  on  the  existence  of  a  nereal  or  Syphilitic  Diseases;  translated  from 

pre-auricular  bubo  as  diagnostic  of  gonorrhoeal  the  French  ;  Vol.  i.  p.  245 ;  London,  1819. 

ophthalmia;    but     this   symptom    occasionally  "^  Ibid.  p.  247. 

occurs  in  other   ophthalmiaj,  and  is  not  con-  "  Lectures,  in  the  Lancet;  Vol.  vii.  p.  5; 

slant  in   the   gonorrhoeal.     Annales    d'Oculis-  London,  1825. 


SECTION  X.. — APHTHOUS  OPHTHALMIA. 

Syn. — Conjunctivitis  aphthosa.     Pustular  ophthalmia. 
Fig.  Dalrymple,  PL  XIIL  Figs.  4,  5,  6.     Sichel,  PI.  V.  Fig.  2. 

Having  considered  the  blennorrhoeal  affections  of  the  conjunctiva,  we  have 
now  to  turn  our  attention  to  some  of  its  cutaneous  or  eruptive  diseases.  The 
chief  of  these  are  aphthous  and  phlyctenular  ophthalmice ;  to  which  may  be 
added,  the  inflammation  of  the  conjunctiva  in  measles,  scarlatina,  and  erysi- 
pelas. The  conjunctiva  is  apt  to  suffer  in  all  cutaneous  eruptions.  It  is 
inflamed  during  smallpox.  I  have  seen  it  evidently  affected  in  herpes,  lepra, 
and  elephantiasis.  I  was  called  into  consultation  with  Dr.  Lawrie,  to  see  a 
child  in  whom  pompholyx  began  on  one  eyelid,  fopr  days  after  birth,  and 
spread  over  most  of  the  body,  ending  with  inflammation  of  the  conjunctiva, 
and  an  ulcer  on  the  cornea,  of  the  eye  first  affected.  A  patient  called  on  me 
with  a  syphilitic  tubercular  eruption  on  his  face  and  body ;  a  tubercle  occu- 
pied the  sclerotic  conjunctiva.  It  died  away  with  the  other  tubercles  under 
the  action  of  mercury.^ 

The  aphthous  variety  of  eruptive  conjunctivitis  is  distinguished  from  the 
phlyctenular  in  the  following  respects  : — 

1.  Instead  of  minute  elevated  points  on  the  cornea,  or  close  to  its  edge, 
we  observe,  in  the  present  disease,  one  or  more  pretty  large  aphthae,  which 
bursting,  form  broad  elevated  ulcers,  generally  at  the  distance  of  half  a  line 
or  a  line  from  the  edge  of  the  cornea.  Although  this  disease  is  often  called 
pustular  ophthalmia,  the  eruption  which  takes  place  on  the  conjunctiva  is  not 
properly  one  of  pustules.  No  purulent  matter  is  discharged  when  they  burst, 
l3ut  only  a  watery  fluid,  so  that  they  are  rather  aphthte  than  pustules. 

2.  The  redness,  instead  of  being  fascicular,  is  rather  reticular.  It  radiates 
commonly  round  the  aphthae,  but  is  sometimes  pretty  generally  spread  over 
the  conjunctiva,  and  is  occasionally  attended  with  small  ecchymoses  under  that 
membrane. 

3.  The  aphthous  ophthalmia  is  often  combined  with  catarrhal  conjunc- 
tivitis. 

4.  There  is  much  less  intolerance  of  light  in  aphthous,  than  in  phlyctenular 
ophthalmia,  often  none,  and  never  the  continued  blepharospasm  so  character- 
istic of  the  latter  disease. 

5.  We  never  meet  with  aphthous  ophthalmia  in  teething  children.  The 
common  subjects  are  children  of  10  or  12  years  of  age,  and  not  unfrequently 
young  adults. 

6.  The  aphthous  ophthalmia  is  less  dangerous  and  more  tractable  than  the 


476  PHLYCTENULAR   OPHTHALMIA. 

phlyctenular,  into  which,  or  into  the  scrofulo-catarrhal,  it  sometimes  has  a 
tendency  to  pass. 

Treatment. — The  present  disease  generally  yields  readily  to  a  few  simple 
remedies. 

1.  The  eye  is  to  be  touched  once  a-day  with  a  solution  of  from  4  to  10 
grains  of  nitrate  of  silver  in  an  ounce  of  distilled  water,  and  bathed  thrice  a- 
day  with  a  solution  of  1  grain  of  muriate  of  mercury  and  6  grains  of  muriate 
of  ammonia  in  8  ounces  of  water. 

2.  After  a  smart  dose  of  calomel  and  jalap,  the  patient  ought  to  take  from 
10  to  20  grains  of  precipitated  carbonate  of  iron  thrice  a-day. 


'  See  case  by  Smee,  Medical  Gazette;  Vol.  xxxv.  p.  347;  London,  1844. 


SECTION  XI. — PHLYCTENULAR  OPHTHALMIA. 

gyn. — Conjunctivitis  phlyctenulosa.  Scrofulous  ophthalmia.  Strumous  ophthalmia. 
Photophobia  infantum  scrofulosa.  Exanthematous  ophthalmia ;  Wardrop.  Remittent 
ophthalmia ;  Hancock. 

Fig.  Wardrop,  PI.  I.  Figs.  2,  3.  PI.  II.  Figs.  1.  2.  PI.  V.  Fig.  1.  PI.  YII.  Fig.  3.  PI.  X. 
Fig.  I.  Ammon,  Thl.  I.  Tab.  IV.  Fig.  2.  Dalrvmple,  PI.  VIII.  PI.  XIII.  Figs.  2,  3.  PL 
XIV.  Figs.  1,  2,  3.     Sichel,  PI.  V.  Fig.  1.     PI.  IX.  Fig^.  3,  5,  6. 

Phlyctenular  ophthalmia  is  the  disease  most  commonly  known  by  the  name 
of  scrofulous  ophthalmia.  It  is  distinguished  from  all  the  other  inflammations 
of  the  eye  by  symptoms  so  very  striking,  that  any  one  who  has  seen  the  dis- 
ease a  few  times  cannot  mistake  it.  Slight  redness,  great  intolerance  of  light, 
phlyctenuliB  at  the  edge  or  on  the  surface  of  the  cornea,  and  ulcers  and  specks 
resulting  from  these  phlyctenule,  are  the  symptoms  which  characterize  this 
ophthalmia;  a  disease  to  which  children  are  so  liable,  that  out  of  the  100 
cases  of  inflammation  of  the  eyes  in  young  subjects,  90  are  of  this  kind.  This 
ophthalmia  is  very  often  the  first  manifestation  of  a  scrofulous  constitution ; 
and,  neglected  or  mistreated,  frequently  becomes  the  cause  of  permanently 
impaired  vision,  or  even  of  entire  loss  of  sight.  It  seldom  attacks  infants  at 
the  breast;  from  the  time  of  weaning  till  about  eight  years  of  age,  is  the 
period  of  life  during  which  it  is  most  prevalent.  It  is  rare  indeed  for  adults 
to  be  affected  with  it,  unless  they  have  suffered  from  it  at  an  early  period  of 
life.  Sometimes  only  one  eye  is  inflamed;  at  other  times,  both  are  aff'ected 
from  the  first.  Not  unfrequently  the  disease  passes  from  the  one  eye  to  the 
other.  When  both  are  inflamed  at  once,  the  one  is  generally  much  worse  than 
the  other. 

Symptoms. — 1.  Redness.  At  the  commencement  of  the  disease,  the  redness 
of  the  conjunctiva  is  generally  very  slight.  It  often  exists  only  on  the  inside 
of  the  lids.  Sometimes  a  few  scattered  vessels  are  seen  coursing  through  the 
conjunctiva  towards  the  cornea;  in  other  cases,  no  enlarged  vessels  are  per- 
ceived, so  that  the  disease  in  this  incipient  stage  is  distinguished  more  by  in- 
tolerance of  light  than  by  any  direct  signs  of  inflammation.  Perhaps  three 
or  four  enlarged  vessels  are  discovered,  running  from  either  angle  towards  the 
cornea,  or  over  its  edge,  evidently  superficial,  or  even  rising  above  the  level 
of  the  conjunctiva.  Not  unfrequently  the  inflamed  vessels  form  a  single  con- 
siderable fasciculus  (Fig.  63,  p.  434).  Although  in  by  far  the  greater  num- 
ber of  cases  the  redness  is  scattered,  it  sometimes  happens  that  it  is  pretty 
general  over  the  conjunctiva,  even  from  the  first.  As  the  disease  advances, 
the  redness,  becomes  increased,  and  the  sclerotica  also  appears  somewhat 
injected. 


PHLYCTENULAR   OPHTHALMIA.  4lt 

2.  Phlyctenulce —  Ulcers — Protrusions — Specks. — This  ophthalmia,  like  that 
considered  in  the  last  section,  is  an  eruptive  disease.  It  affects  the  conjunc- 
tiva, not  as  a  mucous  membrane,  but  as  a  continuation  of  skin  over  the  eye. 
One  of  its  most  remarkable  symptoms  is  the  existence  of  one  or  more  phlyc- 
tenular, or  small  pimples,  on  the  surface  of  the  eyeball.  In  many  instances, 
a  single  minute  elevated  point,  of  an  opaque  white  color,  near  the  centre  of 
the  cornea,  is  all  that  is  to  be  seen  of  this  kind;  in  other  cases,  numerous 
))hlyctenulffi  are  present,  some  on  the  cornea,  and  others  just  at  its  edge. 
This  last  is  a  very  common  situation  for  them.  They  vary  in  size  according 
to  the  part  in  which  they  appear,  being  commonly  smallest  on  the  cornea. 

The  phlyctenulte  may  be  absorbed ;  and  then,  if  situated  on  the  cornea, 
they  generally  leave  a  small  albugo,  the  effect  of  that  effusion  of  coagulable 
lymph  which  surrounds  every  circumscribed  abscess,  but  which  will,  in  general, 
be  totally  removed  by  absorption  in  the  course  of  time.  Occasionally  it 
happens  that,  after  an  albugo  is  removed  by  absorption,  a  transparent  dimple 
is  left  in  the  cornea,  which  is  long  of  filling  up.  In  some  cases,  instead  of 
disappearing,  an  albugo  begins  to  grow,  rising  above  the  level  of  the  cornea, 
and  spreading  over  it  in  an  irregular  manner;  red  vessels  of  considerable  size 
are  seen  running  into  it ;  and  additional  lymph  being  supplied  to  it,  it  forms 
what  I  call  a  vascular  sj)eck,  which  is  a  very  tedious  and  troublesome  symptom. 

More  frequently  the  phlyctenulse  suppurate,  burst,  and  become  ulcers, 
sometimes  superficial  and  considerable  in  extent,  often  deep  and  funnel-shaped. 
This  symptom,  which  is  preceded  by  the  appearance  of  additional  red  vessels 
running  to  the  phlyctenula,  is  one  of  the  most  dangerous  symptoms  of  the 
disease.  Over  the  sclerotica,  indeed,  an  ulcer,  arising  from  the  rupture  of  a 
phlyctenula,  is  of  less  consequence  ;  but  on  the  cornea,  the  transparent  inlet 
of  light,  an  ulcer  of  any  description  is  an  event  exceedingly  to  be  dreaded. 
It  is  very  apt  to  disfigure  the  eye  ;  and  by  the  opaque  cicatrice  which  it  leaves 
behind,  permanently  to  obstruct  vision. 

The  formation  of  an  ulcer,  especially  if  it  be  situated  on  the  cornea,  always 
produces  an  increase  of  pain,  greatly  aggravated  on  any  attempt  to  move 
the  eye. 

It  but  too  often  happens  that  an  ulcer  penetrates  gradually  through  the 
whole  thickness  of  the  cornea,  into  the  anterior  chamber.  In  many  cases, 
this  serious  event  must  be  ascribed  to  neglect  or  mismanagement.  Through 
the  little  fistulous  opening  of  the  cornea  formed  by  the  penetration  of  an 
ulcer,  the  aqueous  humor  is  suddenly  discharged,  and  a  small  portion  of  the 
iris  protruding  looks  not  unlike  the  head  of  a  fly.  Hence  this  symptom  is 
termed  myocephalon.  This  piece  of  iris,  unless  drawn  away  from  the  cornea 
by  belladonna,  unites,  by  adhesive  inflammation,  to  the  opening  through  which 
it  is  prolapsed  {synechia  anterior),  the  ulcer 
around  it  gradually  contracts  and  whitens  ^ig-  65. 

at  the  edge,  the  protruded  portion  of  iris  ^^^^^g^^^'fe^ 

disappears,  the  pupil  is  drawn  to  one  side,         0i^^^^^^^'  ^"^^^ 
and  a  white  indelible  cicatrice  of  the  cornea         i''^^^ 
partially  or  entirely  prevents  vision.  (Fig.  --^ss^'S^s^^r- 

65.)     A  cicatrice  of  the  cornea  is  called         '  .^^^MHH^^ 

leucoma,  in  contradistinction  to  albugo  \  the  ^^^   '^^B^^^ 

latter  opacity  being  the  result  of  exudation,  C^^;        ^w^Br /^ 

not  of  ulceration.     If  the   ulcer  has   ex-  ^^^SCi  ^^^^      ^ 

tended  deep  into  the  substance  of  the  cor-  ^^^^'^W0^^ 

nea,  and  much  more  if  it  has  penetrated  ^ 

through  it  completely,  the  leucoma  which 

follows,  being  the  result  of  the  formation  of  fibrous  substance  unlike   the 
natural  tissue,  remains  for  life,  although  in  the  progress  of  growth,  and  after 


478  PHLYCTENULAR   OPHTHALMIA. 

a  length  of  time,  it  may  contract  considerably.  The  cicatrice  resulting  from 
a  superficial  ulcer,  may  entirely  disappear.  Indeed,  the  cicatrice  from  a 
superficial  ulcer  is  sometimes  transparent  from  the  first,  forming  a  variety  of 
dimple  different  from  the  one  already  noticed. 

If  several  phlyctenulte  form  on  the  cornea  at  the  same  time,  it  sometimes 
happens  that  they  unite  with  one  another  before  they  burst,  so  that  the  puru- 
lent matter  they  contain  is  infiltrated  between  the  lamellte,  and  thus  a  kind  of 
onyx  is  formed.  At  other  times,  onyx  appears  at  the  lower  edge  of  the 
cornea,  independently  of  the  phlyctenula?. 

In  some  cases  of  ulcer  of  the  cornea,  the  progress  of  the  ulcer  is  unimpeded 
till  the  whole  thickness  of  the  cornea  is  penetrated,  except  the  lining  mem- 
brane, or  posterior  elastic  lamina,  which  withstands  for  a  time  the  ulcerative 
process,  but  being  unable  to  support  the  pressure  of  the  aqueous  humor,  is 
jDrojected  through  the  ulcer  in  the  form  of  a  small  vesicle.  This  is  what  is 
called  hernia  cornece.  At  last,  this  protrusion  of  the  lining  membrane  gives 
way,  the  aqueous  humor  escapes,  prolapsus  of  the  iris  follows,  and  a  dense 
opaque  cicatrice  will  be  the  result. 

Where  there  has  been  an  extensive  prolapsus  of  the  iris  through  an  ulcer 
of  the  cornea,  the  cicatrice  or  pseudo-cornea  which  is  formed  over  the  pro- 
truded portion  of  iris,  is  sometimes  unable  to  sustain  the  aqueous  humor,  and 
is  pressed  forwards  so  as  to  form  a  partial  staphyloma. 

3.  Pain — Intolerance  of  light — Blepharospasm — Epiphora. — The  excessive 
intolerance  of  light,  which  in  general  attends  phlyctenular  ophthalmia,  is  one 
of  its  most  characteristic  and  distressing  symptoms.  The  child  (for  children 
are  the  usual  subjects  of  the  disease)  is  often  quite  unable  to  open  the  eyes 
in  the  ordinary  light  of  day,  or  by  any  act  of  volition  to  expose  them  so  as 
to  permit  a  satisfactory  examination  of  their  state;  all  his  attempts  to  look 
up  are  instantaneously  interrupted  by  spasmodic  contraction  of  the  eyelids  ; 
for  days,  weeks,  or  months,  a  child  affected  with  this  disease  will  lie  on  his 
face  in  bed  ;  or  if  forced  out  of  bed,  he  will  stand  pressing  his  eyes  against 
his  arm,  and  no  persuasion  will  bring  him  to  lift  up  his  head  or  look  at  the 
light.  The  intolerance  of  light  is  always  most  severe  during  the  day.  In 
the  evening  it  often  remits  so  much  as  to  allow  the  patient  to  open  his  eyes, 
and  enjoy  vision  to  a  considerable  degree,  for  some  hours. 

It  might  perhaps  be  supposed  that  this  excessive  intolerance  of  light  and 
spasmodic  contraction  of  the  orbicularis  palpebrarum  should  attend  only 
the  worst  cases,  or  where  there  is  a  great  degree  of  inflammation.  But  it  is 
not  so.  The  mother,  or  the  nurse  taking  up  the  child,  lays  it  across  her  lap, 
while  the  surgeon,  receiving  the  head  firmly  between  his  knees,  and  laying 
hold  of  the  eyelids,  without  suffering  the  conjunctiva  to  become  everted  or 
protruded,  raises  the  upper  eyelid,  so  as  to  expose  the  sclerotica;  the  cornea 
is  turned  up  out  of  view,  and  it  sometimes  requires  considerable  management 
to  elevate  the.  upper  lid  and  depress  the  eyeball  so  as  to  expose  the  cornea 
completely.  But  still  this  may  be  done ;  and  before  any  prognosis  can  be 
given,  must  be  done.  In  many  cases  we  are  astonished,  when  we  thus  ex- 
amine the  eye,  to  find  only  a  very  insignificant  degree  of  redness,  scarcely 
more  than  we  should  find  were  we  to  examine  a  healthy  eye  in  the  same  way, 
the  cornea  often  perfectly  transparent  and  entire,  or  perhaps  presenting  a 
single  minute  spot  of  opacity,  with  a  few  red  vessels  running  over  the  sclero- 
tica. The  excessive  intolerance  of  light  in  many  cases  constitutes  the  only 
symptom,  which  has  led  Benedict  to  treat  of  it*  as  a  separate  disease  under 
the  name  oi photophoMa  infantum  scrofulosa. 

This  symptom  is  attended  with  epiphora,  and  often  by  violent  fits  of  sneez- 
ing. Whenever  the  patient  voluntarily  attempts  to  open  the  eye,  or  when- 
ever we  forcibly  expose  it,  a  gush  of  tears  succeeds  ;  the  eye  is  thereby  red- 


PHLYCTENULAR   OPHTHALMIA.  4*79 

dened,  the  eyelids  swell,  and  the  cheek  is  apt  to  become  chafed  and  exco-  _ 
riated.     A  pustular  eruption  rises  upon  the  face  from  the  irritation  of  the 
tears,  and  the  cheek  sometimes  becomes  exceedingly  swollen,  red,  and  painful 
from  the  same  cause.     This  symptom  is  often  aggravated  by  the  improper 
use  of  poultices. 

There  does  not  appear  to  be  in  general  any  very  great  degree  of  absolute 
or  inflammatory  pain  attendant  on  phlyctenular  ophthalmia,  except  when  the 
patient  attempts  to  open  the  eye.  If  w^e  let  the  child  alone,  he  will  lie  all 
day  in  some  dark  corner  of  the  room,  without  complaining  much  of  pain. 
But  so  excessively  disagreeable  to  him  is  the  least  access  of  light,  that  he 
will  rather  forego  all  his  little  amusements,  both  within  and  out  of  doors, 
than  open  his  eyes.  Moving  the  eyes  to  look  at  the  light,  or  at  any  object, 
brings  on  a  sensation  as  if  they  were  full  of  sand,  and  sometimes  causes  a 
feeling  of  intolerable  glare  and  dazzling.  Pain  during  the  night,  how- 
ever, is  not  an  unfrequent  symptom.  It  seems  to  occur  even  during  sleep, 
for  the  child  often  awakes  screaming  with  pain  in  the  eyes.  Commonly  a 
great  degree  of  itchiness  of  the  eyes  attends  this  disease,  so  that  the  patient 
rubs  them  much. 

An  anatomical  fact,  to  which  I  have  already  had  occasion  to  refer,  may 
aid  us  in  accounting  for  the  extreme  intolerance  of  light,  spasmodic  contrac- 
tion of  the  eyelids,  and  epiphora  which  accompany  scrofulous  ophthalmia, 
even  in  cases  where  scarcely  any  rednes  is  present ;  namely,  that  the  lachrymal 
nerve,  after  supplying  the  lachrymal  gland,  goes  to  the  conjunctiva  and  orbic- 
ularis palpebrarum,  and  may  serve  to  establish  a  strong  nervous  sympathy 
between  these  parts.  We  see  the  same  reflex  action  called  forth  when  any 
minute  particle  of  dust  fixes  on  the  inside  of  the  upper  eyelid.  We  have 
then  the  same  intolerance  of  light,  spasm  of  the  orbicularis  palpebrarum,  and 
rush  of  tears,  which  we  meet  with  in  phlyctenular  conjunctivitis,  so  that  it 
would  appear  that  this  disease,  even  in  its  incipient  stage,  excites  very  much 
the  same  train  of  effects  which  follows  the  irritation  produced  by  a  particle 
of  dust  on  the  inside  of  the  upper  eyelid.  It  excites  the  sensitive  nerve  of 
the  eye  or  fifth  pair,  whence  arises  a  reflex  action  of  the  muscular  nerve  or 
portio  dura. 

The  intolerance  of  light  in  this  disease  has,  by  one  author,^  been  regarded 
as  depending  on  an  affection  of  the  retina,  as  being,  in  fact,  a  reflex  action 
of  the  orbicularis  palpebrarum,  produced  by  the  incidence  of  light  upon  the 
retina  in  an  irritable  state.  This  idea  seems  to  derive  some  degree  of  sup- 
port from  the  fact  that,  in  the  dusk,  the  patient  is  able  to  open  his  eyes, 
whereas,  were  this  symptom  dependent  merely  on  the  state  of  the  conjunctiva, 
it  should  remain  the  same  in  obscure  as  in  bright  light,  and  be  more  marked 
perhaps  in  catarrhal  ophthalmia  than  in  phlyctenular.  The  evening  remis- 
sion is  a  peculiarity  of  the  disease  which  we  cannot  completely  explain. 

4.  Ophthalmia  tarsi — Iritis — Asthenopia — Amaurosis — Atrophia  hulbi. — 
Other  local  symptoms,  besides  those  already  enumerated,  are  often  present. 
Very  frequently  we  find  this  disease  combined  with  ophthalmia  tarsi.  In 
many  cases  we  observe  zonular  iuflamraation  of  the  sclerotica  ;  and  although 
iritis  is  a  much  more  frequent  attendant  on  the  corneitis  than  on  phlyctenular 
ophthalmia,  yet  we  occasionally  find  the  pupil  small,  with  a  want  of  lustre 
or  even  slight  discoloration  of  the  iris,  though  generally  without  effusion  or 
adhesion.  Choroiditis  is  still  moi'e  rarely  associated  with  this  disease.  From 
neglect  or  mismanagement,  however,  it  is  sometimes  allowed  to  end  in  inter- 
nal scrofulous  ophthalmia,  characterized  by  nebulous  capsule,  contracted,  ir- 
regular pupil,  unnatural  hardness  of  the  eyeball,  and  a  more  or  less  imperfect 
sensibility  of  the  retina. 

In  one  case  which  I  saw,  the  intolerance  of  light  and  spasm  of  the  lids  had 


480  PHLYCTENULAR   OPHTHALMIA. 

continued  for  more  than  a  year.  When  at  length  they  abated,  which  they 
did  of  themselves  without  the  influence  of  medicine  (the  mother  having  neg- 
lected to  attend  at  the  Eye  Infirmary),  the  child  groped  with  its  hands,  as  if 
blind,  although  it  saw  ;  so  strongly  confirmed  was  the  habit  of  using  the  sense 
of  touch  in  preference  to  that  of  sight. 

In  another  case,  on  the  photophobia  subsiding,  I  discovered  the  child  to  be 
amaurotic,  although,  until  seized  with  the  ophthalmia,  it  had  seen  perfectly. 
Asthenopia  and  incomplete  amaurosis  are  common  sequeljE  of  scrofulous  oph- 
thalmia, and  seem  attributable  to  impeded  nutrition,  and  change  of  texture, 
in  the  internal  parts  of  the  eye,  arising  partly  from  inflammatory  action,  and 
partly  from  the  long-continued  external  pressure  on  the  eyes,  exercised  by 
the  patient  in  neglected  cases. 

^ot  unfrequently,  the  interruption  to  nutrition  in  long-continued  phlyc- 
tenular ophthalmia,  is  such  that  the  eye))all  remains  through  life  dwarfish  or 
atrophic. 

5.  Other  scrofulous  symptoms  may  be  detected  in  almost  every  case  ;  as, 
eruptions  about  the  head,  sore  ears,  swelling  of  the  upper  lip,  running  from 
the  nose,  excoriation  of  the  nostrils,  enlarged  lymphatic  glands  under  the  jaw, 
hyperostosis  of  the  fingers,  swollen  joints,  tabes  mesenterica,  &c.  With 
some  of  these  symptoms  we  often  find  the  ophthalmia  to  alternate,  being 
aggravated,  for  instance,  when  sore  ears  cease  to  run,  and  abating  when  they 
again  begin  to  discharge.  I  have  seen  this  ophthalmia  repeatedly  alternate 
with  scrofulous  swelling  of  the  knee.  The  eruption  on  the  scalp,  which  is 
generally  observed  along  with  this  disease,  is  porriginous.  Not  unfrequently, 
an  impetiginous  eruption  over  the  body  is  found  to  be  present,  especially  in 
children  who  live  much  on  milk. 

G.  Dyspepsia,  disordered  bowels,  and  a  tumid  and  hard  abdomen,  commonly 
attend  scrofulous  ophthalmia.  The  appetite  is  variable  ;  generally  deficient, 
sometimes  craving.  The  stomach  and  bowels  appear  to  be  loaded  with 
morbid  secretions.  The  evacuations  are  sometimes  dark ;  often  pale,  of  a 
grayish  color,  or  of  the  appearance  of  moist  clay.  The  breath  is  fetid  ;  the 
teeth  rot  away,  from  acidity  in  the  stomach.  The  tumidness  of  the  belly 
seems  to  be  owing  in  part  to  muscular  weakness. 

1.  Although  the  patients  are  often  of  a  gross  habit  of  body,  this  comes 
to  be  attended  by  considerable  general  debility,  especially  in  cases  of  long 
continuance.  The  skin  becomes  loose  and  flabby,  and  sometimes  a  great 
degree  of  emaciation  is  present.  This  state  of  the  body  often  precedes  the 
occurrence  of  the  ophthalmia,  and  is  always  aggravated  when  the  eyes  become 
aff"ected.  The  patient  is  hot  and  restless  in  the  early  part  of  the  night,  and 
sweats  profusely  towards  morning.  A  great  degree  of  fretfulness  is  produced 
by  the  disease,  and  prolongs  its  continuance. 

Remote  or  predisposing  causes.  —  1.  IVie  scrofulous  constitution  may  be 
regarded  as  the  chief  remote  or  predisposing  cause  of  this  ophthalmia. 

2.  Food — Air — Exercise — Clothing. — While  we  regard  the  scrofulous  con- 
stitution as  a  principal  predisposing  cause  of  this  ophthalmia,  we  must  not 
omit  to  mention  that  other  remote  causes  powerfully  operate  in  its  production; 
namely,  improper  diet,  want  of  air  and  exercise,  and  insufficient  clothing.  It 
is  from  the  operation  of  these  causes  that  this  ophthalmia  and  other  scrofu- 
lous diseases  are  so  frequent  in  large  and  crowded  towns ;  and  prevail  so 
abundantly  among  the  children  of  the  poor,  who  live  in  narrow  streets  and 
alleys,  breathing  an  impure  atmosphere,  confined  to  scanty  and  unnutritious 
diet,  regardless  of  cleanliness,  and  ill-protected  from  changes  of  weather. 
This  ophthalmia  may  be  regarded  as,  in  a  great  measure,  a  secondary  affec- 
tion, originating  in  a  peculiar  condition  of  the  general  system,  arising  from 
impaired  nutrition.     Imperfect  lactation  during  infancy,  followed,  after  the 


PHLYCTENULAR   OPHTHALMIA.  481 

period  of  weaning,  by  an  irregular  or  improper  diet,  gives  rise  to  an  impover- 
ished condition  of  the  blood ;  and  this,  aided  by  the  other  detrimental  causes 
I  have  enumerated,  shows  its  effects  in  various  local  diseases,  one  of  the  most 
frequent  of  which  is  the  ophthalmia  in  question.  The  confinement  of  children 
to  filthy,  small,  ill-aired  nurseries  is  also  a  cause,  scarcely  less  prolific,  of  scro- 
fulous ophthalmia. 

3.  Climate.. — Our  variable  climate  is  a  powerful  promoter  of  this  disease, 
while  in  the  South  of  Europe,  in  the  inland  parts  of  Italy,  for  instance,  it  is 
rare,  even  among  the  poorest  of  the  people,  whose  food  is  the  least  digestible 
and  least  nourishing.^  "We  see  the  effects  of  climate  on  tins  ophthalmia,  in  the 
rapid  changes  which  it  undergoes  when  the  weather  becomes  either  suddenly 
cold  and  wet,  or  dry  and  warm.  All  the  symptoms  are  greatly  aggravated 
by  the  former,  and  as  remarkably  relieved  by  the  latter.  New  attacks,  both 
in  those  who  have,  and  those  who  have  not  previously  suffered  from  this  dis- 
ease, are  most  prevalent  during  northeasterly  winds. 

Exciting  causes. — 1.  One  of  the  most  frequent  exciting  causes  is  exposure 
to  cold,  and  especially  to  weather  at  once  wet  and  cold.  Standing  in  a  draught 
of  cold  air,  so  as  to  bring  on  a  chill,  we  often  find  to  produce  a  relapse  in 
patients  who  were  previously  recovering. 

2.  Measles,  scarlet-fever,  and  smallpox  rouse  into  activity  the  scrofulous 
diathesis.  These  diseases  themselves  affect  the  eyes,  and  leave  them  tender 
and  apt  to  fall  into  this  ophthalmia. 

3.  Catarrhal  ophthalmia,  brought  on  in  the  common  way,  is  extremely  apt 
to  degenerate,  in  scrofulous  children,  into  the  phlyctenular. 

4.  Excessive  use  of  the  eyes  on  minute  objects,  and  especially  by  candle 
light,  is  often  the  exciting  cause  of  scrofulous  ophthalmia. 

5.  Teething  is  a  frequent  exciting  cause.  It  would  appear  that  from  the 
communications  existing  between  the  second  and  third  divisions  of  the  fifth 
nerve  and  the  lachrymal  nerve,  teething  excites  lachrymation,  blepharospasm, 
and  ultimately  phlyctenular  conjunctivitis. 

6.  Injuries,  as  those  produced  by  particles  of  dust  lodging  in  the  folds  of 
the  conjunctiva,  scratches  of  the  eyes,  slight  blows,  and  the  like,  are  often 
the  occasional  causes  of  phlyctenular  ophthalmia. 

Prognosis. — It  is  necessary  to  give  a  very  cautious  prognosis  in  this  dis- 
ease. Much  depends  on  whether  the  friends  of  the  patient  are  able  and  will- 
ing to  pursue  the  treatment  methodically,  not  only  till  the  cure  seems  complete, 
but  for  a  considerable  length  of  time  after,  and  till  the  constitutional  health 
is  established.  No  disease  is  so  apt  to  relapse  ;  the  parents  should  be  made 
aware  of  this,  and  directed  to  make  instant  application  whenever  they  observe 
a  recurrence  of  any  of  the  symptoms. 

When  ulcers  are  present  on  the  cornea,  opacities  must  necessarily  follow. 
These  will  prove  more  or  less  obstinate  according  to  the  depth  of  the  pre- 
vious ulceration,  and  will  impede  vision  in  proportion  as  they  extend  more 
or  less  over  the  pupil.  Perforating  ulcer,  followed  by  protrusion  of  the  iris, 
leaves  almost  uniformly  a  dense  leucoma,  with  deformed  pupil. 

I  have  already  mentioned  the  danger  of  iritis,  retinitis,  &c.,  supervening  to 
phlyctenular  ophthalmia.  I  may  add,  that  in  after-life  many  become  amau- 
rotic, with  hardness  of  the  eye  and  glaucoma,  who  in  youth  suffered  from  this 
disease.  Eyes  which  have  been  long  and  severely  affected  with  scrofulous 
inflammation,  are  never  so  good  afterwards,  and  are  more  apt  than  others  to 
become  amaurotic,  if  they  are  much  fatigued,  or  if  other  detrimental  causes 
come  into  operation,  such  as  a  sedentary  occupation,  the  use  of  tobacco,  alco- 
hol, &c. 

Treatment. — We  are  obliged  to  speak  of  the  treatment  of  phlyctenular  oph- 
thalmia in  very  different  language  from  what  we  employ  in  advising  remedies 
31 


482  PHLYCTENULAR   OPHTHALMIA. 

for  almost  any  other  inflammatory  disease  of  the  eye.  In  other  ophthalmise, 
we  say,  Follow  this  plan  of  treatment  which  we  recommend,  and  the  disease 
will  speedily  be  overcome.  We  speak  thus  of  the  catarrhal  ophthalmia,  and 
of  several  others ;  but  we  cannot  speak  in  this  way  of  the  phlyctenular.  We 
are  forced  to  confess  that,  in  many  cases,  this  ophthalmia  proves  rebellious. 
If  it  be  asked.  Why  it  does  not  yield,  even  to  the  best-directed  treatment  ? 
we  answer  this  question  by  proposing  another ;  namely.  Why  does  an  inflamed 
gland  of  the  neck  in  a  scrofulous  individual  prove  so  troublesome,  going  on 
to  suppurate  in  spite  of  every  means  adopted  to  promote  resolution,  and  after 
it  has  suppurated  and  burst,  continuing  to  discharge  for  years  ?  The  scrofu- 
lous constitution  is  the  cause  of  the  extreme  tediousness  of  this  ophthalmia, 
as  well  as  of  the  frequently  intractable  nature  of  other  scrofulous  affections; 
and  till  we  discover  means  for  curing  scrofula,  this  ophthalmia  will  continue 
occasionally  to  mock  by  its  stubbornness,  even  the  best  and  most  carefully 
pursued  plan  of  cure. 

Is  it  incurable,  then?  Are  we  to  do  nothing  for  it  but  shake  our  heads, 
and  leave  the  eyes  to  be  destroyed  ?  Not  at  all.  Much  may  be  done  to 
relieve  this  disease.  Although  it  is  difficult  to  cure  it  thoroughly,  especially 
when  the  patient  continues  exposed  to  the  influence  of  the  same  causes  which 
originally  produced  it,  yet  it  is  rare  indeed  that  medical  treatment  does  not 
greatly  moderate  the  symptoms,  and  avert  those  changes  in  the  transparent 
front  of  the  eye,  which  in  neglected  cases  so  often  cause  loss  of  sight.  But 
when  the  practitioner  does  meet  with  cases,  as  sometimes  he  must  do,  which 
receive  no  benefit  for  weeks  or  mouths,  but  perhaps  rather  get  worse,  not- 
withstanding all  that  is  done  for  them,  he  must  not  blame  himself  too  much, 
but  reflect  on  the  intractable  diathesis  with  which,  in  such  cases,  he  is  called 
to  contend.  This  he  cannot  change,  and  often  fails  even  in  the  smallest  de- 
gree to  ameliorate. 

In  the  treatment  of  this  disease,  it  is  necessary  constantly  to  bear  in  mind 
that  it  depends  on  a  constitutional  cause.  To  endeavour  to  relieve  the  local 
affection,  therefore,  will  not  be  sufficient;  we  must  improve  the  general  health. 

General  remedies.  1.  Bleeding. — General  bloodletting  is  rarely  required; 
scarcely  ever  indeed,  except  in  adults  or  adolescents  affected  with  supra-orbital 
pain :  nor  need  local  bleeding  be  had  recourse  to,  unless  considerable  febrile 
excitement,  as  well  as  local  distress,  be  present.  When  the  inflammatory  action 
runs  higher  than  ordinary,  or  where  it  is  suddenly  or  violently  augmented  by 
the  formation  of  ulcers  on  the  cornea,  it  is  proper  to  moderate  the  impetus  of 
the  blood,  by  the  application  of  leeclies  in  the  neighborhood  of  the  eye,  over 
the  nasal  vein,  to  the  temple,  or  behind  the  ear.  If  the  constitution  is  not  as 
yet  impaired  by  long  continuance  of  the  disease  and  the  employment  of  many 
debilitating  remedies,  repeated  recourse  must  be  had  to  tlie  use  of  leeches,  so 
long  as  the  redness  of  the  conjunctiva  is  considerable,  and  the  intolerance  of 
light  acute.  It  must  be  kept  in  mind,  however,  that  not  unfrequently  we  may 
dispense  with  bleeding  entirely,  by  putting  the  patient  under  the  influence  of 
tartar  emetic,  by  the  administration  of  the  sulphate  of  quinia,  and  by  various 
other  means,  general  and  local;  and  that  by  depletion  alone  no  case  of  this 
disease  can  ever  be  cured.  On  the  contrary,  repeated  bleedings,  without  the 
use  of  other  remedies,  reduce  too  much  the  general  strength,  and  render  the 
eye  more  susceptible  of  destructive  changes. 

2.  Emetics  andnauseants. — One  of  the  most  powerful  and  successful  methods 
of  treating  phlyctenular  ophthalmia  is  by  means  of  tartar  emetic,  either  in  such 
doses  as  to  produce  vomiting;  in  smaller  quantities  frequently  repeated,  so  as 
to  excite  nausea ;  or  combined  with  a  purgative.  Tliere  is,  perhaps,  no  remed}^ 
in  the  whole  materia  medica  which  possesses  equal  powers  of  a  sedative  kind 


PHLYCTENULAR  OPHTHALMIA.  *  483 

in  this  disease.  It  reduces  very  considerably  the  necessity  of  general  and  local 
bloodletting. 

I  generally  commence  the  treatment  with  an  emetic,  either  of  ipecacuan  or 
tartar  emetic,  and  uniformly  with  good  effects.  Four  grains  of  the  latter  being 
dissolved  in  6  ounces  of  water,  a  tablespoonful  is  given  every  five  minutes  till 
free  vomiting  is  produced. 

In  cases  where  there  is  considerable  quickness  of  pulse  and  heat  of  skin,  I 
frequently  put  the  patient  on  a  course  of  nauseants,  or  of  emeto-cathartics. 
For  instance,  to  an  adult  a  mixture  may  be  given  of  from  1  to  4  grains  of 
tartar  emetic,  with  from  1  to  2  ounces  of  sulphate  of  magnesia,  dissolved  in 
a  pound  of  water.  Of  this  solution  2  or  3  tablespoonfuls  may  be  taken  every 
half  hour  till  vomiting  is  excited ;  after  which,  the  dose  is  to  be  repeated  at 
intervals  of  three,  four,  or  six  hours,  as  circumstances  may  require.  This  is 
the  method  to  be  followed  in  acute  cases.  In  chronic  cases,  the  nauseant 
may  be  exhibited  at  longer  intervals.  It  may  then  be  conveniently  exhibited 
in  pills ;  each  pill  containing  from  a  quarter  to  half  a  grain  or  more  of  the 
tartar  emetic. 

To  children  the  same  solution  of  tartar  emetic  and  salts  may  be  given,  or  a 
solution  of  tartar  emetic  by  itself,  or  powders  of  the  same  rubbed  up  with  a 
little  sugar.  From  the  12th  to  the  6th  of  a  grain  may  be  given,  according 
to  the  age  of  the  child,  thrice  a  day.  When  there  is  much  febrile  excitement, 
this  plan  will  often  prove  effectual,  while  purgatives  or  tonics  would  produce 
little  or  no  good. 

3.  Purgatives. — In  children  laboring  under  phlyctenular  ophthalmia  there 
is  commonly  a  full  and  hard  abdomen,  and  a  loaded  state  of  the  stomach  and 
bowels.  Even  in  feeble  and  emaciated  children,  it  will  usually  be  found  that, 
by  the  exhibition  of  purgatives,  a  large  quantity  of  morbid  feculent  matter 
will  be  discharged.  In  such  cases  the  administration  of  purgatives  is  followed 
by  marked  benefit ;  and  without  these,  other  remedies  avail  but  little.  In 
recent  cases,  a  purge  of  calomel,  with  jalap,  rhubarb,  or  scammony,  will  often 
be  sufficient  to  remove  the  attack  of  ophthalmia  altogether.  Such  a  purga- 
tive is  to  be  repeated  at  intervals  of  two,  three,  or  more  days,  according  to 
the  urgency  of  the  symptoms.  It  not  only  empties  the  bowels,  but  reduces 
very  powerfully  the  impetus  of  the  blood  in  the  affected  part,  increases  the 
action  of  the  absorbents,  and  restores  to  a  healthy  state  the  secretions  of  the 
digestive  organs.  It  proves,  in  short,  alterative  as  well  as  depletive  ;  and  its 
use  as  such  may  be  persisted  in,  in  many  cases,  for  a  length  of  time,  with  very 
decided  benefit.  I  have  found  a  powder,  containing  from  the  sixth  to  the 
third  of  a  grain  of  tartar  emetic,  with  from  5  to  10  grains  of  rhubarb,  given 
each  night,  to  be  of  much  service.  The  purgative  plan  is  more  useful  than 
any  other  in  those  cases  in  which  an  impetiginous  eruption  over  the  body 
accompanies  the  affection  of  the  eyes.  Care,  however,  must  be  taken  not  to 
push  its  debilitating  action  too  far. 

4.  Sulphate  of  quina  and  other'  tonics. — In  scrofulous  ophthalmia  it  is  of 
great  importance  to  remove  the  debilitated  state  of  the  patient;  for  unless  this 
is  done,  the  eye  will  not  recover.  We  attempt  to  increase  the  strength  of  the 
patient  chiefly  by  improving  his  powers  of  digestion.  Tliis  is  often  accom- 
plished by  the  remedies  mentioned  under  the  last  head;  and  especially  by  the 
use  of  rhubarb,  which  both  keeps  the  bowels  regular  and  improves  the  action 
of  the  stomach.  There  are  several  other  remedies  belonging  more  decidedly 
to  the  class  of  tonics,  which  prove  strikingly  beneficial  in  the  treatment  of 
phlyctenular  ophthalmia. 

After  a  trial  of  many  internal  medicines  in  this  disease,  I  have  found  none 
so  useful  as  the  sulphate  of  quina.  It  exercises  a  remarkable  power  over  the 
constitutional  disorder  which  attends  this  ophthalmia,  and  thereby  over  the 


484  PHLYCTENULAR   OPHTHALMIA. 

local  complaint.  The  dose  which  I  employ  is  generally  a  grain  thrice  a  day; 
in  very  young  children,  half  a  grain;  and  in  adolescents  or  adults,  2  grains. 
It  may  be  given  rubbed  up  with  a  little  sugar;  but  it  appears  to  act  best 
when  administered  in  solution.  For  this  purpose  I  use  the  acidum  sulphuri- 
cum  aromaticum,  to  which  I  add  a  sufficient  quantity  of  syrup  and  water. 
In  most  instances  the  effects  are  very  remarkable.  Although  I  have  met  with 
a  few  cases  which  ajipeared  to  resist  its  beneficial  influence,  in  most  of  the 
little  patients  to  whom  I  have  administered  sulphate  of  quina,  it  has  acted  as 
a  charm  ;  abating,  commonly  in  a  few  days,  the  excessive  intolerance  of  light 
and  profuse  epiphora,  promoting  the  absorption  of  phlyctenulae,  and  hastening 
the  cicatrization  of  ulcers  of  the  cornea.  As  soon  as  the  stomach  has  been 
cleared  by  an  emetic,  and  the  bowels  put  to  rights  by  repeated  doses  of  calo- 
mel with  rhubarb,  or  some  other  such  purgative,  the  use  of  this  medicine  may 
be  begun,  unless  the  pulse  is  very  quick  and  the  skin  hot,  when  small  doses 
of  tartar  emetic  will  be  preferable;  or  when  an  impetiginous  eruption  is  ob- 
served on  the  surface  of  the  body,  in  which  case  a  course  of  purgatives  ought 
to  be  adopted. 

I  cannot  forbear  quoting  from  the  journals  of  the  Glasgow  Eye  Infirmary 
the  two  following  cases,  illustrative  of  the  good  efi'ects  of  sulphate  of  quina : — 

Case  277. — Jane  Thompson,  aged  nine,  was  admitted  on  the  23d  of  July,  1828,  with 
phlyctenular  ophthalmia  of  the  right  eye,  of  14  days'  standing.  There  was  a  deep  ulcer 
near  the  centre  of  the  cornea,  surrounded  by  a  broad  eifusion  of  lymph;  and  there  was  an 
onyx  at  the  lower  edge  of  the  cornea.  She  was  affected  with  night-sweats,  and  was  miich 
reduced  in  general  health  by  bleeding,  purging,  and  blistering.  She  was  ordered  to  take 
3  grains  of  quina  daily,  a  drop  of  the  nitras  argenti  solution  was  applied  to  the  eye,  and 
fihe  had  the  murias  hydrargyri  collyrium. 

On  the  24th,  the  onyx  was  all  but  gone.  On  the  27th,  the  ulcer  was  reported  as  con- 
tracted. On  the  29th,  on  account  of  an  attack  of  bowel  complaint,  she  was  ordered  2 
grains  of  calomel  with  a  quarter  of  a  grain  of  opium  at  bedtime.  After  this,  the  case 
continued  steadily  to  improve,  the  ulcer  cicatrized,  the  eye  became  strong,  and  the  leucoma 
grew  thin.  In  all  probabilitj',  the  cornea  would  speedily  have  been  penetrated  by  the  ulcer, 
if  the  depletory  treatment  had  been  persisted  in,  which  this  patient  was  undergoing  before 
she  came  to  the  Eye  Infirmary.  Within  24  hours,  the  sulphate  of  quina  had  evidently 
arrested  the  progress  of  the  disease. 

Case  278. — James  Tassie,  aged  eight,  was  admitted  on  the  15th  of  August,  1828,  with 
phlyctenular  ophthalmia  of  the  right  eye.  He  had  been  troubled  with  this  complaint,  more 
or  less,  for  seven  years.  There  was  formerly  a  considerable  albugo  on  the  right  cornea; 
but  it  had  diminished  much  till  within  a  fortnight  before  his  admission,  when  a  relapse 
took  place.  The  cornea  appeared  to  be  rough  and  nebulous,  but  the  intolerance  of  light 
was  so  great  that  it  was  with  difficulty  that  any  part  of  it  could  be  exposed.  The  nitras 
argenti  solution  was  applied,  and  he  had  a  solution  of  tartar  emetic,  in  divided  doses,  till 
vomiting  was  produced.  Next  day  he  could  open  the  eye  better,  and  an  onyx  was  now 
observed  at  the  lower  edge  of  the  cornea,  which  had  not  been  perceived  on  the  previous 
day.  He  was  ordered  to  take  a  grain  of  sulphate  of  quina  thrice  a-day,  ami  to  use  the 
murias  hydrargyri  collyrium.  ^j  the  18th,  the  onyx  was  gone.  The  extract  of  belladonna 
was  applied  to  the  eyebrow  and  forehead,  some  fears  being  entertained  regarding  the  state 
of  the  iris.  By  the  20th,  the  intolerance  of  light  having  considerably  subsided,  the  cornea 
could  be  more  completely  seen.  The  centre  of  it  was  found  to  be  perforated  by  an  ulcer, 
and  the  pupil  contracted.  On  the  22d,  tjie  eye  continued  easier,  but  the  iris  was  observed 
to  be  everywhere  in  contact  with  the  cornea.  The  sulphate  of  quina,  belladonna,  and 
collyrium,  were  continued.  On  the  27th,  the  iris  appeared  to  be  returning  a  little  into  its 
natural  place,  the  pupil  was  partly  visible,  and  he  saw  a  little  with  the  eye.  On  the  28th, 
the  pupil  was  evidently  expanding  and  the  cornea  clearing.  By  the  1st  of  September, 
the  pupil  was  free  of  the  cornea,  except  at  its  inner  edge,  where  it  still  adhered  by  a 
single  point.  By  the  16th,  the  iris  was  entirely  free.  Soon  after  this,  the  nicer  of  the 
cornea  cicatrized,  the  speck  gradually  cleared  and  the  eye  retained  a  very  considerable 
share  of  vision. 

This  last  case  was  one  of  the  most  remarkable  and  pleasing  recoveries  from 
penetrating  ulcer  of  the  cornea  and  involved  iris,  which  I  have  met  with.  The 
recovery  was  mainly  attributable  to  the  salutary  operation  of  the  sulphate  of 


PHLYCTENULAR   OPHTHALMIA.  485 

quina  on  the  inflammatory  affection,  and  to  the  effect  on  the  iris  produced  by 
the  belladonna. 

As  a  substitute  for  the  sulphate  of  quina,  the  sulphate  of  bebeerina  may  be 
given.     The  dose  requires  to  be  doubled. 

Chalybeates  stand  next  to  the  sulphates  of  quina  and  bebeerina  among  the 
tonic  medicines  worthy  of  confidence  in  the  treatment  of  scrofulous  ophthalmia. 
The  precipitated  carbonate  of  iron,  and  the  tartrate  of  potash  and  iron,  are 
the  forms  which  I  have  found  most  useful.  They  are  more  effectual,  however, 
in  aphthous,  than  in  phlyctenular  ophthalmia.  In  both  these  affections  such 
compounds  as  the  citrate  of  iron  and  quina,  and  iodide  of  iron  and  quina,  will 
be  found  useful,  and  may  be  given  in  the  form  of  syrup. 

The  mineral  acids,  and  especially  the  sulphuric,  will  also  produce  a  tonic 
effect. 

We  may  set  down  the  cold  plunge  or  shower  bath  as  a  very  efficient  tonic 
in  scrofulous  ophthalmia  ;  but  it  is  not  to  be  employed  till  after  the  acute 
symptoms  have  subsided.  It  proves  one  of  the  very  best  means  for  pre- 
venting relapses. 

The  employment  of  tonics,  both  medicinal  and  dieteticial,  must  be  con- 
tinued long  after  all  the  inflammatory  symptoms  have  disappeared,  in  order, 
if  possible,  to  communicate  to  the  constitution  that  degree  of  vigor,  which 
may  enable  it  to  resist  any  tendency  to  relapse,  which  may  still  linger  in  the 
eyes,  and  which,  were  this  precaution  not  adopted,  might,  on  exposure  to  the 
slightest  exciting  cause,  lead  to  a  new  and  severe  attack. 

We  may  class  change  of  air  among  the  tonic  remedies  for  this  disease,  or 
rather  among  the  preventives  which  are  to  be  employed  after  a  first  attack  is 
subdued.  A  dry,  warm,  inland  situation  is  preferable  to  the  sea-coast.  The 
glare  from  the  sea  is  very  apt  to  aggravate  slight  attacks,  and  give  rise  to 
relapses. 

5.  Antacids.. — There  is  reason  to  believe  that  phlyctenular  ophthalmia  fre- 
quently depends  on  acid  generated  in  the  stomach,  whence  proceeding  into 
the  bowels,  it  mixes  with  the  bile,  and  produces  green  stools  and  general 
irritation.  The  teeth,  in  such  cases,  are  apt  to  become  carious.  Under 
these  circumstances,  relief  may  often  be  obtained  by  using  antacids,  such  as 
magnesia,  its  carbonate,  or  a  mixture  of  rhubarb  and  bicarbonate  of  soda,  in 
small  doses  frequently  repeated.  Carbonate  of  ammonia,  with  tincture  of 
gentian,  as  recommended  by  Dr.  Charles  Armstrong*  in  common  cases  of 
scrofula,  may  also  be  employed  with  good  effect. 

6.  Mercury. — Calomel  is  very  often  administered  in  phlyctenular  ophthal- 
mia ;  more  frequently,  however,  as  a  purgative  than  as  an  alterative.  That 
this  medicine  is  often  injurious  to  children  does  not  admit  of  doubt.  That 
their  constitutions  are  shattered  by  an  indiscriminate  use  of  calomel,  and  that 
in  this  way  they  are  rendered  more  susceptible  of  suffering  from  the  exciting 
causes  of  scrofula,  is  a  truth  which  is  too  much  overlooked. 

Given  as  an  alterative  in  phlyctenular  ophthalmia,  I  have  frequently  known 
mercury  prove  injurious,  because  mistimed ;  that  is  to  say,  it  was  admin- 
istered' before  the  irritation  attending  the  acute  stage  of  the  disease  was 
moderated  by  depletion.  After  local  bloodletting,  and  the  use  of  evacuants, 
we  sometimes  fjnd  decided  advantage  from  the  exhibition  of  blue  pill,  or 
even  of  calomel  with  opium.  In  some  cases  this  combination  may  be  pushed 
with  advantage,  till  the  mouth  is  affected ;  as  was  done  in  the  following 
case : — 

Case  279. — Isabella  Fitzsimmons,  aged  nine,  was  admitted  at  the  Glasgow  Eye  Infirm- 
ary, 3d  of  August,  1831,  with  the  following  symptoms.  Numei-ous  plilyctenula3  rovmd  the 
upper  edge  of  the  right  cornea,  considerable  reticular  inflammation  of  the  conjunctiva; 
tongue  white  ;  she  is  feverish  and  tosses  during  the  night. 


486  PHLYCTENULAR   OPHTHALMIA. 

Tartar  emetic,  in  divided  doses,  was  ordered  as  an  emetic,  and  a  solution  of  nitrate  of 
silver  of  the  strength  of  4  grains  to  the  ounce  of  distilled  water,  was  applied  to  the  eye. 
On  the  5th,  the  phlyctenulie  were  observed  to  be  diminishing  in  size,  and  the  redness  was 
less.  On  the  9th,  the  symptoms  still  abated.  On  the  12th,  the  phlyctenulae  were  all  but 
gone. 

On  the  17th,  a  new  phlyctenula  was  observed  at  the  lower  edge  of  the  cornea.  She 
was  ordered  an  ounce  of  sulphate  of  magnesia.  On  the  19th,  there  was  general  vascu- 
larity of  the  conjunctiva.  On  the  21st,  a  small  ulcer  was  present  on  the  centre  of  the 
cornea.  She  was  ordered  12  grains  of  sulphate  of  quina  in  a  12-ounce  solution;  a  table- 
spoonful  to  be  taken  thrice  a-day.  On  the  2d  Sept.,  the  inflammation  was  found  to  be 
increased,  with  an  onyx  at  the  lower  edge  of  the  cornea.  Six  leeches  were  applied  to  the 
right  lids;  a  dose  of  calomel  and  jalap  administered,  and  the  quina  augmented  to  ^i  in 
12  ounces.  Next  day,  a  blister  was  applied  behind  the  ear.  On  the  8th,  the  onyx  was 
less.  On  the  9th,  the  quina  was  increased  to  ^i.  On  the  13th,  a  considerable  effusion 
of  lymph  was  observed  on  the  internal  surface  of  the  cornea,  below  the  level  of  the  ulcer. 
The  eye  was  evidently  in  imminent  danger.  Extract  of  belladonna  was  smeared  on  the 
brow  and  upper  lid.  The  quina  was  continued ;  but  as  this  is  a  remedy  of  little,  if  any, 
power  over  adhesive  inflammation,  2  grains  of  calomel,  with  the  third  of  a  grain  of  opium, 
were  ordered  at  bedtime. 

On  the  15th,  the  pupil  was  somewhat  dilated,  and  the  lymph  on  the  internal  surface  of 
the  cornea  was  less.  On  the  16th,  the  lymph  was  much  diminished.  On  the  18th,  it  was 
all  but  gone.  The  ulcer  was  still  deep,  but  smooth.  Numerous  red  vessels  were  seen 
creeping  over  the  lower  edge  of  the  cornea.  The  pupil  still  kept  dilated.  The  remedies 
were  continued  as  ordered  on  the  13th. 

On  the  22d,  the  pupil  Avas  widely  dilated,  the  lymph  completely  gone,  the  ulcer  con- 
tracted, and  the  cornea  free  of  red  vessels.  The  belladonna  was  omitted.  On  the  27th, 
the  calomel  and  opium  were  stopped.  On  the  1st  November  a  very  small  leucoma  was 
the  only  remaining  symptom. 

This  case  affords  a  good  example  of  the  spread  of  inflammation  from  the 
investing  membrane  of  the  cornea  to  its  proper  substance,  and  from  this  to 
its  lining  membrane.  It  shows  the  danger  of  trusting  to  quina  in  every  cir- 
cumstance of  scrofulous  ophthalmia,  and  the  favorable  influence  of  calomel 
and  opium,  when  adhesive  inflammation  of  the  cornea  occurs  in  this  disease. 

Y.  Iodine. — My  experience  of  iodine  and  its  preparations  in  phlyctenular 
ophthalmia,  has  not  been  sufficiently  extensive  to  enable  me  to  recommend 
them. 

8.  DiapJioretics. — Keeping  up  a  healthy  action  of  the  skin  is  of  much  im- 
portance. This  may  be  promoted  by  the  wearing  of  flannel  next  the  skin, 
and  by  the  use  of  the  tepid  bath  every  night,  or  every  second  night.  The 
warm  bath  often  greatly  relieves  the  intolerance  of  light.  It  proves  soothing 
and  refreshing,  and  ought  to  be  frequently  employed.  A  tepid  salt-water 
bath  is  highly  useful.  The  tepid  pediluvium  every  night,  for  weeks  or  months 
together,  proves  very  serviceable ;  also  warm  fomentations  of  the  belly,  as  in 
infantile  remittent  fever.  Dover's  powder  at  bedtime  sometimes  proves  use- 
ful, by  exciting  a  healthy  action  of  the  skin,  as  well  as  soothing  irritation 
and  procuring  sleep.  In  cases  where  the  perspiration  is  immoderate,  this 
medicine  is  not  less  remarkable  for  its  good  effects  than  where  the  surface  of 
the  body  is  dry  and  husky.  Tartar  emetic  operates  also  with  good  effect  on 
the  skin,  and  sympathetically  on  the  conjunctiva. 

9.  Anodynes. — Besides  opium,  which,  in  various  forms,  we  find  it  expe- 
dient to  exhibit  occasionally  in  phlyctenular  ophthalmia,  a  remarkable  effect 
is  obtained  in  soothing  the  pain  and  intolerance  of  light  attendant  on  this 
disease,  from  the  internal  use  of  belladonna.  The  dried  leaf,  in  powder,  is 
the  form  usually  chosen ;  and  of  this  from  one  to  two  grains  thrice  a-day  is 
the  dose.  If  the  vinous  tincture  is  chosen,  from  three  to  ten  drops  may  be 
given  to  a  child  thrice  a-day. 

10.  Inhalation  of  ancesthetics. — In  March,  184Y,  I  began  to  administer  the 
vapor  of  sulphuric  ether  in  several  cases  of  scrofulous  ophthalmia  attended 
with  great  intolerance  of  light.     I  gave  it  to  the  extent  of  producing  slight 


PHLYCTENULAR   OPHTHALMIA.  48T 

insensibility  for  some  minutes.  The  first  dose,  in  one  case,  removed  an  in- 
tolerance of  light  of  three  months'  standing,  such  that  the  patient,  a  girl  of 
16,  had  always  been  led  to  the  Eye  Infirmary,  with  her  eyes  spasmodically 
closed.  That  very  day,  and  ever  afterwards,  she  opened  her  eyes  freely.  In 
other  cases,  the  same  practice  repeated  daily,  or  every  second  day,  produced 
similar  good  effects.  I  have  derived  the  same  benefit  from  the  inhalation  of 
chloroform. 

The  inhalation  of  anaesthetics  not  merely  enables  us  deliberately  to  examine 
the  state  of  the  eyes  while  the  patient  is  in  the  insensible  state,  and  to  make 
such  applications  to  them  as  we  may  deem  necessary,  but  proves  a  valuable 
means  of  subduing  permanently  the  great  irritability  which  so  frequently  at- 
tends the  disease. 

11.  Diet. — During  the  continuance  of  an  attack  of  active  inflammation, 
abstinence  from  animal  food,  and  from  all  kinds  of  fermented  and  heating 
liquors,  should  be  strictly  enjoined  ;  but  when  the  acute  symptoms  have  sub- 
sided, and  the  disease  has  assumed  a  chronic  character,  the  patient  ought  to 
be  put  upon  a  rather  generous  diet.  As  there  can  be  no  doubt  that  unwhole- 
some food  is  one  of  the  chief  causes  of  this  ophthalmia  among  the  poor,  it  is 
of  much  importance  to  procure  for  the  patients  in  these  circumstances  a  more 
invigorating  diet.  It  is  necessary  strictly  to  forbid  the  use  of  articles  likely 
to  derange  the  stomach ;  as,  pastry  of  every  sort,  comfits,  vegetable  jellies, 
and  preserves ;  and  of  indigestible  substances,  as,  unripe  fruits,  nuts,  raisins, 
and  the  like. 

12.  Temper. — This  disease  is  extremely  apt  to  render  the  child  fretful,  and, 
by  mismanagement,  to  lay  the  foundation  of  bad  temper,  which,  in  its  turn, 
tends  much  to  prolong  and  aggravate  the  symptoms.  We  find  that  in  good- 
natured  children,  and  in  those  who  are  under  proper  management,  the  disease 
disappears  much  more  readily ;  while  in  spoiled  children,  who  cry  perhaps 
for  hours  after  the  eyes  are  examined,  or  after  the  application  of  aiiy  remedy, 
it  is  apt  to  become  almost  incurable.  It  is  of  much  importance  to  excite 
hope  in  the  patient. 

13.  Exercise — Sleeji. — Children  affected  with  this  disease  would  lie  in  bed 
all  day.  This  is  not  to  be  allowed.  They  should  be  washed  and  dressed  be- 
times ;  and,  weather  permitting,  taken  out  of  doors,  however  great  may  be 
the  intolerance  of  light.  On  the  other  hand,  they  are  not  to  sit  up  late,  nor 
to  fatigue  their  eyes  by  attempting  to  read,  draw,  sew,  or  the  like,  by  arti- 
ficial light,  but  are  to  retire  early  to  rest.  "  Si  enim  quid  est  juvans  oculos, 
est  somnus  ipse."^ 

14.  Positio7i  in  bed. — The  head  should  be  raised  as  much  as  possible  dur- 
ing the  night.  On  no  account  ought  the  child  to  be  suffered  to  lie  burying 
its  face  in  the  pillow. 

Local  remedies.  1.  Shading  the  eyes.  —  The  morbi(J|  irritability  which 
marks  this  disease  so  strikingly  through  all  its  stages,  is  to  be  relieved  by 
wearing  a  broad  hat  or  bonnet,  or  by  a  green  or  black  shade  for  both  eyes. 
All  employment  of  the  eyes  upon  minute  objects,  especially  in  a  strong  light, 
is  to  be  avoided.  It  will  not  be  necessary  to  confine  the  patient  to  a  dark 
room,  nor  to  forbid  him  going  abroad  in  fine  weather.  On  the  contrary, 
every  inducement  to  open  the  eyes,  to  use  them  moderately  upon  large  ob- 
jects, and  to  take  exercise  out  of  doors,  ought  to  be  held  out  to  the  patient. 
We  often  see  children  laboring  under  this  ophthalmia,  having  handkerchiefs 
bound  over  one  or  both  of  their  eyes,  especially  when  they  are  taken  out  of 
doors.  This  practice  is  decidedly  injurious,  heating  the  eyes  too  much,  fos- 
tering the  intolerance  of  light,  and  if  one  eye  only  is  covered,  often  produc- 
ing a  squint. 

2.  Evaporation. — In  recent   slight  attacks,  the  inflammation,  pain,  and 


488  PHLYCTENULAR   OPHTHALMIA. 

irritability,  may  be  moderated  by  the  use  of  evaporating  and  slightly  astring- 
ent lotions,  applied  tepid  or  cold  according  to  the  feelings  of  the  patient. 
In  most  instances,  they  agree  better  in  the  tepid  state.  Decoction  of  poppy- 
heads,  with  a  few  drops  of  alcohol ;  water,  acidulated  with  a  little  vinegar,  or 
to  which  a  small  quantity  of  sweet  spirit  of  nitre  is  added ;  rose-water,  or  a 
weak  solution  of  acetate  of  ammonia,  will  often  answer  the  purpose.  The 
application  of  cold  water  to  the  eyelids,  face,  and  head,  generally  gives  relief; 
but  in  many  cases  the  reaction  which  follows  seems  hurtful.  The  same  may 
be  said  of  vinegar  poultices,  and  alum  curd,  inclosed  in  a  thin  linen  bag,  and 
laid  over  the  lids  at  bedtime. 

3.  Fomentations. — When  the  symptoms  are  in  any  degree  severe  or  of  long 
continuance,  warm  soothing  applications  will  be  found  more  useful  than  cold 
ones.  By  means  of  a  piece  of  sponge  or  flannel,  the  eyes  may  be  fomented, 
several  times  in  the  course  of  the  day,  with  a  decoction  of  chamomile  flowers, 
poppy-heads,  or  digitalis  leaves,  or  with  a  watery  infusion  of  opium,  heated 
to  about  100°  Fahr.  Much  relief  is  experienced  from  exposing  the  eyes  to 
the  steam  of  warm  water,  or  the- vapor  of  laudanum  or  camphor,  raised  by 
means  of  a  cupful  of  hot  water.  Belladonna  and  hyoscyamus  in  vapor  or  in  fo- 
mentation are  of  great  service  in  relieving  the  intolerance  of  light.  A  solution 
of  1  grain  of  corrosive  sublimate,  and  6  grains  of  sal  ammoniac,  in  6  ounces  of 
water,  with  2  drachms  of  vinum  belladonna3,  or  from  1  to  2  grains  of  sulphate  of 
atropia,  is  the  collyrium  which  I  have  found  the  most  useful ;  a  tablespoonful 
being  mixed  with  an  equal  quantity  of  hot  water.  It  is  to  be  used  thrice  a-day ; 
and  after  the  eyelids  are  carefully  bathed  with  it  externally,  for  the  space  of  five 
minutes,  a  little  of  it  ought  to  be  allowed  to  flow  in  upon  the  eye. 

4.  Scarification  of  the  inside  of  the  eyelids,  especially  in  chronic  cases, 
where  the  palpebral  conjunctiva  is  much  loaded  with  red  vessels,  will  be 
found  one  of  the  most  valuable  means  of  cure.  In  cases  of  vascular  speck, 
division  of  the  fasciculus  of  vessels  running  over  the  sclerotica  to  the  albugo, 
can  scarcely  be  dispensed  with  ;  no  other  remedy  having  the  same  power  in 
checking  this  very  annoying  and  dangerous  symptom. 

5.  Counter-irritation. — In  scrofulous  subjects  we  frequently  find  that  the 
occurrence  of  disease  in  one  part  relieves  another  part  which  was  previously 
suffering.  Imitating  this  natural  conversion  of  disease,  when  we  find  other 
means  to  fail,  we  employ  blistering  in  scrofulous  ophthalmia,  and  generally 
with  great  benefit.  The  intolerance  of  light  is  often  suddenly  removed  by 
this  remedy ;  the  child  being  enabled,  in  a  few  hours  after  the  blister  rises, 
to  open  its  eyes,  although  it  had  not  done  so  for  months  before.  The  temples, 
behind  the  ears,  the  crown  and  back  of  the  head,  and  the  nape  of  the  neck, 
are  the  situations  generally  chosen  for  the  application  of  blisters.  The  last 
is  the  most  painful,  but  not  the  least  effectual.  In  general,  the  discharge 
ought  to  be  kept  up,  by  the  use  of  some  stimulating  dressing;  or,  if  this  is 
not  done,  a  quick  succession  of  blisters  ought  to  be  employed. 

Friction  on  the  nape  of  the  neck  with  tartar  emetic  ointment  is  sometimes 
had  recourse  to  in  this  disease,  for  the  purpose  of  bringing  out  a  crop  of 
pustules.  This  is  a  practice  much  more  painful  than  blistering,  the  pustular 
eruption  sometimes  spreads  over  the  body  and  causes  considerable  constitu- 
tional disturbance ;  the  pustules,  if  considerable  in  size,  leave  indelible  pits, 
and,  from  mismanagement  of  the  remedy,  large  portions  of  skin  are  sometimes 
made  to  slough;  so  that  on  the  whole,  blistering  is  preferable.  Dr.  Salomon 
regards  the  tartar  emetic  eruption  as  the  only  sure  remedy  for  the  intolerance 
of  light.6 

Issues  on  the  neck  or  on  the  arm  were,  at  one  time,  much  employed,  and 
certainly  proved  beneficial  in  relieving  the  symptoms  of  phlyctenular  ophthal- 
mia, and  in  preventing  relapses.     They  were  in  many  respects,  however, 


PHLYCTENULAR   OPHTHALMIA.  489 

objectiouable.  I  have  known  an  issue  in  the  arm  to  cause  atrophy  of  the 
extremity,  which  continued  for  life.  The  improvements  whicli  have  talcen 
place  of  late  years  in  ophthalmic  medicine,  have  rendered  such  means  less 
necessary. 

6.  Stimulants  applied  to  the  inflamed  surface  of  the  eye,  in  this  disease, 
are  decidedly  useful.  Indeed,  it  is  scarcely  possible  to  effect  a  cure  without 
them.  The  impetiginous  state  of  the  conjunctiva,  or,  in  other  words,  of  the 
skin  covering  the  eye,  in  this  ophthalmia,  not  merely  bears  stimulants,  but 
like  most  other  chronic  cutaneous  diseases,  is  benefited  by  their  application, 
if  they  be  well  chosen,  carefully  used,  and  properly  timed.  They  often  act 
as  the  best  local  sedatives,  if  applied  after  the  acute  inflammatory  excitement 
is  subdued  by  the  general  remedies  already  enumerated.  Employed  before 
this  is  effected,  they  will  scarcely  fail  to  prove  hurtful.  In  this  respect  the 
treatment  of  phlyctenular  ophthalmia  is  directly  contrary  to  that  of  the  puro- 
mucous  inflammations  of  the  conjunctiva  ;  for  in  them  we  employ  stimulants 
from  the  very  first,  but  in  the  phlyctenular  we  must  wait  till  the  symptoms  of 
irritation  are  somewhat  abated. 

Yarious  stimulants  have  been  used  in  scrofulous  ophthalmia ;  but  the  nitras 
argenti  solution  and  the  red  precipitate  salve  are  the  most  deserving  of  confi- 
dence. Next  to  them  I  would  place  the  vinum  opii.  Whichever  be  selected, 
its  application  must  be  continued  with  regularity  once  a-day,  or  once  every 
two  days,  the  child  being  laid  in  the  horizontal  position,  the  head  fixed 
between  the  knees,  and  the  lid  opened  so  as  fully  to  expose  the  diseased 
membrane. 

The  solution  of  4  grains  of  the  nitras  argenti  in  1  ounce  of  distilled  water, 
is  the  stimulant  whicli  I  generally  employ.  It  evidently  possesses  very  con- 
siderable power  in  abating  the  vascularity  of  the  conjunctiva,  hastening  the 
absorption  of  phlyctenulce,  promoting  the  cicatrization  of  ulcers,  and  clearing 
specks  of  the  cornea.  The  relief  which  it  affords  to  the  intolerance  of  light, 
is  not  the  least  of  its  good  effects.  We  not  unfrequently  observe  that  a 
single  application  of  this  remedy  will  effect  so  much  relief  that,  by  next  day, 
the  patient  is  able  in  a  moderate  light  to  keep  the  eyes  half  open,  without 
uneasiness,  although  previously  he  could  not  bear  the  least  accession  of  light. 
In  producing  this  effect,  it  probably  operates  by  inducing  the  healing  of 
minute  ulcerations,  and  the  contraction  of  enlarged  bloodvessels,  both  of 
which  give  rise  to  the  sensation  of  sand  in  the  eye,  to  spasm  of  the  lids,  and 
epiphora.  Whenever  ulceration  is  present  on  the  cornea,  recourse  should 
be  had  to  the  solution  of  nitras  argenti.  A  stronger  solution  than  that  of  4 
grains  to  the  ounce  may  be  employed,  and  with  a  small  camel-hair  pencil 
applied  directly  to  the  surface  of  the  ulcer,  without  permitting  the  solution 
to  spread  over  the  rest  of  the  eye. 

The  staining  of  the  conjunctiva  of  an  indelible  olive  hue,  and  the  black 
cicatrice  of  the  cornea,  which  sometimes  follow  the  use  of  nitrate  of  silver, 
are  serious  objections  to  this  remedy.  I  am  unable  to  say  anything  farther 
regarding  the  latter  effect,  than  simply  that  I  am  convinced  of  its  occasional 
occurrence.  The  former  effect  is  the  result  only  of  a  long  continued  daily 
application  of  the  solution  in  question,  and  may  therefore  be  avoided. 

t.  Solid  caustic. — When  an  ulcer  threatens  to  penetrate  deep  into  the 
substance  of  the  cornea,  or  when  it  has  already  perforated  into  the  anterior 
chamber,  it  is  proper  to  touch  the  ulcer,  or,  if  there  is  prolapsus  of  the  iris, 
the  myocephalon,  every  second  or  third  day,  with  a  pencil  of  lunar  caustic, 
filed  to  a  sharp  point.  Scarpa  has  given''  the  best  account  of  the  effects  of 
this  remedy,  to  which  I  shall  again  have  occasion  to  refer,  under  the  head  of 
Ulcers  of  the  Cornea. 

8.  Mydriatics. — The  case  of  James  Tassie,  already  detailed  at  page  484, 


490  MORBILLOUS   AND    SCARLATINOUS   OPHTHALMIA. 

strikingly  illustrates  the  utility  of  the  extract  of  belladonna  in  central  ulcer 
of  the  cornea.  Even  when  a  portion  of  iris  is  involved  in  such  an  ulcer,  the 
dilating  power  of  the  belladonna  may  be  sufficient  to  free  it,  and  thus  to 
preserve  the  pupil  entire.  In  cases  of  perforating  ulcer  near  the  edge  of  the 
cornea,  we  can  have  recourse  to  the  use  of  belladonna  with  less  confidence  ; 
for  while  the  dilatation  cannot,  in  this  case,  be  carried  so  far  as  to  remove 
the  iris  from  the  vicinity  of  the  ulcer,  it  is  doubtful  whether  the  state  into 
which  the  iris  is  thrown,  is  not  apt  to  favor,  rather  than  prevent  prolapsus. 

Belladonna  is  of  great  service  in  subduing  the  intolerance  of  light;  indeed, 
it  may  be  regarded  as  a  specific  for  this  distressing  symptom.  A  good  mode 
of  applying  it  is  to  expose  the  eyes  to  a  teaspoonful  of  its  vinous  solution, 
raised  into  vapor,  by  being  added  to  a  teacupful  of  boiling  water.  An  oint- 
ment, containing  extract  of  belladonna,  rubbed  round  the  eye,  is  serviceable  ; 
as  is  also  the  collyrium  of  murias  hydrargyri  with  vinum  belladonnas,  already 
noticed.  Similar  benefit  is  to  be  derived  from  the  salts  of  atropia,  and 
from  other  mydriatics,  besides  belladonna ;  such  as  hyoscyamus  and  stra- 
monium. 

9.  Apj)lications  to  the  Schneiderian  membrane. — It  has  been  suggested  by 
M.  Morard,  that  scrofulous  ophthalmia  is  caused  and  kept  up  by  a  diseased 
state  of  the  mucous  membrane  of  the  nostrils.  He  cures  this  by  the  applica- 
tion of  a  solution  of  nitrate  of  silver,  of  the  strength  of  a  scruple  to  an  ounce 
of  water,  and  by  this  means,  he  says,  the  ophthalmia  is  removed.^  It  is  cer- 
tainly proper  to  endeavor  to  cure  all  the  concomitants  of  the  disease ;  although 
it  seems  more  likely  that  the  irritating  discharge  of  the  tears  is  the  cause 
of  the  inflamed  state  of  the  nostrils,  than  that  the  latter  keeps  up  the  oph- 
thalmia. 

Relapses. — ISTo  disease  is  so  apt  to  recur  as  phlyctenular  ophthalmia.  It  is 
therefore  necessary  for  children  who  have  once  suffered  from  it,  to  be  sub- 
mitted, from  time  to  time,  to  the  inspection  of  their  medical  attendant,  who 
must  endeavor  promptly  to  subdue  every  symptom  of  a  re-attack,  and  to  con- 
duct his  patients  safely  through  that  period  of  life  which  is  most  exposed  to 
the  disease.  In  this  way  much  mischief  will  easily  be  prevented,  which,  should 
the  disease  be  neglected,  may  require  years  to  remove,  or  prove  altogether 
beyond  remedy. 


•  Beitriige  fiir  practischo  Medizin  und  Oph-  '  Fallopius. 

thalmiatrik;  Vol.  i.  p.  3;  Leipzig,  1812.  '  Ammon'sZeitschrift  fiir  die  Ophthalmologie; 

^  jMirault,  Archives  Gencrales  de  Medecine;  Vol.  ii.  p.  329;  Dresden,  1832. 

Tome  XX.  p.  477;  Paris,  1829.  ■"  Trattato  delle  prineipali  Malattie  degli  Oc- 

^  AVeller,  Krankheiten  des  inonschlichen  Au-  chi;  Vol.  i.  p.  280;  Pavia,  1816. 

ges.  p.  469;  Wien,  1831.  '  British   and  Foreign  Medical   Review   for 

*  Essay  on  Scrofula;  in  which  an  Account  of  April  1847,  p.  373:  Edwards,  Lancet,  April  8, 
the  Effect  of  the  Carbonas  Ammonite,  as  a  Re-  1848,  p.  3S9. 

medy  in  that  Disease,  is  submitted  to  the  Medical 
Profession ;  London,  1812. 


SECTION  Xn. — MORBILLOUS  AND  SCARLATINOUS  OPHTHALMLiE. 

Fig.  Beer,  Band  I.  Taf.  II.  Fig.  3. 

A  certain  degree  of  conjunctivitis  always  attends  measles  and  scarlet  fever, 
but  is  in  general  much  less  severe  than  the  variolous  inflammation  of  the  eye. 
In  measles  and  scarlet  fever,  the  change  which  the  skin  undergoes,  amounts 
to  little  more  than  vascular  congestion  ;  and  the  conjunctiva,  a  prolongation 
of  skin,  betrays  therefore  little  more  during  the  presence  of  these  diseases, 
than  some  degree  of  redness,  with  intolerance  of  light,  slight  pain,  and  epi- 


VARIOLOUS   OPHTHALMIA.  491 

phora.  Occasionally,  however,  we  meet  with  phlyctenular,  onyx,  and  ulcers 
of  the  cornea,  brought  on  by  the  morbillous  and  scarlatinous  ophthalmife, 
particularly  when  the  subject  is  scrofulous.  Indeed,  it  is  difficult  to  distin- 
guish either  of  these  ophthalmias  from  the  scrofulous  till  the  eruption  of  the 
skin  makes  its  appearance.  On  the  other  hand,  we  often  hear  of  the  dregs  of 
the  measles  or  scarlet  fever  producing  affections  of  the  eye  and  eyelids.  By 
this  it  is  generally  meant,  that  the  scrofulous  diathesis  has  been  called  into 
action  by  these  diseases,  and  that  ophthalmia  tarsi,  or  phlyctenular  conjunc- 
tivitis has  been  the  result. 

In  measles  there  is  a  catarrhal  affection  of  the  Schneiderian  membrane, 
with  sneezing  and  cough,  and  occasionally  the  attending  conjunctivitis  is  not 
so  much  eruptive  as  blennorrhoeal.  I  have  seen  cases  in  which  the  eye  had 
been  destroyed  by  severe  puro-mucous  ophthalmia  excited  by  measles.  In 
scrofulous  subjects  exposed  to  cold  after  measles,  a  puro-mucous  inflammation 
of  the  conjunctiva,  or  scrofulo-catarrhal  ophthalmia,  is  a  frequent  occurrence. 
In  weakly  ill-nourished  infants,  cough,  great  emaciation,  and  ulceration  of  the 
cornea,  ending  in  staphyloma,  are  not  uncommon  sequelae  of  measles.  I  have 
also  seen  a  case,  in  which  both  eyes  collapsed  after  scarlatina,  bursting,  as  I 
understood,  from  puro-mucous  ophthalmia.  The  child  was  at  the  same  time 
totally  deprived  of  hearing  from  suppuration  of  the  ears.  Mr.  Bowman 
mentions  an  instance  of  five  boys  of  one  family  having  scarlet  fever,  of  whom 
two  lost  their  sight  by  sloughing  of  the  cornea,  within  a  week  of  their  seizure. 
One  of  the  two  died;  the  other  was  brought  to  Mr.  B.  with  the  globes  sunk. 
There  was  no  previous  debility  discoverable  in  these  children,  to  account  for 
this  unusual  destruction  of  the  cornea.' 

In  some  rare  cases  of  scarlatinous  ophthalmia,  the  iris  and  capsule  of  the 
lens  become  affected.  I  operated,  some  time  ago,  on  a  boy  of  about  eight 
years  of  age,  in  whom  specks  of  the  anterior  hemisphere  of  the  capsule  were 
brought  on  in  this  way. 

Treatment. — The  affection  of  the  eye  in  measles  and  scarlet  fever,  does  not 
in  general  require  active  treatment.  The  eyes  should  be  guarded  from  strong 
light,  bathed  occasionally  with  tepid  water,  and  the  bowels  kept  freely  open. 
If  the  symptoms  are  more  than  commonly  severe,  leeches  may  be  set  on  the 
temples,  and  blisters  applied  behind  the  ears,  or  to  the  nape  of  the  neck.  The 
nitras  argenti  solution  will  be  found  highly  useful,  whether  the  ophthalmia  be 
eruptive  or  puro-mucous.  Sulphate  of  quiua  may  be  given  internally  with 
good  effects. 


'  Lectures  on  the  Parts  concerned  in  the  Operations  on  the  Eye,  p.  110;  London,  1849, 


SECTION  XIII. — VARIOLOUS  OPHTHALMIA. 
Fig.  Beer,  Band  L  Taf.  IL  Fig.  2. 

In  former  times,  smallpox  proved  but  too  often  the  cause  of  serious  injury 
to  the  eyes,  or  even  of  entire  loss  of  sight.  It  was  by  far  the  most  frequent 
cause  of  partial  and  total  staphyloma.  But  since  the  introduction  of  inocu- 
lation, and  still  more  of  vaccination,  such  injurious  effects  from  variolous  oph- 
thalmia, are  comparatively  rare. 

Symptoms. — In  most  cases  of  smallpox,  pustules  form  on  the  external  sur- 
face, and  on  the  margins  of  the  eyelids.  When  they  are  numerous,  as  in  con- 
fluent smallpox,  they  cause  such  swelling  of  the  lids  as  completely  to  close 
the  eyes.  As  the  disease  proceeds,  matter  is  discharged  partly  from  the 
Meibomian  follicles,  partly  from  the  variolous  pustules ;  the  eyelids  are  glued 


492  VARIOLOUS   OPHTHALMIA. 

together  so  that  the  eyes  cannot  be  opened  for  days ;  and  merely  from  this 
state,  without  any  pustules  being  formed  on  the  conjunctiva,  the  eyes  are 
irritated  and  painful.  At  last,  as  the  disease  subsides,  the  swelling  of  the 
lids  falls,  so  that  they  are  again  opened,  and  the  eyes  may  be  found  uninjured. 
It  is  in  this  way  that  the  vulgar  talk  of  persons  being  blind  in  smallpox  for 
so  many  days,  and  recovering  their  sight.  But  although  the  cornea  has  not 
suffered  in  such  cases,  the  eyelids  and  the  lachrymal  apparatus  are  often  left  in 
an  injured  state;  and  not  unfrequently  smallpox  proves  the  exciting  cause 
of  scrofulous  affections  of  the  eyes  and  eyelids,  which  may  continue  trouble- 
some for  years.  The  smallpox  pustules  on  the  lids  are  apt  to  destroy  the 
eyelashes,  to  leave  red  marks  and  scars,  render  the  edges  irregular  and  liable 
to  inflammation  and  excoriation  from  slight  causes,  and  to  produce  ophthal- 
mia tarsi,  and  very  frequently  trichiasis  and  distichiasis.  Chronic  blennor- 
rhoea  of  the  lachrymal  sac,  and  phlyctenular  conjunctivitis,  are  also  frequent 
sequelo3  of  smallpox. 

Schemes  have  been  proposed  for  preventing  the  pustules  of  smallpox  from 
spreading  to  the  face,  or  at  least  for  moderating  the  effects  of  the  eruption. 
We  find  that  this  disease  is  apt  to  attack  with  peculiar  severity  any  part  of 
the  surface  of  the  body  laboring  at  the  time  under  accidental  irritation,  and 
hence  it  has  been  supposed  that  soothing  applications  might  moderate  the 
eruption  and  its  effects.  Covering  the  face  with  a  cloth  spread  with  cerate, 
and  fomenting  it  from  time  to  time  with  chamomile  decoction,  have  been  used 
for  this  purpose,  and  can  do  no  harm.  When  the  pustules  on  the  eyelids  are 
fully  matured,  we  may  afford  considerable  relief  by  pricking  them  one  by  one 
with  a  needle,  so  as  to  evacuate  their  contents;  and  by  carefully  removing 
the  crusts  w^hich  form  after  the  pustules  burst,  having  first  softened  them  wdth 
some  mild  ointment.  The  lids  are  frequently  to  be  bathed  with  tepid  milk  and 
water,  and  bits  of  soft  rag  moistened  with  the  same  are  to  be  laid  over  them. 

§  1.  Conjunctivitis  variolosa. 

There  is  in  every  case  of  smallpox,  some  redness  of  the  conjunctiva,  con- 
stituting the  jnimary  variolous  ojyJitlialmia — conjunctivitis  variolosa.  But 
danger  has  been  chiefly  apprehended  from  the  formation  of  a  variolous  pus- 
tule or  pustules  on  the  cornea.  A  pustule,  on  the  cornea,  forming  at  the 
time  of  the  general  eruption,  would  certainly  be  extremely  apt  to  prove  de- 
structive. The  pustule  bursting,  an  ulcer  would  be  formed,  W'hich  would 
probably  deepen  and  spread.  If  the  cornea  were  penetrated,  the  iris  would 
advance  and  adhere  to  the  cornea,  and  the  pupil  might  thus  be  obliterated. 
A  considerable  portion  of  the  cornea  being  destroyed  by  ulceration,  partial 
staphyloma  might  be  the  result.  In  bad  cases,  almost  the  whole  cornea  might 
be  destroyed,  by  infiltration  of  matter  and  ulceration,  and  total  staphyloma 
would  then  ensue. 

During  the  suppurative  stage  of  smallpox  it  is  difficult  to  say  what  extent 
of  mischief  may  be  going  on  in  the  eye,  under  the  closed  and  swollen  eyelids. 
If  the  patient  feels  pain  in  the  ball  itself,  with  dryness,  stiffness,  and  a  sensa- 
tion of  sand  in  the  eye ;  if  the  uneasiness  be  much  increased  on  attempting 
to  move  the  eye,  or  on  exposing  it  to  light  even  through  the  swollen  lids;  and 
if,  in  addition  to  the  matter  discharged  from  the  pustules  on  the  edges  of  the 
lids  and  from  the  Meibomian  follicles,  there  is  a  frequent  discharge  of  hot 
tears ;  then  it  is  probable  that  there  is  acute  variolous  conjunctivitis.  If  the 
eye  is  easy,  only  shut  up  from  the  state  of  the  lids,  there  is  probably  no  danger. 

When  the  eyes  come  to  open,  the  cornea,  though  seldom,  if  ever,  disorgan- 
ized, may  be  found  totally  opaque  from  interstitial  deposition,  so  that  the  pupil 
and  iris  cannot  be  seen. 


VARIOLOUS  OPHTHALMIA.  493 

§  2.    Corneitis  postvariolosa. 
Syn. — Das  Nachpocken,  Beer. 

The  eyes  are  not  safe,  even  after  the  smallpox  pustules  over  the  body  have 
blackened  and  the  scabs  fallen  off.  On  the  contrary,  it  is  then  that  the  chief 
danger  is  apt  to  occur.  I  have  often  seen  both  central  abscess  of  the  cornea 
and  onyx  at  its  lower  edge,  produced  after  the  general  eruption  was  completely 
gone.  This  state  has  been  called,  with  sufficient  propriety,  secondary  vario- 
lous ophthalmia — corneitis  postvariolosa.  It  generally  occurs  about  the  12th 
day  of  the  eruption,  when  the  pustules  over  the  body  are  subsiding,  but  some- 
times as  late  as  five  or  six  weeks  after  the  patient  has  recovered  from  the 
primary  disease.  In  children,  especially  scrofulous  children,  the  disease  is 
truly  a  corneitis ;  in  adults,  there  is  often  a  combination  of  iritis  with  corneitis, 

A  dull  whitish  point  is  observed  a  little  below  the  centre  of  the  cornea,  with 
surrounding  haziness;  the  whiteness  becomes  slightly  elevated  and  more  ex- 
tensive, amounting  perhaps  to  the  12th  of  an  inch  in  diameter,  and  then  the 
part  becomes  yellow,  and  is  almost  certain  to  fall  into  a  state  of  ulceration. 
If  two  or  more  such  points  should  form,  the  whole  cornea  is  rendered  nebu- 
lous; or  this  effect  may  be  produced  even  from  one  large  central  abscess.  An 
onyx  at  the  same  time  may  appear  at  the  lower  edge  of  the  cornea.  The  scle- 
rotica is  reddened.  Pain  and  epiphora  are  excited  on  exposure  to  light.  In 
adults,  the  iris  is  discolored,  and  the  pupil  contracted,  irregular,  and  more  or 
less  filled  with  lymph. 

The  secondary  variolous  ophthalmia  seldom  leads  to  destruction  of  the 
cornea,  unless  the  case  is  altogether  neglected.  By  proper  treatment,  the 
matter  of  the  abscess  or  onyx  is  generally  absorbed.  In  other  cases,  ulcera- 
tion takes  place,  leaving,  after  cicatrization,  a  leucoma,  which  is  likely  to  be 
permanent.  The  surrounding  haziness  of  the  cornea  is  gradually  dissipated; 
vision  is  injured  according  to  the  situation  and  size  of  the  leucoma.  By  the 
formation  of  an  artificial  pupil,  vision  may  in  some  cases  of  this  sort  be  re- 
stored. Even  when  partial  staphyloma  has  formed,  this  operation  is  occa- 
sionally applicable.  If  the  whole  cornea  is  destroyed  by  suppuration  and 
ulceration  in  the  course  of  secondary  variolous  ophthalmia,  the  result  is  total 
staphyloma.  This  rarely  happens,  unless  there  is  a  high  degree  of  secondary 
fever,  with  much  feebleness  and  emaciation.  Indeed,  we  seldom  meet  with 
secondary  variolous  ophthalmia,  without  the  skin  being  hot  and  dry,  the  pulse 
quick,  and  other  symptoms  of  synocha  present.  When  the  constitutional 
symptoms  run  high,  and  the  eye  falls  into  phlegmonous  ophthalmitis,  or  com- 
plete suppuration,  the  case  is  apt  to  terminate  fatally.  Puncturing  the  eye 
under  such  circumstances  as  Louis^  recommended,  may  be  the  means  of  saving 
the  life  of  the  patient. 

The  general  notion,  that  pustules  are  apt  to  form  on  the  conjunctiva  and 
cornea,  at  the  time  of  the  general  eruption,  has  been  controverted  by  Dr. 
George  Gregory.  In  a  report'^  of  some  observations  of  his  at  the  Westmin- 
ster Medical  Society,  he  is  made  to  say,  that  except  the  mucous  membrane 
of  the  fauces,  larynx,  and  trachea,  no  mucous  membrane  is  capable  of  taking 
on  the  variolous  action.  Even  the  eye,  which  so  frequently  suffers  from  small- 
pox, Dr.  Gregory  affirms  to  do  so  from  common  inflammation  only,  the  pus- 
tule on  the  cornea  not  appearing  till  the  eruption  is  on  the  decline,  and  there- 
fore not  being  a  primary  or  essential  feature  of  the  disease.  I  have  never 
seen  a  primary  variolous  pustule  on  the  cornea,  nor  on  any  part  of  the  con- 
junctiva. Dr.  W.  Brown  informs  me  that,  along  with  the  primary  eruption, 
he  once  saw  a  pustule  on  the  inside  of  the  lower  lid.  The  opinion  of  Dr. 
Gregory  has  been  supported  by  Mr.  Marson,^  whose  position  as  surgeon  to 


494  VARIOLOUS   OPHTHALMIA. 

the  Smallpox  Hospital  in  London,  has  afforded  him  opportunities  for  inves- 
tigating the  point  in  question.  Mr.  Mai'son  has  never  seen  a  smallpox  pus- 
tule on  the  eye.  The  eye  appears  to  him  to  possess  complete  immunity  from 
the  primary  eruption.  He  considers  the  destructive  inflammation  of  the  eye 
which  follows  smallpox,  as  entirely  a  secondary  affection,  and  as  analogous 
to  the  sloughing  of  the  cellular  membrane,  in  other  parts  of  the  body,  which 
is  a  frequent  sequela  of  the  disease.  As  far  as  I  am  able  to  judge,  the  de- 
struction of  the  eye  in  the  secondary  variolous  ophthalmia  is  effected  by  the 
formation,  not  of  a  pustule  on  the  surface,  but  of  an  abscess  in  the  substance 
of  the  cornea. 

Treatment. — 1.  The  best  general  treatment  of  smallpox  must  be  followed, 
in  the  first  instance;  a  moderate  temperature,  tepid  ablution,  and  a  cool 
regimen.  Emetics  are  occasionally  useful ;  even  bloodletting  may  be  cau- 
tiously employed  in  some  cases,  and  laxatives  are  always  to  be  administered. 
If  the  eyes  are  particularly  affected,  they  must  be  frequently  bathed  with 
tepid  water  or  poppy  decoction,  and  the  edges  of  the  lids  smeared  with  a 
little  cold  cream.  In  many  cases,  the  lids  are  so  much  swollen,  and  so  com- 
pletely sealed  up,  that  it  would  be  in  vain  to  attempt  any  application  to  the 
conjunctiva,  till  the  eruption  begins  to  fade  and  the  swelling  to  fall.  Leeches 
may  be  applied,  not  only  without  impropriety,  but  with  decided  advantage, 
behind  the  ears  or  on  the  temples,  and  followed,  if  it  appear  necessary,  by 
blisters.  Perhaps  we  might  prevent  the  eyes  from  becoming  much  affected, 
by  applying  leeches  behind  the  ears.  Two  or  three  leeches  being  allowed  to 
hang  till  they  fall  off,  two  or  three  others  are  to  be  applied,  and  so  on,  till  a 
considerable  quantity  of  blood  has  been  abstracted.  This  is  likely  to  reduce 
the  irritation  about  the  face,  and  to  save  the  eyes.  About  the  eighth  or 
ninth  day  of  the  eruption,  free  purging  will  be  found  useful,  not  merely  in 
reducing  the  suppurative  fever,  but  in  relieving  the  uneasy  and  inflamed  state 
of  the  eyes.  The  lids  now  begin  to  be  opened,  so  that  a  little  fluid  can  be 
injected  between  them  and  the  eyeball.  A  weak  solution  of  nitras  argenti, 
or  diluted  vinum  opii,  may  be  used  for  this  purpose.  The  absorption  of 
opaque  depositions  in  the  cornea  will  be  promoted  by  these  applications,  and 
by  the  internal  use  of  tonics  and  alteratives. 

2.  As  for  the  treatment  of  secondary  variolous  ophthalmia,  I  have  found 
tartar  emetic,  given  so  as  to  vomit  and  purge  freely,  to  be  productive  of  the 
best  effects,  in  abating  the  inflammation  and  promoting  the  absorption  of  any 
abscess  which  may  have  formed  in  the  cornea.  Leeches  and  blisters  are  also 
useful.  As  soon  as  the  inflammation  is  somewhat  reduced  by  these  means, 
advantage  will  be  gained  by  putting  the  patient  on  a  course  of  sulphate  of 
quina.  In  cases  of  chronic  ulcer,  mercury  acts  very  beneficially  ;  or  a  mix- 
ture of  mercury  with  sulphate  of  quina,  such  as  one  grain  of  the  sulphate  of 
quina  with  a  grain  and  a  half  of  hydrargyrum  cum  creta,  thrice  a  day.  Un- 
diluted vinum  opii  appears  to  answer  best  as  a  local  application.  The  eye 
is  to  be  touched  with  it  once  a  day.  Belladonna  is  to  be  applied  to  the  eye- 
brow and  eyelids,  in  order  to  keep  the  pupil  dilated.  If  iritis  is  present,  the 
patient  must  be  bled  and  brought  under  the  constitutional  action  of  mercury. 


'  See  case  of  two  sisters,  Mcmoires  de  TAca-        "^  Medical  Gazette;  Vol.  r.  p.  222;   London, 
demie  Royale  de  Chiiurgie;  Tome  xiii.  p.  281;     1S30. 
12  mo.;  Paris,  1774.  '  Ibid.;  Vol.  xxiv.  p.  204;  London,  1839. 


ERYSIPELATOUS   OPHTHALMIA,  495 

SECTION  XIV. — ERYSIPELATOUS  OPHTHALMIA. 
Fig.  Beer,  Band  I.     Taf.  1.  Fig.  3. 

Idiopathic  erysipelatous  conjunctivitis  is  a  rare  disease.  It  is  easily  dis- 
criminated from  any  other  form  of  conjunctival  inflammation. 

Symptoms. — It  commences  with  a  slight  feeling  of  tension  in  the  eye  and 
parts  immediately  surrounding  it.  The  conjunctiva  becomes  of  a  pale  red 
color,  and  rises  in  soft  yellowish-red  vesicles  round  the  cornea.  These  take 
a  different  form  from  every  motion  of  the  eyelids,  and  are  sometimes  so  large 
as  to  project  from  between  their  edges.  On  strained  or  rapid  motion  of  the 
eyeball  or  eyelid.s,  the  patient  feels  a  pricking  pain  in  the  eye.  When  the 
eyelids  are  a  little  open,  the  folds  of  the  swollen  conjunctiva  give  the  patient 
the  appearance  of  one  who  is  weeping,  and  we  expect  that  every  moment  the 
tears  will  drop  from  his  eye ;  but  on  a  nearer  inspection,  and  on  pressing 
down  the  lower  eyelid,  we  discover  the  mistake,  into  which  we  are  the  more 
ready  to  fall,  as  during  this  inflammation  there  frequently  is  a  discharge  of 
tears,  especially  on  sudden  changes  of  temperature.  The  eye  is  somewhat 
impatient  of  light.  No  other  diseased  appearances  are  observed  in  the  eye 
itself,  and  the  eyelids  may  be  entirely  free  from  redness  or  swelling.  At  the 
end  of  the  acute  stage,  the  pain  of  the  whole  eye  is  increased,  still  exciting 
in  the  mind  of  the  patient  the  comparison  of  pressing  or  stretching,  espe- 
cially on  moving  the  eye  or  eyelids. 

As  the  disease  continues,  the  redness  of  the  conjunctiva  increases.  It  be- 
comes, indeed,  so  generally  red,  that  we  discover  no  longer  a  mere  network 
of  bloodvessels  ;  but  a  general,  yet  pale  and  sometimes  livid  redness.  Yet 
this  pale  red  color  is  not  uniform.  It  is  contrasted  with  spots  of  different 
sizes,  of  a  bright  red  color,  which  arise  from  extravasation  of  blood  into  the 
areolar  tissue  between  the  conjunctiva  and  sclerotica.  The  vesicles  become 
more  considerable,  and  project  still  more  from  between  the  half-opened  eye- 
lids. The  spaces  between  the  vesicles  are  covered  with  a  thin  white  mucus, 
which  is  secreted  in  unnatural  quantity  by  the  conjunctiva  and  Meibomian 
glands.  The  discharge  of  tears  is  also  increased.  During  the  night  the 
eyelids  are  glued  slightly  together;  when  they  are  opened,  the  cornea  ap- 
pears somewhat  dim  ;  but  after  the  eye  has  been  carefully  cleaned,  we  see 
that  the  apparent  dimness  of  the  cornea  arises  from  mucus  collected  on  its 
surface. 

As  the  disease  subsides,  the  secretion  of  mucus  returns  to  its  natural 
quantity,  the  redness  of  the  conjunctiva  disappears,  and  those  portions  of  the 
membrane  which  had  been  elevated  in  folds  or  vesicles,  re-approach  and  re- 
attach themselves  to  the  tunica  albuginea  and  sclerotica.  The  discharge  of 
tears  ceases  to  be  so  frequent  and  so  abundant.  The  spots  from  extravasated 
blood  are  the  last  symptom  to  disappear.  There  continues  even  for  a  long  time, 
such  a  diminution  of  the  connection  between  the  conjnnctiva  and  sclerotica 
at  these  places,  that  the  conjunctiva  falls  into  wrinkles  whenever  the  eyeball 
is  moved.     It  is  long  before  it  completely  recovers  its  natural  elasticity. 

Causes. — This  disease  arises  from  sudden  changes  of  atmosphere,  slight 
blows,  the  stings  of  insects,  and  various  other  causes.  I  have  more  than 
once  seen  the  irritation  arising  from  chlorine  gas,  produce  erysipelatous  oph- 
thalmia. 

Treatment. — Much  depletion  is  not  necessary.  The  exhibition  of  a  pur- 
gative, and  the  use  of  gentle  diaphoretics,  will  in  most  cases  constitute  the 
whole  of  the  general  treatment.  It  may  sometimes  be  proper  to  open  the 
vesicles  with  the  point  of  a  lancet.  The  local  treatment  may  be  gathered 
from  the  following  case  : — 


496  RHEUMATIC   OPHTHALMIA. 

Case  280. — Mary  Macdonald,  aged  20,  was  admitted  at  the  Glasgow  Eye  Infirmary  on 
the  1st  March  1832,  eight  days  before  which  she  had  rigors,  followed  by  headache  and 
erysipelatous  inflammation  of  the  conjunctiva,  without  any  affection  of  the  integuments. 
The  conjunctivae  were  of  a  pale  red  color,  and  on  one  side  the  membrane  hung  in  soft 
masses  from  between  the  eyelids.  The  tongue  was  white,  and  the  patient  complained  of 
thirst.  She  had  applied  leeches  to  the  temples,  and  taken  a  dose  of  sulphate  of  magnesia. 
She  was  inclined  to  attribute  the  affection  of  her  eyes  to  exposure  to  the  emanation  from 
a  solution  of  chloride  of  lime.  She  was  ordered  1  grain  of  muriate  of  mercm-y  in  8  ounces 
of  water  as  a  coUyrium. 

On  the  2d,  the  swelling  of  the  conjunctivEe  was  much  abated,  and  the  eyes  easier.  The 
four-grain  solution  of  the  nitrate  of  silver  was  applied  to  the  inflamed  surface. 

On  the  6th,  the  swelling  was  gone,  and  the  redness  much  less.  The  solution  and  colly- 
rium  were  continued. 

On  the  10th,  she  was  ordered  gj  of  precipitated  carbonate  of  iron  thrice  a-day ;  and 
on  the  18tb,  was  dismissed  cured. 


SECTION  XV. — RHEUMATIC  OPHTHALMIA. 

Syn. — Sclerotitis.     Sclerotitis  idiopathica. 
Fig.  Wardrop,  Medico-cbirurgical  Transactions,  Vol.  X.  PI.  I. 

It  has  been  already  stated,  that  there  are  three  ophthalmiae  frequently  pro- 
duced in  adults  from  atmospheric  influences ;  viz :  the  catarrhal,  the  rheumatic, 
and  the  catarrho-rheumatic. 

Diagnosis. — The  following  particulars  will  serve  sufficiently  to  distinguish 
rheumatic  from  catarrhal  ophthalmia  : — 

1.  Seat  of  the  disease. — The  catarrhal  ophthalmia  is  an  affection  of  the 
conjunctiva ;  the  rheumatic  has  its  seat  in  the  albuginea  and  sclerotica,  and 
frequently  extends,  in  some  degree,  to  the  iris,  and  even  to  the  retina. 

2.  Redness. — The  redness  in  the  catarrhal  ophthalmia  is  reticular,  and  the 
turgid  vessels  are  evidently  conjunctival ;  in  the  rheumatic,  the  chief  redness 
is  radiated  or  zonular  (Fig.  62,  p.  433),  and  seated  under  the  conjunctiva, 
or  in  the  deep-seated  conjunctival,  or  sclerotic,  network.  We  never  see  spots 
of  blood  extravasated  under  the  conjunctiva  in  rheumatic  ophthalmia;  whereas, 
this  is  a  frequent  occurrence  in  catarrhus  oculi. 

3.  Nature  of  the  inflammation. — The  catarrhal  ophthalmia  is  an  inflamma- 
tion of  a  mucous  membrane,  and  is  a  blennorrhceal  or  profluvial  disease, 
attended  with  an  increased  and  morbid  secretion  of  mucus ;  the  rheumatic 
attacks  the  fibrous  membranes  of  the  organ  of  vision,  and  is  unattended  by 
any  morbid  secretion  from  the  surface  of  the  eye. 

4.  Pain. — The  pain  in  the  catarrhal  ophthalmia  ai'ises  on  the  surface  of 
the  conjunctiva,  is  compared  to  the  sensation  of  roughness,  or  to  the  feeling 
which  might  be  excited  by  sand  or  broken  glass  under  the  eyelids,  does  not 
extend  to  the  head,  and  is  felt  most  in  the  morning,  or  when  the  eyes  begin 
to  be  moved  ;  the  pain  of  the  eyes  in  the  rheumatic  ophthalmia  is  pulsative 
and  deep  seated;  the  chief  pain,  however,  is  not  so  much  in  the  eyeball,  as 
round  the  orbit,  under  the  eyebrow,  and  in  the  temple,  cheek,  and  side  of 
the  nose,  and  is  severely  aggravated  from  sunset  till  sunrise. 

Were  I  asked,  "What  is  meant  by  rheumatic  ophthalmia?"  I  should 
answer  to  the  following  effect : — 

1.  By  rheumatic  ophthalmia,  I  mean  simply  inflammation  of  the  fibrous 
membrane  of  the  eye  (the  sclerotica),  and  of  the  adjacent  parts  of  similar 
structure,  excited  by  exposure  to  cold. 

2.  I  do  not  regard  this  ophthalmia  as  an  inflammation,  differing  in  kind 
from  common  inflammation,  in  consequence  of  the  existence  of  what  has  been 
called  the  rheumatic  habit,  or  diathesis.     The  train  of  symptoms  seems  to 


RHEUMATIC   OPHTHALMIA.  49T 

depend,  not  on  the  constitution  of  the  person,  but  on  the  structure  and  func- 
tions of  the  part  affected. 

3.  Rheumatic  subjects  are  by  no  means  exempt  from  this  ophthalmia;  yet 
it  frequently  occurs  in  individuals  who  have  never  suffered  from  rheumatism 
in  any  other  part  of  the  body. 

4.  When  rheumatism  quits  a  joint  and  attacks  the  heart,  we  say  it  is  a 
metastasis ;  but  such  a  translation  of  rheumatic  inflammation  to  the  eye,  I 
have  never  myself  observed.  In  all  the  cases  of  rheumatic  sclerotitis  which  I 
have  witnessed,  the  disease  was  primary,  whether  in  rheumatic  or  non-rheu- 
matic subjects ;  never  metastatic. 

5.  I  have  adopted  the  term  rheumatic  ojiJithalmia ;  but,  perhaps,  sclerotitis 
idiopatfdca  would  be  a  truer  appellation.  It  must  be  confessed,  however, 
that  this  inflammation  of  the  eye  resembles  rheumatism  in  its  exciting  causes, 
accompanying  pain,  exacerbations,  and  cure.  It  has  not  been  generally 
recognized  as  rheumatic,  probably  because  it  attacks  structures  which  are 
covered  only  by  a  thin  semitransparent  membrane,  and  therefore  exposed  to 
direct  examination  ;  while  the  other  seats  of  rheumatism  are  hid  from  our  view 
by  the  whole  thickness  of  the  integuments,  and  are  the  subjects,  therefore, 
more  of  conjecture  than  of  actual  observation. 

Degree  of  frequency. — Pure  rheumatic  ophthalmia  is  comparatively  a  rare 
disease.  For  one  case  of  pure  rheumatic,  we  meet  with  perhaps  ten  cases  of 
catarrhal  ophthalmia,  and  six  of  that  mixed  kind  called  catarrho-rheumatic, 
in  which  both  conjunctiva  and  sclerotica  are  affected,  and  the  symptoms  of 
the  two  former  ophthalraiae  are  combined.  We  seldom  see  both  eyes  affected 
with  rheumatic  ophthalmia  at  once.  When  both  are  attacked,  the  one  is 
always  much  more  severely  inflamed  than  the  other. 

Local  symptoms. — 1.  The  fasciculi  of  vessels  advance  in  radii  towards 
the  edge,  and  sometimes  even  a  little  over  the  edge  of  the  cornea.  They  are 
of  a  bright  red  color,  and  surround  the  cornea  pretty  equally  on  all  sides. 
Although  probably  the  same  radiating  vessels  which  are  seen  in  iritis,  they 
appear  larger  and  more  turgid  than  in  that  disease,  and  rise  more  from  the 
surface  of  the  sclerotica.  In  iritis,  these  vessels  are  filled  only  sympathetically ; 
here  they  are  affected  idiopathically.  The  conjunctivitis  which  attends  this 
ophthalmia  is  slight,  and  never  such  as  to  mask  the  radiated  inflammation  of 
the  sclerotica. 

2.  There  is,  in  general,  no  tendency  to  chemosis  in  pure  rheumatic  oph- 
thalmia, nor  do  the  eyelids  take  part  in  the  disease,  so  as  to  glue  the  eye  up 
after  sleep. 

3.  Dimness  of  vision  uniformly  attends  this  ophthalmia,  depending  on  an 
accompanying  haziness  of  the  cornea  and  pupil,  attended  by  a  slight  contrac- 
tion of  the  latter,  and  sluggishness  in  the  movements  of  the  iris.  If  only 
one  eye  is  affected,  which,  at  least  for  some  time,  is  generally  the  case,  the 
pupil  of  that  eye  is  seen  at  once  to  be  less  than  that  of  the  sound  eye.  The 
iris  becomes  slightly  discolored  ;  it  becomes  greenish,  for  instance,  if  naturally 
blue  ;  and  the  attending  iritis  may  proceed  even  to  effusion  of  coagulable 
lymph  within  the  pupil.  It  must  be  understood,  however,  that  a  severe  de- 
gree of  iritis  rarely  attends  rheumatic  ophthalmia. 

4.  Except  haziness  of  the  cornea  and  pupil,  which  may  be  attributed  to 
slight  effusion,  it  has  never  happened  to  me  to  witness  any  other  of  the  second- 
ary phenomena  of  inflammation  in  idiopathic  sclerotitis.  I  have  not  seen  the 
disease  terminate  in  any  form  of  suppuration  or  of  ulceration,  both  of  which 
are  very  common  in  catarrho-rheumatic  ophthalmia. 

5.  The  access  of  light  does  not  in  general  prove  very  distressing  to  the  pa- 
tient.    The  affected  eye  feels  dry  and  hot  in  the  early  period  of  the  disease  ; 

32 


498  RHEUMATIC   OPHTHALMIA. 

but  after  a  time,  especially  when  the  symptoms  are  somewhat  abated  by 
bloodletting,  there  is  considerable  epiphora. 

6.  The  pain  which  attends  rheumatic  ophthalmia  at  its  commencement,  is 
of  a  stinging  kind,  and  extends  from  the  ej^eball  to  the  orbit  and  neighboring 
parts  of  the  head.  These  parts  feel  hot  to  the  patient,  and  even  to  the  hand 
of  the  observer.  The  pain  is  strikingly  augmented  by  warmth  ;  but  relieved 
by  perspiration.  It  often  affects  the  forehead,  the  cheek-bone,  and  the  teeth ; 
extending  sometimes  even  to  the  lower  jaw.  Occasionally,  it  is  precisely  con- 
fined to  one-half  of  the  head.  In  some  instances,  it  is  severe  on  the  side  of 
the  nose,  or  within  its  cavities,  or  in  the  ear.  But,  above  all,  the  superciliary 
ridge  is  it  chief  seat,  and  next  to  it  the  temple  and  the  cheek.  Not  unfre- 
quently  the  pain  has  the  acute  pulsatory  character  of  phlegmon,  especially 
when  felt  chiefly  in  the  eyeball ;  in  other  cases,  and  particularly  around  the 
orbit,  it  consists  rather  in  an  agonizing  kind  of  feeling,  which  distresses  and 
wearies  out  the  patience  of  the  person  affected.  It  never  ceases  entirely,  so 
long  as  the  disease  continues ;  but  it  varies  much  in  degree,  coming  on  with 
severity  about  four,  six,  or  eight  o'clock  in  the  evening,  continuing  during 
the  night,  becoming  most  severe  about  midnight,  and  abating  towards  five 
or  six  in  the  morning ;  till  then,  totally  preventing  sleep,  and  occasioning 
great  distress.  The  patient  never  fails,  in  the  history  he  gives  of  his  case,  to 
insist  on  the  nocturnal  pain,  and  with  his  finger  to  point  out  its  supra-ocular 
or  circumorbital  seat.  It  affects  much  more  the  forehead,  temple,  cheek, 
and  side  of  the  nose,  than  the  eyeball.  It  is  reasonable  to  conclude  that,  in 
this  disease,  the  periosteum,  in  and  round  the  orbit  and  the  fascia  of  the 
temporal  muscle,  structures  similar  in  nature  to  the  sclerotica,  may  also  be 
affected  with  rheumatism.  The  chief  seat  of  the  pain,  however,  appears  to  be 
one  or  more  of  the  six  branches  of  the  fifth  nerve,  which,  radiating  from  the 
orbit,  are  distributed  to  the  face,  and  we  may  fairly  suppose  a  considerable 
portion  of  the  pain  to  arise  from  the  sympathy  which  these  nerves  have  with 
those  distributed  to  the  interior  of  the  eyeball,  and  which  lie  imbedded  on  the 
inside  of  the  sclerotica. 

Constitutional  symptoms. — A  considerable  degree  of  symptomatic  fever 
attends  this  disease,  increasing  along  with  the  nocturnal  paroxysms  of  pain. 
The  pulse  becomes  frequent,  and  sometimes  strong,  full  and  hard.  The  tongue 
is  white  and  furred,  and  the  mouth  ill-tasted  ;  there  is  more  or  less  nausea, 
and  the  skin  is  hot  and  dry.  The  digestive  organs  are  deranged,  the  appe- 
tite impaired,  the  bowels  generally  confined,  and  the  excretions  morbid. 

The  progress  and  severity  of  the  disease  vary  much  in  different  cases.  In 
some  the  attack  is  slight,  and  soon  goes  off,  without  permanently  injuring  the 
organ.  At  other  times,  it  is  extremely  severe,  and  if  misunderstood,  may 
soon  destroy  vision.  Not  unfrequently  the  disease  falls  into  a  chronic  state, 
without  being  very  severe. 

Exciting  causes. — Rheumatic  ophthalmia  may  be  distinctly  traced,  in  most 
instances,  to  exposure  of  the  eye  to  a  continued  stream  of  cold  air,  while  the 
head  and  face  are  in  a  state  of  perspiration.  The  patient,  in  the  history  which 
he  gives  of  his  case,  commonly  mentions  some  particular  exposure  of  this  sort, 
sooa  after  which  the  redness  and  rheumatic  pain  commence ;  for  example, 
sleeping  with  the  head  exposed  to  the  air  entering  by  a  chink  in  the  wall,  or 
by  a  broken  pane  of  glass ;  travelling  during  the  night  in  a  carriage,  with 
one  side  of  the  head  close  to  a  broken  window ;  suddenly  issuing  from  a 
crowded  room  into  the  cold  air  of  the  street ;  exposure  to  the  current  of  air 
which  flows  from  the  stage  into  the  body  of  a  theatre ;  keeping  wd;  clothes  on 
the  head  when  overheated  ;  and  the  like. 

I  have  not  observed  that  this  disease  is  much  more  apt  to  occur  at  one 
season  of  the  year  than  another.     It  is  certainly  more  prevalent  when  the 


RHEUMATIC   OPHTHALMIA.,  499 

wind  is  cold  and  northeasterly.  It  is  much  more  apt  to  attack  persons  of 
middle  age  than  either  the  young  or  the  old.  Indeed,  I  have  never  seen  it 
in  children,  nor  in  those  far  advanced  in  life.  Probably  the  same  exciting 
causes  which,  in  persons  of  middle  life  and  robust  constitution,  are  apt  to 
produce  rheumatic  ophthalmia,  would  in  a  child  excite  catarrhal  or  scrofulous 
ophthalmia,  and  in  an  old  person  the  catarrho-rheumatic  or  arthritic.  Rheu- 
matic ophthalmia  is  very  apt  to  reattack  an  individual  who  has  previously 
suffered  from  it. 

Prognosis. — If  the  disease  is  taken  in  time,  the  prognosis  is  favorable. 
Allowed  to  proceed  in  its  course,  the  pupil  may  close,  or  the  anterior  crys- 
talline capsule  bfr  left  opaque. 

Treatment.  1.  Bloodletting. — In  all  cases  of  rheumatic  ophthalmia,  it  is 
necessary  to  take  away  blood  from  the  arm,  and  in  general,  to  follow  this  up 
by  the  application  of  leeches  to  the  forehead  and  temple.  I  feel  myself 
obliged  wholly  to  differ  from  Mr.  Wardrop's  opinion,  that  patients  affected 
with  rheumatic  ophthalmia,  neither  bear  bleeding  to  a  great  extent,  nor  are 
much  relieved  by  this  remedy.  He  has  even  stated  the  little  relief  afforded 
by  bleeding  in  this  disease  as  one  of  its  diagnostic  characters.*  This  entirely 
disagrees  with  my  experience ;  and  is,  I  apprehend,  altogether  contrary  to 
what  we  observe  in  other  rheumatic  affections.  Bleeding,  both  general  and 
local,  I  have  uniformly  found  extremely  useful  in  rheumatic  ophthalmia,  and 
I  believe  it  ought  seldom,  if  ever,  to  be  omitted.  The  blood  drawn  is 
generally  very  buffy.  The  buffy  coat  is  not  dark  yellow  as  in  hepatitis  or  in 
syphilis  ;  but  whitish,  as  in  pleuritis.  The  first  night,  after  taking  from  15  to 
20  ounces  from  the  arm,  the  patient  is  often  so  much  relieved  as  to  get  some 
sleep,  even  though  no  other  remedy  be  employed.  Next  day,  I  am  in  the 
habit  of  applying  a  dozen  of  leeches  around  the  eye;  but,  if  the  pulse  be  still 
strong  and  full,  and  the  circumorbital  pain  not  relieved,  I  first  repeat  the  vene- 
section, and  I  have  had  cases  under  my  care  which  required  venesection  to  be 
repeated  five  or  six  times,  before  the  severe  circumorbital  pain  and  other  acute 
symptoms  subsided  in  any  considerable  degree. 

2.  Calomel  and  opium. — I  have  never  failed  to  find  this  combination 
highly  useful  in  checking  the  circumorbital  pain,  and  dissipating  the  other 
symptoms.  A  pill,  containing  4  grains  of  calomel  with  I  grain  of  opium, 
is  to  be  administered  every  evening,  till  the  gums  begin  to  be  affected,  when 
the  calomel  may  be  omitted,  and  10  grains  of  Dover's  powder  substituted  for 
the  opium.  In  some  cases,  smaller  but  more  frequent  doses  of  calomel  and 
opium  may  be  proper,  such  as  2  grains  of  calomel  with  half  a  grain  of  opium 
thrice  a-day.  Mr.  Wardrop  states  that  mercury,  given  in  this  disease  so  as 
to  produce  ptyalism,  aggravates  more  than  mitigates  the  symptoms.  This 
does  not  correspond  with  what  I  have  observed.  I  do  not,  indeed,  push  the 
mercury  to  make  the  mouth  sore,  but  I  have  not  witnessed  any  bad  effects 
from  the  gums  becoming  affected. 

3.  Opiate  frictions. — The  patient  experiences  great  relief  from  carefully 
rubbing  the  forehead  and  temple  with  warm  laudanum,  or  with  extract  of 
belladonna  infused  in  laudanum.  This  ought  to  be  done  about  an  hour  before 
the  nocturnal  paroxysm  is  expected,  which  it  will  greatly  assuage,  and  some- 
times entirely  prevent.  In  chronic  cases,  equal  parts  of  laudanum  and 
tincture  of  cantharides  form  a  useful  liniment. 

4.  Blisters  behind  the  ear,  and  to  the  temple,  but  above  all  a  large  blister 
to  the  nape  of  the  neck,  will  be  found  useful. 

5.  Belladonna. — During  the  whole  course  of  rheumatic  ophthalmia,  the 
pupil  of  the  affected  eye  ought  to  be  kept  under  the  influence  of  belladonna, 
either  by  painting  the  moistened  extract  upon  the  eyebrow  and  eyelids 
morning  and  evening,  but  especially  at  bedtime,  or  by  infusing  1  drachm  of 


500  CATARRHO-RHEUMATIC   OPHTHALMIA. 

the  extract  in  each  ounce  of  the  laudanum  which  is  used  for  rubbing  the 
head. 

6.  Purgatives. — A  smart  dose  of  laxative  medicine  ought  to  be  adminis- 
tered at  the  commencement  of  the  treatment.  Afterwards,  a  laxative  clyster 
every  morning,  or  a  small  dose  of  Epsom  salts  may  be  employed,  to  obviate 
the  constipating  effects  of  the  opium.  More  powerful  purgatives  are  now 
improper,  as  they  would  carry  off  the  calomel  and  opium,  and  thereby  pre- 
vent their  good  effects. 

7.  Sudorijics. — The  warm  pediluvium  at  bedtime,  with  diluent  drinks 
towards  evening,  operating  along  with  the  opium,  will,  in  general,  excite  a 
sufficient  degree  of  diaphoresis.  Mr.  Wardrop  recommends  antimonial  pow- 
der, and  Beer  employed  guaiac,  for  exciting  the  skin  in  this  disease. 

8.  Tonics. — Small  doses  of  sulphate  of  quina,  or  of  the  mineral  acids,  will 
be  found  advantageous  in  the  chronic  stage  of  the  disease,  and  during  con- 
valescence. In  old  mistreated  cases,  Fowler's  solution  sometimes  gives 
great  relief,  in  doses  of  from  8  to  12  drops  thrice  a-day. 

9.  Vinum  opii. — Applications  to  the  eye  itself  have  but  little  power  over 
this  disease.  Those  which  are  so  useful  in  other  ophthalmise,  are  often  hurt- 
ful in  the  rheumatic.  The  lunar  caustic  solution,  for  instance,  which  may  be 
regarded  as  a  specific  in  catarrhal  ophthalmia,  is  in  the  present  disease  de- 
cidedly injurious.  When  all  the  febrile  and  painful  symptoms,  however,  are 
gone,  and  little  more  than  lingering  redness  with  weakness  of  the  eye,  re- 
mains, the  vinum  opii,  in  a  diluted  state,  will  be  found  beneficial,  dropped 
upon  the  eye  twice  or  thrice,  or  the  pure  vinum  opii,  once,  daily. 

The  first,  second,  third,  and  fifth  of  these  remedies  are  to  be  had  recourse 
to  in  the  first  instance.  I  have  never  found  them  fail  in  any  acute  case,  how- 
ever severe ;  nor  have  I  witnessed  any  permanent  sequela?,  when  the  plan  of 
treatment  now  explained  was  adopted  with  the  necessary  vigor. 


Medico-Chirurgical  Transactions;  Vol.  x.  p.  13;  London,  1S13. 


SECTION  XVI. — CATARRHO-RHEUMATIC  OPHTHALMIA. 

Syn. — CoDJunctivo-sclerotitis. 
Fig.  London  Medical  and  Physical  Journal,  April,  1827, 

This  compound  ophthalmia  is  one  of  the  most  common,  and  also  one  of  the 
most  severe  and  dangerous  diseases  of  the  eye.  In  old  persons  especially,  it 
is  often  the  source  of  permanently  diminished  vision,  and  not  unfrequently  of 
entire  loss  of  sight  in  the  eye  attacked. 

Symptoms. — 1,  As  both  the  conjunctiva  and  the  sclerotica  are  affected,  the 
symptoms  are  more  complicated,  and  also  more  various,  than  those  of  unmixed 
conjunctivitis  or  sclerotitis. 

2.  The  feeling  of  roughness  or  of  sand  between  the  eyelids  and  eyeball,  and 
the  secretion  of  puriform  mucus,  are  sufficiently  indicative  of  the  part  taken 
in  this  disease  by  the  conjunctiva.  The  nocturnal  accession  of  racking  circum- 
orbital  pain  marks  the  affection  of  the  sclerotica. 

3.  In  some  cases  of  catarrho-rheuraatic  ophthalmia,  the  conjunctivitis  is 
severe,  the  sclerotitis  slight;  but  more  frequently  the  sclerotitis  is  severe,  and 
the  conjunctivitis  not  so  considerable. 

4.  In  this  disease,  the  conjunctiva  and  sclerotica  are  attacked  simultane- 
ously. Occasionally  it  happens  in  the  course  of  pure  rheumatic  ophthalmia, 
that  the  patient,  from  some  new  exposure,  becomes  affected  also  with  catarrhal 


CATARRHO-RHEUMATIC   OPHTHALMIA,  501 

conjunctivitis;  more  rarely  does  an  attack  of  rheumatic  sclerotitis  supervene 
in  catarrhal  ophthalmia.  But  in  catarrho-rheumatic  ophthalmia,  both  mem- 
branes appear  to  be  attacked  at  once  in  consequence  of  the  influence  of  one 
and  the  same  exciting  cause. 

5.  The  redness  is  evidently  both  conjunctival  and  sclerotic.  Under  the 
movable  network  of  the  conjunctiva,  we  perceive  the  immovable  zonular  in- 
flammation of  the  sclerotica.  In  pure  catarrhal  ophthalmia,  the  sclerotica,  no 
doubt,  participates  in  the  inflammation,  but  no  paroxysms  of  rheumatic  pain  are 
present;  the  sclerotica  suffers  sympathetically,  not  primarily.  In  pure  rheu- 
matic ophthalmia,  also,  the  conjunctiva  is  reddened,  from  contiguous  sympathy 
with  the  structure  which  it  covers,  just  as  the  skin  is  reddened  over  a  joint  suf- 
fering from  acute  rheumatism;  but  neither  the  conjunctiva  in  the  one  instance, 
nor  the  skin  in  the  other,  is  the  seat  of  the  primary  disease.  Besides,  in  pure 
rheumatic  ophthalmia,  the  conjunctiva  betrays  no  marks  of  profluvial  disease. 

6.  Chemosis,  or  inflammatory  oedema  of  the  subconjunctival  cellular  mem- 
brane, is  by  no  means  an  uncommon  attendant  on  catarrho-rheumatic  oph- 
thalmia.    When  it  does  occur,  it  hides  from  view  the  sclerotic  redness. 

T.  The  discharge  from  the  conjunctiva  in  this  disease  is  never  profuse,  and 
seldom  opaque.  It  amounts,  in  general,  rather  to  a  mere  increase  of  mucus, 
than  to  a  flow  of  pus,  and  renders  the  lids  more  than  usually  moist  and  slip- 
pery. 

8.  The  eyelids  adhere  together  in  the  morning,  from  the  inspissated  mucus 
and  Meibomian  secretion.  Kot  unfrequently  the  lids  are  also  externally  red 
and  swollen. 

9.  Considerable  intolerance  of  light  and  epiphora  attend  this  ophthalmia 
in  all  its  stages;  but  especially  in  those  cases  in  which  the  structure  of  the 
cornea  is  affected. 

10.  The  conjunctival  i>ain,  which  is  compared  to  the  feeling  produced  by 
sand  between  the  eyelids  and  eyeball,  is  felt  most  in  the  morning,  or  when  the 
eyelids  are  moved.  The  sclerotic  pain  is  nocturnal,  and  observes  the  same 
periods  of  renewal,  violence,  and  abatement,  as  in  rheumatic  ophthalmia. 
The  conjunctival  pain  is  referred  to  the  surface  of  the  eye,  and  sometimes  to 
the  forehead.  The  sclerotic  pain  is  either  immediately  under  the  eyebrow,  or 
circumorbital. 

11.  The  cornea  is  extremely  apt  to  suffer  from  ulceration,  and  from  effusion 
of  pus  between  its  lamellae.  Indeed,  there  is  no  ophthalmia  to  which  adults 
are  exposed,  in  which  ulcer  of  the  cornea  and  onyx  are  so  frequent  as  in  the 
catarrho-rheumatic.  If  the  disease  is  neglected  for  eight  or  ten  days,  and 
especially  if  the  patient  be  far  advanced  in  life,  we  almost  uniformly  meet  with 
one  or  other,  and  not  unfrequently  with  both  of  these  symptoms. 

12.  The  ulcer  is  generally  peculiar,  in  so  far  as  it  is  apt  to  spread  over  the 
surface,  and  rarely  penetrates  deeply  into  the  substance  of  the  cornea.  It 
often  seems  the  result  of  exfoliation  of  a  considerable  portion  of  the  corneal 
epithelium.  I  have  seen  such  a  portion  loose  and  raised  up  apparently  by  the 
intervention  of  a  fluid.  It  must  be  this  appearance  which  Beer  describes  as 
a  phlyctenula ;  but  it  is  more  extensive  than  a  phlyctenula,  and  is  neither  so 
circular  nor  so  circumscribed.  The  ulcer  which  occurs  in  this  ophthalmia, 
often  cicatrizes  without  leaving  any  opacity,  the  cornea  remaining  merely 
irregular,  as  if  part  of  it  had  been  hacked  off  with  the  lancet ;  and  vision,  of 
course,  from  disturbed  refraction,  indistinct.  If  the  case  continues  to  be  neg- 
lected, or  if  it  be  mistreated,  the  ulcer  ceases  to  be  superficial,  the  substance 
of  the  cornea  is  more  deeply  attacked,  and  a  leucoma  at  least  will  be  the  re- 
sult; but  the  cornea  may  even  give  way,  allowing  the  aqueous  humor  to  be 
evacuated,  and  giving  rise  to  adhesion  of  the  iris  to  the  cornea. 

13.  Onyx,  or  effusion  of  pus  between  the  lamellse,  or  into  the  cellular  tex- 


502  CATARRHO-RHEUMATIC   OPHTHALMIA. 

ture  of  the  cornea,  is  one  of  the  most  alarming  of  all  the  symptoms  of  this 
ophthalmia.  It  generally  commences  at  the  lower  edge  of  the  cornea,  in 
shape  like  the  white  spot  at  the  root  of  the  nails,  its  upper  edge  presenting  a 
convexity.  It  gradually  increases,  mounting  upwards,  separating  more  and 
more  the  lamellae  between  which  it  is  effused,  and  greatly  adding  to  the  suf- 
ferings of  the  patient.  It  reaches  not  unfrequently  to  such  a  height  as  to  im- 
plicate more  than  half  of  the  cornea.  The  pus  of  an  onyx  in  catarrho-rheu- 
matic  ophthalmia  is  very  rarely  absorbed.  The  cornea  becomes  ulcerated  over 
the  centre  of  the  onyx  ;  the  pus  is  evacuated ;  too  often  the  ulcer  penetrates 
through  the  posterior  lamellae  of  the  cornea;  the  aqueous  humor  escapes  ;  the 
iris  falls  forward  into  contact  with  the  ulcerated  cornea ;  in  nine  cases  out  of 
ten  these  parts  adhere  together,  and  if  much  of  the  cornea  has  been  destroyed, 
the  result  may  be  partial  or  total  staphyloma. 

14.  At  the  same  time  that  the  onyx  goes  on  advancing,  the  color  of  the  iris 
changes,  and  there  is  commonly  au  effusion  of  lymph  into  the  pupil,  which 
becomes,  first  of  all,  less  vivid  in  its  motions,  then  hazy  and  contracted,  and 
at  last  perhaps  obliterated. 

15.  In  some  cases,  the  onyx  is  accompanied  by  hypopium  or  effusion  of 
pus  into  the  anterior  chamber,  or  we  may  have  hypopium  without  onyx.  In 
other  cases,  but  very  rarely,  an  onyx  bursts  into  the  anterior  chamber  ;  false 
hypopium  is  thus  produced,  and  ultimately  the  cornea  gives  way. 

16.  If  fortunately  the  matter  of  an  onyx  be  absorbed,  all)ugo  remains 
for  a  considerable  time,  but  gradually  diminishes,  and  may  ultimately  almost 
entirely  disappear.  If  the  onyx  is  dispersed  by  the  cornea  giving  way, 
leucoma  is  the  result  and  never  entirely  disappears.  Staphyloma  cannot  re- 
sult, unless  the  cornea  has  been  more  or  less  destroyed  l>y  ulceration,  and  the 
iris  has  become  partially  or  totally  involved  in  the  consequent  cicatrice.  Mr. 
Wardrop  has  remarked,  that  partial  staphyloma  generally  affects  the  inferior 
half  of  the  cornea.^  The  reason  is,  that  partial  staphyloma  is  commonly  the 
consequence  of  onyx,  which  in  nine  cases  out  of  ten  takes  place  at  the  low^er 
edge  of  the  cornea. 

IT.  In  catarrho-rheumatic  ophthalmia,  the  pulse  is  generally  quick  and 
sharp,  the  tongue  white,  and  the  mouth  ill-tasted.  The  nocturnal  pain  com- 
pletely prevents  sleep,  till  about  sunrise.  Inflammation  of  the  mucous  mem- 
brane of  the  nostrils  or  the  bronchi  sometimes  attends,  and  adds  to  the  febrile 
symptoms. 

18.  We  generally  find  that  the  rheumatic  symptoms  yield  first  to  treatment; 
the  catarrhal  continuing  for  some  days  longer.  But  in  some  cases  I  have 
observed  the  reverse  ;  the  circumorbital  pain  continuing,  at  least  in  a  certain 
degree,  after  the  catarrhal  symptoms  were  gone. 

Causes. — The  causes  of  catarrho-rheumatic  ophthalmia  appear  to  be  simi- 
lar atmospheric  influences  to  those  already  enumerated  as  giving  rise  to 
catarrhal  and  rheumatic  ophthalmiie.  Amongst  the  poor,  the  disease 
may,  in  general,  be  traced  to  cold,  to  which  the  patients  have  been  exposed, 
particularly  during  the  night,  from  deficient  clothing  and  want  of  proper 
shelter.  Like  other  inflammatory  and  rheumatic  affections,  it  is  more  pre- 
valent during  northeasterly  winds. 

Beer  thought  that  a  cold  draught  of  air  {eine  Jcalte  Zugluft),  playing  upon 
the  eye,  excited  rheumatic  ophthalmia;  and  that  foul  air  {ein  zersetzer  ver- 
dorbe?ier  Luftkreis)  caused  catarrhal  ophthalmia.  According  to  this  view, 
air,  at  once  corrupted  and  impelled  with  force  against  the  eye,  especially 
when  the  head  is  covered  with  perspiration,  will  be  the  most  likely  cause  of 
catarrho-rheumatic  ophthalmia.  * 

That  the  discharge  from  the  conjunctiva  in  catarrho-rheumatic  ophthalmia, 
if  applied  to  the  conjunctiva  of  a  healthy  eye,  will  excite  a  puro-mucous  con- 


CATARRHO-RIIEUMATIC   OPHTHALMIA.  503 

junctivitis,  is  extremely  probable.  We  can  be  at  no  loss  to  distinguish  catar- 
rho-rheuraatic  ophthalmia  from  that  stage  of  contagious  conjunctivitis,  in 
which  the  inflammation  spreading  inwards  to  the  deep-seated  textures  of  the 
eyeball,  excites  sympathetic  circumorbital  pain. 

We  meet  with  catarrho-rheumatic  ophthalmia  much  more  frequently  in  old 
persons  than  in  the  young  or  middle-aged.     I  have  never  seen  it  in  children. 

Treatment. — The  successful  treatment  of  this  disease  does  not  depend  so 
much  on  any  new  remedies,  as  on  a  proper  selection  of  some  of  the  means 
already  recommended,  either  for  the  catarrhal  or  for  the  rheumatic  ophthal- 
mia. 

1.  Venesection  appears  to  be  as  necessary  in  the  catarrho-rheumatic  as  in 
the  pure  rheumatic  cases ;  and  is  attended  by  relief  as  remarkable  to  all  the 
symptoms,  especially  to  the  circumorbital  pain.  According  to  the  severity 
of  the  case,  and  the  age  and  constitution  of  the  patient,  from  10  to  30  ounces 
of  blood  may  be  taken  from  the  arm ;  and  the  same  qua^ty  on  the  day  fol- 
lowing, if  the  symptoms  are  not  greatly  relieved.  We  must  not  be  deterred 
from  depletion,  although  we  find  the  patient  much  weakened  and  sunk  by 
the  pain  attending  the  disease.  The  abstraction  of  blood,  by  removing  the 
pain  and  thus  affording  an  opportunity  for  rest,  restores  the  strength  and 
spirits. 

2.  Leeches  to  the  temple  are  highly  useful,  particularly  when  applied  soon 
after  venesection. 

3.  Scarification  of  the  conjunctiva  of  the  eyelids,  is  to  be  employed  when 
there  is  any  considerable  degree  of  chemosis. 

4.  Calomel  and  opium  are  productive  of  the  same  good  effects  in  this 
ophthalmia  as  in  the  pure  rheumatic. 

5.  Opiate  frictions  on  the  forehead  and  temple  are  to  be  used,  about  an 
hour  before  the  expected  attack  of  circumorbital  pain. 

6.  Belladonna  is  to  be  applied  to  keep  the  pupil  dilated. 

T.  Blisters  behind  the  ear  or  to  the  nape  of  the  neck,  are  to  be  employed. 

8.  Purgatives,  as  a  brisk  dose  of  calomel  and  jalap  at  the  beginning,  and 
a  gentle  laxative  every  morning  during  the  course  of  the  disease,  do  good. 

9.  Sudorifics,  as  the  solution  of  acetate  of  ammonia,  with  diluent  drinks, 
the  warm  pediluvium,  and  a  flannel  under-dress,  will  be  found  useful. 

10.  Tonics,  as  sulphate  of  quina  and  the  mineral  acids,  are  to  be  given  on 
the  decline  of  the  disease. 

11.  Solution  of  nitras  argenti. — As  in  the  catarrhal,  so  in  the  catarrho- 
rheumatic  ophthalmia,  the  solution  of  from  4  to  10  grains  of  nitras  argenti 
in  an  ounce  of  distilled  water,  dropped  upon  the  conjunctiva  once  or  twice 
a-day,  relieves  the  feeling  of  sand,  and  speedily  removes  the  other  symptoms 
of  conjunctivitis.  This  application,  however,  has  no  effect  on  the  sclerotic 
part  of  the  disease.  In  this  ophthalmia,  I  should  consider  it  a  very  danger- 
ous mistake  to  trust  almost  solely  to  this  remedy,  as  we  often  do  in  pure  ca- 
tarrhal inflammation  of  the  eye,  and  thus  neglect  the  appropriate  means  for 
reducing  the  attendant  inflammation  of  the  sclerotica. 

12.  Vinuni  opii. — Before  the  catarrhal  part  of  the  disease  is  subdued  by 
the  solution  of  nitrate  of  silver,  vinum  opii  rather  aggravates  the  symptoms. 
After  the  conjunctivitis  and  the  acute  sclerotitis  have  yielded,  it  operates 
favorably,  as  in  the  chronic  stage  of  the  pure  rheumatic  ophthalmia. 

13.  The  collyrium  muriatis  hydrargyri,  1  grain  to  8  ounces,  is  to  be  used, 
tepid,  three  or  four  times  daily,  for  bathing  the  eye. 

14.  The  imguentuni  prcBcipitati  rubri  \%  to  he  ^VAQ?iVQ(\.  oXow'g  the  edges  of 
the  eyelids  at  bedtime.  These  two  remedies  are  employed  as  part  of  the 
treatment  suitable  for  the  conjunctival  part  of  the  disease. 

15.  Paracentesis  cornecB —  Opening  abscess  of  cornea. — Puncturing  the  cor- 


504  SCROFULOUS   SCLEROTITIS. 

uea,  near  its  edge,  so  as  to  evacuate  the  aqueous  humor,  is  likely  to  be  highly 
advantageous,  and  may  be  employed  when  ulcer  of  the  cornea  is  present,  or 
even  when  there  is  an  onyx  ;  but  the  puncture  should  be  made  at  a  distance 
from  the  ulcer  or  abscess,  and  through  a  healthy  part  of  the  cornea. 

As  to  direct  interference  with  an  onyx,  my  own  experience  would  lead  me 
to  recommend  that  no  attempt  be  made  to  evacuate  with  the  lancet,  the  pus 
effused  between  the  lamellaj  of  the  cornea.  The  pus,  being  infiltrated  into 
the  spongy  substance  of  the  part,  will  not  escape,  although  an  incision  be 
made.  In  every  case  in  which  I  have  made  such  an  incision,  partial  or  total 
staphyloma  has  been  the  result.  When  I  have  left  the  onyx  to  itself,  the  case 
has  sometimes  recovered  beyond  my  most  sanguine  expectations.  This  I 
attribute  to  the  natural  tendency  of  the  absorbents  to  remove  deposits  of 
matter  or  lymph,  after  the  inflammation  which  gave  rise  to  them  has  abated, 
aided  by  the  sorbefacient  influence  of  the  calomel  over  the  lymphatic  eS"usion 
into  the  pupil,  which  always  attends  extensive  onyx;  to  the  continued  use  of 
belladonna ;  and  to  the  gradual  preparation  of  the  cornea  by  nature  for  its 
giving  way,  and  for  its  healing  up — a  preparation  which  must  be  entirely 
defeated  when  we  venture  to  open  the  onyx  with  the  knife.  A  very  different 
view  of  this  question  has  been  taken  by  Mr.  Guthrie,  who  advises  the  cornea 
to  be  laid  open  with  a  keen-edged  cataract-knife,  which  being  introduced 
immediately  below  the  edge  of  the  interstitial  abscess,  is  to  divide  the  cornea, 
by  a  vertical  incision  extending  to  a  like  distance  beyond  the  abscess.  The 
internal  opening  in  the  cornea  is  to  be  made  as  large  as  the  external  one, 
thus  allowing  the  aqueous  humor  and  the  matter  of  the  abscess  to  be  suddenly 
discharged,  and  the  iris  to  fall  or  be  pressed  forward  against  the  opening. 
After  this  operation,  the  eye  is  to  be  fomented  frequently  with  warm  water, 
and  to  be  kept  shut  and  padded.  Instead  of  a  total  loss  of  cornea,  Mr. 
G.  states  that  the  result  is  the  formation  of  a  scar  of  limited  extent.^ 


»  Morbid  Anatomy  of  the   Eye ;  Vol.  i.  p.        "^  Medical  Times,  February  24,  1844,  p.  363  ; 
106;  London,  1819.  March  9,  1844,  p.  409. 


SECTION  XVII. — SCROFULOUS  SCLEROTITIS.' 

Si//i. — Sclerotlco-choroicUtis.     Sclerotitis  attenuans.     Cirsophthalmia. 

Fig.  Beck,  Taf.  VII.  Fig.  1.     Demours,  PI.  LXIII.  Fig.  1.     Ammon,  ThI.  I.  Taf.  IV.  Fig.  21. 
Dalrymple,  Pi.  XX.  Figs.  1,  4,  6.     PI.  XXIV. 

That  it  is  of  importance  to  distinguish  the  disease  which  I  am  now  about 
to  describe,  will  appear  evident,  when  we  consider  its  dangerous  nature.  Its 
symptoms,  as  we  shall  immediately  see,  are  very  different  from  those  of  any 
other  ophthalmia ;  and  although  ultimately  the  whole  eye  may  be  involved 
by  inflammation  commencing  iu  the  sclerotica,  yet  this  variety  of  sclerotitis, 
in  the  early  stage,  exists  without  any  signs  which  might  lead  us  to  suspect 
that  a  disease  was  before  us,  likely  to  involve,  as  it  proceeded,  the  choroid 
and  the  iris,  the  cornea  and  the  conjunctiva,  and  in  fact  the  whole  textures  of 
the  eyeball.  I  consider  this  variety  of  sclerotitis  as  completely  a  primary 
and  distinct  disease.  At  the  same  time,  it  must  not  be  overlooked  that  it  is 
apt  to  be  superadded  to  other  ophthalmias,  and  especially  to  scrofulous  cor- 
neitis  and  iritis,  and  to  syphilitic  and  arthritic  iritis.  I  have  seen  it  preceded 
by  aphthous  conjunctivitis. 

The  subjects  of  the  present  disease  are  generally  adults,  and  more  fre- 
quently females  than  males.     If  it  is  not  entirely  a  scrofulous  disease,  those 


SCROFULOUS   SCLEROTITIS, 


505 


of  scrofulous  constitution  are  mucli  more  liable  to  it  than  others.    I  have  very 
rarely  seen  it  in  children. 

Symptoms.  1.  Redness. — One  or  more  of  the  recto-muscular  arteries  are 
enlarged ;  and  running  towards  the  edge  of  the  cornea,  are  seen  to  end  there 
in  a  broad  lash  of  small  vessels.  There  is  scarcely  ever  any  general  redness 
over  the  eyeball,  or  much  inflammation  of  the  conjunctiva.  The  portion  of 
the  sclerotica  subjacent  to  the  enlarged  vessels,  frequently  presents,  in  the 
early  stage  of  the  disease,  a  pinkish  blush,  and  by  and  by  a  thickened  and 
fleshy  appearance.  The  conjunctiva  also  appears  thickened.  It  is  probable 
that,  even  in  this  early  stage,  a  preternatural  adhesion  takes  place  between 
the  sclerotica  and  the  choroid. 

2.  Discoloration  of  the  ivhite  of  the  eye. — If  the  disease  is  checked  before 
any  other  symptoms  manifest  themselves  than  those  already  mentioned,  the 
portion  of  sclerotica  which  was  inflamed,  frequently  continues  to  appear 
thickened,  and  gradually  assumes  an  opaque  white  color ;  but  if  the  disease 
proceeds,  the  exterior  tunics  of  the  eye  become  softened  and  attenuated,  so 
that  the  choroid  shows  its  dark  color  through  the  sclerotica,  which  therefore 
appears  blue  or  purplish.  This  is  one  of  the  most  remarkable  symptoms, 
and  takes  place  in  many  cases  at  a  very  early  period  of  the  disease,  the  blue- 
ness  shining  obscurely  through  the  inflamed  sclerotica  and  conjunctiva.  We 
often  observe  one  part  of  the  sclerotica  thickened  and  loaded  with  enlarged 
vessels,  and  another  part  thinned  so  as  to  allow  the  choroid  to  shine  through. 
The  degree  of  discoloration  is  different,  according  to  the  severity  and  dura- 
tion of  the  attack,  being  at  the  early  stage  merely  perceptible  on  comparing 
the  diseased  with  the  healthy  eye,  or  the  diseased  side  of  the  eye  with  the 
healthy  side,  while  in  advanced  cases  it  amounts  to  a  deep  blue.  About  the 
eighth  of  an  inch  behind  the  edge  of  the  cornea  is  the  most  frequent  situa- 
tion of  the  discoloration,  which  generally  occupies  only  a  portion  of  the  circum- 
ference of  the  eye,  but  it  is  very  apt  to  go  round  the  cornea  completely.  It  is  at 
first  narrow  in  extent,  but  afterwards  becomes  broader,  both  approaching  the 
cornea  anteriorly,  and  stretching  backwards  over  the  sclerotica. 

3.  Sclerotico-choroid  staphyloma. — After  continuing  for  a  time  discolored 
merely,  the  part  affected  protrudes.  The  sclerotica  and  choroid  having  in 
general  become  preternaturally  adherent,  and  being  softened  in  their  texture 
from  the  inflammation  they  have  undergone,  lose  their  supporting  power. 
Atrophied  and  thinned,  they  cannnot  sustain 
the  contents  of  the  eyeball,  but  give  way  and 
become  protruded.  As  the  previous  redness 
and  consequent  thinning  of  the  sclerotica  com- 
monly occupy  only  one  side  of  the  eyeball,  so 
does  the  protrusion  in  question.  The  protru- 
sion is  generally  near  the  cornea,  as  if  the  cor- 
pus ciliare  was  the  seat  of  the  disease,  and  more 
frequently  above,  or  to  the  temporal  side  of 
the  cornea,  than  below  or  to  its  nasal  side. 
In  some  cases,  there  is  only  one  protrusion, 
which  may  enlarge  to  the  size  and  prominence 
of  a  filbert ;  in  others,  a  ring  more  or  less 
complete  (Fig.  66),  or  numerous  tumors,  of 
various  sizes,  closely  surround  the  cornea ; 
while,  in  a  third  set,  the  whole  eye  is  enlarged, 
and  the  sclerotica  attenuated  in  its  entire  cir- 
cumference. Such  tumors,  or  protrusions  of  the  choroid  have  received  the 
names  of  cirsophthalmia,   varicositas   oculi,  hernia,   choroidece,   staphyloma 


Fig.  66. 


506  SCROFULOUS   SCLEROTITIS. 

corporis  ciliaris,  and  staphyloma  scleroticce.    They  generally  present  numerous 
varicose  vessels  ramifying  over  tliera. 

The  front  of  the  eye,  however,  is  not  the  only  seat  of  staphyloma  of  the 
sclerotica  and  choroid.  Scarpa  tells '^  us,  that  he  had  never  met  with  any  tumor 
or  elevation  of  the  sclerotica  on  its  anterior  surface,  resembling  a  staphyloma; 
but  that  he  had  twice  happened  to  meet,  in  the  dead  body,  with  staphyloma 
of  the  posterior  hemisphere  of  the  sclerotica. 

The  first  time  was  in  the  eye  of  a  women  of  40  years  of  age.  The  eye 
was  of  an  oval  figure,  and  upon  the  whole,  more  voluminous  than  the  sound 
eye  on  the  other  side.  On  the  posterior  hemisphere  of  the  diseased  eye,  and 
to  the  external  or  temporal  side  of  the  entrance  of  the  optic  nerve,  the 
sclerotica  was  elevated  in  the  form  of  an  oblong  tumor,  like  a  small  nut.  As 
the  cornea  was  sound  and  pellucid,  and  the  humors  still  preserved  their 
natural  transparency,  on  looking  through  the  pupil,  there  appeared  towards 
the  bottom  of  the  eye,  an  unusual  brightness,  produced  by  the  light  pene- 
trating that  part  of  the  sclerotica,  which  had  become  thin  and  transparent 
where  it  was  occtipied  by  the  staphyloma.  When  the  eye  was  opened,  the 
vitreous  humor  was  found  entirely  disorganized,  and  converted  into  limpid 
water,  and  the  crystalline  lens  somewhat  yellowish,  but  not  opaque.  When 
the  posterior  hemisphere  of  the  eye  was  immersed  in  spirits  of  wine,  with  a 
few  drops  of  nitrous  acid  added  to  it,  in  order  to  give  the  retina  consistence 
and  opacity,  it  was  distinctly  perceived  that  there  was  a  deficiency  of  the 
nervous  expansion  of  the  retina  within  the  cavity  of  the  staphyloma  ;  that 
the  choroid  was  very  thin  at  this  part,  deprived  of  its  natural  color,  and  of 
its  usual  vascular  network ;  and  that  the  sclerotica,  particularly  at  the  apex 
of  the  staphyloma,  was  so  thin  as  scarcely  to  equal  the  thickness  of  writing 
paper.  The  woman  from  whom  this  eye  was  taken,  had  lost  the  faculty  of 
seeing  on  that  side  some  years  before,  during  an  obstinate  ophthalmia,  at- 
tended with  severe  pain  of  the  head. 

Scarpa  had  an  opportunity  of  making  similar  observations  on  an  eye  met 
with  accidentally  by  Monteggia.  It  was  taken  from  a  woman,  35  years  of 
age,  was  of  an  oval  figure,  and  longer  than  its  fellow.  The  staphyloma  was 
situated  exactly  as  in  the  former  instance.  The  vitreous  humor  was  dissolved ; 
the  crystalline  capsule  was  distended  by  a  thin  whitish  fluid;  the  lens  yellow- 
ish, and  less  than  natural ;  the  retina  deficient  within  the  staphyloma  ;  the 
choroid  and  sclerotica,  forming  the  tumor,  thinned,  so  as  to  transmit  the 
light.     Nothing  positive  could  be  ascertained  regarding  this  woman's  sight. 

4.  Effusions  of  aqueous  fluid  within  the  eyeball. — That  the  vessels  of  the 
choroid  are  sometimes  greatly  enlarged  in  this  disease,  does  not  admit  of 
doubt.  At  the  same  time,  the  distension  which  the  choroid  and  sclerotica 
suffer,  is  seldom  owing  to  any  thickening  of  the  former  coat,  or  to  any  vari- 
cose distension  of  its  bloodvessels,  but  is  often  connected  with  an  effusion  of 
watery  fluid  within  the  eyeball.  I  have  already  stated  the  probability  that, 
even  in  the  early  stage  of  the  disease,  a  preternatural  adhesion  takes  place 
between  the  sclerotica  and  choroid.  On  extirpating  staphylomata  of  these 
tunics,  I  have  found  them  firmly  adherent  to  each  other,  and  I  think  it  likely 
that  this  is  generally  the  case.  At  the  same  time,  it  has  been  ascertained  by 
dissection^  that  a  watery  fluid  is  sometimes  present  in  sclerotic  staphyloma 
between  the  sclerotica  and  the  choroid,  whereby  the  latter  tunic  is  pressed 
inwards  and  the  former  outwards.  There  are  also  good  grounds  for  believing 
that  a  similar  effusion  forms  occasionally  between  the  choroid  and  the  retina. 
If  the  fluid  collected  in  the  latter  situation  is  not  evacuated  by  puncturing 
the  staphyloma,  it  may  accumulate  to  such  a  degree  as  to  press  the  retina 
before  it,  and  having  at  last  produced,  by  means  of  its  continued  pressure, 
an  absorption  of  the  vitreous  humor,  it  will  gather  the  retina  into  a  cord,  as 


SCROFULOUS   SCLEROTITIS. 


50t 


sometimes  happens  in  arthritic  and  in  mismanaged  cases  of  syphilitic  oph- 
thalmia. A  third  situation  of  the  hydrophthalmic  effusion  is  between  the  retina 
and  the  hyaloid.  Perhaps  within  the  hyaloid  is  as  frequent  a  seat  of  the 
watery  effusion  as  any  other ;  and  in  this  case  the  structure  of  the  vitreous 
body  is  broken  up  and  dissolved. 

5.  Displacement  of  the  jmpil. — Although  the  iris  is  seldom  affected  with 
inflammation  in  this  disease,  the  pupil,  in  many  of  the  cases  which  I  have 
witnessed,  underwent  a  remarkable  change  of  place.  The  iris  is  always 
narrowed  towards  the  portion  of  the  sclerotica  which  is  affected,  and  in  many 
instances  the  pupil  is  observed  to  have  moved  so  much  out  of  its  natural 
situation,  as  to  be  almost  directly  behind  the  edge  of  the  cornea.  Upwards, 
and  upwards  and  outwards,  are  the  directions  in  which  the  pupil  is  most  fre- 
quently observed  to  become  displaced.  It  occasionally  continues  small  and 
movable,  in  other  cases  it  is  immovable,  but  not  dilated  ;  in  very  severe 
cases  it  is  greatly  enlarged,  the  iris  having  entirely  disappeared  at  that  part  of 
its  circumference  towards  which  the  displacement  of  the  pupil  has  happened. 

The  remarkable  displacement  of  the  pupil  which  attends  scrofulous  sclero- 
titis is  owing  probably  to  some  affection  of  the  ciliary  or  iridal  nerves,  which, 
running  forward  between  the  sclerotica  and  the  choroid,  pass  through  the  or- 
biculus  ciliaris  or  ciliary  muscle,  and  ultimately  reach  the  iris.  Displacement  of 
the  pupil  has  been  remarked  by  Beer,  as  an  attendant  on  syphilitic  iritis. 
That  it  is  not  a  constant  attendant  is  well  known.  I  have  seen  it  in  other 
varieties  of  iritis.  It  has  never  been  attributed  to  any  affection  of  the  choroid, 
nor  has  any  explanation  of  its  cause  been  offered. 

The  pupil  does  not  return  to  its  place,  even  although  the  other  symptoms 
are  subdued. 

"We  sometimes  observe  the  iris,  in  cases  of  scrofulous  sclerotitis,  of  a  slate 
color,  and  bulging  towards  the  cornea,  while  the  pupil  is  more  or  less  filled 
with  lymph,  an  adherent  by  its  margin  to  the  capsule  of  the  lens.  These 
changes  denote  the  previous  existence  of  iritis ;  they  often  become  compli- 
cated with  cataract. 

6.  Opacity  of  the  cornea  is  not  a  necessary,  although  a  frequent  attendant 
on  scrofulous  sclerotitis,  and  may  occur  in  the  first  stage  of  the  disease,  along 
with  the  thickened  and  opaque  state  of  the  sclerotica,  although  generally 
later.  It  is  the  edge  of  the  cornea  nearest  to  the  portion  of  affected  sclero- 
tica, which  becomes  opaque,  so  as  to  resemble  part  of  a  broad  arcus  senilis, 
or  as  if  the  sclerotica  were  intruding  on  the  cornea,  the  rest  of  the  cornea  re- 
maining perfectly  clear.  In  other  cases,  there 
are  pretty  extensive,  but  very  irregular  spots 
of  whiteness,  more  the  effect  apparently  of  in- 
terrupted nutrition  than  of  inflammation.  In 
some  cases,  I  have  observed  the  cornea  smaller 
than  natural,  but  more  frequently,  as  the  disease 
advances,  it  not  only  becomes  almost  quite 
opaque,  but  partaking  in  the  staphylomatous  de- 
generation of  the  neighboring  tunics,  it  even  un- 
dergoes a  degree  of  dilatation,  so  as  to  become 
considerably  broader  and  more  prominent  than 
in  its  natui'al  state,  and  scarcely  distinguishable 
from  the  attenuated  sclerotica.  (Fig.  67.)  In 
this  state  of  the  cornea,  its  epithelium  is  apt  to 
become  thickened,  and  loosened  from  the  ante- 
rior elastic  lamina,  so  as  to  cause  the  feeling 

as  if  a  foreign  body  were  in  the  eye.  From  the  changed  condition  of  the 
cornea  alone,  independently  of  the  interior  changes  of  the  eye,  the  patient's 


Fia:.  67. 


508 


SCROFULOUS   SCLEROTITIS. 


vision  may  be  almost  or  altogether  lost.  Figs.  66  and  67,  represent  the 
eyes  of  a  young  woman,  a  patient  of  the  Glasgow  Eye  Infirmary.  In  the 
right  eye,  the  disease  formed  a  staphyloma  of  the  sclerotica  and  choroid, 
around  the  temporal  half  of  the  cornea;  in  the  left  eye,  the  whole  eye,  includ- 
ing the  cornea,  partook  of  the  staphylomatous  degeneration. 

7.  Exophthalmos  and  exophthalmia. — In  consequence  of  scrofulous  sclero- 
titis, the  eye  may  enlarge  so  much  as  to  protrude  from  the  orbit  to  a  very 
considerable  degree.  After  a  time  the  eye,  in  this  state  of  exophthalmos,  is 
apt  to  suffer  external  inflammation,  from  being  but  imperfectly  protected  by 
the  lids,  from  being  perpetually  fretted  by  the  loose  epithelium  of  the  cornea, 
or  from  cold  or  mechanical  injury.  This  condition  of  the  eye  may  be  alle- 
viated by  its  being  punctured,  either  through  the  cornea,  or  through  the  scle- 
rotica ;  but  if  this  is  neglected,  the  inflammation  may  run  to  a  great  height,  the 
conjunctiva  become  chemosed,  and  puriform  fluid  be  deposited  behind  the  cor- 
nea, or  between  its  lamellas ;  the  eye  may  burst,  assume  a  fungous  appearance, 
bleed  profusely,  and  being  productive  of  great  pain  and  deformity,  although 
entirely  free  from  any  malignant  degeneration,  require  to  be  extirpated. 

8.  Intolerance  of  light  and  epijihora  generally  attend  this  disease,  in  a  con- 
siderable degree. 

9.  Pain. — This  varies  much  in  different  individuals.  When  there  is  as  yet 
no  protrusion,  the  pain  is  generally  moderate ;  but  sometimes  considerable, 
and  supra- oi'bital.  When  the  sclerotica  is  much  distended,  and  especially 
when  this  takes  place  suddenly,  and  is  attended  with  considerable  increase  of 
redness,  the  pain  in  the  eye  becomes  severe,  and  sometimes  furious.  Hemi.- 
crania  is  also  present,  affecting  principally  the  top  of  the  head,  the  high  part 
of  the  temple,  and  the  cheek.  It  is  not  strictly  circumorbital,  nor  is  it  strik- 
ingly nocturnal.  The  patient  complains  of  stupor  and  giddiness  on  stooping 
or  turning  quickly,  and  on  any  sudden  transition  from  light  to  darkness,  or 
from  darkness  to  light. 

10.  Vision  is  variously  affected  in  scrofulous  sclerotitis.  In  some  in- 
stances, the  very  first  symptom  is  dimness  of  sight.  The  patient  generally 
complains  of  photopsia,  of  the  eye  being  dazzled,  and  not  unfrequently  of  iride- 
scent vision.  Hemiopia,  all  objects  to  one  or  other  side  of  a  vertical  line,  or 
above  or  below  a  horizontal  line,  appearing  dim,  all  objects  appearing  con- 
fusedly, and  as  if  double,  even  when  viewed  with  one  eye,  are  symptoms  which 
not  unfrequently  distress  the  patient  long  before  the  redness  or  blueness  of  the 
eye  attracts  attention.  If  the  disease  goes  on,  we  sometimes  find  that  total 
blindness  ensues,  even  when  the  eyeball  appears  but  partially  affected ;  while 
in  other  cases  the  whole  organ  is  evidently  enlarged  and  discolored,  and  yet  a 
considerable  degree  of  vision  is  retained. 

Stages  of  the  disease. — From  the  preceding  account  of  the  symptoms,  the 
reader  will  perceive  that  the  disease  presents  three  stages.  In  the  first,  the 
sclerotica  appears  inflamed,  thickened,  and  opaque  ;  in  the  second,  it  is  thinned 
so  that  the  choroid  shines  through  it ;  in  the  third,  these  tunics  are  protruded, 
and  the  eye  hydrophthalmic. 

Constitutional  symptoms. — I.  Various  degrees  of  febrile  excitement  attend 
scrofulous  sclerotitis.  In  the  early  stage,  before  distension  brings  on  acute 
pain,  the  pulse  is  not  affected ;  after  the  patient  has  suffered  much,  a  cachec- 
tic state  is  apt  to  follow,  with  quick  pulse,  pale  or  sallow  complexion,  exces- 
sive nervous  irritability,  and  great  general  weakness.  The  patient  is  inactive, 
complains  of  coldness  of  the  extremities,  and  evidently  labors  under  a  deficient 
cutaneous  circulation. 

2.  The  digestive  organs  are  frequently  much  deranged,  even  from  the  very 
first.  Want  of  appetite,  frequent  acidity  of  stomach,  costiveness.  flatulence, 
and  foul  tongue,  attend  the  disease  in  many  instances. 


SCROFULOUS   SCLEROTITIS.  509 

Remote  and  exciting  causes. — I  have  been  led  to  ascribe  the  commencement 
of  scrofulous  inflammation  of  the  sclerotica  to  such  causes  as  the  following: — 

1.  Want  of  exercise;  too  much  confinement  within  doors, 

2.  Derangement  of  the  stomach  and  bowels. 

3.  Over-use  of  the  eyes,  in  reading,  sewing,  miniature-painting,  and  other 
minute  works. 

4.  Exposure  to  too  much  heat  and  light,  and  especially  to  the  glare  of  hot 
fires,  and  to  sudden  changes  from  heat  to  cold. 

5.  Penetrating  wounds  and  blows  on  the  eye,  falls  on  the  head,  and  other 
injuries. 

6.  Depressing  affections  of  the  mind ;  and,  in  females,  a  scanty  and  irreg- 
ular state  of  the  menstrual  secretion. 

Prognosis. — Recovery  is  always  slow.  If  the  disease  has  gone  to  any  con- 
siderable length,  it  is  scarcely  ever  completely  removed.  The  vestiges  of  it 
are  in  general  permanent,  even  after  it  has  been  completely  checked  in  its 
progress.  In  many  cases,  we  may  reckon  ourselves  fortunate,  if  we  arrest 
the  disease.  Yet  it  sometimes  happens  that  the  cure  proceeds  to  a  degree 
beyond  our  expectation.  I  attended  a  gentleman  who,  many  years  before, 
had  lost  all  useful  vision  in  the  left  eye  from  this  disease.  The  right  was 
now  attacked.  Both  pupils  were  greatly  displaced  ;  the  visible  arteries  of  the 
right  eye  were  much  dilated,  and  the  sclerotica  at  diiierent  places  consider- 
ably attenuated;  the  left  eye  was  enlarged,  of  a  pretty  deep  blue  color,  and  a 
great  part  of  the  cornea  opaque.  By  bloodletting,  counter-irritation,  and 
other  remedies,  the  disease  was  arrested  in  the  right  eye,  and  very  unexpect- 
edly the  left  eye  recovered  to  such  a  degree,  that  he  was  again  able  to  read 
with  it  an  ordinary  type.  Many  relapses,  in  the  course  of  twenty  years,  ulti- 
mately destroyed  both  eyes. 

Treatment. — 1.  Bloodletting  does  more  good  in  the  early  stage  of  this  dis- 
ease, than  all  other  remedies  put  together.  Yet  we  might  perhaps  not  be 
tempted  to  bleed  at  this  peroid  of  the  disease,  from  the  circumstance  that  in 
many  instances  there  are  no  external  signs  of  intense  inflammation,  and  the 
patient  does  not  suffer  any  acute  pain.  The  practitioner,  therefore,  who  is  not 
acquainted  with  the  nature  and  symptoms  of  this  ophthalmia,  might  be  apt  to 
trifle  away  time  in  the  application  of  a  few  leeches,  when  he  should  be  opening 
the  temporal  artery,  and  removing  a  large  quantity  of  blood.  I  have  known 
the  blueness  and  evident  distension  of  the  sclerotica,  which,  notwithstanding 
leeching  and  other  remedies,  had  continued  unabated  for  many  weeks,  disap- 
pear suddenly  and  completely,  after  the  loss  of  20  or  30  ounces  of  blood  from 
the  temple.  Bleeding  from  the  jugular  vein,  or  from  the  arm,  is  also  highly 
useful.  Twenty-four  or  more  leeches  round  the  eye,  every  second  day,  I  have 
seen  attended  by  the  best  effects. 

In  chronic  cases,  we  must  not  neglect  the  frequent  and  liberal  application 
of  leeches.  In  the  repeated  and  often  severe  attacks  of  pain  which  occur 
in  the  course  of  the  chronic  stage,  if  the  pulse  is  not  affected,  blood  taken 
from  the  arm  is  not  buffy,  and  venesection  does  little  good. 

2.  Purgatives  are  of  essential  service.  The  disordered  state  of  the  biliary 
and  other  digestive  organs,  indicates  the  use  of  calomel  as  a  cholagogue,  fol- 
lowed by  salts  and  senna,  or  some  other  brisk  purgative.  Such  remedies  are 
to  be  repeated  frequently,  during  the  course  of  the  treatment.  In  some  cases 
emmenagogues  are  particularly  indicated. 

3.  Vapor  bath. — Every  means  must  be  adopted  likely  to  equalize  the  cir- 
culation, remove  the  coldness  of  the  feet,  and  bring  on  cutaneous  perspiration. 
One  of  the  most  useful  remedies  for  this  purpose  is  the  vapor  bath,  every 
second  night. 

4.  Mercury. — We  are  naturally  led  to  advise  mercury  in  this  disease,  from 


510  SCROFULOUS   SCLEROTITIS. 

observing  its  happy  effects  in  iritis.  In  some  rare  instances,  it  has  been 
attended  with  evident  advantage.  The  form  in  which  I  have  found  it  most 
useful  is  the  blue  pill  combined  with  aloes.  This  combination  purges  pretty 
smartly  at  first,  but  soon  touches  the  gums.  On  the  whole,  however,  I  must 
confess  that  I  have  seldom  witnessed  any  remarkable  benefit,  either  from 
making  the  mouth  sore,  or  from  small  doses  long  continued.  I  have  used 
this  medicine  both  in  friction  round  the  orbit,  and  in  various  forms  internally ; 
but  it  has,  in  most  cases,  appeared  to  be  of  no  avail. 

5.  Iodide  of  potassium,  as  a  remedy  possessing  great  power  over  the  fibrous 
membranes  is  likely  to  be  of  advantage.  I  have  known  it  prove  highly  bene- 
ficial, both  in  the  first  and  second  stages  of  the  disease. 

6.  Tonics. — After  due  depletion,  I  have  seen  much  benefit  accrue  from  the 
precipitated  carbonate  of  iron,  and  the  sulphate  of  quina.  They  may  be 
given  separately  or  together. 

7.  Arsenious  acid — Arseniate  of  potass. — Under  the  influence  of  these  pre- 
parations, I  have  had  the  satisfaction,  in  a  number  of  instances,  to  observe  the 
varicose  vessels  shrink,  the  discoloration  and  tumor  of  the  sclerotica  and 
choroid  diminish,  and  the  patient's  vision  and  health  improve.  The  dose 
with  which  I  have  generally  commenced,  is  the  32d  part  of  a  grain,  thrice 
a-day,  in  the  form  of  pill. 

8.  Counter-irritation  {?,  decidedly  useful.  A  tartar  emetic  eruption  betwixt 
the  shoulders  is  perhaps  the  most  efiFectual. 

9.  Belladonna,  in  the  form  of  extract,  applied  to  the  eyelids  in  the  usual 
manner,  or  the  sidphate  ofatropia,'m  solution,  dropped  on  the  eye,  is  of  service. 

10.  Paracentesis  oculi. — Puncturing  the  sclerotica  and  choroid,  so  as  to 
evacuate  the  fluid  collected  Avithin  the  eye,  is  a  remedy  of  much  importance 
in  the  treatment  of  this  disease.  It  is  not  to  be  employed  in  the  acute  stage, 
at  least  I  have  not  dared  to  try  it  except  in  chronic  cases,  and  where  there 
was  an  evident  commencement  of  choroid  staphyloma.  The  operation  is  per- 
formed with  the  extraction-knife  or  with  a  broad  cataract  needle,  thrust,  not 
in  the  direction  of  the  lens,  which  it  might  readily  wound  and  render  opaque, 
but  towards  the  centre  of  the  vitreous  humor.  The  instrument  need  not  pene- 
trate deeper  than  the  eighth  of  an  inch.  A  little  blood  is  usually  discharged, 
along  with  aqueous  fluid  of  a  slightly  glutinous  consistence.  The  operation, 
though  sometimes  followed  by  considerable  pain  and  constitutional  disturbance, 
generally  gives  great  relief  to  the  feeling  of  distension  or  pressure  in  the  eye, 
and  to  the  attending  headache.  It  may  be  repeated  every  eight  days,  or  at 
longer  intervals,  according  to  the  state  of  the  eye.* 

When  the  cornea  is  much  dilated,  and  its  epithelium  loose,  it  should  be 
punctured  from  time  to  time,  so  as  to  evacuate  the  aqueous  humor. 

11.  Stimtdants. — Although  local  applications  are  not  of  much  use  in  scro- 
fulous sclerotitis,  I  have  witnessed  good  effects,  in  the  early  stage,  from  the 
employment  of  the  collyrium  of  bichloride  of  mercury,  and  the  solution  of 
nitrate  of  silver. 

12.  Partial  or  total  extirpation  of  the  eye. — Choroid  staphyloma,  from  its 
size  and  prominence,  may  demand  extirpation,  merely  the  tumor  being  re- 
moved and  the  rest  of  the  eye  left.  The  dark  aspect  of  the  tumor  sometimes 
gives  rise  to  a  suspicion,  that  the  anterior  of  the  eye  is  the  seat  of  melanosis 
or  some  other  malignant  growth.  If  the  case  is  one  of  choroid  staphyloma, 
a  puncture  of  the  eye,  by  giving  exit  to  a  large  quantity  of  fluid,  settles  the 
question.  The  whole  eyeball  in  one  case  being  enlarged  and  projecting  from 
the  orbit,  so  much  that  it  could  with  difficulty  be  covered  by  the  lids,  I 
passed  a  ligature  through  it  from  the  temporal  to  the  nasal  side.  There 
immediately  drained  away  a  large  quantity  of  aqueous  fluid,  the  coats  became 
flaccid,  and  I  easily  snipped  off  with  the  scissors  the  anterior  half  of  the  eye. 


CORNEITIS.  511 

Tn  othei'  cases,  I  have  removed  a  lateral  portion,  sometimes  nearly  a  lateral 
half,  of  the  dilated  eyeball.  Total  extirpation  will  seldom  be  necessary  in 
choroid  staphyloma,  however  general  it  may  be,  and  however  much  the  eye 
may  be  protruded. 

•  To  the  disease  which  forms  the  subject  of  Ocehi;  Vol.  ii.  p.   146;  Pavia,  1816.     On  sta- 

this    Section,    I   formerly    (Glasgow    Medical  phyloma  posticum,  consult  Amnion,  Zeitschrift 

Journal  for    February,  1830,  p.    1)     gave   the  fiir  die  Ophthalmologic ;  Vol.  ii.  p.  247 ;  Dres- 

name  of  choroiditis.     In  the  second  edition  of  den,  18.^(2. 

the    present    work,   from    the    prominent   part  =  Amnion,  Op.  cit. ;  Vol.  ii.  p.  252  ;  Vol.  v.  p. 

which  the   sclerotica  takes  in    the    disease,  I  364;   Heidelberg,  1S36. 

changed    the    name    to    sclerotico-choroiditis.  *  Martland,  Edinburgh  Medical  and  Surgical 

Further  consideration  has  led  me   to   transfer  Journal;  Vol.  xxiii.  p.  69;  Edinburgh,  1825  : 

the  name  choroiditis  to  a  different  affection.  Lechla,  Amnion's  Zeitschrift  fiir  die  Ophthal- 

'^  Trattato    delle    principali    Malattie    degli  mologie;  Vol.  ii.  p.  336 ;  Dresden,  1832. 


SECTION  XVIII. — CORNEITIS. 
Syn. — Keratitis. 


Although  the  cornea,  in  its  fully  developed  and  healthy  state,  is  a  non- 
vascular part,  yet  it  suffers  frequently  and  severely  from  inflammation.  Its 
anterior  elastic  lamina  and  epithelium,  its  lamellated  or  proper  tissue,  and  its 
lining  membrane,  are  all  of  them  liable  to  be  affected  by  inflammatory 
changes.  When  any  cause  capable  of  exciting  inflammation  acts  especially 
on  the  cornea,  congestion  takes  place  in  the  surrounding  conjunctiva  and 
sclerotica,  and  in  the  anastomotic  wreath  placed  close  to  the  edge  of  the  cor- 
nea, and  which  is  derived  from  the  bloodvessels  of  those  tunics.  Exudation 
manifests  itself,  at  the  same  time,  in  the  cornea  itself,  affecting  most  frequently 
the  exterior  lamellae,  sometimes  the  proper  substance,  and  occasionally  the 
lining  membrane,  and  always  impairing  the  transparency  of  the  part.  By 
and  by,  bloodvessels  are  developed  in  the  exuded  matter,  and  then  the  cor- 
nea becomes  red.  The  disease  proceeding,  ulterior  changes,  such  as  suppu- 
ration, ulceration,  and  even  gangrene  take  place. 

Injuries,  such  as  those  of  which  we  have  already  spoken  (pp.  251,  391), 
are  a  very  frequent  cause  of  inflammation  of  the  cornea ;  and  the  more  se- 
vere of  them  are  often  followed  by  total  suppuration  and  disorganization  of 
its  structure.  This  result  is  also,  unfortunately,  a  too  common  consequence 
of  the  wound  of  the  cornea,  made  in  extraction  of  the  cataract. 

In  most  of  the  ophthalmife  already  considered,  the  cornea  is  liable  to  suffer 
more  or  less  directly.  In  the  acute  stage  of  the  puro-mucons  ophthalmise, 
the  chief  danger  arises  from  the  cornea  participating  in  the  inflammation,  so 
that  it  becomes  infiltrated  with  pus,  or  destroyed  by  ulceration ;  while,  in  the 
chronic  stage,  the  irritation  caused  by  the  granular  state  of  the  palpebral 
conjunctiva,  produces  a  vascular  and  nebulous  state  of  its  surface.  The  cor- 
nea is  a  common  seat  of  the  phlyctenulag  which  attend  scrofulous  conjuncti- 
vitis ;  and  often  in  this  disease  it  is  penetrated,  layer  after  layer,  by  ulceration. 
In  post-variolous  ophthalmia,  the  formation  of  an  abscess  in  the  cornea  is  one 
of  the  most  remarkable  symptoms,  and  often  leads  to  the  loss  of  visioiij  In 
catarrho-rheumatic  ophthalmia,  as  I  have  explained  in  Section  XVI.,  the 
cornea  is  exceedingly  apt  to  become  ulcerated  on  its  surface,  or  infiltrated 
with  pus.  I  have  also  had  occasion  repeatedly  to  refer,  in  the  preceding 
pages,  to  instances  of  adhesive  inflammation  of  the  lining  membrane  of  the 
cornea.  Various  inflammations,  then,  of  this  part  of  the  eye  have  already 
come  before  us,  which  we  might  arrange  under  the  heads,  external,  paren- 
chjmatous,  and  internal,  according  to  their  seats.     But  the  inflammation  of 


512  SCROFULOUS   CORNEITIS. 

the  cornea  to  whicli  we  have  now  to  attend,  is  specifically  different  from  every 
other  ophthalmia.  It  is  neither  a  puro-mucous,  nor  an  eruptive  affection.  Its 
development  and  progress  are  slow,  occupying  weeks,  months,  or  years. 
The  superficial  layers  appear  to  be  chiefly  aftected  in  this  disease  ;  which, 
however,  may  extend  to  all  the  tissues  of  the  cornea,  and  involve  other  parts 
of  the  eye,  as  the  iris,  the  crystalline  capsule,  the  choroid,  and  even  the  retina. 
According  to  the  majority  of  ophthalraological  authors,  inflammation  of 
the  cornea  is  either  greatly  promoted  by  weakness  of  constitution,  or  occurs 
much  more  frequently  in  scrofulous,  than  in  other  subjects.  "  It  is  most  fre- 
quent in  the  young,"  says  Mr.  Lawrence,^  "and  seldom  seen  after  the  middle 
period  of  life.  It  occurs  in  those  of  unhealthy  constitutions,  especially  the 
strumous;  or  where  the  general  powers  have  been  considerably  reduced." 
"I  do  not  recollect,"  says  Mr.  Tyrrell,^  "to  have  seen  a  single  case,  of  pure 
corneitis,  in  a  subject  possessing  a  proper  degree  of  general  power."  "  It 
must  be  admitted,"  says  Mr.  Walker,^  "that  strumous  subjects  are  most  fre- 
quently attacked  with  the  disease."  Hence,  the  disease,  as  it  occurs  in  young 
subjects,  is  often  designated  as  scrofulous  corneitis.  It  would  be  difficult, 
Indeed,  to  describe  idiopathic  corneitis,  except  only  by  representing  the  symp- 
toms as  being  attended  by  somewhat  less  suffering  from  ])ain  and  intolerance 
of  light,  and  as  running  generally  a  more  acute  course,  than  in  the  scrofulous 
or  common  variety.  We  also  meet  with  cases  of  corneitis  in  old  persons,  in 
whom  the  symptoms  are  either  distinctly  modified  by  the  gouty  diathesis,  or 
present  such  local  appearances  as  vindicate  their  being  distinguished  by  the 
term  arthritic. 

§  1.   Scrofulous  Corneitis. 

Syn. — Keratitis  scrofulosa. 

fw.  Froriep  de  Corneitido  Scrofulosa.     Ammon,  Thl.  I.  Taf.  III.  Fiffp.  1,2,  .3, 18, 19.    Dalrymple, 
PL  XVI.  Fig.  1.     Sichel,  PI.  VI.  Fig.  2.  PI.  VII.  Fig.  5. 

Symptoms. — 1.  The  redness  is  principally  in  the  sclerotica  and  on  the 
surface  of  the  cornea.  The  sclerotic  redness  is  in  general  not  very  consider- 
able, of  a  lake  color ;  the  vessels  very  minute,  and  arranged  in  scattered  radii 
round  the  cornea.  Not  unfrequently  there  is  a  reddish  ring,  seldom  complete, 
often  in  the  shape  of  a  crescent,  somewhat  elevated,  formed  around  or  upon 
the  edge  of  the  cornea,  while  other  red  vessels,  more  or  less  numerous,  are 
prolonged  over  its  surface  to  its  centre.  In  some  cases,  the  whole  cornea  is 
so  much  covered  that  it  assumes  a  red  color,  and  has  been  compared  in  this 
state  to  a  piece  of  red  cloth  ;  a  symptom  which  has  therefore  been  styled 
pannus.  This  is  generally  an  evident  result  of  increased  vascularity  ;  but,  in 
some  cases,  it  bears  a  resemblance  to  an  ecchymosis,  till  it  is  examined  with 
a  magnifying-glass,  when  the  red  patch  is  seen  to  resolve  itself  into  innumer- 
able vessels.  In  chronic  cases,  the  bloodvessels  derived  from  the  recti 
muscles,  and  which  are  visible  during  health,  are  much  dilated,  and  extend 
over  the  cornea. 

2.  The  cornea  is  more  or  less  opaque  and  rough,  its  epithelium,  and  prob- 
ably its  anterior  elastic  lamina,  being  thickened  and  changed  in  texture.  The 
roughness  frequently  resembles  the  dotting  which  might  be  produced  by 
touching  the  surface  of  the  cornea  all  over  with  the  point  of  a  pin ;  in  other 
instances,  the  depressions  are  somewhat  larger.  In  every  case,  we  find  that 
the  surface  of  the  cornea  has  lost  its  natural  polish  ;  and  from  this  circum- 
stance, even  when  no  great  opacity  is  present,  the  eye  appears  dull,  resembling 
a  glass  that  has  been  breathed  upon,  and  vision  is  indistinct.  Dimness  of 
sight  and  slight  opacity  are  the  earliest  symptoms  of  the  disease.  They  are 
often  present  without  any  perceptible  increase  of  vascularity.     In  some  in- 


SCROFULOUS   COKNEITIS.  513 

stances,  the  opacity  amounts  to  haziness  only ;  in  others,  it  consists  of  a 
streaked  or  speckled  whiteness,  arising  from  depositions  of  coagulated  lymph, 
with  interstices  of  clear  coi'nea.  Not  unfrequently  the  surface  becomes  com- 
pletely and  almost  uniformly  white,  one  patch  of  opaque  deposition  taking 
place  after  another,  or  the  opacity  creeping  slowly  from  one  or  other  edge  of 
the  cornea  over  to  the  opposite  edge,  and  thus  affecting  its  whole  extent. 
As  the  disease  subsides,  the  cornea  often  presents  a  greenish  hue.  Here  and 
there  we  occasionally  observe  upon  it  elevated  points  of  a  yellowish  color, 
which  rarely  suppurate  or  ulcerate.  I  have  sometimes  seen  deep  ulceration 
in  corneitis.  This  was!  the  case  in  a  lad  who  became  violently  affected  with 
the  disease  while  at  sea,  and  in  whom  the  whole  cornea  was  red,  of  a  conical 
form,  and  presented  at  its  centre  a  white  and  sloughy  ulcer. 

Although  it  is  generally  the  superficial  lamiua3  which  are  affected  with 
haziness  or  opacity,  we  sometimes  see  the  inner  lamina  opaque,  while  the 
surface  is  pretty  clear.  I  do  not  mean  that  the  internal  elastic  lamina,  or 
membrane  of  Descemet,  is  spotted  with  minute  opacities,  as  in  aquo-capsuli- 
tis ;  but  that  apparently  between  that  membrane  and  the  proper  substance  of 
the  cornea,  there  is  a  pretty  extensive  and  irregular  opaque  deposition.  We 
sometimes  see  this  appearance  in  the  one  eye,  while  the  other  presents  an  affec- 
tion chiefly  of  the  superficial  laminae.  Although  the  external  surface  clears, 
such  deep-seated  opacities  scarcely  ever  disappear. 

3.  In  most  cases  of  scrofulous  corneitis  which  have  lasted  a  considerable 
time,  we  find  the  cornea  more  convex  than  natural,  and  the  aqueous  humor 
superabundant ;  or  in  other  words,  there  is  a  degree  of  hydropthalmia.  In 
some  instances,  the  cornea  becomes  somewhat  conical ;  and  we  often  observe 
the  whole  eyeball  to  partake  in  the  conical  form,  along  with  an  attenuation 
of  the  anterior  part  of  the  sclerotica,  so  that  the  choroid  shines  through  of  a 
blue  color,  an  approach  to  staphyloma  of  the  corpus  ciliare.  Common  staphy- 
loma of  the  cornea  and  iris  rarely,  if  ever,  results  from  corneitis.  The  cor- 
nea, from  its  conical  form  and  its  great  opacity,  sometimes  bears  a  resemblance 
to  such  a  staphyloma ;  but  as  the  symptoms  subside,  the  iris  is  seen  to  be 
unconnected  with  the  cornea. 

Not  unfrequently  we  meet  with  the  cornea  of  a  blunt  conical  form,  the 
centre  presenting  a  white  spot,  while  the  rest  of  its  extent  is  quite  red,  or  in 
the  state  of  pannus.  As  the  disease  proceeds,  the  white  spot  ulcerates,  and 
then  the  pannus  begins  to  clear ;  the  iris  and  the  pupil  come  gradually  into 
view,  and  a  cure  more  or  less  perfect,  is  accomplished.  In  such  cases,  it 
generally  happens  that,  till  the  central  opaque  spot  ulcerates,  no  improve- 
ment is  effected.  Such  cases  are  apt  to  leave  the  cornea  considerably  reduced 
in  size,  or  in  other  words,  partially  atrophied. 

Proper  conical  cornea  sometimes,  but  very  rarely,  results  from  corneitis, 
the  conical  form  being  assumed  as  the  nebulousness  subsides. 

4.  Dilatation  of  the  pupil  not  unfrequently  attends  corneitis,  and  in  many 
cases,  there  is  reason  to  suspect  a  tendency  to  amaurosis.  But  in  other 
instances,  the  inflammation  extends  from  the  cornea  to  the  iris ;  and  when 
this  is  the  case,  the  pupil  becomes  contracted,  and  may  even,  from  effusion 
of  coagulable  lymph,  adhere  to  the  capsule  of  the  lens.  In  many  cases  of 
corneitis,  it  is  difficult  to  recognize  the  state  of  the  iris  and  pupil,  through 
the  hazy  or  speckled  cornea.  Considerable  assistance  will  be  derived,  under 
such  circumstances,  from  concentrating  the  light  upon  the  surface  of  the 
cornea,  by  means  of  a  double  convex  lens,  and  by  observing  the  effect  pro- 
duced by  the  application  of  extract  of  belladonna  to  the  surface  of  the  eye- 
lids, or  the  instillation  of  a  solution  of  sulphate  of  atropia. 

5.  There  is  not,  in  general,  any  great  degree  of  intolerance  of  light  in  this 
disease ;  scrofulous  corneitis  presenting  in  this  respect  a  striking  contrast  to 

33 


514  SCROFULOUS   CORNEITIS, 

phlyctenular  conjunctivitis.  This  symptom,  however,  is  variable;  for  in  some 
cases,  especially  those  attended  with  pannus,  the  patient  cannot  bear  the  light, 
and  there  is  considerable  epiphora. 

6.  In  general,  there  is  little  or  no  pain,  except  perhaps  in  the  commence- 
ment of  the  complaint.  It  sometimes  happens,  however,  that  very  acute  pain 
is  experienced  in  the  eyeball,  coming  on  in  paroxysms ;  this  may  be  the  case, 
although  there  is  no  inflammation  of  the  iris  present.  After  a  time,  the  eye 
falls  into  a  chronic  indolent  state  of  inflammation,  unattended  by  pain,  espe- 
cially after  the  whole  cornea  has  become  opaque. 

T.  The  pulse  is  quickened,  the  patient  is  restless  in  the  night,  and  the  skin 
is  commonly  harsh  and  dry.     The  extremities  are  often  habitually  cold. 

8.  The  subjects  of  scrofulous  corneitis  are,  in  general,  from  8  to  18  years 
of  age;  and  in  the  female  the  complaint  frequently  appears  in  connection  with 
amenorrhoea.  In  the  female  as  well  as  in  the  male,  the  skin  of  those  affected 
with  corneitis  is  often  coarse  and  flabby,  with  the  sebaceous  follicles  of  the 
face  much  developed,  and  I  have,  in  many  instances,  observed  it  coincident 
with  deafness  and  a  peculiar  hoarseness  of  voice.  In  more  than  one  case  I 
have  witnessed  this  disease  along  with  total  deafness.  In  one  of  them  the 
deafness  occurred  a  week  or  two  before  the  corneitis.  Other  scrofulous  symp- 
toms are  generally  present,  especially  swollen  lymphatic  glands  under  the  jaw ; 
not  unfrequently  nodes  on  the  tibiae,  sometimes  effusion  into  the  bursa  under 
the  tendon  of  the  extensores  cruris. 

Causes. — The  occasional  causes  of  scrofulous  corneitis  are  often  obscure. 
I  have  known  it  arise  from  exposure  during  the  night  to  the  glare  of  flambeaux, 
from  over  exertion  of  the  eyes,  and  from  want  of  sleep.  Slight  injuries,  such 
as  the  intrusion  of  a  gnat  into  the  eye,  may  produce  it.  In  many  cases  it  is 
attributable  to  exposure  to  cold  and  wet. 

As  it  is  well  known  that  division  of  the  fifth  nerve  in  brutes  produces  in- 
flammation, opacity,  and  ulceration  of  the  cornea,  it  becomes  a  question  how 
far  corneitis  in  the  human  subject  may  not  occasionally  depend  on  some  mor- 
bid affection  of  that  nerve.  The  experiment  shows  how  inflammation  may 
be  brought  on  by  suspending  the  nervous  influence  communicated  to  a  part. 

In  one  case,  which  came  under  my  care,  in  which  the  pain  was  excessively 
severe,  the  patient  recovered  perfectly  from  the  corneitis,  but  died  not  long 
after,  from  disease  in  the  head.  Scrofulous  tubercles  were  found  at  the  basis 
of  the  brain,  pressing  on  one  of  the  optic  nerves. 

Prognosis. — Corneitis,  even  in  its  mildest  form,  is  always  tedious,  and  in 
its  consequences  generally  dangerous  to  vision.  The  amount  of  recovery 
however,  in  consequence  of  the  gradual  absoi'ption  of  opaque  depositions,  is 
often  wonderful,  even  when  little  or  nothing  was  expected.  In  this  way  vision 
may  be  perfectly  regained.  On  the  other  hand,  it  is  often  permanently  de- 
teriorated, being  rendered  myopic  by  change  of  figure  in  the  cornea,  limited 
by  indelible  opacities,  and  affected  by  the  deeper-seated  changes  owing  to 
implication  of  the  iris,  the  capsule  of  the  lens,  or  the  retina.  The  prognosis 
must  always  depend,  in  a  great  measure,  on  the  prospect  we  have  of  improving 
the  general  strength  of  the  patient.  It  is  proper,  in  every  case,  to  state  that 
amendment  will  be  slow. 

General  treatment. — 1.  Depletion  may,  perhaps,  appear  to  be  but  seldom 
indicated,  at  least  by  any  urgency  of  pain,  or  signs  of  active  inflammation. 
Yet  we  find  considerable  advantage  from  the  application  of  leeches  in  the 
neighborhood  of  the  eye,  especially  if  they  are  had  recourse  to  early  in  the 
disease.  When  the  inflammation  affects  the  proper  substance  of  the  cornea, 
and  not  merely  its  superficial  laminae,  and  the  patient  complains  of  pain  or 
tension  of  the  eye  or  across  the  forehead,  leeches  are  necessary.  If  there  are 
violent  paroxysms  of  pain,  venesection  must  be  employed.     Local  bleeding 


SCROFULOUS   CORNEITIS.  515 

ought  to  be  repeated  from  time  to  time ;  but  not  so  frequently  as  to  reduce 
much  the  general  strength. 

2.  Emetics  and  purgatives  are  also  useful.  They  are  to  be  employed  ac- 
cording to  the  directions  laid  down  at  page  483. 

3.  Tartar  emetic,  as  a  sedative  and  alterative,  I  have  found  decidedly  advan- 
tageous, both  by  itself  in  doses  of  from  the  12th  to  the  4th  of  a  grain  thrice 
a-day,  and  along  with  Peruvian  bark,  or  sulphate  of  quina.  This  combina- 
tion is  no  doubt  unchemical;  but  I  have  certainly  derived  more  benefit  from 
these  two  medicines  given  together,  than  from  either  of  them  singly. 

4.  Diaphoretics  are  indicated  by  the  dry  and  harsh  state  of  the  skin.  Tartar 
emetic  will  operate  favorably  on  the  skin,  and  may  be  assisted  by  the  warm 
pediluvium,  and  Dover's  powder  at  bedtime. 

5.  Mercury,  carried  to  such  a  length  as  to  touch  the  gums,  is  of  great  ser- 
vice in  the  treatment  of  this  disease.  When  there  are  severe  paroxysms  of 
pain,  mercury  should  be  promptly  administered ;  else  the  pupil  may  contract 
morbid  adhesions;  but  in  general,  this  remedy  is  not  to  be  commenced  till  the 
acute  symptoms  have  been  removed  by  depletion  of  different  kinds,  and  the 
employment  of  tartar  emetic  in  small  doses.  When  the  mercury  begins  to 
act  decidedly  on  the  constitution,  we  generally  find  that  the  enlarged  vessels 
on  the  cornea  contract,  and  the  newly  deposited  matter  becomes  absorbed. 
The  clearing  of  the  cornea  commences  around  its  circumference,  the  favorable 
change  slowly  advancing  towards  the  centre.  The  best  form  in  which  to  ad- 
minister mercury  in  this,  as  in  some  of  the  former  ophthalmise,  is  calomel  with 
opium.  Mercury  is  peculiarly  necessary  in  those  cases  which  are  attended 
with  iritis,  and  in  them  ought  to  be  employed  from  the  first. 

6.  Sulphate  of  quina  exei'cises  an  influence  over  scrofulous  corneitis, 
slower  of  manifestation,  but  in  the  end  not  less  beneficial,  than  that  which 
the  same  medicine  displays  in  phlyctenular  ophthalmia.  I  have  treated  many 
cases  with  this  remedy  alone.  Violent  cases,  however,  will  not  yield  to  it, 
but  require  depletion,  and  mercury.  A  combination  of  sulphate  of  quina 
with  a  purgative,  such  as  the  compound  colocynth  pill,  often  proves  highly 
useful.  When  we  find  the  patient,  on  our  being  called  in,  affected  with  great 
debility,  flabbiness  of  the  skin,  and  night-sweats,  it  may  be  proper  to  put  him 
on  sulphate  of  quina  from  the  first.  I  have  treated  many  cases  with  a  mix- 
ture of  calomel  and  sulphate  of  quina. 

T.  Turpentine,  in  doses  of  from  half  a  drachm  to  a  drachm  thrice  daily, 
has  been  found  to  be  beneficial.* 

8.  Vegetable  alteratives  and  tonics,  as  colchicum,  sarsaparilla,  elm  bark, 
and  bebeerine,  are  useful  remedies  in  scrofulous  corneitis,  although  inferior 
to  cinchona  and  sulphate  of  quina.  I  have  witnessed  excellent  effects  from 
frequent  small  doses  of  columba,  rhubarb,  and  supercarbonate  of  soda,  in 
this  disease.  Aconite,  and  belladonna,  given  internally,  prove  useful,  espe- 
cially when  there  is  much  pain,  intolerance  of  light,  and  epiphora. 

9.  Cod  liver  oil,  and  preparations  containing  iodine,  and  especially  the 
iodide  of  potassium,  may  be  given  with  advantage,  when,  from  debility  or 
other  causes,  we  deem  it  prudent  to  refrain  from  the  exhibition  of  mercury. 

10.  Muriate  ofbarytes  is  strongly  recommended  by  Amraon.  Arsenic  has 
sometimes  been  employed.  Whatever  remedy  is  selected,  it  must  not  be  soon 
abandoned,  although  slow  in  manifesting  beneficial  effects.  Many  cases  are 
under  treatment  for  a  whole  year,  or  even  longer,  before  they  perfectly 
recover. 

11.  The  cure  is  greatly  promoted  by  good  nourishment,  warm  clothing, 
pure  air,  and  regular  exercise. 

Local  means  of  cure. — 1.  Warm  fomentations  with  poppy  decoction,  or 
with  a  warm  infusion  of  belladonna  leaves  or  extract,  and  exposing  the  eyes 


516  ARTHRITIC   CORNETTIS. 

to  the  vapor  of  hot  water  and  laudanum,  give  great  relief  in  those  cases  in 
which  the  presence  of  light  proves  irritating. 

2.  Collyria,  such  as  have  already  (p.  488)  been  recommended  for  phlyc- 
tenular ophthalmia,  are  to  be  employed  also  in  corneitis,  and  especially  the 
collyriura  of  the  bichloride  of  mercury  with  belladonna. 

3.  Blisters  and  issues  on  the  neck,  behind  the  ear,  and  on  the  temple,  are 
useful  and  generally  necessary.  A  tartar  emetic  eruption  is  often  of  great 
service. 

4.  Hydrocyanic  acid,  applied  in  the  form  of  vapor,  proves  decidedly 
useful,  when  the  acute  stage  is  over ;  its  influence  evidently  lessening  the 
redness  and  clearing  the  cornea.  Immediately  after  the  eye  is  exposed  for  a 
few  minutes  to  the  vapor,  it  is  advantageous  to  drop  upon  the  eye,  the 
solution  of  nitrate  of  silver  of  the  strength  of  from  four  to  ten  grains  to  the 
ounce  of  distilled  water,  and  to  paint  the  eyelids  with  the  extract  of  bella- 
donna.    I  have  known  these  three  remedies  to  act  very  beneficially  together. 

5.  Stimulants. — I  have  tried  many  different  remedies  of  this  class.  They 
are  admissible,  only  after  the  symptoms  of  acute  inflammation  have  been  sub- 
dued, and  the  disease  has  fallen  into  the  indolent  stage.  On  the  whole,  most 
advantage  appears  to  be  derived  from  vinum  opii,  used  once  a-day.  Next  to 
vinum  opii,  I  would  place  strong  red  precipitate  salve.  About  the  bulk  of  a 
split  pea  is  to  be  introduced  daily  between  the  lids  and  the  eyeball,  and  then 
carefully  rubbed  upon  the  surface  of  the  cornea  through  the  medium  of  the 
upper  lid.  From  half  a  drachm  to  a  drachm  of  red  precipitate,  triturated 
along  with  an  ounce  of  white  sugar  into  an  impalpable  powder,  and  a  small 
quantity  blown  into  the  eye  through  a  quill,  is  another  mode  of  applying  the 
same  substance.  The  lunar  caustic  solution,  applied  in  the  usual  way,  and  a 
solution  of  4  grains  of  sulphate  of  zinc  in  an  ounce  of  water,  injected  over 
the  surface  of  the  eye,  are  attended  with  good  etfects.  Very  evident  advant- 
age is  sometimes  derived  from  employing,  in  the  course  of  the  24  hours,  more 
than  one  of  these  stimulants ;  for  example,  vinum  opii  in  the  morning,  and 
red  precipitate  salve  at  bedtime. 

6.  Belladonna  extract  is  to  be  painted  on  the  eyebrow  and  eyelids,  or  a 
solution  of  sulphate  of  atropia  dropped  upon  the  eye,  every  evening,  for 
dilating  the  pupil,  when  there  are  either  evident  symptoms,  or  even  only  a 
suspicion,  of  inflammation  of  the  iris. 

7.  Evacuation  of  the  aqueous  humor  appears  to  be  indicated  in  those  cases 
in  which  there  exists  a  tendency  to  hydrophthalmia.  Jtingken  recommends 
it  highly.^ 

§  2.  Arthritic  Corneitis. 

Syn. — Keratitis  arthritica. 

In  elderly  people,  and  especially  in  subjects  who  have  suffered  from  gout, 
we  occasionally  meet  with  corneitis,  characterized,  in  addition  to  the  usual 
roughness,  and  haziness  of  the  cornea,  by  varicose  dilatation  of  the  blood- 
vessels on  the  surface  of  the  eye,  and  the  presence  of  a  bluish-white  ring 
close  to  the  edge  of  the  cornea.  Opaque  spots,  of  greater  or  less  extent, 
are  seen  in  the  cornea;  the  iris  is  not  affected,  or  only  very  partially  so,  there 
being  perhaps  a  single  tag  of  adhesion  between  the  edge  of  the  pupil  and  the 
capsule  of  the  lens.  A  loose  fold  of  thickened  conjunctiva  not  unfrequently 
forms  at  the  edge  of  the  cornea,  and  keeps  the  eye  in  a  state  of  irritation ; 
and  sometimes  a  portion  of  the  epithelium  of  the  cornea  in  a  thickened  state, 
becomes  loose,  as  if  separated  from  the  anterior  elastic  lamina  by  the  inter- 
vention of  a  watery  fluid.  There  is  much  lachrymation,  and  often  neuralgic 
pains  round  the  orbit.     Vision  is  much  impaired. 


\ 


IRITIS  IN  GENERAL.  511 

The  same  causes  excite  this  corneitis  as  that  last  described.  A  slight 
scratch  of  the  cornea  I  have  known  to  excite  it  in  a  highly  gouty  subject. 
In  a  lady  whom  I  had  operated  on  successfully  for  cataract  by  extraction, 
this  kind  of  corneitis  occurred,  sixteen  years  after  the  operation,  and  was 
attended  by  the  peculiar  detachment  of  the  corneal  epithelium  which  I  have 
mentioned. 

Moderate  depletion,  and  the  exhibition  of  warm  purgatives,  followed  by 
sulphate  of  quina,  I  have  found  the  best  general  treatment.  Belladonna,  given 
internally,  lessens  greatly  the  lachryraation.  Warm  fomentations  to  the  eye, 
and  the  external  use  of  belladonna,  are  proper.  The  thickened  fold  of  con- 
junctiva at  the  edge  of  the  cornea  should  be  excised. 


1  Treatise  on  Diseases  of  the  Eye,  p.  347;        *  Oculist's   Vade-mecum,   p.    112;    London, 
London,  1841.  1843. 

'^  Practical  Work  on  the  Diseases  of  the  Eye;        '  Obre,  Lancet,  April  30,  1842,  p.  150. 
Vol.  1.  p.  217;  London,  1840.  '  Ammon's  Zeitsclirift  fiir  die  Ophthalmolo- 

gie ;  Vol.  ii.  p.  154 ;  Dresden,  1832. 


SECTION  XIX. — IRITIS  IN  GENERAL. 

gyn^ — Iriditis,  Oood.     Uveitis,  Simeons.     Inflammation  of  the  eyeball,  Jacob. 

Fi-g.  Wardrop,  PL  VIIL  Figs.  2,  3.     Aramon,  Thl.  I.  Taf.  XIV.  Figs.  8—11,  13,  14,  17—21, 
23.     Ammon  de  Iritide.     Dalrymple,  PI.  XIX.  Figs.  1—3,  5.     Sichel,  PL  X.  Figs.  1—3. 

It  is  remarkable  that,  although  the  effects  of  inflammation  of  the  iris  were 
observed  by  Hippocrates,  for  the  expressions  which  on  one  occasion*  he  ap- 
plies to  the  pupil,  can  refer  only  to  that  opening  when  filled  with  lymph, 
contracted  and  irregular  from  adhesions,  and  although  these  and  other  symp- 
toms of  the  disease  must  have  been  noticed  by  all  succeeding  observers,  we 
owe  the  first  distinct  description  of  iritis  to  a  German  surgeon  of  the  present 
century.®  From  the  fact  that  the  iris  is  nourished  in  a  great  measure  by  two 
arteries,  completely  distinct  from  those  which  belong  to  the  other  textures  of 
the  eye,  we  may  readily  conceive  how  iritis  may  exist  as  independently  of 
inflammation  in  the  other  membranes  of  this  organ,  as  does  conjunctivitis, 
sclerotitis,  or  corneitis.  From  the  two  arteries  in  question,  and  from  other 
sources,  the  iris  is  supplied  with  a  quantity  of  red  blood  large  in  proportion 
to  its  size ;  it  can  scarcely  be  doubted  that  it  is  also  supplied  with  nerves 
both  of  the  motive  and  sensitive  class  ;  hence  its  great  liability  to  inflamma- 
tion. One  chief  danger  to  be  dreaded  from  iritis  arises  from  the  fact,  that 
the  inflammation  to  which  the  iris  is  generally  subject,  is  of  the  adhesive  kind, 
so  that  in  the  course  of  a  neglected  or  misunderstood  attack,  the  pupil  may 
become  obliterated  by  an  eS"usion  of  coagulable  lymph.  There  always  attends 
upon  iritis,  a  degree  of  retinitis ;  and  this  constitutes  another  not  less  dan- 
gerous part  of  the  disease.^  Besides  this,  there  is  always  present  some  scle- 
rotic and  conjunctival  inflammation;  the  anterior  hemisphere  of  the  crystalline 
capsule  is,  in  every  case,  more  or  less  affected ;  and  often  the  inflammatory 
action  involves  the  choroid.  Yet  the  iris  is  plainly  the  focus  of  the  diseased 
action,  and  the  seat  of  the  most  striking  morbid  changes.  It  is  at  the  pupil- 
lary edge  of  the  iris  that  the  disease  generally  appears  to  commence,  whence 
it  spreads  to  the  rest  of  the  iris,  to  the  capsule  of  the  lens,  and  to  the  choroid 
and  retina,  while  the  sclerotic  and  conjunctival  inflammation  which  attends  it, 
appears  to  be  sympathetic.  That  the  iris  is  often  the  only  part  which  has 
permanently  suffered,  is  inferred  from  the  fact,  that  the  formation  of  an  arti- 
ficial pupil  is  sometimes  found  to  restore  vision,  in  cases  where  iritis  has 


518 


IRITIS   IN   GENERAL. 


obliterated  the  natural  pupil,  plainly  showing  that  the  choroid  and  retina  have 
not  been  seriously  involved. 

Symptoms. — There  are  certain  symptoms  which  characterize  inflammation 
of  the  iris,  from  whatever  cause  it  proceeds. 

1.  Zonular  sclerotitis  ;  fine  hair-like  vessels,  running  in  radii  towards  the 
edge  of  the  cornea.     (Fig.  62,  p.  433.) 

2.  Discoloration  of  the  iris ;  so  that,  if  naturally  blue,  it  becomes  green- 
ish ;  if  dark-colored,  reddish  ;  the  result  of  inci'eased  vascularity,  and  sub- 
sequently of  effusion  of  lymph  into  its  substance,  or  on  its  posterior  surface.* 

3.  Contraction,  irregularity,  and  immobility  of  the  pupil. 

4.  Effusion  of  coagulable  lymph  into  the  pupil  and  posterior  chamber,  and 
occasionally  into  the  anterior. 

5.  Adhesions  of  the  iris,  especially  of  its  pupillary  edge,  to  the  capsule  of 
the  lens ;  in  some  rare  cases,  to  the  cornea. 

6.  Tubercles,  pustules,  or  abscesses  of  the  iris. 

7.  Opacity  of  the  lens,  or  of  its  capsule. 

8.  Dimness  of  sight,  and  sometimes  total  blindness. 

9.  Pain  in  the  eye,  and  nocturnal  circumorbital  pain. 

In  every  case  a  sufficient  number  of  these  symptoms  will  be  met  with,  to 
enable  the  observer  to  decide  that  the  disease  before  him  is  iritis.  All  of 
them  are  by  no  means  invariably  present.  We  sometimes  find,  for  instance, 
a  dilated  pupil  in  iritis,  probably  from  the  co-existence  of  amaurosis ;  and  in 
some  otherwise  well  marked  cases,  there  is  not  the  slightest  pain  in  the  eye 
or  head.  Iritis  may  also  exist  in  a  very  marked  manner,  without  any  effusion 
of  lymph,  morbid  adhesions,  or  tubercles  of  the  iris,  these  being  part  of  the 
changes  which  take  place  only  in  the  second  stage  of  the  disease,  and  even 
then  not  in  every  case. 

Different  seats  of  the  disease. — When  inflammation  affects  principally  the 
covering  prolonged  over  the  front  of  the  iris  from  the  cornea,  the  disease  is 
styled  iritis  serosa ;  when  the  proper  substance  of  the  iris  is  aftected,  it  is 
called  iritis  parenchymatosa  ;  when  the  posterior  surface  seems  chiefly  involved 
the  term  uveitis  has  been  employed.^ 

Causes. — Inflammation  of  the  iris  arises  from  various  causes.  Those  best 
ascertained  are  the  following  : — 

1.  Sudden  transitions  from  heat  to  cold,  exposure  to  cold  draughts,  overuse 
of  the  eyes  on  minute  objects,  especially  by  artificial  light,  and  various  other 
influences,  give  rise  to  idiopathic  or  rheumatic  iritis. 

2.  Constitutional  syphilis,  and  syphiloid  diseases. 

3.  Gonorrhoea,  followed  by  synovitis,  operating  through  the  constitution. 

4.  Scrofulous  inflammation  of  the  iris  occurs  along  with  corneitis,  as  a 
secondary  disease;  while  in  some  less  frequent  cases,  we  meet  with  a  scrofulous 
iritis  which  may  be  regarded  as  primary. 

5.  There  is  a  very  peculiar  iritis  called  arthritic  by  the  Germans,  who 
regard  it  as  depending  on  gout.  It  seems  frequently,  if  not  always,  connected 
with  the  diseased  state  of  the  body,  produced  by  the  long-continued  opera- 
tion of  poisonous  substances,  especially  alcohol  and  tobacco,  on  the  assimilat- 
ing and  nervous  systems. 

6.  Injuries.  Such  wounds,  for  example,  as  are  inflicted  in  the  different 
operations  for  cataract. 

I  exclude  from  the  above  enumeration,  those  instances  of  iritis  which,  like 
that  which  follows  scrofulous  corneitis,  are  extensions  of  inflammation  from 
some  of  the  other  textures  of  the  eye  to  the  iris ;  such  as  that  which  occurs 
sympathetically,  in  consequence  of  injm'ies  of  the  cornea  and  iris  of  the  op- 
posite eye,  and  that  which  follows  remittent  fever.  In  both  tliese  cases,  I 
believe  the  original  disease  to  be  inflammation  of  the  retina,  not  of  the  iris. 


IRITIS   IN   GENERAL.  519 

Stages. — Iritis  has  been  considered^  as  presenting  three  stages.  The  first 
stage  is  characterized  by  increased  vascularity  of  the  sclerotica,  discoloration 
of  the  iris,  haziness  and  inactivity  of  the  pupil,  dimness  of  sight,  and  pain  in 
and  round  the  eye.  In  the  second  stage,  we  have  effusion  of  lymph  into  the 
pupil,  abscesses  of  the  iris,  contraction  of  the  pupil,  adhesions  of  the  iris  to 
the  crystalline  capsule,  increase  of  pain,  and  greater  defect  of  sight.  The 
tldrd  stage  presents  red  vessels  ramifying  on  the  iris  and  in  the  pupil,  the 
pupil  closed,  the  lens  and  its  capsule  opaque,  the  retina  insensible,  the  eye- 
ball changed  in  shape,  being  flattened  under  the  recti,  the  choroid  protruding 
through  the  attenuated  sclerotica,  and  the  eye  boggy  to  the  touch. 

Degrees  and  forms  of  the  disease — Prognosis. — The  course  of  iritis  presents 
not  only  different  stages,  but  the  disease  is  met  with  of  very  different  degrees 
of  severity.^  In  slight  and  recent  cases,  complete  restoration  may  be  pro- 
mised ;  in  more  serious  cases,  the  recovery  which  can  take  place  is  only  par- 
tial ;  in  severe  and  neglected  cases,  it  is  but  too  often  evident  that  no  hope 
can  be  held  out  of  our  being  able  to  restore  vision,  or  even  to  save  the  form 
of  the  eye. 

The  distinction  of  acute  and  chronic  iritis  is  of  considerable  importance.^ 

The  disease  occurs  in  an  acute  form,  in  robust  individuals  of  full  habit, 
where  a  powerful  cause  has  acted  on  the  organ,  and  more  especially  if  the 
case  has  been  neglected  at  the  commencement,  or  the  cause  has  continued  to 
act.  With  bright  external  redness,  great  distension  of  vessels,  rapid  and  ge- 
neral change  of  color  in  the  iris,  contraction  of  the  pupil,  effusion  of  lymph, 
dulness  of  the  cornea,  loss  of  sight,  agonizing  pain  of  the  eye,  and  severe 
headache,  there  is  considerable  fever,  with  restlessness  and  want  of  sleep.  In 
a  few  days  vision  is  irreparably  lost. 

On  the  other  hand,  iritis  may  arise  so  imperceptibly,  and  proceed  so  slowly 
to  effusion  of  lymph,  and  to  diminution  or  even  loss  of  sight,  that  no  pain  is 
felt  in  the  part,  and  scarcely  any  redness  takes  place.  No  alteration  is  ob- 
served by  others,  and  sometimes  not  even  by  the  patient,  who  has  been  known 
to  discover  the  disease  accidentally  on  shutting  the  sound  eye,  and  finding  the 
vision  of  the  other  gone. 

Inflammation  more  readily  extends  from  the  iris  to  the  rest  of  the  organ  in 
acute  cases,  yet  this  extension  may  occur  when  the  disease  is  chronic.  The 
prognosis  must  be  drawn  from  a  combined  consideration  of  the  time  the  affec- 
tion has  lasted,  the  cause  upon  which  it  depends,  and  the  visible  effects  al- 
ready produced.  Irreparable  injury  to  the  organ  may  occur  in  a  few  days, 
when  the  inflammation  is  acute.  A  fortnight,  three  weeks,  or  a  month, 
may  elapse,  when  it  is  of  ordinary  severity,  without  any  serious  mischief; 
while  a  still  longer  duration  does  not  preclude  the  expectation  of  recovery,  in 
the  more  chronic  form  of  the  complaint. 

SequelcE. — Among  the  most  striking  effects  of  iritis,  are  the  changes  which 
the  pupil  undergoes,  and  which  are  often  of  a  permanent  kind.  Adhesion  of 
the  pupil  to  the  cornea  {synechia  anterior)  is  amongst  the  rarest  results  of 
the  disease.  Adhesion  to  the  capsule  of  the  lens  {synechia  posterior)  is  very 
common.  Contraction  of  the  pupil,  or  atresia  iridis,  and  false  cataract,  or 
cataracta  lymphatica,  are  sequelce  of  great  importance  ;  and  not  less  so  is 
amaurosis.  The  inflammatory  symptoms,  to  whatever  degree  of  violence  they 
may  have  reached,  after  an  indefinite  period  begin  to  abate,  even  without 
medical  interference;  in  idiopathic  cases,  however,  seldom  without  contraction 
of  the  pupil,  and  synechia  posterior;  in  syphilitic  cases,  seldom  without  atro- 
phy of  the  eye  ;  in  arthritic  cases,  seldom  without  total  loss  of  sight.  The  best- 
directed  treatment  may  sometimes  fail  in  preventing  these  disastrous  results. 

The  pupil  may  be  almost  completely  closed,  and  filled  up  by  a  grayish 
membrane.     On  dissection,  false  membranes  are  found  radiating  from  the 


520  IRITIS   IN   GENERAL. 

pupil,  behind  the  iris,  and  even  coating  the  internal  surface  of  the  choroid. ^ 
The  power  of  vision  is,  in  general,  entirely  lost.  This  state  is  called  by 
Schmidt,  atresia  iridis  completa. 

Perhaps  there  has  been  no  profuse  quantity  of  effused  lymph,  and  when 
the  inflammatory  symptoms  subside,  the  pupil,  though  remaining  small  and 
irregular,  is  found  still  to  possess  some  degree  of  mobility.  The  coagulable 
lymph  by  which  the  pupil  had  been  occupied,  may  be  reduced  to  the  state  of 
a  fine  pseudo-membrane,  opaque  in  most  instances  at  its  centre,  but  somewhat 
transparent,  and  perhaps  reticulated,  towards  its  edge.  The  pupillary  margin 
of  the  iris  may  not  adhere  all  around  to  this  pseudo-membrane,  but  only  at 
some  points,  the  rest  being  free,  and  hence  the  pupil  is  very  irregular, 
especially  when  artificially  dilated.  Vision  under  these  circumstances  is  im- 
paired, not  destroyed  ;  and  is  sometimes  greatly  improved  by  the  application 
of  belladonna,  so  as  to  dilate  the  pupil,  and  allow  light  to  penetrate  through 
the  clear  spaces  in  the  pseudo-membrane.  This  constitutes  atresia  iridis  in- 
completa. 

In  a  third  set  of  cases,  only  part  of  the  iris  has  been  affected  with  inflam- 
mation. When  this  has  gone  off,  a  mere  thread  of  opaque  matter  remains  in 
the  otherwise  transparent  pupil.  By  this  thread,  a  single  point  of  the  mar- 
gin of  the  pupil  is  kept  fixed,  while  every  other  part  is  free  and  movable. 
This  is  termed  atresia  iridis  partialis. 

If  appropriate  treatment  has  been  begun  late  in  the  disease,  or  followed  out 
inefficiently,  amaurosis  is  apt  to  be  the  result.  The  pupil  may  expand  and 
even  become  clear,  yet  the  retina  may  be  so  affected,  especially  in  syphilitic 
cases,  that  vision  does  not  return. 

A  very  common  sequela  of  iritis  is  myodesopia. 

Diagnosis. — The  diseases  with  which  iritis  is  apt  to  be  confounded,  are 
rheumatic  and  catarrho-rheumatic  ophthalmia,  corneitis,  aquo-capsulitis,  in- 
flammation of  the  crystalline  capsule,  and  retinitis. 

1.  Rheumatic  ophthalmia,  catarrho-rheumatic  ophthalmia,  and  rheumatic 
iritis,  are  three  diseases  which  merge  into  one  another.  A  degree  of  iritis 
almost  invariably  attends  the  two  former  inflammations.  Exactly  as  it  is 
difficult  in  many  cases  of  catarrho-rheumatic  ophthalmia,  to  say  whether  the 
disease  affects  more  the  conjunctiva  or  the  sclerotica,  so  it  is  often  doubtful 
whether  we  should  set  down  some  cases  of  pure  internal  ophthalmia,  which 
we  meet  with,  as  examples  of  sclerotitis  or  of  iritis. 

2.  Although  there  are  present  in  corneitis  a  sclerotic  zone  of  inflammation, 
dimness  of  vision,  and  supra-orbital  pain,  as  in  iritis,  still  an  attentive  exa- 
mination of  the  state  of  the  cornea  will  easily  enable  us  to  distinguish  the 
two  diseases.  The  cornea  is  generally  much  more  opaque  in  corneitis  than 
it  ever  becomes  in  any  case  of  iritis,  the  opacity  is  speckled  and  streaked  in 
a  peculiar  manner,  and  partially  covered  by  the  ramifications  of  red  vessels. 
If  through  the  cornea  we  observe  the  pupil  moving  briskly,  according  to  the 
various  degrees  of  light  to  which  the  eye  is  exposed,  we  may  conclude  that 
the  case  is  one  of  pure  corneitis ;  but  as  has  already  been  mentioned,  we  meet 
with  cases  in  which  iritis  and  corneitis  are  conjoined,  and  as  the  cornea  is 
often  too  dim  to  permit  of  the  iris  itself  being  distinctly  seen,  we  are  obliged 
to  judge  of  the  existence  of  this  combination  by  the  size  and  mobility  of  the 
pupil.     If  it  be  contracted  and  fixed,  iritis  is  undoubtedly  present. 

3.  In  inflammation  of  the  lining  membrane  of  the  cornea,  or  aqueous 
capsule,  there  is  radiated  sclerotitis,  seldom,  however,  surrounding  the 
whole  cornea,  with  dull  aching  pain  in  the  forehead,  so  that  in  these  respects 
there  is  a  resemblance  to  iritis.  The  opacities  on  the  internal  surface  of  the 
cornea  are  very  diagnostic  of  aquo-capsulitis  ;  they  are  milky  spots  pro- 
ducing a  peculiar  mottled  appearance,  very  unlike  any  of  the  common  specks 


IRITIS  IN   GENERAL.  521 

of  the  cornea.  It  often  happens,  however,  that  in  aquo-capsulitis  there  is  an 
extension  of  inflammation  from  the  lining  membrane  of  the  cornea  to  the  iris, 
producing  tags  of  the  pupil  to  the  crystalline  capsule. 

4.  The  disease  most  resembling  iritis  is  inflammation  of  the  crystalline 
capsule,  first  accurately  described  by  Professor  Walther.  Partial  zonular 
sclerotitis,  discolored  iris,  nebulous,  contracted,  and  fixed  pupil,  and  even  ad- 
hesions between  the  iris  and  the  capsule,  are  present  in  this  disease;  and  yet 
it  appears  specifically  different  from  iritis.  The  pain  which  attends  it  is 
less,  the  inflammation  is  generally  limited  to  one  spot  of  the  capsule,  it  is 
slower  in  its  progress  than  iritis,  and  is  much  less  under  the  influence  of  re- 
medies of  any  kind.  It  cannot  be  denied,  however,  that  inflammation  of  the 
crystalline  capsule  is  always  accompanied  by  some  degree  of  iritis. 

5.  Retinitis  resembles  iritis  in  the  appearance  of  the  external  redness  by 
which  it  is  attended,  and  in  the  closure  of  the  pupil  which  an  extension  of 
the  inflammation  speedily  produces ;  but  its  attack  is  more  sudden,  its  pro- 
gress much  more  rapid,  vision  and  even  the  perception  of  light  being  de- 
stroyed much  earlier,  without  pain,  and  even  before  the  pupil  is  affected. 

General  cure  of  iritis. — The  chief  objects  to  be  attended  to  in  the  treat- 
ment of  iritis  are :  I.  To  subdue  the  congestion.  II.  To  prevent  the  effu- 
sion of  coagulable  lymph,  or  to  promote  its  absorption,  if  it  is  already  effused. 
III.  To  preserve  the  pupil  entire,  or  to  dilate  it,  if  already  contracted.  lY. 
To  assuage  the  attending  pain.  To  fulfil  these  objects  we  have  recourse  to 
a  combination  of  remedies. 

1.  Bloodletting  must  in  no  case  be  neglected,  and  when  the  patient  is  robust 
and  the  inflammation  severe,  must  be  vigorously  and  repeatedly  employed. 
Local  bleeding  is  by  no  means  adequate  to  arrest  iritis  even  of  moderate 
severity.  General  bleeding  must  be  premised  and  repeated  till  the  constitu- 
tional irritation  and  local  symptoms  abate.  In  no  disease  of  the  eye  is  vene- 
section so  remarkable  for  its  sudden  effects  as  in  iritis.  The  patient  who 
could  not  previously  discern  the  face  of  a  person  standing  before  him,  except 
as  a  mere  mass,  will  often  exclaim,  on  opening  the  eye  after  venesection,  that 
he  sees  clearly.  I  have  observed  this  especially  in  syphilitic  iritis.  The 
blood  taken  from  the  arm  in  iritis  is  very  bufify,  especially  when  the  disease  is 
rheumatic  or  syphilitic.  Cupping  is  not  to  be  trusted  to  as  a  substitute  for 
venesection.  It  is  comparatively  of  no  effect.  After  venesection,  leeches 
may  be  applied  freely  round  the  eye,  and  repeated  every  day,  or  every  second 
day,  till  the  inflammation  is  subdued.  Scarification  of  the  conjunctiva  is 
generally  useless,  or  even  hurtful,  in  iritis. 

2.  Purging,  Sfc. — The  use  of  cathartics,  and  diuretics,  with  a  spare  and 
cool  diet,  confinement  within  doors,  rest  of  the  whole  body,  and  exclusion  of 
the  light  from  the  eyes,  will  be  found  powerful  auxiliaries.  In  many  cases, 
I  have  noticed  mercury  to  do  little  good  till  it  purged,  or  till  purgatives 
were  administered. 

3.  Antimony,  and  other  nauseants,  prove  useful  in  two  ways.  They 
moderate  the  circulation,  and  render  the  system  more  susceptible  of  the  in- 
fluence of  mercury. 

4.  Opiates  are  in  general  imperiously  demanded  in  iritis,  by  the  severity 
of  the  nocturnal  circumorbital  pain,  as  well  as  by  the  distress  which  the  pa- 
tient experiences  in  the  eye  itself. 

5.  3Iercury  given  so  as  to  affect  the  constitution,  is  a  most  valuable  remedy 
in  iritis.  By  subduing  the  inflammation,  it  prevents,  as  was  first  pointed  out 
by  Professor  Beer,  the  effusion  of  coagulable  lymph  from  the  iris,  or  if  that 
substance  is  already  effused,  powerfully  promotes  its  absorption.  It  is  plain 
that  mercury  must  be  given  so  as  to  act  more  promptly  in  iritis  than  in 
primary  syphilis,  on  account  of  the  danger  of  allowing  contraction  and  ad- 


522  IRITIS   IN   GENERAL, 

hesions  of  the  pupil  to  form.  At  the  same  time,  we  should  avoid  producing 
sudden  and  severe  ptyalism,  lest  we  be  obliged  to  stop  the  mercury  prema- 
turely, and  thus  the  disease  be  allowed  to  march  on  and  destroy  vision,  be- 
fore we  can  venture  to  resume  it.  The  most  useful  form  for  administering 
mercury  in  iritis,  is  calomel  with  opium,  given  in  small  doses  frequently 
repeated.  Nichet^"  gives  from  10  to  20  grains  of  calomel  daily,  with  or 
without  opium,  according  to  circumstances.  He  thinks  prompt  salivation 
important.     In  five  days,  and  sometimes  in  two  days,  he  obtains  this  efTect. 

6.  Iodide  of  2iotassium  possesses  very  considerable  power  over  iritis.  I 
should  never  trust  to  it,  however,  in  the  first  instance ;  but  when  we  are 
obliged  to  interrupt  the  employment  of  mercury,  this  preparation  may  be 
substituted  in  its  room. 

7.  Turpentine  has  been  recommended  as  a  remedy  which,  taken  internally 
in  cases  of  iritis,  displays  properties  analogous  to  those  of  mercury." 

8.  Sulphate  of  quina,  not  only  in  the  scrofulous  variety  of  iritis,  but  even 
in  the  syphilitic,  often  proves  of  great  service. 

9.  Blisters  behind  the  ears,  or  to  the  nape  of  the  neck,  are  of  material  use 
after  sufficient  abstraction  of  blood.     Previously  to  this,  they  do  harm. 

10.  Belladonna,  in  the  first  stage  of  iritis,  speedily  expands  the  pupil; 
subsequently,  it  has  no  apparent  effect,  till  the  inflammation  is  considerably 
subdued  by  bloodletting  and  the  use  of  mercury.  It  ought  to  be  employed 
in  every  case,  and  in  all  stages  of  the  disease.  The  usual  mode  of  employ- 
ing it  is  in  extract,  moistened  to  the  consistence  of  cream,  and  liberally 
painted  on  the  eyebrow  and  eyelids  morning  and  evening.  As  it  is  during 
the  night  that  the  disease  appears  to  make  most  progress,  and  as  during  sleep 
there  is  a  natural  closure  of  the  pupil,  which  must  favor  the  permanent  con- 
traction which  iritis  tends  to  produce,  the  evening  is  evidently  the  most  pro- 
per time  to  apply  the  belladonna, ^^  if  used  only  once  in  the  twenty-four  hours. 
As  it  ceases  to  act  after  becoming  dry,  the  parts  covered  with  it  should 
frequently  be  moistened  with  a  little  water,  by  means  of  the  finger  or  a  camel- 
hair  ])encil. 

Belladonna  acts  much  more  powerfully  in  dilating  the  pupil,  after  blood 
has  been  taken  from  the  arm.  Having  been  waited  on  one  morning  by  a 
gentleman  with  iritis,  I  applied  belladonna  and  advised  him  some  mercurial 
pills.  Being  sent  for  to  see  him  in  the  evening,  I  found  the  pupil  irregular, 
but  not  expanded.  I  bled  him  at  the  arm,  and  on  returning  two  hours  after, 
I  found  the  pupil  widely  dilated,  although  no  more  belladonna  had  been 
applied. 

As  soon,  in  general,  as  the  inflammation  has  subsided  in  any  considerable 
degree,  and  the  fibres  of  the  iris  have  become  somewhat  freed  from  the  effused 
lymph,  the  pupil  will  begin  to  expand ;  and  even  in  neglected  cases,  where 
it  has  been  allowed  to  become  almost  obliterated,  the  continued  use  of  bella- 
donna for  months  is  sometimes  attended  by  a  gradual  dilatation  of  the  pupil, 
an  elongation  of  the  threads  that  bind  it  to  the  capsule,  and  a  corresponding 
improvement  in  vision.  After  the  acute  inflammation  is  gone,  a  filtered 
aqueous  solution  of  the  extract  of  belladonna,  or  a  solution  of  the  sulphate 
of  atropia  may  be  dropped  upon  the  eye,  morning  and  evening.  Applied 
thus  to  the  conjunctiva,  belladonna  has  more  effect  than  when  painted  on  the 
skin,  and  sometimes  breaks  through  adhesions  when  smearing  the  outside  of 
the  eyelids  has  failed. 

There  is  an  occasional  effect  of  belladonna,  which  perhaps  may  appear  to 
afford  ground  for  objecting  to  its  use  in  the  acute  stage  of  iritis,  namely,  its 
operation  on  the  proper  substance  of  the  iris,  so  as  to  cause  it  to  contract, 
but  at  the  same  time  leave  the  pigmentum  nigrum,  or  uvea,  attached  to  the 
capsule  of  the  lens,  whence  it  never  afterwards  appears  to  separate.     That 


RHEUMATIC   IRITIS.  523 

this  tearing  of  the  iris  from  the  uvea  sometimes  happens  from  belladonna,  is, 
I  believe,  undeniable.  It  is,  however,  a  rare  occurrence  ;  very  rare,  if  pro- 
per means  are  promptly  adopted  to  subdue  the  inflammation  ;  more  apt  to 
occur  if  the  case  is  trusted,  as  some  have  recommended,  to  mercury,  without 
bloodletting.  After  taking  away  blood,  I  never  hesitate  to  apply  bella- 
donna. 

Dr.  Robertson  mentions"  a  case  in  which  an  extraordinary  effect  arose 
from  belladonna ;  for  the  pupil,  expanding  in  consequence  of  its  application, 
became  fixed  in  the  dilated  state,  giving  the  eye  an  amaurotic  appearance. 
Dr.  Robertson  thinks  it  probable  that  this  arose  from  lymph  being  effused, 
and  matting  together  the  fibres  of  the  iris  while  under  the  influence  of  the 
belladonna. 

The  above-mentioned  remedies  are  suited,  more  or  less,  to  every  kind  of 
iritis ;  but,  of  course,  peculiar  modifications  in  the  treatment  will  be  neces- 
sary according  to  the  different  causes  of  the  disease,  whether  these  be  syphi- 
litic, scrofulous,  arthritic,  or  of  whatever  other  nature,  and  according  to  the 
different  symptoms  which  each  species  presents  in  individual  cases. 

Stimulating  applications  to  the  conjunctiva  are  in  general  useless  and  even 
hazardous  in  iritis.  At  any  rate,  they  are  never  to  be  ventured  on  in  the 
acute  stage. 


'  PrfBdictionum,  Lib.  ii.  28.  ■"  Essay  on  Iritis,  by  the  late  George  C.  Mon- 

'^  Schmidt,  Ueber  Nachstaar  und  Iritis  nach  teath,   M.D.,  Glasgow  Medical  Journal;  Vol. 

Staaroperationen ;  Wien,  1801.  ii.  p.  43,-  Glasgow,  1829. 

^  On  retinitis,  as  a  part  of  the  disease  called  '  Lawrence's  Lectures   in  the  Lancet;    Vol. 

iritis,  see  Jacob's  Treatise  on  the  Inflammations  x.  p.  257  ;  London,  1S26. 

of  the  Eyeball,  p.  i. ;  Dublin,  1849.  =  Cloquet,   Pathologie  Chirurgicale ;    PI.  x. 

*  On    the  changes  in    the   color  of    the  iris  fig.  15;  Paris,  1831. 

produced  by  inflammation,  see  Hunter,  London  '°  Gazette  Medicale  de  Paris,  31  Dec.  1836. 

and  Edinburgh   Monthly  Journal   of   Medical  "  Observations  on  the  Efficacy  of  Turpen- 

Scienee;  February,  1841,  p.  79.  tine  in  the  Venereal    and    other    deep-seated 

'  Dzondi,  Griife  und  Walther's  Journal  der  Inflammation  of  the   Eye;    by  Hugh    Carmi- 

Chirurgie  und  Augenheilkunde  :  Vol.  i.  p.  238  ;  chael ;  Dublin,  1829. 

Berlin,  1S20:    Simeons,  ibid.  Vol.  xi.  p.  293;  '^  London  Medical    and  Physical    Journal; 

Berlin,  1828:  Schindler,  ibid.  Vol.  sii.  p.  180;  Vol.  liv.  p.  113;  London,  1825. 

Berlin,  1828.  '=  Edinburgh  Medical  and  Surgical  Journal; 

'  Jacob,  Op.  cit.  p.  22.  Vol.  xxxii.  p.  291 ;  Edinburgh,  1829. 


SECTION  XX. — IDIOPATHIC  OR  RHEUMATIC  IRITIS. 
Fi-g.  Beer,  Taf.  L  Fig.  6.     Taf.  II.  Fig.  1.     Dairy mple,  PI.  XVIII.  Fig.  1. 

It  has  already  been  mentioned,  that  attendant  on  rheumatic  and  catarrho- 
rheumatic  ophthalmisB,  there  is,  in  general,  a  degree  of  iritis.  There  is  a 
third  set  of  cases,  chiefly  arising,  like  these  two  ophthalmise,  from  exposure 
to  atmospheric  changes,  suppressed  perspiration,  or  overuse  of  the  eyes,  in 
which  the  iris  is  all  along  the  part  principally  affected,  and  in  which  the  at- 
tack is  sudden,  in  this  last  respect  resembling  other  diseases  caused  by  exter- 
nal influences,  and  differing  from  those  which,  originating  entirely  in  some 
constitutional  or  internal  cause,  advance  slowly  and  insidiously.  With  this 
idiopathic  or  rheumatic  iritis  sometimes  both  eyes  are  simultaneously  affected, 
with  nearly  equal  severity.  In  other  cases,  only  one  eye  is  inflamed,  or  the 
one  much  more  severely  than  the  other. 

Local  symptoms. — Dimness  of  sight  is  often  the  earliest  symptom.  The 
letters  of  a  book  appear  pale,  and  the  eye  is  soon  fatigued.  This  state  may 
continue  for  some  days,  with  very  little  redness  of  the  eye.  By  and  by, 
everything  is  seen,  as  if  through  a  thick  fog,  probably  from  a  thin  coating 


524  RHEUMATIC   IRITIS. 

of  lymph  over  the  capsule  of  the  lens.  To  these  subjective  symptoms,  cer- 
tain objective  changes  are  speedily  added,  indicative  of  the  peculiar  seat  of  the 
disease.  These  changes  commence  upon  the  edge  of  the  pupil,  whence  they 
extend  gradually  towards  the  ciliary  circumference  of  the  iris.  The  pupil  is 
seen  to  be  contracted,  the  motions  of  the  iris  impeded,  and  the  pupillary 
opening  deprived  of  the  bright  black  color  which  is  natural  to  it.  The 
color  of  the  iris  is  next  observed  to  undergo  a  change ;  first,  in  the  lesser 
circle,  which  becomes  of  a  dark  hue,  and  afterwards  in  the  greater,  which 
grows  green,  if  it  had  been  grayish  or  blue  ;  and  reddish,  if  it  had  been  dark- 
colored.  This  change  of  color  is  a  never  failing  index  of  the  substance  of 
the  iris  being  inflamed,  and  is  apt  to  continue  after  all  the  other  symptoms  of 
iritis  have  been  subdued.  As  soon  as  this  change  of  color  has  taken  place  to 
a  considerable  degree  in  the  greater  circle,  the  iris  swells  and  projects  towards 
the  cornea,  while  the  pupillary  margin,  losing  its  sharply  defined  edge,  seems 
somewhat  thickened,  and  is  turned  back  towards  the  capsule  of  the  lens. 

The  redness  accompanying  these  changes  is  by  no  means  considerable,  and 
is  at  first  confined  to  the  sclerotic  coat,  in  which  a  number  of  very  minute 
rose-red  vessels  are  seen,  running  towards  the  cornea.  By  and  by,  the  red- 
ness increases,  and  is  seen  to  arise  partly  from  vessels  developed  in  the  con- 
junctiva. The  vascularity  is  greatest  round  the  cornea ;  towards  the  folds 
of  the  conjunctiva  it  fades  away. 

The  patient  complains  of  pain  in  the  eye,  in  many  cases  severe  and  pulsa- 
tive,  and  increased  on  motion  of  the  organ ;  pain  beneath  the  eyebrow ;  and 
circumorbital  nocturnal  pain,  similar  to  what  is  met  with  in  rheumatic  scle- 
rotitis. 

If  the  disease  be  not  checked,  the  pupil  loses  its  circular  form,  it  becomes 
irregular,  sometimes  nearly  triangular,  and  at  the  same  time  presents  a  gray- 
ish appearance.     Examined  through  a  magnifying  glass  of  short  focus,  or 
even  by  merely  concentrating  the  rays  of  light  upon  the  pupil  through  a 
double-convex  lens,  this  grayish  appearance  is  seen  to  be  produced  by  a  deli- 
cate flake  of  coagulable  lymph.     Into  this  the  processes  or  dentations  of  the 
irregular  pupillary  margin  of  the  iris  seem  to  shoot,  and  it  is  afterwards 
found  that,  at  these  points,  adhesions  between  the  iris  and  capsule  are  apt  to 
be  established.     It  is  owing  to  these  adhesions  that  the  patient, 
Fig.  68.       whose  vision  has  been  all  along  indistinct,  sometimes  complains 
of  now  being  able  to  see  only  one  side,  or  part  of  an  object. 
For  a  time,  there  may  be  only  one  or  two  tags  of  adhesion,  the 
rest  of  the  pupil  being  free,  so  that  on  applying  belladonna  this 
aperture  assumes  a  very  irregular  form  (Fig.  68).     A  patient 
under  my  care  had  five  tags,  so  that  his  pupil  had  the  shape  of 
an  oak  leaf.     Several  or  all  of  such  adhesions  may  break  across, 
Fig.  69.       under  the  influence  of  belladonna,  especially  when  dropped  upon 
the  conjunctiva,  and  assisted  by  depletion  and  mercury.     Fig. 
69  shows  the  effect  of  one  of  the  two  tags,  represented  in  Fig. 
68  having   thus   given  way.     After  the  tags  have  given  way, 
minute  whitish  spots  may  be  detected  on  the  capsule,  at  the  points 
where  the  adhesions  existed. 
If  the  disease  proceeds  unchecked,  the  effusion  of  lymph  into  the  pupil 
increases.     It  takes  place   likewise  behind  the  iris,  so  that  adhesions  are 
formed  between  the  uvea  and  the  capsule  of  the  lens.     The  lymph  becomes 
organized,  red  vessels  shooting  into  it  from  the  iris. 

In  neglected  cases,  the  pupil  is  often  left  much  contracted,  tagged,  and 
angular,  with  the  iris  of  a  greenish  or  slate  color,  and  destitute  of  its  healthy 
sti'iated  appearance  and  natural  lustre.  The  lens  sometimes  becomes  opaque, 
and  disorganized. 


RHEUMATIC   IRITIS,  525 

By  this  time,  the  morbid  sensibility  to  light,  which  preyailed  at  the  com- 
mencement of  the  disease,  is  diminished ;  from  the  retina  being  involved  in 
the  disease,  as  well  as  from  the  state  of  the  pupil,  the  powers  of  vision  be- 
come gradually  more  and  more  limited,  and  at  length  little  more  than  the 
perception  of  light  remains.  Not  unfrequently,  the  patient  complains  of  the 
sensation  of  a  black  spot,  like  a  fly,  or  of  several  black  or  hazy  spots,  placed 
as  it  were  at  some  distance  before  the  eye,  and  partially  intercepting  the  view 
of  the  objects. 

As  the  disease  proceeds,  the  cornea  loses  somewhat  of  its  peculiar  bril- 
liancy, and  occasionally  very  striking  changes  take  place  on  the  anterior 
surface  of  the  iris.  Spots  of  lymph  form  upon  it ;  and,  in  other  cases,  lymph 
appears  to  be  deposited  in  the  substance  of  the  iris ;  for,  while  it  projects 
more  and  more  towards  the  cornea,  its  fibres  get  collected  into  bundles,  giv- 
ing to  its  surface  a  peculiar  plaited  or  puckered  appearance.  In  some  very 
rare  cases,  one  or  more  yellowish-red  elevations  form  on  the  anterior  surface 
of  the  iris,  most  frequently  about  the  union  of  its  greater  and  lesser  circles. 
Small  at  first,  such  an  elevation  gradually  enlarges,  projects  towards  the 
cornea,  and  is  at  length  distinctly  seen  to  be  a  cyst  containing  pus,  which, 
finally  bursting,  discharges  its  contents  into  the  anterior  chamber,  and  thus 
gives  rise  to  spurious  hypopium.  A  small  quantity  of  blood  is  sometimes 
estravasated  at  the  same  time  into  that  cavity. 

Such  is  the  general  history  of  a  neglected  case  of  rheumatic  iritis.  We 
meet,  of  course,  with  many  degrees  of  severity  in  this  disease ;  while  its 
sequelae  are,  as  has  been  described  in  the  last  section,  varied  and  more  or 
less  detrimental  to  vision.  The  inflammation  will  at  length  subside,  even 
though  no  remedies  are  employed  ;  but,  in  such  cases,  vision  will  in  general 
be  lost. 

Constitutional  symptoms. — Like  rheumatic  sclerotitis,  this  inflammation  of 
the  iris  may  attack  an  individual  who  has  never  suffered  from  rheumatism  in 
any  other  part  of  the  body.  Not  unfrequently,  however,  the  subjects  of  this 
disease  have  long  been  subject  to  other  rheumatic  afi'ections,  although  the  iritis 
appears  in  every  case  to  be  excited  by  some  new  exposure  to  cold  or  similar 
cause,  and  never,  as  far  as  I  have  seen,  to  be  metastatic.  Thirst,  whiteness 
of  the  tongue,  and  accelerated  pulse,  attend  rheumatic  iritis.  The  bowels  are 
frequently  confined,  and  there  is  occasionally  a  disposition  to  nausea. 

Causes. — These  are  the  same  with  those  already  enumerated  as  producing 
rheumatic  ophthalmia.  Some  individuals  of  confirmed  rheumatic  habit,  suflTer 
exceedingly  from  one  or  more  attacks  of  this  disease  every  year,  each  succeed- 
ing attack  leaving  the  eye  in  a  worse  state,  till  at  length  vision  is  destroyed. 

This  iritis  frequently  occurs  during,  or  after  the  use  of  mercury,  in  conse- 
quence of  this  medicine  powerfully  predisposing  the  whole  body  to  suff'er  from 
the  exciting  causes  of  rheumatic  inflammation. 

I  have  known  rheumatic  iritis  excited  by  incessant  reading  for  some  days, 
during  confinement  from  a  cold.  The  irritation  of  a  decayed  tooth,  or  stump, 
communicated  through  the  fifth  nerve  to  the  brain,  and  thence  by  reflection  to 
the  eye,  has  produced  the  disease. 

Treatment.  1.  Bloodletting. — The  degree  of  synocha  which  is  present  in  rheu- 
matic iritis  must  guide  us  as  to  the  extent  and  kind  of  bleeding.  Repeated 
venesection  is  almost  always  necessary,  followed  by  the  liberal  application  of 
leeches  round  the  eye. 

2.  Mercury. — Scarcely  is  the  mouth  affected  by  the  use  of  mercury,  when  we 
observe  the  most  marked  abatement  of  the  symptoms.  Two  grains  of  calomel, 
with  one-third  of  a  grain  of  opium,  may  be  given  in  acute  cases,  every  six 
hours,  and  less  frequently  in  chronic  cases,  taking  care  not  to  make  the  mouth 
sore  too  Boon. 


526  RHEUMATIC  IRITIS, 

It  cannot  be  denied,  however,  that,  unless  the  patient  be  careful  to  avoid 
new  exposure  to  cold,  the  mercurial  treatment  may  actually  prove  injurious. 
He  ought  to  leave  off  his  usual  employment,  confine  himself  within  doors,  and, 
if  the  case  is  severe,  keep  his  bed.  Unless  this  be  done,  the  disease  is  apt  to 
recur  with  redoubled  fury,  even  from  such  slight  causes  as  changing  the  head- 
dress, passing  from  one  room  to  another,  and  the  like.  It  becomes  a  question, 
when  the  patient  is  poor,  and  unprovided  with  proper  clothing  and  shelter, 
whether  we  should  give  mercury  at  all,  unless  the  patient  be  admitted  into  an 
hospital.  We  are  almost  certain  by  its  omission  to  ruin  the  eye,  and  by  its 
exhibition  seriously  to  endanger  the  general  health.  The  patient's  room  should 
be  darkened,  and  have  a  moderate  fire  in  it  in  winter. 

3.  Iodide  of  potassium,  in  doses  of  4  or  5  grains,  thrice  a  day,  may  be  given, 
if  from  any  cause  the  use  of  mercury  is  interrupted. 

4.  Turpentine  may  be  tried  with  some  hope  of  success  in  similar  circum- 
stances, in  the  manner  recommended  by  Mr.  Carmichael  for  syphilitic  iritis. 
See  next  Section. 

5.  Rest  and  the  antiphlogistic  regimen,  must  be  strictly  enjoined.  The  pa- 
tient must  relinquish  animal  food,  and  fermented  liquors. 

6.  Opiates. — If  we  give  calomel,  we  combine  it  with  opium.  If  we  refrain 
from  the  internal  use  of  mercury,  a  powerful  opiate  ought  to  be  given  every 
night,  to  assuage  the  pain.  Friction  of  the  head  with  warm  laudanum,  is  also 
to  be  employed,  or  friction  with  mercurial  ointment  mixed  with  opium.  Should 
this,  along  with  the  opiate  taken  internally,  fail  to  prevent  the  nocturnal  attack 
of  pain  in  the  eye  and  round  the  orbit,  considerable  relief  may  be  obtained  by 
fomenting  the  eyelids  and  parts  around  with  hot  flannel  cloths,  wrung  out  of 
decoction  of  poppy-heads,  or  belladonna  leaves,  care  being  taken  to  dry  the 
parts  well  as  soon  as  the  fomentation  is  finished,  and  then  cover  them  with  a 
linen  compress,  previously  heated  at  the  fire. 

t.  Purgatives. — As  much  castor  oil  or  sulphate  of  magnesia  as  will  open  the 
bowels  moderately,  is  to  be  given  every  morning. 

8.  Diuretics. — Small  doses  of  nitre  and  cream  of  tartar,  every  two  or  three 
hours,  are  useful. 

9.  Diaphoretics  are  of  service,  but  are  liable  to  the  same  objection  as  mer- 
cury. Unless  the  patient  can  protect  himself  from  cold,  they  ought  to  be 
avoided. 

10.  Cinchona  is  undoubtedly  a  remedy  of  considerable  utility  in  the  treat- 
ment of  rheumatic  iritis.  I  am  as  much  opposed,  however,  to  the  idea  of 
trusting  to  it  almost  alone,  as  I  am  to  the  plan  of  confiding  solely  in  the  anti- 
phlogistic and  sorbefacient  powers  of  mercury  in  this  disease,  to  the  neglect 
of  bloodletting  and  other  depletory  means  of  cure.  In  an  inflammation  of 
so  dangerous  a  nature  as  iritis,  we  should  be  ready  to  avail  ourselves  of  every 
remedy,  and  never  allow  ourselves  to  be  beguiled  into  bad  practice  by  an 
afl'ectation  of  simplicity. 

11.  Blisters  behind  the  ear,  on  the  temple,  and  on  the  back  of  the  neck,  are 
of  more  service  in  the  rheumatic  than  in  any  other  kind  of  iritis.  To  produce 
a  more  moderate  degree  of  counter-irritation,  the  laudanum  with  which  the 
head  is  rubbed  when  the  nocturnal  pain  threatens  to  begin,  may  be  mixed 
with  an  equal  quantity  of  tincture  of  cantharides. 

12.  Belladonna  should  be  freely  applied,  morning  and  evening,  to  the  eye- 
brow and  eyelids.  In  general,  it  has  little  apparent  effect  till  the  inflammation 
is  considerably  subdued  by  bleeding  and  calomel.  It  is  often  used  for  eight 
days  or  more,  and  little  or  no  dilatation  of  the  pupil  is  produced,  till,  upon 
taking  away  more  blood,  or  the  gums  becoming  touched,  the  pupil  suddenly 
expands ;  an  event  to  be  hailed  as  very  favorable. 

13.  Vinum  opii  is  serviceable  in  the  decline  of  this  disease.     Any  applica- 


SYPHILITIC   IRITIS.  52T 

tion  to  the  eye  itself  in  the  form  of  collyrium,  droji,  or  salve,  is  worse  than 
useless,  in  the  acute  stage. 

Prevention. — Those  who  are  subject  to  rheumatic  iritis,  must  carefully  avoid 
the  exciting  causes ;  especially,  sudden  transitions  from  heat  to  cold,  violent 
exercises,  crowded  assemblies,  late  hours,  card-playing,  much  reading  or  writ- 
ing, excess  in  eating  and  drinking,  and  the  like.  Sea-bathing  in  summer  is 
sometimes  of  use  in  preventing  relapses.  For  the  same  purpose  I  have  known 
a  long-continued  course  of  sarsaparilla  very  serviceable.  Removal  to  a 
southern  climate  during  the  winter,  may  be  the  means  of  saving  a  patient 
from  his  usual  attack. 


SECTION  XXI. — SYPHILITIC   IRITIS. 


Fig.  Beer,  Taf.  II.  Fig.  4.      Dalrymple,  PI.  XVIIL  Figs.  3-6.      PI.  XIX.  Fig.  4.      Sichel,  PL 
XI.  Fig.  6.  PI.  XIIL  Figs.  2,  4-6. 

Like  other  secondary  syphilitic  affections,  syphilitic  ophthalmia  is  insidious 
in  its  early  stage,  but  after  a  time  rapidly  and  extensively  destructive.  If 
left  to  itself,  it  does  not  fail  to  disorganize  almost  every  texture  of  the  eye- 
ball, commencing  with  the  iris,  and  extending  its  destructive  influence  to  the 
choroid  and  retina,  the  vitreous  humor,  and  even  the  cornea  and  sclerotica. 

Local  symptoms. — The  general  diagnostic  symptoms  of  iritis,  as  enumerated 
at  page  518,  are  in  general  well  marked  in  the  syphilitic  species ;  but  it  is 
important  to  observe,  that  in  the  incipient  stage,  they  are  sometimes  very 
slight,  syphilitic  differing  in  this  respect  from  rheumatic  iritis,  which  from 
the  external  nature  and  sudden  action  of  its  exciting  cause,  is  generally  cha- 
racterized even  from  the  commencement,  by  signs  which  can  scarcely  be  over- 
looked or  mistaken.  In  the  syphilitic  species,  on  the  other  hand,  the  redness 
is  sometimes,  for  a  length  of  time,  scattered  or  fascicular  rather  than  zonular, 
and  the  changes  in  the  appearance  of  the  iris  and  pupil  very  slight.  This 
shows  the  necessity,  in  suspected  cases,  perhaps  I  ought  to  say  in  all  cases  of 
iritis,  of  examining  with  attention  the  state  of  the  skin  and  throat,  and  in- 
quiring into  the  history  of  the  patient's  previous  health.  We  almost  always 
find  the  remains  of  a  syphilitic  eruption,  or  sore  throat,  attendant  on  syphilitic 
inflammation  of  the  iris  ;  in  many  cases  this  ophthalmia  is  coexistent  with 
active  secondary  symptoms  in  various  textures  of  the  body ;  sometimes, 
though  rarely,  with  primary  symptoms;  and  in  all  instances,  the  history  of 
the  patient's  health  will  throw  a  degree  of  light  on  the  affection  of  the  eye, 
which  may  be  the  means  of  preventing  the  most  disastrous  consequences. 

It  is  unnecessary  to  repeat  any  description  of  the  zonular  redness,  discolor- 
ation of  the  iris,  contraction,  irregularity,  and  immobility  of  the  pupil,  effu- 
sion of  lymph,  and  other  general  symptoms  of  iritis,  as  they  occur  in  the 
syphilitic  species.  In  none  of  these  symptoms,  nor  in  the  dimness  of  sight, 
and  pain  which  attend  them,  does  there  appear  anything  really  diagnostic  ; 
although  some  authors  have  imagined,  that  they  had  discovered  in  certain  of 
these  symptoms,  peculiarities  upon  which  a  diagnosis  could  be  founded. 
The  fact  that  even  directly  contrary  appearances  have  been  enumerated  as 
diagnostic  of  syphilitic  iritis,  shows  that  to  distinguish  this  species  from  the 
rheumatic,  something  more  must  be  taken  into  account  than  any  differences 
which  may  be  observed  in  the  general  symptoms  of  the  disease.  Perhaps  I 
ought  to  except  a  tawny  or  rusty  color  of  the  iris  near  its  pupillary  edge, 
which  is  certainly  observed  in  many  syphilitic  cases,  and  in  them  almost  only. 

Beer  has  described  two  remarkable  appearances  as  characteristic  of  syphi- 


528  SYPHILITIC   IRITIS. 

litic  iritis ;  viz :  dislocation  of  the  pupil,  and  condylomata  sprouting  from 
the  iris. 

The  first  of  these  symptoms  consists  in  a  gradual  movement  of  the  pupil 
upwards  and  inwards,  so  that  instead  of  being  placed,  as  it  is  in  health, 
nearly  in  the  centre  of  the  iris,  it  comes  to  be  situated  considerably  closer  to 
the  upper  and  inner  edge  of  that  membrane.  This  displacement  I  have  seen 
in  chronic  rheumatic  iritis ;  and  still  more  frequently  in  scrofulous  sclerotitis, 
unattended  by  iritis.  I  cannot  regard  it,  then,  as  diagnostic  of  syphilitic 
iritis.  That  it  is  occasionally  met  with  in  this  disease,  I  have  no  doubt,  but 
I  believe  it  to  be  a  symptom,  not  so  much  of  the  iritis  as  of  an  affection  of 
the  ciliary  or  iridal  nerves. 

As  for  the  condylomata  described  by  Beer  as  diagnostic  of  this  disease, 
they  are  really  tubercles,  pustules,  or  small  abscesses,  very  rarely  met  with 
except  in  syphilitic  cases,  and  generally  accompanied  or  preceded  by  a 
syphilitic  eruption  over  the  body.  On  first  showing  themselves,  they  are  of 
a  reddish-brown  color,  their  surface,  which  is  somewhat  irregular,  appearing, 
when  viewed  through  a  lens  of  short  focus,  to  be  covered  with  innumerable 
red  vessels.  By  and  by,  they  assume  a  yellowish  hue,  project  from  the  plane 
of  the  iris,  and  enlarge  sometimes  to  such  a  size  as  almost  to  touch  the  cor- 
nea. Dr.  Monteath  supposed  that  they  sometimes  form  on  the  posterior 
surface  of  the  iris,  pushing  it  forwards,  and  forcing  a  passage  between  its 
fibres.  At  length  they  burst,  and  discharge  the  purulent  matter  they  con- 
tain, into  the  anterior  chamber.  After  this,  the  cyst  which  contained  the 
matter,  shrinks;  but  from  the  corresponding  portion  of  the  edge  of  the  pupil 
being,  I  believe,  always  adherent  to  the  capsule,  as  the  shrinking  of  the  cyst 
goes  on,  the  ciliary  edge  of  the  iris  is  apt  thereby  to  be  separated  from  the 
choroid,  or  its  fibres  to  be  lacerated  and  absorbed,  so  that  either  the  uvea 
comes  into  view,  of  a  black  color,  or  actually  an  aperture  is  formed  in  the 
iris,  which  never  perfectly  closes. 

Tubercles  may  form  at  any  part  of  the  iris,  close  to  the  pupil,  near  the 
ciliary  edge  or  midway  between  them.  When  situated  at  the  ciliary  edge, 
they  sometimes  disappear  from  the  anterior  chamber,  form  a  projection  of 
the  choroid  and  sclerotica,  behind  the  cornea,  and  burst  externally.  This  I 
never  myself  observed;  but  in  more  than  one  instance  I  have  seen  this  disease 
combined  with  a  hard  elevation,  of  a  dark  red  color,  somewhat  like  a  phleg- 
mon, behind  the  edge  of  the  cornea,  ending  in  attenuation  of  the  sclerotica 
and  protrusion  of  the  choroid. 

As  to  the  question,  whether  such  tubercles  occur  only  in  syphilitic  cases,  I 
have  seen  a  small  yellow  cyst  form  on  the  surface  of  the  iris  in  rheumatic 
iritis,  but  this  is  a  very  rare  event. ^  The  existence  of  tubercles,  therefore, 
ought  immediately  to  rouse  suspicion  that  the  case  is  syphilitic. 

If  syphilitic  iritis  is  neglected,  not  only  is  the  pupil  speedily  closed,  and 
bound  down  to  the  capsule  of  the  lens  by  effused  lymph,  but  the  iris  is  re- 
markably changed  in  its  appearance,  much  more  so  than  in  any  other  species 
of  the  disease.  The  cornea,  also,  becomes  hazy,  and  sometimes  dotted  oyer 
with  minute  brown  spots.  The  anterior  chamber  becomes  less  in  size,  from 
the  iris  being  pushed  forwards,  and  at  length  from  the  cornea  shrinking  in 
diameter.  Tne  sclerotica,  choroid,  and  retina  all  partake  in  the  inflammation  ; 
the  retina  becoming  insensible  to  light,  while  the  choroid  protrudes,  here 
and  there,  of  a  deep  bluish  color,  through  the  attenuated  sclerotica.  A  pa- 
tient at  the  Glasgow  Eye  Infirmary  was  convalescent,  and  stayed  away  for 
some  weeks.  When  he  returned,  his  right  eye  presented  a  very  large  and 
prominent  choroid  staphyloma,  encircling  the  temporal  side  of  the  cornea  ; 
the  edge  of  the  pupil  was  drawn  back,  and  the  surface  of  the  ii'is  tawny.  He 
still  retained  tolerable  vision  with  the  eye  in  this  condition. 


SYPHILITIC   IRITIS.  529 

The  degrees  of  syphilitic  iritis,  and  its  sequelae,  are  of  course  very  various. 
Sometimes  the  pupil  is  dilated  to  twice  its  natural  diameter,  the  centre  re- 
maining black,  while  its  edge  is  surrounded  by  tubercles.  In  such  cases, 
though  part  of  the  pupil  is  pretty  clear,  the  patient  sees  little  or  none  on 
account  of  the  condition  of  the  retina ;  yet  from  this  state  the  eye  may  com- 
pletely recover,  by  appropriate  treatment.  The  terminations  of  the  disease, 
if  not  counteracted  by  an  early  employment  of  mercury,  are  closure  of  the 
pupil,  obliteration  of  the  anterior  and  posterior  chambers,  and  atrophy  of 
the  eyeball. 

Yery  differently  from  what  happens  in  neglected  rheumatic  iritis,  the  inflam- 
mation in  syphilitic  iritis  does  not  wear  itself  out,  and  end  in  simple  loss  of 
vision  by  closure  of  the  pupil,  but  goes  on  from  one  texture  of  the  eye  to 
another,  till  the  whole  are  involved  in  a  process  of  disorganization,  which 
leaves  scarcely  a  trace  of  natural  structure. 

In  extreme  cases,  the  lens  and  vitreous  humor  are  disorganized,  being  con- 
verted into  a  pultaceous  mass,  which  may  at  last  be  observed  forming  whitish 
projecting  points  through  the  choroid  and  sclerotica.  From  such  a  state  of 
disease  it  is  impossible  for  the  eye  to  recover,  so  as  to  preserve  its  natural 
form.  Neither  do  we  find  that  puncturing  the  eye  in  such  a  state,  affords 
any  relief  to  the  pain  which  the  patient  suffers ;  it  is  not  from  any  collection 
of  purulent  fluid,  that  the  appearance  above  mentioned  arises,  and  nothing  is 
discharged  on  passing  the  lancet  through  the  tunics.  If  the  system  is  brought 
under  the  action  of  mercury,  the  eye  will,  under  these  circumstances,  shrink 
to  a  small  size ;  but  if  this  is  not  done,  if  an  insufficient  quantity  of  mercury 
be  given,  or  that  medicine  be  too  soon  abandoned,  the  sclerotica  may  give 
way,  and  fungous  excrescence  protrude.  At  last,  from  the  severity  of  the 
pain  in  the  eye  and  head,  the  ineflficacy  of  opiates,  the  fever  and  debility 
which  are  induced,  and  from  the  unseemly  and  disorganized  state  of  the  eye, 
we  shall  be  obliged  to  remove  it  with  the  knife. 

In  many  cases  of  syphilitic  iritis,  the  treatment  has  the  effect  of  completely 
removing  all  the  objective  symptoms  of  the  disease ;  but  the  retina  falls  into 
a  state  of  more  or  less  complete  insensibility. 

The  pain  which  attends  syphilitic  iritis  varies  much  in  severity.  In  general, 
it  is  considerable  both  in  the  eye  and  round  the  orbit,  attended  by  lachryma- 
tion  and  photophobia,  and,  like  syphilitic  pains  in  the  bones,  greatly  aggra- 
vated during  the  night. 

Constitutional  symj)toms. — This  disease  is  generally  accompanied  by  very 
evident  manifestations  of  syphilitic  cachexia.  The  pulse  is  quick,  the  general 
sti-ength  impaired,  the  appetite  lost,  the  countenance  pale  or  sallow,  and  the 
skin  covered,  especially  during  the  night,  with  a  clammy  perspiration.  If 
syphilitic  iritis  has  been  long  neglected,  and  attended  with  severe  nocturnal 
pain,  the  patient  becomes  emaciated  and  greatly  enfeebled.  The  local  second- 
ary symptoms  with  which  I  have  most  frequently  found  syphilitic  iritis  associ- 
ated, have  been  pustular,  papular,  and  scaly  eruptions  on  the  face  and  over 
the  body,  and  next  to  these,, sore  throat.  The  pustules  on  the  face,  which  I 
have  met  with  as  attendants  on  syphilitic  iritis,  have  frequently  been  of  a  dark 
livid  color,  large,  hard,  and  seated  so  deeply  in  the  skin  as  almost  to  deserve 
the  name  of  tubercles.  The  scaly  eruptions  on  the  face  have  occasionally 
presented  an  approach  to  the  areolar  form  of  lepra.  Over  the  body,  again, 
where  the  eruption  has  generally  been  of  a  more  acute  character,  the  appear- 
ance has  been  that  of  numerous  circular  elevated  spots,  of  a  brownish-red 
color,  about  the  size  of  a  split  pea,  ending  in  a  desquamation  of  successive 
thin  pellicles  of  cuticle,  and  leaving  copper-colored  stains,  with  a  deficient 
state  of  the  rete  mucosum,  so  that  they  feel  depressed  when  the  finger  passes 
over  them ;  a  state  which  continues  through  life. 
34 


530  SYPHILITIC   IRITIS, 

Infantile  cases. — Iritis  is  not  uufrequently  the  consequence  of  congenital 
syphilis,  and  is  sometimes  the  first  .symptom  which  is  observed.  Besides 
zonular  redness  and  discoloration  of  the  iris,  the  surface  of  the  crystalline 
capsule  in  such  cases  is  apt  to  become  quite  red.  The  pupil  closes  after  a 
time,  the  anterior  chamber  fills  with  pus,  and  the  cornea  becomes  opaque. 
The  usual  copper-colored  eruption  appears  over  the  body.  The  infant  may 
have  derived  the  disease  from  the  father,  without  the  mother  having  shown 
any  syphilitic  symptom. 

Exciting  causes. — Although  this  disease  is  unquestionably  an  effect  of  the 
contamination  of  the  constitution  by  syphilis,  and  although  it  commences, 
in  many  cases,  without  any  known  exciting  cause,  yet  it  not  unfrequently 
happens  that,  like  other  secondary  symptoms  of  syphilis,  and  especially  sore 
throat,  it  is  excited  by  exposure  to  cold.  Slight  blows  on  the  eye,  imprudent 
over-exertion  of  the  organ,  and  intemperance,  seem  in  other  instances  to 
aid  in  bringing  on  this  disease,  which,  therefore,  may  be  regarded,  at  least  in 
many  cases,  as  an  effect  of  certain  external  causes  operating  on  a  constitution 
imbued  with  a  morbid  poison. 

Relapses. — Even  when  syphilitic  iritis  terminates  in  the  most  favorable 
manner,  the  eye,  for  a  long  time  afterwards,  is  peculiarly  sensitive  to  the 
influence  of  cold  and  moisture.  Oq  every  exposure  to  these,  the  sclerotic 
circle  of  inflammation  may  be  observed  to  return,  the  light  is  felt  to  be  dis- 
agreeable, and  the  eye  discharges  a  superabundant  quantity  of  tears.  For 
the  same  reason,  the  formation  of  an  artificial  pupil,  when  this  is  required 
from  the  effects  of  syphilitic  iritis,  is  generally  followed  by  such  a  degree  of 
renewed  inflammation  as  to  frustrate  the  attempt  to  restore'vision. 

Treatment. — 1.  Bloodletting  is  generally  necessary  in  syphilitic  iritis.  Dr. 
Mouteath's  testimony  on  this  point  is  valuable.  "Judging  from  my  own 
experience,"  says  he,*  "I  differ  decidedly  from  those  who  put  their  whole 
faith  in  mercury  in  the  cure  of  this  species,  to  the  exclusion  of  the  other 
remedies,  such  as  bleeding,  blistering,  &c.  In  my  own  practice,  I  have  seen 
the  disease  running  on  with  rapid  strides  to  dangerous  hypopion,  notwith- 
standing the  full  action  of  the  mercury,  and  its  further  progress  at  once  arrested 
by  a  full  bleeding  from  the  arm,  and  a  blister  on  the  hind-head." 

I  have  been  obliged  to  bleed  repeatedly  at  the  arm,  besides  applying  leeches, 
before  the  symptoms  yielded  sufficiently  to  permit  of  much  benefit  being  de- 
rived from  the  mercury  which  was  employed. 

2.  Regimen. — The  patient  must  abstain  from  animal  food  and  fermented 
liquors.  We  may  be  tempted,  when  the  system  seems  in  a  weak  and  shattered 
state  from  syphilitic  cachexia  and  other  causes,  to  put  the  patient  on  an  ani- 
mal diet,  prescribing  at  the  same  time  small  doses  of  mercury.  Under  this 
plan,  the  general  health  may  improve,  but  the  case  will  probably  end  in  closure 
of  the  pupil. 

3.  Opiate  frictions  round  the  orbit  are  carefully  to  be  employed,  about  an 
hour  before  the  nightly  attack  of  pain  is  expected;  after  which  the  eye  is  to 
be  covered  with  a  fold  of  linen,  warmed  at  the  fire.  Whenever  the  pain 
threatens  to  recur  (and  it  is  particularly  apt  to  do  so  about  midnight),  the 
opiate  friction  ought  to  be  repeated.  Laudanum,  an  infusion  of  extract  of 
belladonna  in  laudanum,  a  mixture  of  laudanum  with  tincture  of  cautharides, 
moistened  opium,  opiate  mercurial  ointment,  or  tincture  of  tobacco,  will  be 
selected  for  this  purpose,  according  to  the  circumstances  of  the  case  and  the 
opinion  of  the  practitioner. 

4.  Mercury. — Upon  this  medicine  we  place  our  chief  reliance  for  arresting 
syphilitic  inflammation  of  the  iris,  and  removing  the  morbid  changes  which 
may  have  already  been  produced  in  that  membrane,  and  in  the  pupil.  It  is 
not  an  alterative  course  of  mercury,  however,  which  is  to  be  employed.  The 
constitution  must  be  thoroughly  mercurialized,  and  the  mouth  made  distinctly 


SYPHILITIC   IRITIS.  531 

sore.  In  many  cases,  I  have  known  little  effect  produced  till  pretty  profuse 
salivation  was  established.  I  remember  one  case  in  which  mercury  had  been 
tried,  and  laid  aside  as  ineffectual,  by  the  family  doctor;  even  after  it  was  re- 
commended, it  produced  but  very  slight  benefit,  until  the  patient  having  taken 
10  grains  of  calomel,  with  5  of  opium,  daily,  for  several  days  in  succession, 
the  mouth  suddenly  became  soi'e,  and  the  iritis  went  off  as  by  a  charm.  It 
was  a  very  decided  syphilitic  case,  the  body  being  covered  by  a  copper- 
colored  eruption. 

The  combination  of  calomel  with  opium  is  the  best  form  for  exhibiting 
mercury  in  this  disease.  A  pill,  containing  2  grains  of  the  former,  with  from 
a  quarter  of  a  grain  to  a  whole  grain  of  the  latter,  may  be  given  morning, 
noon,  and  night,  till  the  gums  are  decidedly  affected;  after  which  two  pills 
daily  may  be  continued  for  some  time ;  and  when  the  mercurialization  is  more 
advanced,  one  at  bedtime  only.  This  is  the  plan  to  be  followed  in  severe 
cases,  where  it  is  important  instantly  to  arrest  the  progress  of  the  disease, 
prevent  deposition  of  lymph  into  the  pupil,  or  procure  its  absorption,  if  already 
effused.  In  milder  cases,  we  may  trust  to  a  pill  morning  and  evening  from 
the  beginning. 

Other  forms  of  mercury  have  been  employed  in  the  cure  of  this  disease, 
especially  inunction  round  the  eye,  and  corrosive  sublimate  taken  internally. 
But  neither  of  these  can  be  relied  on  when  the  symptoms  are  urgent,  and  in 
all  circumstances  they  are  greatly  inferior  to  calomel  and  opium,  the  soothing 
and  dirigent  effects  of  the  opium  being  of  no  small  importance. 

In  plethoric  subjects,  the  exhibition  of  mercury  must  be  preceded  by  vene- 
section, and  accompanied  by  evacuants  and  low  diet;  in  anaemic  cases  it  may 
be  given  along  with  the  preparations  of  iron. 

Mercm-y,  in  one  form  or  other,  will  require  to  be  continued  for  a  consider- 
able length  of  time,  that  not  only  the  iritis  may  be  arrested,  and  its  effects 
removed,  as  far  as  this  is  practicable,  but  that  the  constitutional  syphilis  also 
may  be  completely  cured.  A  removal  of  the  iritis  must  not  be  depended  on 
as  a  proof  of  the  constitution  being  freed  of  the  syphilitic  virus;  while,  on 
the  other  hand,  a  removal  of  the  constitutional  disease,  in  many  cases,  is  or 
appears  to  be  affected,  although  there  remains  much  to  be  done,  and  that 
chiefly  by  the  operation  of  mercury,  before  the  eye  is  freed  from  the  iritis  and 
its  consequences. 

5.  Iodide  of  potassium. — Cases  of  syphilitic  iritis  occasionally  occur,  where 
from  a  variety  of  circumstances,  such  as  great  weakness  of  the  patient,  or 
severe  salivation,  the  administration  of  mercury  is,  for  the  time,  altogether  in- 
admissible. The  medicine  most  to  he  relied  on,  in  such  circumstances,  is  the 
iodide  of  potassium.  From  5  to  10  grains  may  be  given,  dissolved  in  water, 
thrice  daily. 

6.  Turpentine  has  been  recommended  by  Mr.  Hugh  Carraichael,  of  Dublin, 
in  syphilitic  iritis  and  other  deep-seated  inflammations  of  the  eye.  The  cases 
which  he  has  related,  afford  indubitable  evidence  that  this  medicine  has  oc- 
casionally removed  that  species  of  iritis  which  is  considered  as  syphilitic;  and 
even  after  lymph  has  been  effused  into  the  pupil,  and  tubercles  have  risen  on 
the  surface  of  the  iris,  has  restored  these  parts  to  their  perfectly  healthy  state. 
It  was  from  the  acknowledged  influence  of  turpentine  in  peritonitis,  and  from 
a  supposed  analogy  in  point  of  morbid  effects  between  inflammation  of  the 
peritoneum  and  that  of  the  iris,  in  both  cases  a  serous  membrane  being  en- 
gaged, and  in  both  adhesions  being  produced  between  surfaces  intended  to 
be  free,  that  Mr.  C.  was  led  to  use  turpentine  in  iritis.  As  it  is  in  syphilitic 
cases  chiefly  that  he  has  found  turpentine  useful,  he  is  aware  of  the  objection 
likely  to  be  started  that  this  medicine  has  never  been  known  to  possess  anti- 
syphilitic  virtues.  To  this  he  might  have  effectively  replied  by  an  appeal  to 
the  non-mercurial  treatment  of  syphilis,  and  to  the  overpowering  testimony 


532  SYPHILITIC   IRITIS. 

of  the  facts  which  he  himself  has  recorded.  He  seems  at  first  disposed,  how- 
ever, rather  to  chime  in  with  the  scepticism  of  Mr.  Travers,  who  is  at  a  loss 
to  determine  whether  what  is  generally  considered  as  syphilitic  iritis,  is  ac- 
tually a  venereal  inflammation,  or  a  symptom  which  merely  resembles  syphilis, 
or  a  disease  infri'afted  on  the  syphilitic,  or  an  etfect  produced  by  the  poison 
of  mercury.  I3ut  in  a  more  advanced  part  of  his  inquiry,  Mr.  C.  declares  in 
favor  of  the  doctrine,  that  mercury  operates  in  the  favorable  manner  in  which 
it  is  universally  acknowledged  to  do  in  syphilitic  iritis,  not  so  much  by  means 
of  any  peculiar  anti-syphilitic  property  which  it  possesses,  as  in  consequence 
of  its  power  to  excite  the  action  of  the  absorbents ;  and  this  same  sorbefacient 
power  he  claims  for  the  oil  of  turpentine.  This  claim  is  abundantly  vindi- 
cated by  the  cases  which  Mr.  C.  has  related ;  and  not  only  so  but  he  has  also 
^demonstrated  that  this  medicine  possesses  a  controlling  power  over  the  inflam- 
matory process,  upon  which  the  effusion  of  lymph,  in  syphilitic  iritis,  depends. 

Although  Mr.  Carmichael  has  the  merit  of  having  brought  forward  a  new 
medicine  in  syphilitic  iritis,  of  unquestionable  utility,  he  is  by  no  means  blind 
to  the  virtues  of  other  remedies.  He  acknowledges  that  the  same  antiphlo- 
gistic and  sorbefacient  effects  which  he  has  derived  from  turpentine,  may  be 
produced  in  a  more  decided  manner  by  mercury;  while  he  very  properly 
urges,  that  the  rapidity  with  which  turpentine  pervades  the  body,  and  conse- 
quently brings  disease  under  its  influence,  together  with  the  absence  of  fever 
during  its  operation  on  the  constitution,  must  render  its  use  a  matter  of  inte- 
rest and  utility,  though  the  same  effects  might  be  accomplished,  even  in  a 
more  decided  manner,  by  other  means. 

The  dose  of  oil  of  turpentine  is  a  drachm  thrice  a  day.  Its  disagreeable 
flavor  and  nauseating  effects,  may  be  obviated  by  giving  it  in  the  form  of 
emulsion.  If  it  induces  strangury,  linseed  tea  and  camphor  julep  may  be 
administered,  or  its  use  suspended  for  a  time.  The  tendency  to  heartburn, 
which  it  sometimes  causes,  may  be  prevented  by  an  addition  of  10  or  15 
grains  of  carbonate  of  soda  to  every  ounce  of  turpentine,  or  every  8  ounces 
of  the  emulsion. 

When  the  local  inflammation  is  high,  and  acute  pain  present  in  the  eye 
and  side  of  the  head,  abstraction  of  blood  ought  by  no  means  to  be  neglected, 
notwithstanding  the  statement  of  Mr.  C.  that  he  has  frequently,  even  when 
these  symptoms  were  urgent,  relied  solely  on  the  turpentine  mixture,  and 
reaped  from  it  the  most  decided  and  expeditious  benefit.  The  condition  of 
the  bowels  will  also  require  attention;  the  beneficial  effects  of  the  turpentine 
appearing  to  be  suspended  when  constipation  is  present,  and  again  called 
forth  when  this  is  removed.  Perfect  rest,  too,  if  not  absolutely  necessary, 
W'ill  be  found  highly  conducive  to  the  complete  production  of  the  salutary 
effects  of  the  turpentine.  Mr.  C.  states,  that  in  a  few  patients  who,  from 
their  particular  situations  in  life,  were  obliged  to  continue  in  active  employ- 
ment, the  same  satisfactory  results  did  not  follow  its  exhibition,  nor  was  its 
influence  fully  established,  until  this  was  attended  to. 

In  some  of  the  cases  given  by  Mr.  C.  sedatives  were  employed  along  with 
turpentine;  such  as  opium,  henbane,  and  cicuta.  These  may  be  exhibited, 
both  internally  and  externally;  and,  of  course,  the  application  of  belladonna 
ought  not  to  be  omitted. 

Mr.  C.  states,  that  the  administration  of  turpentine  has  very  seldom  failed 
in  effecting  a  perfect  cure  of  syphilitic  iritis,  and  that  an  amendment  has 
generally  been  quite  perceptible  the  day  after  it  was  commenced.  The  ave- 
rage period  of  cure  seems,  in  his  hands,  to  have  been  about  11  days. 

Other  practitioners  have  not  reported  so  favourably  of  this  remedy.  Mr. 
Guthrie  states'*  that  "  in  some  cases  it  has  succeeded  admirably ;  in  others, 
it  has  been  of  little  service;  and  in  some,  unequal  to  the  cure  of  the  com- 
plaint."    Mr.  Foote,  junior,*  is  inclined  "to  think  that  turpentine  acts  by 


PSEUDO-SYPHILITIC   IRITIS.  533 

exciting  irritation  in  the  intestinal  canal  and  urinary  apparatus."  He  states, 
that  the  cases  which  had  been  most  successful  under  his  observation,  were 
those  in  which  severe  strangury  was  excited.  When  it  was  found  impossible 
to  produce  this  kind  of  irritation,  no  benefit  was  experienced. 

T.  Sulphate  of  quina. — Dr.  Colles  states,^  that  if  iritis  takes  place  when 
the  system  is  beginning  to  throw  off  a  smart  salivation,  if  we  have  used 
mercury  for  the  cure  of  iritis,  and  produced  ptyalism,  without  effecting  much 
improvement  in  the  state  of  the  eye,  or  if  mercury  is  not  acting  in  a  kindly 
manner  on  the  system,  we  cannot  attempt  to  cure  the  disease  by  mercury, 
but  must  have  recourse  to  other  means.  He  states  sulphate  of  quina  to  be 
the  remedy  which  he  has  most  frequently  employed  under  such  circumstances, 
and  generally  with  the  happiest  effect.     He  recommends  large  doses. 

8.  Belladonna  is  to  be  painted  liberally  on  the  eyebrow  and  eyelids,  night 
and  morning;  and  when  the  acute  symptoms  have  subsided,  a  filtered  aqueous 
solution  of  it,  or  a  solution  of  sulphate  of  atropia,  may  be  dropped  several 
times  a  day  upon  the  conjunctiva.  This  remedy  ought  to  be  continued  regu- 
larly for  months,  unless  the  pupil  has  completely  regained  its  natural  freedom 
and  mobility. 

9.  Nauseants,  sudorifics,  diuretics,  jnircjatives,  and  counter-irritation  hy 
blisters,  have  each  their  use  in  syphilitic  iritis.  Blisters  prove  highly  ser- 
viceable after  depletion,  and  after  the  gums  are  touched  by  mercury. 


'  The  appearance  of  such  a  cyst,  in  rheuma-  °  Glasgow  Medical  Journal;  Vol.  ii.  p.  59; 

tic  iritis,  must  be  regarded  as  quite  anomalous.  Glasgow,  1829. 

I  may   here   mention    another   appearance  of  '  London  Medical  Gazette ;  Vol.  iv.  p.  599  ; 

similar  character,  which  I  once  observed  in  a  London,  1829. 

case  of  rheumatic  iritis — viz.,  the  whole  sur-  *  London  Medical  and  Surgical  Journal  for 

face  of  the  iris  strewed  with  red  vessels.     The  September  1831,  p.  229. 

case  was  of  three  weeks'  standing;  yet  there  '  Practical    Observations    on    the    Venereal 

was  no  effusion  of  lymph,  and  the  pupil  was  Disease  and  on  the    Use  of  Mercury,  p.  165  ; 

regular.  Loudon,  1837. 


SECTION   XXII. — PSEUDO-SYPHILITIC   IRITIS. 

(S'yH.— Iritis  syphiloidea. 

It  is  generally  admitted,  that  there  are  various  diseases,  either  communi- 
cated by  impure  venereal  intercourse,  or  arising  in  the  system  without  any 
communication  of  that  sort,  which  present  a  series  of  morbid  phenomena, 
milder  and  more  rapid  in  general,  but  still,  in  many  respects  similar  to  those 
of  syphilis.  Till  a  more  accurate  description  of  the  diseases  in  question  be 
obtained,  we  may  be  allowed  to  speak  of  them  as  syphiloid  or  pseudo- 
syphilitic. 

The  pustular  eruption  spoken  of  by  Bateman,  under  the  name  of  ecthyma 
cachecticum,  appears  to  be  one  of  the  disorders  apt  to  be  confounded  with 
true  syphilis  ;  and  there  is  no  doubt  that  it  occasionally  affects  the  iris,  in  a 
manner  closely  resembling  the  iritis  we  have  just  been  considering. 

This  disease  occurs.  Dr.  Bateman  tells  us,  in  connection  with  a  state  of 
cachexia,  apparently  indicative  of  the  operation  of  a  morbid  poison.  It 
much  resembles  some  of  the  secondary  symptoms  of  syphilis,  and  is  often 
treated  as  syphilitic,  although  there  can  be  no  doubt  that  it  originates  fre- 
quently, if  not  always,  from  derangement  of  the  general  health,  independent 
of  anything  like  infection. 

It  generally  commences  with  a  febrile  paroxysm  which  is  sometimes  con- 
siderable. In  the  course  of  two  or  three  days,  numerous  scattered  pustules 
appear,  with  a  hard  inflamed  base,  on  the  breast  and  extremities  ;  and  these 
are  multiplied,  day  after  day,  by  a  succession  of  similar  pustules,  which  con- 


534  GONORRHCEAL   IRITIS. 

tinue  to  rise  and  decline  for  several  weeks  until  the  skin  is  thickly  studded 
with  the  eruption,  under  various  phases.  For,  as  the  successive  pustules  go 
through  their  stages  of  inflammation,  suppuration,  scabbing,  and  desquama- 
tion, at  similar  periods  after  their  rise,  examples  of  all  these  conditions  are 
necessarily  seen  at  the  same  time  ;  the  rising  pustules  exhibiting  a  bright  red 
hue  at  the  base,  which  changes  to  a  purple  or  chocolate  tinge  as  the  inflamma- 
tion declines,  and  the  little  laminated  scabs  form  upon  their  tops.  When 
these  fall  off,  a  dark  stain  is  left  upon  the  site  of  the  pustules.  The  eruption 
is  sometimes  confined  to  the  extremities,  but  it  frequently  extends  also  over 
the  trunk,  face,  and  scalp. 

The  febrile  symptoms  are  diminished,  but  not  removed,  on  the  appearance 
of  the  eruption ;  for  a  constant  hectic  continues  daring  the  progress  of  the 
disease.  It  is  accompanied  by  great  languor,  and  much  depression,  both  of 
tlte  spirits  and  muscular  strength  ;  by  headache,  and  pains  of  the  limbs ;  and 
restlessness  and  impaired  digestion,  with  irregularity  of  the  bowels.  There 
is  commonly  some  degree  of  conjunctivitis,  and  the  fauces  are  the  seat  of 
slow  inflammation,  accompanied  by  superficial  ulcerations. 

This  disease  is  stated  by  Bateraan  to  continue  from  two  to  four  months,  in 
the  course  of  which  time,  by  the  aid  of  vegetable  tonics,  cinchona,  sarsapa- 
rilla,  serpentaria,  &c.  with  antimonials,  and  the  warm  bath,  the  constitution 
gradually  throws  off  the  morbid  condition  which  gives  rise  to  it.  He  adds 
that  the  administration  of  mercury  is  neither  necessary  to  its  cure,  nor  appears 
to  accelerate  recovery.^ 

Dr.  Monteath  tells  us  that  the  resemblance  of  the  iritis  produced  by  this 
eruption  to  that  which  is  the  consequence  of  syphilis,  is  so  striking,  that  for 
several  years  of  his  practice  he  invariably  treated  the  cases  he  met  with,  and 
successfully,  by  the  free  use  of  mercury,  believing  them  to  be  syphilitic.  "The 
small  circle  of  the  iris,  and  the  border  of  the  pupil,"  adds  he,  "are  often 
studded  with  the  small  reddish-yellow  papula3  or  pustules,  so  characteristic 
of  the  venereal  iritis.  It  was  in  consequence  of  several  such  cases  applying 
to  me  with  the  disease  evidently  declining,  and  the  pupil  clearing,  after  two 
or  three  weeks'  continuance,  without  the  patient  having  partaken  of  one  grain 
of  mercury,  and  sometimes  almost  without  any  treatment  that  could  have 
been  useful,  that  I  first  saw  my  error,  and  felt  satisfied  that  these  cases  were 
not  syphilitic."^ 

Notwithstanding  the  possibility  of  this  iritis  being  cured  without  mercury, 
and  the  fact  that  it  is  occasionally  aggravated^  by  an  attempt  to  mercurialize 
the  system,  still  an  alterative  course  of  this  medicine  is  to  be  omitted,  neither 
in  this  nor  in  any  of  the  other  syphiloid  varieties  of  iritis.  They  will  in 
general  yield  to  such  a  course,  aided  by  sarsaparilla,  local  bleeding,  blisters 
behind  the  ears,  the  application  of  belladonna,  mild  diet,  quietude  of  the 
general  frame,  and  rest  of  the  inflamed  organ.  Turpentine,  as  recommended 
by  Mr.  Carmichael  for  syphilitic  iritis,  is  worthy  of  a  trial  in  the  cases  in 
question. 

'  Practical  Synopsis  of  Cutaneous  Diseases,  '  See  a  case  which  occurred  in  the  practice  of 

p.  187  ;  London,  1819.  Mr.  Arnott,  related  in  the  Quarterly  Journal  of 

-  Glasgow  Medical  Journal ;  Vol.  ii.  p.  138  ;  Foreign  Medicine  and  Surgery;  Vol.  i.  p.  78  ; 

Glagow,  1829.  London,  1819. 


SECTION   XXni. — GONORRIKEAL   IRITIS. 


That  the  urethral  discharge  in  gonorrhoea  is  productive,  through  the  me- 
dium of  the  constitution,  of  synovitis  and  iritis,  has  generally  appeared  so 
improbable,  that  the  fact  has  been  very  slowly  admitted  by  medical  practi- 
tioners.* 


GONORRHEAL  IRITIS.  535 

The  inflammation  of  the  synovial  membranes,  which  arises  from  gonorrhoea, 
seldom  occurs  until  the  decline  of  the  discharge  from  the  urethra.  It  affects 
the  large  joints,  and  especially  the  knees  ;  is  attended  with  copious  effusion 
into  the  synovial  cavities,  and  a  corresponding  degree  of  swelling ;  and  is 
spoken  of  under  the  name  of  gonorrhceal  rheumatism.  The  pain  and  fever, 
which  attend  it,  are  generally  severe,  and  the  cure  tedious.  ^ 

Symptoms. — The  iritis  which  owes  its  origin  to  gonorrhoea,  may  or  may 
not  be  preceded  by  synovitis.  In  general,  the  inflammation  of  the  eye  is 
very  severe.  It  often  commences  with  redness  of  the  conjunctiva  and  scle- 
rotica, and  a  striking  haziness  of  the  lining  membrane  of  the  cornea.  The 
inflammation  speedily  affects  the  anterior  surface  of  th6  iris,  which  loses  its 
natural  color.  The  disease  for  some  days  appears  to  be  an  aqno-capsulitis. 
It  then  merges  into  an  iritis  serosa.  The  pupil  becomes  contracted,  and  the 
vision  dim.  A  profuse  effusion  of  coagulable  lymph  now  takes  place,  speedily 
filling  the  pupil,  and  sometimes  falling  down,  in  a  curd-like  form,  and  in  con- 
siderable masses,  into  the  anterior  chamber.  In  some  cases,  the  anterior 
surface  of  the  iris  is  covered  with  lymph,  as  if  coated  with  white  paint.  The 
anterior  chamber  is  sometimes  almost  filled  with  the  effused  lymph.  In  fact, 
no  other  variety  of  iritis  presents  this  symptom  in  the  same  degree.  There 
is,  in  general,  violent  pain  in  and  round  the  eye,  with  epiphora  and  intolerance 
of  light.  I  have  seen  considerable  chemosis,  or  conjunctival  oedema  attend 
gonorrhceal  iritis ;  but  there  is  no  purulent  discharge  from  the  conjunctiva. 
There  are  no  tubercles  or  abscesses  on  the  surface  of  the  iris,  as  in  syphilitic 
iritis.  The  pupil,  if  the  case  is  left  to  itself,  remains  contracted,  and  adhe- 
rent to  an  opaque  capsule,  with  the  retina  much  more  sensible,  the  iris  less 
changed  in  structure,  and  the  eyeball  altogether  less  thoroughly  disorganized, 
than  in  syphilitic  iritis,  but  with  a  great  disposition  left  for  relapse. 

The  patients  who  have  been  observed  to  suffer  from  gonorrhceal  synovitis 
and  iritis,  have  generally  been  young  men  of  scrofulous  constitution,  who 
lived  hard,  and  were  careless  of  exposure  to  cold.  Each  time  the  patient 
catches  gonorrhoea  he  is  liable  to  an  attack  of  synovitis  or  iritis,  or  suffers  first 
from  the  one  and  afterwards  from  the  other.  In  some  cases,  however,  there 
has  been  no  new  gonorrhoea,  although  a  second  or  third  attack  of  inflamma- 
tion has  affected  the  joints  or  the  eye.  Over-exertion  of  sight  has  sometimes 
produced  a  new  attack  of  severe  gonorrhoea!  iritis.  Generally  one  eye  only 
is  affected ;  sometimes  the  same  eye  suffers  repeatedly.  In  other  instances, 
first  the  one  eye  is  attacked,  and  next  time  the  other  is  inflamed.  Rarely  are 
both  eyes  affected  at  once. 

The  patient  is  generally  troubled  with  gleet,  when  the  iritis  occurs.  In 
some  cases,  the  iritis  alternates  with  synovitis  and  gonorrhoea,  so  that  when 
one  of  them  is  present,  the  others  are  gone.  It  rarely  happens  that  all  three 
are  present  at  once.  In  many  instances,  the  patients  are  harassed  for  years 
by  a  succession  of  the  three,  and  at  last  are  left  in  a  state  of  great  debility, 
their  sight  much  impaired,  and  several  of  their  joints  incapable  of  motion. 
An  eruption  (ecthyma  cachecticum  ?)  covers  in  some  the  scalp  and  the  extre- 
mities, and  the  nails  of  the  fingers  and  toes  are  de.^^troyed. 

Prognosis. — The  gonorrhceal  is  generally  more  rapid  in  its  progress  than 
any  of  the  other  varieties  of  iritis,  and  is  one  of  the  most  severe  and  formida- 
ble while  it  lasts;  but  it  yields  more  promptly  to  decided  treatment  than  any 
of  the  rest,  and  affords  examples  of  perfect  recovery,  even  when  the  aqueous 
chambers  are  filled  with  lymph.  In  no  other  variety  of  iritis  is  the  recovery 
so  striking  and  complete.  A  first  or  second  attack,  energetically  treated, 
gives  way  readily,  and  absorption  proceeds  rapidly,  so  that  it  is  rarely  the 
case  that,  under  such  circumstances,  tags  are  left  between  the  iris  and  the 
capsule.  The  patient  often  suffers  several  severe  attacks,  and  yet  vision  is 
preserved  entire.     It  is  only  from  very  numerous  relapses,  and  when  the 


536  .  GONORRHQEAL  IRITIS. 

treatment  has  been  oi'iginally  mismanaged,  that  the  pupil  is  left  irregular  and 
contracted,  and  vision  permanently  deteriorated. 

After  the  lymph  in  the  anterior  chamber  and  within  the  verge  of  the  pupil 
is  absorbed,  a  cake  of  it  is  sometimes  seen  lying  on  the  centre  of  the  capsule. 
This  is  also  absorbed.  Although  the  disposition,  then,  to  an  effusion  of 
lymph  is  greater  than  in  any  other  iritis,  the  tendency  to  organization  of  the 
effused  lymph  is  less  than  in  the  other  varieties. 

Treatment. — Repeated  and  copious  venesection;  leeches  round  the  eye; 
calomel,  with  opium,  in  frequent  doses,  so  as  rapidly  to  affect  the  system; 
and  the  application  of  belladonna,  make  up  the  treatment. 

If  the  calomel  pui*^es  at  first,  the  benefit  is  augmented ;  if  it  does  not  do 
so,  a  dose  of  castor  oil  should  be  repeated  occasionally  during  the  treatment. 
I  have  treated  the  disease  very  successfully  with  mercurial  frictions,  after  de- 
pletion had  been  freely  employed. 

The  cure  of  gonorrhoeal  iritis  is  not  to  be  trusted  to  any  preparation  of 
iodine,  although  the  synovitis,  which  it  generally  follows,  and  with  which  it 
is  apt  to  alternate,  is  greatly  benefited  by  iodide  of  potassium,  in  doses  of 
8  grains  thrice  a  day,  or  by  proto-iodide  of  mercury,  in  doses  of  1  grain 
thrice  a  day,  made  into  pills  with  liquorice,  or,  if  it  acts  on  the  bowels,  with 
catechu. 

Counter-irritation,  and  especially  blisters  to  the  temple,  do  good  in  this 
variety  of  iritis. ^ 

Case  281. — Major  ,  aged  25,  contracted  gonorrhoea  in  July,  1809.     In  about  a 

fortnight  after  the  appearance  of  the  disease,  he  was  seized  witli  the  usual  symptoms  of 
hernia  humoralis.  As  these  abated,  pain  and  swelling  commenced  in  the  right  knee; 
and  being  at  this  time  under  the  necessity  of  travelling  in  an  open  carriage  for  a  couple 
of  days,  at  the  end  of  the  journey  the  pain  and  swelling  had  extended  to  the  other  knee, 
and  to  the  foot  and  toes,  especially  the  articulation  of  the  great  toe.  Suffering  under 
excruciating  pain,  and  wholly  deprived  of  the  use  of  his  limbs,  he  came  under  the  care  of 
Sir  Henry  Halford ;  but  no  treatment  seemed  to  possess  any  power  in  removing  the 
complaint ;  and  in  addition,  his  right  eye  was  suddenly  attacked  by  a  very  violent  in- 
flammation, which  threatened  destruction  to  the  organ.  Having  given  up  the  use  of 
medicine,  he  went  to  the  country  for  the  restoration  of  his  health ;  and  after  being  there 
three  weeks,  the  gonorrhoea  again  increased  without  any  abatement  of  the  other  symp- 
toms. The  swelling  and  stiff"uess  of  the  joints  rendered  him  scarcely  able  to  crawl  with- 
out assistance.  The  use  of  the  warm  bath  and  a  residence  by  the  sea  were  recommended. 
From  the  former,  he  experienced  little  apparent  benefit;  but  after  a  very  tedious  conva- 
lescence of  two  years,  he  found  himself  able  to  join  his  regiment  in  Spain.  From  this 
time  he  recovered  the  wonted  use  of  his  limbs,  and  experienced  no  return  of  his  com- 
plaint, though  exposed  to  all  the  hardships  of  the  campaign  of  1812.  After  exposure  to 
a  current  of  air  when  in  a  state  of  perspiration,  he  was  seized  with  an  intermittent  fever, 
and  obliged  to  return  to  England.  At  this  time  he  had  some  increase  of  the  stiff'ness  of 
his  joints.  He  continued  to  suff"er  from  ague,  and  an  impaired  state  of  health,  for  nearly 
twelve  months,  when  he  returned  to  the  active  duties  of  his  profession,  and  for  some  time 
enjoyed  perfect  health,  and  the  free  use  of  all  his  joints,  till  December  1814,  when  he 
again  contracted  gonorrhoea,  with  symptoms  of  unusual  violence.  In  a  fortnight  the 
discharge  began  to  abate,  and  violent  pain  with  swelling  attacked  the  great  toe  and  me- 
tatarsal ligaments  of  the  right  foot.  The  disease  then  proceeded  to  the  knees,  with  the 
same  violence  of  pain  and  swelling  as  on  the  former  occasion.  As  the  violence  of  the 
symptoms  began  to  abate  in  the  knees,  the  left  eye  was  attacked  by  violent  ophthalmia, 
which  excited  great  alarm  for  its  safety. 

Dr.  Vetch  saw  this  patient  in  his  convalescence  from  both  the  attacks  of  ophthalmia. 
The  last  inflammation  of  the  eye  appeared  to  have  had  its  seat  in  the  sclerotic  coat ;  and 
on  examining  it  more  closely,  Dr.  V.  found  ,an  irregular  and  conti'acted  pupil,  with  some 
opacity  of  the  capsule  of  the  lens,  and  adhesion  between  it  and  the  iris.  On  causing  him 
to  shut  the  sound  eye,  the  vision  of  the  left  was  found  very  much  impaired.  Under  the 
use  of  belladonna  and  the  muriate  of  mercury,  the  eye  ultimately  recovered  beyond  what 
Dr.  V.  had  encouraged  the  patient  to  expect.  Great  thickening  of  the  synovial  mem- 
brane of  the  knee-joints  remained  in  1816,  and  the  patient  was  still  incapable  of  stand- 
ing or  walking.     The  urethra  continued  subject  to  returns  of  gonorrhoeal  discharge.^ 

The  following  particulars  of  this  case  are  deserving  of  attention :  On  the 
first  attack  of  ophthalmia,  the  right  eye  was  the  seat  of  the  disease;  on  the 


GONORRHCEAL   IRITIS. 


537 


second,  the  left ;  in  neither  was  there  any  symptom  of  purulency  or  chemosis, 
to  indicate  disease  of  the  conjunctiva  ;  the  disease  in  the  urethra  was  neither 
suppressed  nor  modified  by  the  attacks  of  ophthalmia ;  the  last  attack  Avas 
decidedly  one  of  rheumatic  inflammation  of  the  sclerotic  coat  and  iris;  an 
event  (Dr.  Vetch  thinks)  of  more  frequent  occurrence,  though  more  liable  to 
be  overlooked  in  connection  with  gonorrhcea,  than  purulent  inflammation  of 
the  conjunctiva. 


'  The  urethral  discharge  in  gonorrhoea  acts 
as  a  virus,  infecting  the  blood.  So  long  as  the 
discharge  continues,  and  still  more  if  a  new 
infection  has  happened,  the  patient  is  liable  to 
attacks  of  synovitis  and  iritis.  M.  Kicord 
(Lettres  sur  la  Syphilis,  p.  30;  Paris,  1851)  will 
not  admit  the  slightest  resemblance  between 
what  he  terms  blennorrhagic  arthrapath)/  or 
gonorrhoea!  rheumatism,  and  the  sytnptoms 
produced  in  the  osseous  system  by  syphilis. 
No  doubt!  blennorrhagic  arthritis  and  a  syphil- 
itic periostosis  or  exostosis  are  different.  The 
one  is  an  inflammation  of  the  synovial  mem- 
branes produced  by  gonorrhoea,  affecting  the 
constitution  as  a  morbid  poison;  and  the  other 
is  an  inflammation  of  the  fibrous  and  osseous 
tissues,  excited  by  another  morbid  poison,  viz  : 
syphilis. 

Gonorrhoeal  matter,  taken  from  a  non-ulcer- 
ated mucous  surface,  produces,  on  attempted 
inoculation,  no  effect  similar  to  what  is  pro- 
duced by  syphilitic  matter.  Still,  by  affecting 
the  constitution,  it  produces  very  serious  conse- 
quences. It  leads,  not  only  to  sj'novitis  and 
iritis,  but  in  some  instances  to  inflammation  of 
the  serous  membranes.  In  one  of  my  patients 
it  seemed  to  produce  chronic  peritonitis;  and 
in  another  sj'novitis,  followed  jjy  inflammation 
of  all  the  internal  serous  membranes,  with 
tubercular  depositions.  Both  cases  ended  fa- 
tally. 

[With  all  due  deference  to  Mr.  Mackenzie's 
high  authority,  and  with  the  utmost  respect  for 
any  opinion  emanating  from  such  a  source,  we 
feel  constrained  to  enter  a  caveat  against  his 
views  of  the  nature  of  gonorrhoea,  and  of  its 
ability  to  produce  constitutional  poisoning.  Ad- 
mitting the  contagious  character  of  the  purulent 
discharge  of  gonorrhoea,  we  believe,  with  Sichel, 
that  "this  property  of  blennorrhagic  mucus  is 
far  from  constituting  such  a  virulent  and  spe- 
cific character  in  blennorrhagic  affections  as  we 
are  compelled  to  admit  for  true  chancrous  sy- 
philis;" a  doctrine  which  Ricord  has,  to  our 
mind,  established  by  the  most  rigorous  experi- 
mentation that  could  be  desired.  Hence  we 
must  also  state  our  conviction  that  the  disease 
which  the  author  has  just  described  does  not 
owe  its  origin  to  the  cause  which  he  has  as- 
signed. We  do  not  think  that  either  the  author. 
Sir  Benj.  Brodie,  or  Mr.  Lawrence,  all  of  whom 
strongly  advocate  the  specific  origin  of  the  dis- 
ease in  question,  have  sustained  the  position 
they  have  assumed.  Mr.  Lawrence  admits  that 
the  disease  "is  exactly  the  same  as  rheumatic 
inflammation  of  the  sclerotica  and  iris  occur- 
ring independently  of  gonorrhoea,  and  that  as 
its  sytnptoms  must  be  referred  principally  to 
peculiarity  of  constitution,  gonorrhoeal  infection 
is  not  essential  to  their  production."  And  again 
he  says  that  "there  could  be  no  doubt  that  go- 
norrhoea had  been  contracted  in  several  cases, 
of  which  I  investigated  the  history.  In  another 
instance  the  patient  was  convinced  that  he  had 


not  received  infection,  and,  according  to  his 
description,  the  usual  characteristics  of  gonor- 
rhoea virulenta  had  been  wanting."  Sir  B.  Bro- 
die admits  that  the  discharge  from  the  urethra, 
in  some  of  tho  instances  which  he  had  seen,  was 
not  caused  by  infection.  In  one  case,  "the  dis- 
charge from  the  urethra,  brought  on  by  the  use 
of  a  bougie,  was  the  first  symptom."  Neither 
Hunter,  Sichel,  Desmarres,  Miller,  Acton,  Nela- 
ton,  Weller,  Vidal,  Druitt,  or  Wharton  Jones, 
allude  to  the  possibility  of  iritis  being  produced 
by  gonorrhoeal  infection  ;  and  Mr.  Dixon,  after 
an  experience  of  twelve  years  in  one  of  the  most 
numerously  attended  ophthalmic  hospitals  in 
existence  (the  Royal  London,  of  Moorsfield), 
says:  "I  have  never  seen  an  inflammation  of 
the  iris  which  I  could  trace  as  a  consequence  of 
mere  urethral  discharge,  unmixed  with  syphi- 
lis." Hence  the  disease,  admitting  its  existence, 
must  be  an  exceedingly  rare  one.  The  symp- 
toms ascribed  to  it  are  such  as  it  is  admitted 
occur  in  other  forms  of  iritis,  and  what  proof 
have  we  that  the  disease  is  gonorrhoeal?  the 
statement  of  the  patient  that  he  has  had  a  go- 
norrhoea, or  the  positive  observation  of  its  pre- 
sent existence  in  either  an  acute  or  chronic 
form?  Ricord  has  proved,  by  positive  experi- 
mentation and  pathological  observation,  tho 
possibility  of  a  urethral  discharge  having  for 
its  cause  or  origin  a  chancre  concealed  in  the 
urethra;  nay,  more,  he  has  established  the  fact 
that  we  have  no  other  way  of  distinguishing 
a  gonorrhoea  or  urethritis  from  a  chancre  larve 
than  by  absolute  inoculation.  The  chancre 
larve  is  undoubtedly  a  rare  form  of  primary 
syphilis;  but  it  must  also  be  admitted,  at  least, 
that  the  gonorrhoeal  is  a  very  rare  form  of 
iritis,  or  else  why  has  it  not  been  observed  by 
the  astute  authors  cited  above.  May  we  not 
therefore  refer  the  cases  reputed  gonorrheal  to 
a  syphilitic  origin  of  this  kind?  or  have  we  not 
at  least  a  right  to  demand  more  positive  proof, 
than  that  which  is  given,  of  the  gonorrhoeal 
origin  of  the  disease,  and  to  believe  the  cause 
syphilitic  until  it  has  been  proven  otherwise  by 
the  experiment  of  inoculation,  which,  it  must 
be  admitted,  is  the  only  test?  And  we  have  no 
evidence  that  such  a  test  has  been  resorted  to 
in  these  cases. — IL] 

^  Swediaur,  Treatise  upon  the  Symptoms, 
Consequences,  Nature  and  Treatment  of  Vene- 
real or  Syphilitic  Diseases;  Vol.  i.  p.  252; 
London, 1819. 

^  On  gonorrhooiil  iritis,  consult  Brodie  on  the 
Diseases  of  the  Joints;  pp.  55,  60;  London, 
1818:  Cooper's  Lectures  on  the  Principles  and 
Practice  of  Surgery,  p.  482;  London,  1835: 
Lawrence  on  the  Venereal  Diseases  of  tlie  Eye  ; 
p.  53;  London  1830  :  Graves,  London  Medical 
Gazette;  Vol.  xxiii.  p.  410:  Lawrence,  ibid, 
p.  511;  Mayo's  Cold  Water  Cure,  p.  25;  London, 
1845. 

*  Vetch's  Practical  Treatise  on  the  Diseases 
of  the  Eye;  p.  195;  London,  1820. 


538  SCROFULOUS   IRITIS. 

SECTION  XXIV. — SCROFULOUS  IRITIS. 

St/n. — Ophthalmia  scrofulosa  interna. 

The  iris  is  occasionally  the  seat  o^  primary  scrofulous  inflammation,  and  a 
secondary  scrofulous  iritis  is  by  no  means  uncommon.  Cold  affecting  a  scro- 
fulous subject,  occasionally  brings  on  a  mixed  or  compound  ophthalmia,  partly 
phlyctenular,  partly  iritic  ;  or  at  least  we  meet  with  instances  in  which  inflam- 
mation of  the  latter  sort  so  quickly  supervenes  to  the  former,  that  we  may 
regard  them  as  affording  examples  of  primary  scrofulous  iritis.  Such  cases 
sometimes  assume  an  acute  course  much  more  frequently  a  chronic  one. 

1.  The  following  case,  quoted'  by  Dr.  Monteath  from  the  journals  of  the 
Glasgow  Eye  Infirmary,  affords  a  good  illustration  of  acute  primary  scrofu- 
lous iritis. 

Case  282. — Robert  Fleminster,  aged  IG,  applied  on  the  5th  August,  1827,  with  sclerotitis 
and  iritis  of  the  left  eye,  which  had  resisted  remedies  for  a  month.  Six  leeches  were 
applied  to  the  temple,  and  he  M-as  put  on  2  grains  of  calomel  with  a  quarter  of  a  grain  of 
opium,  morning  and  evening.  In  8  days,  the  inflammation  was  gone,  and  the  sight  re- 
stored nearly  to  its  natural  state.  On  the  17th,  he  was  dismissed  cured.  Iritis  being  of 
rare  occurrence  in  subjects  so  young,  Dr.  Monteath  suspected  this  case,  and  pointed  it 
out  as  probably  scrofulous.  What  occurred  in  the  other  eye  proved  the  suspicion  to  be 
just ;  for  on  the  24th,  the  patient  was  readmitted  for  an  attack  of  distinct  external  scro- 
fulous inflammation  of  the  right  eye,  with  pustules  and  an  ulcer  at  the  border  of  the 
cornea.  The  solution  of  the  nitras  argenti  was  had  recourse  to,  two  leeches  were  applied 
to  the  temple,  and  a  blister  behind  the  ear,  and  he  was  directed  to  bathe  the  eye  with  a 
very  weak  solution  of  corrosive  sublimate.  On  the  27th  he  was  no  better,  and  the  color 
of  the  iris  was  observed  to  be  changed.  It  was  now  evident  that  the  inflammation  would 
become  iritic,  as  it  had  done  in  the  other  eye.  Four  leeches  were,  therefore,  applied  to 
the  temple,  and  the  pills  of  calomel  and  opium  commenced  again,  as  before.  On  the  31st, 
the  inflammation  appeared  still  advancing,  and  the  iris  becoming  more  affected.  The 
leeches  were  repeated,  and  the  calomel  with  opium  continued.  In  five  days  after  this, 
the  mouth  was  sore,  and  the  inflammation  nearly  gone.  The  mercury  was  now  omitted  ; 
and,  on  the  14th  September,  he  was  dismissed  cured. 

The  readiness  with  which  this  case  of  acute  primary  scrofulous  iritis  yielded 
to  appropriate  treatment,  is  worthy  of  attention.  Whenever  iritis  is  observed 
in  a  very  young  person,  scrofula  may  be  suspected  as  the  predisposing  cause, 
the  other  species  of  iritic  inflammation  being  rare  in  childhood.  The  treat- 
ment must  be  such  as  was  employed  in  the  case  just  quoted  ;  that  is  to  say, 
in  addition  to  the  treatment  demanded  hy  scrofulous  ophthalmia,  calomel  and 
opium  must  be  given  till  the  mouth  is  affected.  The  pupil  also  ought  to  be 
kept  under  the  influence  of  belladonna. 

2.  Chronic  primary  scrofulous  iritis  is  characterized  by  the  age  of  the 
patients,  who  are  generally  children  under  puberty  ;  its  slowness  compared 
with  the  progress  of  the  other  species ;  the  disease  being  generally  attended 
with  but  slight  pain,  the  inflammation  in  a  great  measure  confined  to  the 
serous  covering  of  the  iris,  and  productive  of  very  little  lymphatic  effusion. 
In  such  cases,  zonular  redness  of  the  sclerotica,  greenness  and  darkness  of  the 
iris,  and  fixedness  of  the  pupil,  may  often  be  observed  for  many  weeks 
together,  without  any  further  morbid  change,  so  slow  is  the  progress  of  the 
disease.  There  is  also,  in  many  cases,  little  or  no  pain  or  fever,  and  the 
patient  often  sleeps  well.  At  length  the  pupil  is  observed  to  be  tagged  to 
the  capsule,  the  capsule  becomes  partially  opaque  from  effused  lymph,  while, 
the  disease  spreading  to  the  retina,  vision  is  more  or  less  seriously  impaired. 
Allowed  to  proceed  in  its  course,  the  disease  is  now  attended  with  more  pain 
in  and  round  the  eye,  and  sometimes  with  considerable  intolerance  of  light. 
The  iris  bulges  forward  towards  the  cornea,  the  pupil  is  obliterated,  and  the 
cornea  and  anterior  half  of  the  eye  become  unnaturally  convex ;  myopia, 
hardness  of  the  eye,  and  amaurosis  follow  more  or  less  promptly.     In  some 


SCROFULOUS   IRITIS.  539 

cases,  the  eyeball  becomes  boggy  and  atropic.     In  other  cases,  the  inflam- 
mation and  thinning  of  the  sclerotica  supervene. 

Chronic  primary  scrofulous  iritis  is  apt  to  follow  the  healing  up  of  porrigo 
capitis.  It  is  also  excited  by  over  exertion  of  the  sight,  and  by  too  much 
exposure  of  the  eye  to  bright  gas-light. 

This  disease  is  not  easily  cured,  especially  after  it  has  continued  for  a  con- 
siderable length  of  time.  It  is  not  nearly  so  much  under  control  as  rheu- 
matic, or  even  syphilitic  iritis. 

Tonics  are  undoubtedly  useful  in  chronic  scrofulous  iritis,  as  in  all  other 
scrofulous  diseases.  Much  good  will  generally  be  accomplished  by  change 
of  air,  and  the  use  of  sulphate  of  quina.  When  there  is  merely  intolerance 
of  light,  smallness  of  the  pupil,  dulness  or  discoloration  of  the  iris,  with 
zonular  redness,  without  effused  lymph  or  adhesions  of  the  pupil,  mercury  is 
not  called  for,  and  sulphate  of  quina  is  more  likely  to  do  good.  But  it  can- 
not be  denied,  that  against  effusion  of  lymph  in  scrofulous  iritis,  mercury  is 
the  most  eifectual  remedy,  and  quina  is  not  to  be  trusted.  When  the  subject 
is  feeble  and  feverish,  with  effusion  of  lymph  into  the  pupil,  sulphate  of 
quina  may  be  given,  along  with  calomel  and  opium.  I  lately  attended  a 
young  man  with  chronic  scrofulous  iritis,  who  derived  much  benefit  from  6 
grains  of  sulphate  of  quina  daily,  calomel  with  opium  at  bedtime,  friction  of 
the  head  with  laudanum  and  belladonna,  and  fomentations  of  the  eyes  with 
belladonna  and  hot  water.  The  iodide  of  potassium,  in  doses  of  5  grains, 
thrice  a-day,  proves  useful. 

3.  A  similar  plan  of  cure  must  be  followed  in  cases  of  secondary  scrofu- 
lous iritis.  We  call  this  variety  secondary,  not  only  because  an  inflammation 
of  the  cornea  is  the  usual  precursor  of  any  affection  of  the  iris,  but  because 
the  iritis  appears  to  arise  more  in  consequence  of  the  continuance  of  corneitis 
or  of  aquo-capsulitis,  and  the  spread  of  inflammation  from  one  part  of  the 
eye  to  another,  than  from  any  new  external  or  internal  cause  operating  on 
the  iris  itself.  I  have  already  hinted  (p.  513)  at  the  difficulty  of  discerning 
through  the  inflamed  cornea,  the  exact  state  of  the  iris  and  the  pupil.  Seve- 
ral of  the  symptoms,  also,  which  attend  scrofulous  corneitis  and  iritis,  are  of 
an  equivocal  sort ;  for  the  zonular  inflammation  of  the  sclerotica,  the  supra- 
ocular or  circumorbital  pain,  and  the  impaired  state  of  vision,  are  common 
to  iritis,  corneitis,  and  aquo-capsulitis,  in  their  separate  state,  as  well  as  when 
iritis  is  combined  with  either  of  the  other  two.  When  the  opacity  of  the 
cornea  is  not  very  great,  we  shall  be  able,  however,  to  discern  at  least  the 
size,  and  degree  of  mobility  possessed  by  the  pupil.  If  that  aperture  is  con- 
tracted, irregular,  and  motionless,  there  can  be  no  doubt  that  iritis  is,  or  has 
been  present.  But  in  many  cases,  by  concentrating  the  light  upon  the  cor- 
nea through  a  double-convex  lens,  we  may  observe  even  the  discoloration  of 
the  iris,  the  tags  between  it  and  the  capsule,  and  the  whitish  web  of  lymph  in 
the  pupil. 

Neglected  cases  of  this  compound  ophthalmia  are  frequently  met  with,  in 
which,  from  the  low  state  of  the  inflammation  and  slightness  of  the  pain, 
the  disease  has  been  allowed  to  go  on  for  years,  till  at  last  vision  has  become 
almost  extinct.  A  remarkable  circumstance  in  such  neglected  cases,  is  the 
great  degree  of  softness  or  bogginess  which  both  the  cornea  and  the  sclerotica 
present,  on  being  pressed  with  the  finger.  This  I  regard  as  a  very  unfavor- 
able sign  ;  denoting  an  atrophic  condition  of  the  vitreous  humor,  always  at- 
tended by  a  considerable  degree  of  amaurosis. 

Whenever  iritis  is  observed  to  coexist  with  scrofulous  corneitis,  an  attempt 
must  be  made  by  mercury  and  belladonna,  to  counteract  the  narrowed  state 
of  the  pupil,  and  the  effusion  of  lymph  from  the  iris.  From  the  peculiar 
constitution  of  the  subjects  of  this  iritis,  as  well  as  the  chronic  nature  of  the 


540  SCROFULOUS   IRITIS. 

disease,  the  administration  of  mercury  must  be  conducted  M'itli  more  than 
ordinary  caution  and  patience  ;  the  gums  will,  in  the  first  instance,  require 
to  be  decidedly  affected,  after  which  repeated  gentle  courses  of  the  medicine 
will  be  necessary,  while  the  system  must  be  supported  during  the  intervals, 
by  nourishing  diet  and  the  use  of  tonics,  and  especially  sulphate  of  quina. 

We  must  beware  of  employing  stimulants,  with  the  view  of  clearing  the 
cornea,  so  long  as  there  is  any  suspicion  of  active  inflammation  being  present 
in  the  iris ;  else  we  may  readily  bring  on  such  a  degree  of  irritation,  as  shall 
end  in  annihilation  of  the  anterior  chamber,  and  of  course  in  irreparable  loss 
of  sight, 

[Although  the  author  alludes,  under  the  head  of  non-malignant  tumors  of 
the  iris,  to  the  formation  of  scrofulous  tubercles  on  that  tissue,  he  seems  to 
have  entirely  overlooked  their  occurrence  in  the  disease  which  he  has  just 
considered;  whereas  Dr.  Jacob,  of  Dublin,  states  as  his  belief  that  this  is  the 
only  form  of  iritis  in  which  we  meet  with  deposits  on  the  iris  resembling  the 
condylomata  of  the  syphilitic  form  of  the  disease.  These  deposits  are,  how- 
ever, not  simply  coagulable  lymph,  as  in  the  latter  disease,  but  are  tubercular 
matter,  "and  instead  of  being  absorbed  as  the  matter  is  in  syphilitic  iritis,  it 
increases  in  bulk,  and  either  bursts  as  an  abscess  externally,  or  sometimes — 
but  very  rarely — into  the  aqueous  humor."  So  great  is  the  value  that  Dr.  J. 
attaches  to  the  presence  of  these  deposits,  that  he  considers  "them  to  be  the 
most  characteristic  and  unequivocal  proof  of  the  scrofulous  nature  of  the  dis- 
ease," and  deems  "all  the  other  changes  in  structure  to  be  but  corroborative 
evidence  of  its  specific  nature,  taken  in  connection  with  constitutional  symp- 
toms." 

We  have  recently  had  under  care  at  the  Wills  Hospital,  an  exceedingly  interesting  case 
of  the  kind  in  a  colored  boy  of  well-marked  strumous  diathesis,  about  seventeen  years  of 
age,  who  had  never  had  any  symptoms  of  syphilitic  disease,  or  been  in  any  way  exposed 
to  its  contagion.  He  was  attacked  with  primary  iritis  a  short  time  before  applying  for 
relief  at  the  hospital,  indicated  by  dimness  of  sight,  pain  confined  to  the  ball  of  the  eye, 
and  other  well-marked  signs  of  the  disease.  When,  however,  he  first  presented  himself 
at  the  clinique,  the  other  tunic  of  the  eye  was  involved,  the  cornea  was  hazy,  the  sclerotic 
deeply  injected,  the  pain  circumorbital  and  intolerable  at  night,  and  photophobia  and 
lachrymation  were  present  in  a  very  marked  degree.  The  disease  progressed  in  spite  of 
depletion  and  speedy  mercurialization ;  indeed,  these  remedies  seemed  rather  to  aggra- 
vate than  control  it,  and  at  the  end  of  the  second  week,  a  small  yellowish  tubercle,  some- 
what larger  than  a  pin's  head,  could  be  perceived  on  the  surface  of  the  iris,  midway 
between  the  pupillary  and  the  ciliary  margins,  and  on  the  inner  side.  When  he  next 
presented  himself  at  the  hospital,  this  little  abscess  had  given  way,  and  there  was  to  be 
seen  a  small  quantity  of  ropy-looking  matter  at  the  most  pendant  part  of  the  anterior 
chamber.  The  symptoms  of  deep-seated  ophthalmia  still  persisted  in  all  their  force,  and 
turpentine  emulsion  and  blistering  were  ordered  in  place  of  depletion  and  mercury.  But 
this  change  in  treatment  seemed  in  no  way  to  benefit  the  case,  and  at  the  end  of  ten  days, 
the  cornea  having  become  still  more  cloudy,  we  could  just  perceive  a  yellowish  spot  on 
the  opposite  side  of  the  iris,  but  nearer  its  ciliary  margin  than  the  first.  In  the  course 
of  three  days  this  spot,  which  was  originally  of  the  same  size  with  the  first  abscess,  could 
scarcely  be  perceived,  from  the  cloudiness  of  the  cornea,  but  it  had  probably  opened  into 
the  anterior  chamber,  as  the  hypopium  was  somewhat  increased  in  size.  The  long-con- 
tinued insomnia,  .from  the  pain  and  loss  of  appetite,  were  now  beginning  to  tell  on  the 
patient's  general  appearance,  and  he  complained  of  being  exhausted  by  hectic  and  night 
sweats.  Under  these  circumstances  he  was  ordered  cod-liver  oil,  with  iron  and  quinine, 
and  to  continue  the  fomentations  of  laudanum  and  belladonna,  which  had  been  ordered 
for  him  early  in  the  treatment  of  his  case,  and  from  which  he  had  derived  very  decided 
benefit.  Since  then  he  has  been  gradually  improving  in  health,  and  has  become  entirely 
relieved  of  all  the  distressing  symptoms  of  his  disease.  The  effusion  into  the  anterior 
chamber  has  gradually  disappeared,  and  the  cornea  has  nearly  entirely  cleared  up,  giving 
a  full  view  of  the  iris,  which  is  contracted — notwithstanding  the  incessant  use  of  bella- 
donna— and  is  very  much  altered  in  color.  Two  small  cicatrices  indicate  the  original 
seats  of  the  abscesses. — H.] 

'  Glasgow  Medical  Journal ;  Vol.  ii.  p.  132 ;  Glasgow,  1829. 


ARTHRITIC   IRITIS.  541 

SECTION   XXV. — ARTHRITIC   IRITIS. 

Syn. — Ophthalmia  arthritica.     Iritis  varicosa,  Ainmon. 

Firj.  Beer,  Band  I.  Taf.  II.  Figs.  5,  6.     Ammon,  Thl.  I.  Tab.  XV.  Fig.  3. 

The  disease  described  by  the  German  ophthalmologists  under  the  name  of 
arthritic  ophthalmia,  is  known  by  many  remarkable  characters,  and  is  un- 
questionably dependent  upon  a  peculiar  state  of  the  constitution.  The  oph- 
thalmias already  considered  are  all  of  them  connected  with  some  appreciable 
cause ;  but  I  must  confess,  the  nature  of  arthritic  ophthalmia  is  to  me  unknown. 
If  it  is  really  a  gouty  inflammation,  then  gout  is  a  much  more  frequent  dis- 
ease than  the  practitioners  of  this  country  are  disposed  to  admit,  and  often 
occurs  among  the  poor  and  ill-fed.  In  this  country,  gout  is  a  disease  rarely 
recognized  in  any  form,  except  among  the  opulent  and  luxurious  ;  while  in 
the  wine  countries  of  the  continent  of  Europe,  and  especially  in  Austria, 
where  wine  is  the  beverage  of  all  ranks,  gout,  and  especially  what  we  term 
irregular  gout,  seems  common,  even  among  the  poorest  of  the  people. 

It  is  certain  that  arthritic  iritis  rarely  occurs  in  what  may  be  termed  the 
first  or  plethoric  period  of  gout,  that  is,  while  the  patients  still  retain  strong 
powers  of  digestion,  and  having  the  means  and  the  inclination,  regale  them- 
selves with  large  supplies  of  food  and  drink.  It  is  most  apt  to  occur  in  the 
second  or  asthenic  period,  after  repeated  attacks  of  the  disease  have  pro- 
duced depression  of  body  and  mind,  with  dyspepsia,  flatulence,  languor,  and 
irregularity  in  the  excretions. 

I  have  seldom  met  with  this  disease  in  regular  gouty  constitutions.  The 
subjects  have  in  general  been  above  50  years  of  age,  of  a  sallow  complexion, 
in  many  instances  tobacco-smokers  and  whiskey-drinkers,  but  not  always  so  • 
they  have  often  labored  under  rheumatic  affections,  been  troubled  much  with 
headache,  bad  gums  and  teeth,  acidity,  flatulence,  and  lowness  of  spirits. 
While  the  other  iritides  occur  in  textures  previously  entire,  I  have  often  been 
led  to  suspect  that  the  peculiarities  of  the  arthritic  variety  arose  from  its 
attacking  textures  already  become  defective  in  sanguineous  nutrition,  from 
age  and  other  causes.  Not  being  able  to  determine  the  diathesis  which  pre- 
disposes to  this  ophthalmia,  I  use  arthritic  as  a  conventional  term,  without 
adopting  it  in  the  strict  sense  of  gouty. 

The  Germans  regard  abdominal  congestion  or  plethora  as  the  great  pre- 
disposing cause  of  arthritic  ophthalmia.  They  trace  the  plethoric  state  of 
the  abdominal  viscera  to  heavy  meals,  and  improper  food,  producing  deposi- 
tion of  fat,  costiveuess,  and  hemorrhoids.  It  is  not  improbable,  that  the 
diathesis  on  which  arthritic  ophthalmia  depends,  is  the  result  of  deteriorated 
digestion.  The  subjects  of  this  disease  are  too  often  dependent  on  stimulants 
for  their  appetite,  and  for  the  disposal  of  their  aliment.  Their  stomach  is 
likely  to  produce  unhealthy  chyle,  and  this  to  deteriorate  their  blood  ;  the 
circulation  becomes  disordered  ;  inflammatory  diseases  of  unhealthy  character 
ensue,  and  among  these  ophthalmia. 

Arthritic  iritis  originates  in  two  ways.  In  one  case,  it  is  the  primarv  and 
sole  affection  of  the  eye ;  in  another,  an  individual  of  the  peculiar  constitu- 
tion in  question  being  alfected  with  some  common  ophthalmia,  as  rheumatic, 
catarrho-rheumatic,  syphilitic,  or  traumatic,  this  degenerates  into  the  arthritic. 
The  same  thing  occasionally  happens  in  regard  to  the  rise  of  syphilitic  iritis. 
The  arthritic  originates  more  frequently  in  this  way  than  in  the  other. 

SymjJtoms. — The  general  symptoms  of  iritis  are  present  in  the  arthritic 
species;  namely,  zonular  sclerotitis,  discoloration  of  the  iris,  turbiduess  of 


.0r 


542  ARTHRITIC   IRITIS. 

the  pupil,  with  changes  in  its  shape,  size,  and  mobility,  impaired  vision,  and 

pain  in  and  around  the  eye.     These  symp- 
Fig.  70.  toms,  however,  are  associated  with  some  pe- 

/'■■■■- -M^i;?^-'--  culiarities,  and  are  modified  in  such  a  manner 

j0^'  ^^^^fc  ^^  ^°  afford  ground  for  a  ready  diagnosis. 

1.  Redness. — The  conjunctiva  is  loaded  with 
enlarged  vessels  as  well  as  the  sclerotica. 
The  redness  is  of  a  purple  hue.  The  visible 
arteries  of  the  eye,  emerging  from  the  recti 
muscles,  or  perhaps  rather  the  accompanying 
veins,  show  from  the  very  first  a  strong  dis- 
position to  become  varicose  (Fig.  64,  p.  434), 
and  at  length  are  so  strikingly  dilated  as  to 
[Arthritic  iritis.  From  w.  Jones.]         form  a  characteristic  symptom  of  arthritic 

iritis.  The  sclerotica  loses  its  natural  ap- 
pearance, and  becomes  of  a  dingy  grayish-violet  color.  Most  of  these  appear- 
ances, and  especially  the  livid  color  and  varicose  dilatation  of  the  bloodvessels, 
are  regarded  as  indicative  of  a  great  tendency  to  atony,  which  may  account 
for  this  variety  of  iritis  being  much  less  amenable  to  antiphlogistic  treatment 
than  the  others. 

2.  Secretion  from  eyelids. — The  epiphora  which  attends  arthritic  inflamma- 
tion of  the  iris,  leads  to  frequent  opening  and  shutting  of  the  eyelids,  by 
means  of  which  there  is  forced  out  from  between  them  a  peculiar  white  frothy 
matter,  which  rests  upon  their  edges,  especially  at  the  angles  of  the  eye,  and 
which  is  easily  distinguished  from  any  of  the  ordinary  secretions  of  the  con- 
junctiva or  Meibomian  follicles.  This  foam  or  froth  appears,  at  first  sight, 
to  consist  of  extremely  minute  globules  of  watery  fluid  ;  but  on  more  attentive 
observation,  it  is  found  to  consist  of  a  thickish  substance  of  a  sebaceous  nature. 
It  has  not,  I  believe,  been  chemically  examined  ;  but  it  has  been  hinted  that 
it  might  contain  urate  of  soda.  Mr.  Canton  has  observed,  that  in  proportion 
as  the  urine  becomes  charged  with  the  lithates,  this  white  deposit  is  lessened 
in  amount  at  the  canthi ;  and  states  that  where  this  symptom  was  present, 
benefit  had  been  derived  from  the  exhibition  of  alkalies,  with  the  tincture  of 
aconite  and  wine  of  colchicum.* 

3.  Arthritic  ring. — What  is  strongly  insisted  on  as  a  diagnostic  mark  of 
arthritic  iritis,  is  the  existence  of  a  narrow  ring  of  a  bluish-white  color  at  the 
edge  of  the  cornea.  This  ring  sometimes  does  not  appear,  particularly  at  the 
commencement  of  the  disease,  all  round  the  cornea,  but  only  at  its  temporal 
and  nasal  sides.  The  ring  in  question,  which  must  not  be  confounded  with 
the  arcus  senilis,  is  formed  by  the  edge  of  the  sclerotica  which  naturally  over- 
laps the  cornea,  and  which  becomes  thicker  and  more  opaque  as  age  advances. 
In  arthritic  iritis,  it  is  seen  in  contrast  between  the  abruptly  terminating  red 
sclerotic  zone  on  the  one  hand,  and  the  transparent  cornea  on  the  other.  Its 
importance  as  a  diagnostic  sign  of  arthritic  ophthalmia,  has  been  exaggerated; 
for  we  sometimes  observe  it  in  syphilitic  or  rheumatic  iritis,  especially  when 
these  occur  in  subjects  far  advanced  in  life.^ 

4.  Changes  in  the  iris  and  pupil — Glaticoma — Amaurosis — Atrophy  of  the 
eye. — Beer  has  described  the  changes  in  the  iris  and  pupil  as  varying  in  two 
different  habits  of  body.  I  have  witnessed,  however,  both  sets  of  changes 
in  the  same  individual.  In  the  right  eye,  a  patient  whom  I  saw,  presented 
the  contracted  pupil;  and  in  a  subsequent  attack  affecting  the  left  eye,  the 
expanded  pupil.  This  difference  I  conceive  to  depend  on  the  coexistence  of 
a  sensible  state  of  the  retina  in  the  one  case,  and  of  amaurosis  in  the  other. 
The  retina  being  sensible,  the  pupil  contracts  during  arthritic  ophthalmia ; 


ARTHRITIC   IRITIS.  543 

when  the  retina  is  insensible,  the  inflammation  is  not  sufficient  to  cause  closure 
of  the  pupil. 

In  some  individuals,  then,  the  pupil  contracts,  and,  being  filled  with  effused 
lymph,  becomes  adherent  to  the  capsule,  as  is  generally  the  case  in  the  other 
species  of  iritis.  In  such  cases,  the  only  characteristic  symptom,  besides  the 
white  ring  round  the  cornea,  is  a  varicose  state  of  the  bloodvessels  of  the  iris, 
so  that  after  the  disease  has  fully  developed  itself,  they  may  be  discerned  rami- 
fying on  the  surface  of  that  membrane,  or  forming  a  vascular  wreath  within 
the  verge  of  the  contracted  pupil.  The  pigment  of  the  iris  sometimes  seems 
absorbed  in  such  cases.  Fragments  of  it  are  often  seen  sticking  to  the  cap- 
sule. Not  unfrequently  the  cornea  presents  a  general  state  of  haziness  and 
roughness,  as  in  corneitis.  In  one  instance  which  came  under  my  observation, 
ulceration  attacked  the  centre  of  the  cornea,  and  penetrated  so  deep  as  to  ex- 
pose the  internal  elastic  lamina  or  membrane  of  Descemet,  which  protruding, 
gave  rise  to  a  very  large  hernia  of  the  cornea.  This  required  to  be  snipt  off, 
and  the  ulcer  to  be  touched  with  lunar  caustic,  before  cicatrization  could  be 
brought  about.  In  arthritic  iritis,  with  contracted  pupil,  if  the  eye  is  left  to 
itself,  it  does  not  suppurate,  but  its  contents  begin  to  be  absorbed,  and  at  last 
its  size  is  extremely  diminished. 

In  other  cases,  again,  the  disease  attacks  an  eye  already  amaurotic,  so  that 
we  have  a  combination  of  amaurosis  with  arthritic  inflammation.  In  such 
cases,  the  pupil  is  often  expanded  only  at  one  or  two  points  of  its  circum- 
ference, so  that  it  assumes  an  irregular  oval  shape.  The  varicose  redness  of 
the  eye,  the  frothy  secretion  on  the  lids,  the  white  ring  round  the  cornea,  and 
the  severe  pain  round  the  orbit,  are  all  present,  but  there  is  no  lymph  depo- 
sited. The  edge  of  the  pupil  is  often  fringed  with  pigment.  The  eyeball 
feels  hard,  like  a  stone.  The  crystalline  becomes  first  of  all  glaucomatous, 
and  then  cataractous.  The  subsequent  changes  which  the  eye  is  apt  to  un- 
dergo, are  those  of  which  I  shall  speak  under  the  head  of  Glaucoma. 

In  the  former  set  of  cases,  or  those  in  which  the  pupil  contracts,  there  is 
reason  to  believe  that,  occasionally  the  vitreous  humor  being  gradually  ab- 
sorbed, a  watery  effusion  takes  place  between  the  choroid  and  the  retina,  in 
consequence  of  which  the  retina  is  compressed  into  the  form  of  a  cord  stretch- 
ing from  the  entrance  of  the  optic  nerve  to  the  back  of  the  lens.*  This  state 
is  generally  attended  by  ossification  of  the  choroid.  Ossification  of  the  cap- 
sule of  the  lens  is  also  not  unfrequent  in  the  atrophic  stage  of  arthritic  iritis. 

5.  Pain. — It  sometimes  happens  that,  before  any  other  signs  of  arthritic 
ophthalmia  make  their  appearance,  the  patient  is  troubled  with  peculiar  ting- 
ling sensations  about  the  eye,  and  a  feeling  of  creeping  over  the  skin  of  the 
face.  The  eye  and  the  orbit  soon  become  the  seat  of  racking  pain,  extend- 
ing to  the  temple  and  shooting  down  into  the  jaws.  While  the  changes  of 
structure  above  detailed  are  going  on,  attacks  of  severe  pain  always  occur ; 
they  are  greatly  aggravated  in  general  towards  midnight,  but  in  some  cases 
al)ate  but  little  at  any  period  of  the  24  hours.  The  patient  is  warned  of  their 
approach  by  a  stinging  sensation  all  around  the  eye,  followed  by  an  increased 
flow  of  tears ;  after  which,  the  pain  sets  in,  and  becomes,  in  many  instances, 
so  violent,  that  the  patient  writhes  under  it,  and  utters  the  most  piercing  cries 
of  distress.     Considerable  fever  attends  the  attacks  of  pain. 

Constitutional  and  exciting  causes. — The  subjects  of  arthritic  iritis  have,  in 
general,  been  long  the  victims  of  various  affections  of  the  stomach  ;  such  as 
nausea,  vomiting,  flatulency,  acid  eructations,  and  pains  in  the  epigastrium. 
Irregular  bowels,  piles,  pains  and  cramps  in  diS'erent  parts  of  the  trunk  and 
extremities,  distortion  of  the  smnll  joints,  headache,  giddiness,  an  eruption  of 
suppurating  tubercles  on  the  face,  with  lowness  of  spirits,  prevail,  more  or  less 
in  those  who  are  attacked  by  this  species  of  ophthalmia.     One  of  the  worst 


544  ARTHRITIC   IRITIS. 

cases  I  have  seen,  was  in  an  innkeeper  who,  without  being  a  drunkard,  had 
for  many  years  labored  under  a  great  degree  of  gutta  rosacea.  Erroneous 
plans  of  diet,  a  sedentary  life,  and  an  indulgence  in  alcoholic  fluids  and  to- 
bacco, will  in  general  be  found  to  have  long  been  deteriorating  the  constitu- 
tion of  those  who  suffer  from  this  iritis. 

The  local  symptoms  already  detailed,  afford  sufficient  ground  for  diagnosis. 
But  it  may  be  added,  that  arthritic  inflammation  in  many  instances  affects  the 
eye,  as  it  does  other  parts  of  the  body,  without  any  apparent  exciting  cause, 
while  rheumatic  iritis  can  generally  be  traced  to  some  exposure  to  cold. 
Arthritic  iritis  sometimes  attacks  the  patient  in  the  middle  of  the  night,  when 
quiet  and  warm  in  bed,  arising  in  fact  from  no  external  exciting  cause,  but 
from  the  state  of  the  constitution,  influenced  perhaps  by  the  digestive  organs. 
Distress  of  mind  often  seems  the  exciting  cause. 

Prognosis. — The  prognosis  is  more  unfavorable  than  in  any  of  the  other 
species  of  iritis.  A  first  attack  may  continue  for  many  months  ;  and  though 
at  last  the  symptoms  may  yield  and  a  tolerable  degree  of  vision  be  saved,  a 
renewal  of  the  disease  is  always  to  be  dreaded,  owing  to  the  extreme  diffi- 
culty, not  to  say  impossibility,  of  removing  the  arthritic  disposition.  A  se- 
vere attack  once  a  year,  or  even  every  two  or  three  years,  ends  at  last  in 
blindness.  I  have  seen  the  patient,  while  recovering  in  one  eye,  suddenly 
seized  in  the  other.  Besides  its  obstinacy,  there  is  another  circumstance  con- 
nected with  arthritic  inflammation  of  the  eye,  which  renders  the  prognosis 
peculiarly  unfavorable ;  namely,  the  strong  tendency  which  the  disease  has 
to  affect  the  choroid,  retina,  and  humors,  so  that  though  the  attack  may  for 
several  successive  times  be  confined  chiefly  to  the  iris,  the  rest  of  the  eyeball 
becomes  at  length  implicated,  and  vision  destroyed. 

Cure. — The  three  most  important  indications  are,  to  remove  the  inflamma- 
tion, subdue  the  pain,  and  prevent  relapses. 

1.  Though  inflammation  be,  as  Dr.  Monteath  has  well  remarked,  the  prox- 
imate cause  of  all  the  evils  in  this  species  of  iritis,  as  in  the  traumatic  or  any 
other,  yet,  as  it  is  of  an  unsound  and  peculiar  nature  and  dependent  on  a 
constitutional  cause,  it  cannot  be  eradicated  by  the  vigorous  use  of  mere  an- 
tiphlogistic means.  A  notion  has  even  prevailed  that  general  bleeding  is  sel- 
dom advisable  in  arthritic  iritis,  that  it  may  aggravate  the  subsequent  course 
of  the  disease,  and  that  even  local  bleeding,  by  cupping  and  leeches,  must  be 
very  cautiously  employed.  I  have  witnessed,  however,  excellent  effects  from 
general  bleeding  in  this  disease.  With  a  full  hard  pulse,  hot  skin,  and  loaded 
tongue,  we  need  not  hesitate  to  bleed,  purge,  and  administer  colchicum ;  but 
even  when  the  pulse  has  not  been  strong,  I  have  bled  at  the  arm  and  given 
mercury,  with  much  advantage.  In  most  cases,  the  application  of  leeches  to 
the  temple,  forehead,  and  eyelids,  will  be  found  advantageous. 

The  bowels  ought  to  be  freely  opened  by  one  or  more  smart  doses  of  calo- 
mel and  colocynth,  followed  after  some  hours  by  salts  and  senna.  If  the 
tongue  still  continues  foul  and  the  mouth  bitter,  a  common  dose  of  ipecacuan 
and  tartar  emetic  may  be  of  much  service.  After  this,  the  bowels  are  to  be 
kept  open  by  purgatives,  and  the  skin  relaxed  by  some  mild  diaphoretic. 

The  vinous  tincture  of  colchicum  root  proves  useful  in  abating  arthi'itic 
inflammation  of  the  eye,  after  bleeding  and  purging  have  been  employed. 
Twenty-five  drops  may  be  given,  every  three  or  four  hours. 

The  free  use  of  mercury  is  as  unsuitable  in  arthritic  iritis  as  profuse  blood- 
letting. An  alterative  course  of  this  medicine,  however,  will  be  of  much  ser- 
vice, and  may  be  continued  for  weeks  or  months,  along  with  other  suitable 
remedies,  so  as  to  change  the  vitiated  habits  of  the  digestive  organs.  To 
arrest  the  morbid  action  of  the  capillaries,  and  check  the  effusion  of  lymph,  in 
this  iritis,  by  the  sudden  introduction  of  mercury,  as  in  other  species  of  this 


ARTHRITIC   IRITIS.  545 

disease,  has  been  found  impracticable.  Whether  any  better  effects  are  to  be 
derived  from  turpentine,  as  recommended  by  Mr.  Carmichael,  future  expe- 
rience must  determine. 

I  have  sometimes  derived  very  striking  benefit  from  the  use  of  the  precipi- 
tated carbonate  of  iron,  in  arthritic  ophthahnia,  after  depletion  and  mercury 
had  been  employed  without  relief. 

Sulphate  of  quina  is  another  remedy  which  does  good.  I  have  found  it 
very  useful,  along  with  Fowler's  solution. 

Arthritis  has  been  supposed  to  be  analogous  to  that  state  of  the  consti- 
tution in  which  uric  acid  is  deposited  from  the  urine.  If  this  is  correct,  it 
.  affords  an  explanation  of  the  benefit  derived,  in  gouty  cases,  from  alkaline 
medicines.     These  may  be  tried  in  arthritic  iritis. 

Counter-irritation,  by  blistering  and  otherwise,  is  of  great  service.  Beer 
particularly  recommends  the  bringing  out  of  an  artificial  eruption  by  means 
of  tartar  emetic  ointment.  Immersion  of  the  hands  or  feet  in  warm  water, 
sharpened  with  mustard  or  Cayenne  pepper,  is  likely  to  be  beneficial.  A  gen- 
tleman had  long  suffered  from  arthritic  inflammation  of  his  eye,  accompanied 
by  severe  pain  in  the  head.  Mr.  Wardrop  recommended  him  to  apply 
sinapisms  to  each  foot ;  and  being  a  man  of  great  fortitude,  he  allowed  them 
to  remain  on,  until  so  violent  an  inflammation  ensued,  that  it  terminated  in 
ulceration  of  the  skin  ;  but  the  pain  in  his  eyes  and  head  was  completely  re- 
lieved. Some  years  afterwards,  on  Mr.  Wardrop's  inquiring  if  he  had  ever 
had  any  return  of  the  inflammation  in  his  eyes,  he  answered  with  a  smile,  that 
the  sinapisms  had  completely  removed  it.^  Xo  patient  liable  to  attacks  of 
arthritic  iritis,  should  be  without  some  permanent  drain,  such  as  a  pea-issue 
or  cord  in  the  neck. 

Dry  warmth  is  almost  the  only  direct  application  to  the  inflamed  organ, 
which  can  at  all  times  be  used  with  impunity.  It  may  be  applied  by  means 
of  several  folds  of  old  linen  heated  at  the  fire,  hung  over  the  eye,  and  renewed 
frequently ;  or  the  eye  may  be  covered  up  with  carded  cotton.  Such  appli- 
cations exclude  the  air,  promote  an  increase  of  the  insensible  perspiration, 
and  in  this  way  are  of  use.  Cold  applications  do  harm  ;  and  even  warm  fo- 
mentations, with  poppy  decoction  and  the  like,  are  not  safe,  if  the  parts  are 
left  wet  and  exposed  after  their  application. 

2.  To  moderate  and  remove  as  quickly  as  possible  the  periodical  fits  of 
pain,  is  a  matter  of  great  importance.  For  this  purpose  Beer  recommends 
simply  opium,  moistened  to  the  consistence  of  a  liniment,  to  be  rubbed  in 
round  the  orbit.  Mercurial  ointment  with  opium  and  extract  of  belladonna, 
laudanum,  tincture  of  tobacco,  or  volatile  liniment,  may  be  used  for  the  same 
purpose.  The  friction  is  to  be  performed  when  the  evening  paroxysm  is  ex- 
pected to  recur,  and  repeated  during  the  night  if  the  pain  is  not  prevented, 
or  if  it  returns  at  any  period  of  the  day  or  night.  The  internal  use  of  opium 
ought  if  possible  to  be  avoided,  till  the  disordered  state  of  the  digestive  or- 
gans is  rectified.  Should  the  pain,  however,  become  very  urgent,  it  cannot 
be  withheld.  Considerable  relief  may  also  be  obtained  from  the  internal  use 
of  stramonium,  hyoscyamus,  belladonna,  colchicum,  and  prussic  acid,  none  of 
which  have  the  same  bad  effects  on  the  liver  and  bowels  as  opium.  I  have 
found  a  vinous  solution  of  the  bichloride  of  mercury  with  belladonna,  a  con- 
venient form  for  exhibiting  the  latter  medicine  as  a  sedative,  and  the  former  as 
an  alterative,  in  this  disease.  The  causes  which  seem  to  produce  accessions  of 
pain,  must  be  carefully  avoided ;  as,  agitation  of  mintl,  sudden  changes  of 
temperature,  &c. 

3.  Relapses  are  to  be  warded  off,  partly  by  constitutional,  partly  by  local 
means. 

The  constitutional  preventive  means  are  partlv  medicinal,  but  chiefly  diet- 
35 


546  AQUO-CAPSULITIS. 

etical.  The  general  health  must  be  confirmed  as  much  as  possible,  by  proper 
management  of  the  digestive  organs,  the  kidneys,  and  the  skin.  A  temper- 
ate diet,  careful  regulation  of  the  bowels  by  gentle  aperients,  and  a  free 
action  of  the  kidneys,  promoted  by  the  use  of  magnesia  or  soda  water,  or  of 
some  mild  aperient  and  diuretic  mineral  water,  will  be  of  much  benefit.  Daily 
tepid  sponging  of  the  body,  followed  by  dry  friction,  will  be  of  service  by 
promoting  an  abundant  secretion  from  the  skin.  The  patient  should  breathe 
pure  country  air,  and  carefully  avoiding  either  to  overheat  himself,  or  to  cool 
himself  too  quicldy,  should  engage  in  regular  and  continued  exercise  of  vari- 
ous kinds.  If  he  has  long  been  accustomed  to  wine,  he  may  be  allowed  a 
small  quantity  of  spirits  and  water. 

After  an  attack  of  gouty  inflammation  in  the  foot,  we  see  the  parts  con- 
tinue long  tumid,  weak,  and  morbidly  sensible,  while  the  most  trifling  acci- 
dent, internal  or  external,  is  apt  to  produce  a  relapse.  The  same  is  observed 
in  regard  to  the  eye,  only  that  in  this  organ  we  have  the  advantage  of  di- 
rectly witnessing  the  exceedingly  relaxed,  varicose,  and  livid  state  of  the  blood- 
vessels ;  an  indication  of  how  much  is  wanting  to  restore  the  affected  parts  to 
their  natural  tone.  After  an  acute  attack  of  arthritic  iritis  is  subdued,  re- 
course should  be  had  to  the  use  of  local  applications  of  a  tonic  kind.  As  a 
means  of  this  sort,  the  Germans  are  in  the  way  of  using  small  bags  of  dried 
aromatic  herbs,  suspended  over  the  eye.  The  bags  are  made  of  old  linen, 
and  are  quilted,  so  as  to  keep  the  herbs  equally  spread  out.  The  aroma, 
constantly  emanating  from  the  herbs,  is  supposed  to  impart  a  stimulus  to  the 
debilitated  bloodvessels  and  nerves.  Herbs  for  the  purpose  are  bruised  cliam- 
omile  flowers,  sage,  rosemary,  marjoram,  and  the  like,  with  or  without  the 
addition  of  a  little  powdered  camphor.  If  the  exhaled  aroma  reproduces 
redness  of  the  eye  or  aversion  to  light,  this  will  indicate  that  the  proper  time 
for  the  use  of  local  stimuli  has  not  yet  arrived,  and  that  they  must  be  post- 
poned. Friction  round  the  orbit,  once  or  twice  daily,  with  alcohol,  tinctura 
aromatica  ammoniata,  or  the  like,  is  another  local  preventive  measure  which 
is  found  of  use.  Even  stimulants  to  the  eye,  as  vinum  opii  and  red  precip- 
itate salve,  beginning  these  preparations  in  a  dilute  state,  and  gradually  aug- 
menting their  strength,  are  found  to  abate  the  morbid  sensibility  of  the  eye, 
and  thus  render  it  less  apt  to  suffer  from  the  ordinary  external,  as  well  as  in- 
ternal causes  of  inflammation.  It  must  not  be  forgotten,  however,  that  reme- 
dies of  this  kind,  used  before  the  acute  inflammation  is  subdued,  will,  as  in 
every  otlier  species  of  iritis,  do  harm. 


'  Medical  Times  .ind  Gazette,  April  24, 1852,  *  See  case  of  C.  D.  with  disseetion,  by  Wat- 

p_  428.  son  ;  Edinburgh   Medical   and    Surfcieal   Jour- 

*  See  Jones,  London   Medical   Gazette;  Vol.  ual  :  Vol.  xxxv.  p.  77  :  Edinburgh,  18.51. 

ixiii.  p.  817.  '  Wardrnp's    Lectures,  in   the    Lancet,   31st 

=  Cloqaet,    Pathologic    Chirurgicale ;    PI.   x.  August,  1833,  p.  713. 
fis.  13;  Paris,  1831. 


SECTION   XXVI. — AQUO-CAPSULITIS. 


Syn. — Inflammatio  tunicte  humoris  aquei.     Hj'dromeningitis  tuberculosa,  Ilasner. 
Keratite  ponctu^e,  Sichel. 

Fig.  Wardrop,  PI.  VIII.  Figs.  1,  2.     Beelf ,  Taf.  I.  Fig.  2.     D.slrymple,  PI.  XVIL  Figs.  2,  3,  5,  6. 

Sichel,  PI.  VL  Figs.  1,  3. 

By  aquo-cajjsulitis,  a  disease  first  described  by  Mr.  Wardrop  in  1808,  is 
meant  inflammation  of  the  parietes  of  the  aqueous  chambers,  and  especially 
of  the  membrane  which  lines  the  internal  surface  of  the  cornea,  and  is  partially 


AQUO-CAPSULITIS.  54T 

continued  in  the  form  of  fine  fibres  into  the  anterior  surface  of  the  iris.  The 
membrane  in  question  is  known  as  the  membrane  of  Descemet,  or  posterior 
elastic  lamina  of  the  cornea.  It  is  a  uniform,  transparent,  homogeneous  layer, 
scarcely  o oVo  i'^*^^^  thick,  and  is  covered,  on  its  internal  surface,  by  a  single 
series  of  flat  epithelial,  nucleated  particles,  constituting  the  only  true  epithe- 
lium in  contact  with  the  aqueous  humor.  The  front  neither  of  the  iris,  nor 
of  the  lenticular  capsule,  has  any  epithelium.  Although  it  is,  therefore,  in- 
correct to  speak  of  the  anterior  and  posterior  chambers  as  lined  by  a  shut  sac 
or  serous  membrane,  or  of  the  aqueous  humor  as  contained  within  a  proper 
capsule,  the  name  aquo-capsulitis,  with  these  explanations,  may  still  be  re- 
tained, to  designate  a  very  distinct  disease.^ 

We  sometimes  meet  with  this  ophthalmia  in  the  acute  form,  when  it  is  at- 
tended with  very  considerable  redness  of  the  sclerotica  and  conjunctiva;  much 
oftener  in  the  chronic,  when  a  peculiar  sort  of  opacity  of  the  cornea  is  one 
of  the  most  remarkable  symptoms.  The  subjects  of  it  are  mostly  adolescents 
or  children,  although  I  have  seen  it  in  adults,  and  even  in  old  people. 

Symptoms. — 1.  In  the  acute  form,  aquo-capsulitis  looks  like  a  partial  rheu- 
matic ophthalmia,  the  redness  consisting  chiefly  in  an  incomplete  sclerotic 
zone,  sometimes  pretty  intense.  The  conjunctival  vessels  are  also  frecjuently 
enlarged. 

2.  The  external  surface  of  the  cornea  is  at  first  perfectly  clear  and  glancing, 
but  its  lining  membrane  soon  appears  more  or  less  dim  or  opaque.  There  is 
at  the  same  time  a  muddiness  in  the  anterior  chamber,  and  occasionally  an 
appearance  as  if  the  eyeball  were  unusually  full  and  prominent.  This  must 
arise  from  an  increase  in  the  quantity  of  the  aqueous  humor,  the  balance  of 
action  being  suspended,  which  naturally  exists  between  the  exhalants  and 
absorbents  of  that  fluid,  or  may  depend  on  an  effusion  of  serum  from  the  sur- 
rounding bloodvessels.  In  more  severe  cases,  coagulable  lymph  is  effused 
from  the  lining  membrane  of  the  cornea ;  and  if  the  iris,  which  is  often  the 
case,  partakes  in  the  inflammation,  this  effusion  may  become  the  medium  of 
adhesion  between  the  iris  and  the  cornea.  More  frequently,  however,  the  iris 
becomes  tagged  to  the  crystalline  capsule,  and  the  pupil  thereby  rendered 
irregular. 

Besides  the  diffused  muddiness,  there  are  often  present  in  this  disease,  and 
especially  in  its  chronic  stage,  a  number  of  circumscribed  milk-like  spots  on 
the  internal  surface  of  the  coraea,  which  even  the  least  experienced  may  readily 
distinguish  from  any  of  the  superficial  opacities  of  that  part.  These  spots  are 
often  very  numerous,  and  affect  most  the  lower  half  of  the  cornea,  giving  it  a 
mottled  appearance,  and  forming  by  far  the  most  characteristic  mark  of  this 
ophthalmia.  Mr.  Wardrop  has  accurately  described  their  more  opaque  cen- 
tral points  as  surrounded  by  a  kind  of  disk,  so  as  to  resemble  what  is  called 
the  eye  of  a  pebble.  He  seems  to  ascribe  the  whiter  point  in  the  centre  to 
opacity  of  the  substance  of  the  cornea,  and  the  disk  to  that  of  the  lining 
memliraue. 

These  punctiform  depositions  of  lymph,  which  are  often  so  small  as  to  re- 
quire the  aid  of  the  oi)hthalmic  microscope  to  make  them  out,  I  have  seen 
very  distinctly  in  many  cases.  "What  was  very  remarkable  in  one  case,  the 
spots  partially  appeared  and  disappeared,  even  in  the  space  of  a  few  hours, 
so  that  the  patient  saw  worse  in  the  morning  when  most  of  the  spots  were 
observed,  and  better  towards  the  evening  when  those  at  the  upper  part  of  the 
cornea  had  considerably  diminished.  In  this  case  there  was  a  general  turbid- 
ness  observable  in  the  morning.  The  whole  appearance  of  the  anterior  cham- 
ber, and  of  the  spots  in  question,  resembled  very  much  the  effect  which  might 
be  supposed  to  be  produced,  had  a  quantity  of  minute  drops  of  ammoniated 
oil  been  mingled  with  the  aqueous  humor,  and  allowed  to  deposit  themselves 


548  AQUO-CAPSULITIS. 

ou  the  internal  surface  of  the  cornea.  This  state  of  the  cornea  was  the  con- 
sequence of  pretty  severe  inflammation,  about  nine  months  before,  in  a  patient 
who  had  long  been  troubled  with  rheumatism. 

The  depositions  in  question  are  regarded  by  Hasner  as  tubercular,  and  as 
situated  in  the  epithelium.  The  membrane  of  Descemet  he  states  never  to 
present  any  opacity  on  dissection. 

3.  During  the  continuance  of  the  inflammatory  symptoms,  there  is  generally 
so  much  muddiness  diffused  over  the  whole  anterior  chamber,  that  no  distinct 
portions  of  effused  lymph  can  be  distinguished,  unless  they  be  of  large  size ; 
but  when  this  turbid  state  goes  off,  flakes  of  lymph  may  sometimes  be  per- 
ceived, and  in  other  instances,  the  whole  surface  of  the  inflamed  membrane  is 
left  covered  by  a  thin  layer  of  it.  In  some  cases  the  effused  lymph  floats  in 
the  anterior  chamber,  appearing  like  a  thick  cloud;  in  other  cases,  it  is  de- 
posited in  streaks,  so  as  to  present  a  reticulated  appearance ;  and  in  others  it 
resembles  a  purulent  fluid.  If  the  effused  lymph  be  not  afterwards  absorbed, 
it  is  apt  to  become  organized ;  and  not  unfrequently  red  vessels  can  be  seen 
ramifying  through  it,  either  along  the  internal  surface  of  the  cornea,  or  over 
the  iris  into  the  pupil. 

4.  Gierl  and  Amnion^  have  observed,  that,  in  this  disease,  opacity  of  the 
external  surface  of  the  cornea  is  often  a  sympathetic  effect  of  inflammation  of 
its  lining  membrane.  A  spot  of  effused  lymph  being  visible  on  the  internal 
surface  of  the  cornea,  red  vessels  are,  by  and  by,  seen  coursing  over  its  ex- 
ternal surface  to  the  corresponding  point,  and  there  becoming  the  source  of 
an  opaque  deposition. 

5.  The  iris  gets  discolored  almost  from  the  first.  Whitish  spots,  like  those 
on  the  inside  of  the  cornea,  are  described  as  appearing  on  it,  and  also  on  the 
surface  of  the  crystalline  capsule.  In  some  cases  the  dropsical  state  of  the 
aqueous  cavity  is  such  that  the  iris  is  bent  back  into  a  funnel  form.  There 
sometimes  attends  this  disease  an  increased  flow  of  tears,  but  the  patient  in 
general  does  not  suffer  much  from  exposure  to  light.  What  is  particularly 
to  be  noted  is  a  sensation  of  distension  and  fulness  in  the  eyeball,  accom- 
panied with  a  dull  aching  pain,  generally  in  the  forehead,  sometimes  also  in 
the  back  part  of  the  head;  symptoms  which  Mr.  Wardrop  assures  us  are  in- 
stantly and  permantly  relieved  by  evacuating  the  aqueous  humor.  In  some 
cases,' the  pain  is  severe,  pulsative,  circumorbital,  and  nocturnal. 

6.  The  constitutional  symptoms  vary  much  in  severity.  Sometimes  the 
pulse  is  frequent  and  hard,  the  skin  hot  and  dry,  the  tongue  loaded,  and  the 
functions  of  the  alimentary  canal  disordered.  In  other  cases,  the  disease  almost 
from  the  commencement  assumes  a  chronic  form,  and  after  continuing  a  cer- 
tain period,  participates  in  any  peculiarity  of  the  patient's  constitution,  and 
becomes  thereby  modified,  the  most  frequent  modifying  cause  of  this  kind 
being  scrofula. 

Diagnosis. — The  turbid  state  of  the  aqueous  humor,  and  the  hazy  condi- 
tion of  the  lining  membrane  of  the  cornea  and  anterior  capsule,  render  the 
two  deep  images  obscure.  They  again  become  distinct  as  the  disease  subsides. 
Aquo-capsulitis  is  sometimes  mistaken  for  amaurosis ;  but  by  examining  the 
eye  through  a  lens  of  short  focusj  or  through  Gulz's  ophthalmic  microscope, 
and  by  using  the  catoptrical  test,  the  diagnosis  becomes  easy. 

Causes. — Long-continued  over-exertion  of  the  eyes,  and  suppressed  per- 
spiration, are  causes  to  which  I  have  traced  this  disease.  Slight  blows  on  the 
eye,  and  exposure  to  cold,  have  been  known  to  produce  it.  In  one  case 
which  I  saw,  the  irritation  arising  fi'om  a  decayed  tooth  seemed  the  cause. 
The  disease  declined  rapidly  after  extraction  of  the  tooth. 

Treatment. — In  the  acute  stage,  I  have  found  the  treatment  for  iritis  com- 
pletely successful ;  viz :  depletion,  mercury,  and  belladonna. 


CHOROIDITIS.  549 

Emetics  and  nauseants,  purgatives  and  counter-irritation,  have  been  recom- 
mended, and  in  some  instances  a  cure  has  been  effected  by  these  means,  witli- 
out  the  use  of  mercury.^ 

This  disease  presents  itself  much  more  frequently  in  the  chronic  than  in  the 
acute  form,  and  in  subjects  in  whom  much  depletion  could  not  be  borne.  A 
combination  of  tonics  and  alteratives  answers  best  under  these  circumstances; 
such  as  a  blue  pill  every  second  night,  with  rhubarb  and  sulphate  of  quina 
twice  or  thrice  a  day.  Sulphate  of  quina,  with  a  small  quantity  of  calomel, 
continued  in  repeated  doses  through  the  day,  till  the  gums  become  touched, 
answers  well. 

Vinum  opii,  pure  or  diluted,  is  one  of  the  best  local  applications  after  the 
disease  has  somewhat  subsided.  Exposing  the  eye  to  the  vapor  of  hydrocy- 
anic acid,  for  a  few  minutes  daily,  aids  in  clearing  away  the  opaque  depositions 
from  the  cornea. 

In  the  cases  recorded  by  Mr.  "Wardrop,  in  the  fourth  volume  of  the  Medico- 
Chirurgical  Transactions,  benefit  appears  to  have  been  derived  from  cupping 
the  temples,  purging,  fomenting,  and  the  application  of  such  stimulants  as 
murias  and  nitras  hydrargyri  in  solution,  red  precipitate  salve,  and  sul- 
phuric ether.  Mr.  Wardrop,  however,  places  most  reliance  on  evacuation  of 
the  aqueous  humor,  stating  that  there  is  no  inflammation  of  the  eye,  in  which 
so  much  benefit  is  derived  from  that  operation,  as  when  the  disease  affects 
the  internal  layer  of  the  cornea.  He  had  never  found  it  fail  in  procuring 
immediate  relief  of  the  pain  of  the  head,  and  instantaneous  restoration  of  the 
transparency  of  the  anterior  chamber. 

Much  benefit  is  obtained  from  leaving  the  confined  air  of  the  town,  and 
going  into  the  country.* 


*  On    the   structures   forming    the   aqueous  '  Prael,  in  Amnion's  Zeitschrift  fiir  die  Oph- 

chambers,  consult  Bowman's  Lectures  on  the  thalraologie;  Vol.  iii.  p.  42;  Dresden,  1833. 

parts  concerned  in  the  Operations  on  the  Eye,  ■*  On    aquo-capsulitis,     consult   Wedemej-er, 

p.  19;  London,  18-19;  on  their  pathology,  Has-  Langenbeck's  Neue-  Bibliothek  fiir  die  Chirur- 

ner's  Entwurf  einer  anatomischen  Begriindung  gie  und  Ophthahnologie,  Vol.  iv.  p.  66  ;   Han- 

der  Augenkrankheiton,  p.  103;  Prag.  ISiT.  never,  1823:  Bedfoid,  Guy's  Hosjiital  Reports, 

"  Grafe  und  Walther's  Journal  dor  Chirur-  Vol.  vii.  p.  359;  London,  1842:  Watson,  Edin- 

gie  und    Augenheilkunde,   Vol.    xiii.   p.  114;  burgh    Medical   and   Surgical   Journal,  July, 

Berlin,  1829.  1845,  p.  98. 


SECTION  XXVn, — CHOROIDITIS. 


Si/n. — Ophthalmitis  arthritica,  Bosas.  Acute  glaucoma.  Arthritic  inflammation  of  the 
internal  tunics,  Lawrence.  Retinitis  and  glaucoma,  Tyrrell.  Arthritic  posterior  in- 
ternal ophthalmia,  Jones.     Amaurosis  glaucomatosa. 

Fig.  Jones,  PI.  II.  Fig.  3. 

In  the  choroid  and  iris,  almost  the  whole  of  the  red  blood  of  the  eyeball 
is  concentrated.  There  is  little  in  the  sclerotica,  not  a  great  quantity  in  the 
retina,  and  none  in  the  cornea,  crystalline,  or  vitreous  body.  The  transpa- 
rency of  the  refractive  parts  of  the  eye  forbids  that  they  should  be  traversed 
by  red  vessels ;  and  were  such  vessels  large  and  numerous  in  the  retina,  its 
sensibility  would  necessarily  be  interfered  with.  To  render  the  iris  and  cho- 
roid opaque,  and  thus  to  secure  the  passage  of  light  into  the  eye  only  by  the 
pupil,  as  well  as  to  prevent  its  reflection  after  it  has  entered  and  has  struck 
the  retina,  the  iris  and  choroid  are  provided  with  the  power  of  secreting  from 
the  red  blood  with  which  they  are  so  amply  supplied,  the  pigment  which  is 
at  once  infiltrated  into  their  substance,  and  deposited  so  copiously  in  their 


550  CHOROIDITIS, 

internal  epithelium.  Added  to  this,  the  ciliary  body,  which  is  a  part  of  the 
choroid,  is  charged,  through  the  medium  of  the  zonula  Zinnii,  with  the  nutri- 
tion of  the  vitreous  body  and  the  lens.  The  only  part  of  the  choroid  which 
is  provided  with  nerves,  is  the  choroid  muscle,  or  orbiculus  ciliaris.  The 
ciliary  nerves,  which  lie  imbedded  on  the  inner  smface  of  the  sclerotica,  go 
to  the  choroid  muscle,  and  thence  to  the  iris.  To  the  high  vascularity  and 
nervous  irritability  of  the  iris,  we  may  attribute  its  great  proneness  to  inflam- 
mation ;  while  the  choroid,  although  extremely  vascular,  from  possessing 
scarcely  any  sensibility,  is  but  little  liable  to  inflame. 

Though  the  choroiditis  be  fortunately  not  a  frequent  disease,  it  is  a  very 
severe  one.  "We  can  readily  conceive  what  must  be  the  effects  of  inflammation 
of  the  choroid.  Its  vessels  becoming  congested,  and  the  membrane  thereby 
swollen,  it  will  necessarily  press  outwards  on  the  ciliary  nerves  and  on  the 
unyielding  sclerotica ;  and  the  consequence  will  be  severe  pain  in  the  eye. 
The  swollen  choroid  will  also  press  inwards  on  the  retina,  and  produce,  only 
in  a  much  greater  degree,  and  not  momentarily  but  without  interruption,  the 
same  effect  as  we  find  to  arise  when  with  the  linger  we  make  pressure  exter- 
nally on  the  eyeball,  namely,  flashes  of  light  and  flaming  spectra.  The  con- 
tinued pressure  on  the  retina  may  obliterate  the  sensibility  of  that  structure 
to  the  impressions  of  light  from  without. 

These  are  evidently  the  primary  effects  which  will  arise  from  inflammation 
of  the  choroid.  As  the  disease  advances,  to  t!ie  accumulation  and  stagnation 
of  red  blood  in  its  vessels  will  be  added  exudation  from  its  surfaces,  especially 
its  internal  surface,  on  which  the  capillaries  are  distributed;  effusion  of  serum, 
which  will  add  still  more  to  the  pressure  produced  by  tlie  turgid  state  of  the 
membrane;  effusion  of  fibrin,  binding  its  surfaces,  one  or  other,  or  both,  to 
the  contiguous  textures  ;  and  formation  of  pus,  breaking  up  the  finer  elements 
of  the  retina,  which  lie  so  closely  in  connection  with  the  choroid  epithelium. 
Into  the  hyaloid,  also,  exudation  will  take  place  from  the  ciliary  body, 
changing  the  nutrition  of  that  structure,  and  affecting  the  constitution  and 
transparency  of  the  lens. 

§  1.  Acute  Choroiditis. 

Symptoms. — Acute  choroiditis  generally  begins  with  the  sudden  occurrence 
of  severe  throbbing  and  darting  pain,  in  the  eyeball  and  coiTesponding  half 
of  the  head,  coming  on  in  fits,  and  much  increased  during  the  night.  The  eye 
feels  stiff,  and  there  is  a  sense  of  fulness  and  distension  in  it,  accompanied 
with  such  excessive  tenderness  that  the  patient  cannot  touch  it,  much  less 
allow  it  to  be  touched.  He  complains  of  frequent  flashes  of  vivid,  reddish, 
or  orange-colored  light,  even  when  all  external  light  is  excluded,  or  of  a  lumi- 
nous spot  in  the  axis  of  vision,  increased  by  everything  which  quickens  the 
circulation,  such  as  taking  food,  or  making  the  slightest  exertion.  The  eye  is 
suffused  with  tears,  and  is  highly  intolerant  of  any  exposure  to  light. 

If  we  succeed  in  such  a  case,  in  obtaining  a  view  of  the  eye,  we  generally 
find  the  redness  of  its  external  coverings  much  less  than  might  have  been 
anticipated  from  the  sufferings  of  the  patient.  The  white  of  the  eye  is  of  a 
dingy  yellowish  color.  The  reticular  and  zonular  injections  of  the  conjuncti- 
val and  sub-conjunctival  networks  is  very  variable  in  degi'ee,  never  excessive, 
and  often  slight.  By  and  by,  the  large  exterior  vessels  of  the  eye  assume  a 
strikingly  varicose  appearance,  and  are  seen  winding  over  the  sclerotica,  and 
anastomosing  round  the  cornea.  (Fig.  52,  p.  434.)  They  are  of  a  livid  hue, 
and  evidently  in  a  state  of  passive  congestion. 

The  edge  of  the  cornea  presents  the  bluish-white  ring,  which  arises  from 
the  overlapping  of  the  sclerotica.  The  cornea  generally  is  more  or  less 
hazy,  and  often  seems  slightly  rough.     At  first  the  pupil  is  contracted,  but 


CHOROIDITIS.  551 

without  any  lymphatic  exudation.  The  iris  assumes  a  slate  color  ;  and  the 
pupil,  fringed  with  pigment,  becomes  dilated,  misshapen,  often  oblong,  dis- 
placed, and  motionless. 

I  have  known  an  attack  of  acute  choroiditis  to  occur  suddenly  during  the 
night,  and  in  the  course  of  a  few  hours  totally  to  abolish  the  sensibility  of  the 
retina.  In  such  a  case,  vision  is  rarely  recovered,  even  although  the  redness 
and  pain  of  the  eye  are  overcome.  In  other  instances,  vision  is  first  dull  and 
misty ;  and  the  seeming  mist  rapidly  increasing,  in  a  few  days  the  eye  is  left 
completely  amaurotic. 

The  subjects  of  the  disease  are  generally  past  middle  life,  much-  oftener 
females  than  males,  of  a  dark  complexion  and  sanguine  temperament,  and 
more  frequently  dark  than  light  eyed.  They  are  not  unfrequently  myopic, 
and  often  present  that  dichromatic  state  of  the  crystalline,  which  is  called 
glaucoma,  in  which  it  reflects  the  incident  light  of  a  greenish  hue.  As  the 
disease  goes  on,  the  glaucomatous  degeneration  increases,  the  lens  appears 
pushed  forward  into  the  dilated  pupil,  and  after  a  time  it  is  apt  to  become 
cataractous.  When  the  finger  is  placed  on  such  an  eye,  it  feels  as  hard  as  a 
pebble,  indicating  that  serous  effusion  has  taken  place  into  the  vitreous  body, 
augmenting  the  contents  of  the  eyeball  beyond  their  normal  quantity. 

From  this  condition,  the  eye  never  recovers.  The  pain  may  relax,  and 
the  eye  become  quiet,  and  ultimately  atrophic.  On  the  contrary,  the  disease 
may  go  on  to  manifest  the  further  disorganizing  changes  of  chronic  glaucoma. 
On  dissecting  an  eye  which  had  become  atrophic  from  choroiditis,  I  have 
found  scarcely  any  trace  of  the  internal  structures  in  a  normal  state,  the 
sclerotica  and  choroid  being  adherent,  copious  deposits  of  organized  fibrin 
covering  the  internal  surface  of  the  choroid,  and  the  retina  no  longer  recog- 
nizable. 

In  some  instances,  the  internal  disorganization  is  accomplished  less  by 
fibrinous,  than  by  serous  effusion.  In  this  case  the  united  choroid  and  scle- 
rotica, unable  to  support  the  contents  of  the  eyeball,  expand,  and  become 
attenuated,  so  as  to  form  one  or  several  staphylomatous  elevations. 

There  is  reason  to  believe  that,  in  some  very  acute  cases,  almost  the  whole 
extent  of  the  choroid  is  inflamed.  These  are  attended  with  the  most  severe 
symptoms,  and  with  total  and  sudden  abolition  of  vision.  The  disease  may 
be  confined  to  the  posterior  part  of  the  choroid,  and  then  photopsia  and  loss 
of  vision  are  the  most  prominent  symptoms.  It  is  in  such  cases  that  we 
sometimes  see  a  change  in  the  color  of  the  fundus  oculi,  from  a  fibrinous 
deposit  between  the  choroid  and  retina,  the  anterior  part  of  the  choroid  re- 
maining comparatively  free,  and  thus  the  lens  suffering  less  from  the  disease. 

[The  objective  symptoms  revealed  by  exploration  of  the  choroid  in  a  state 
of  acute  inflammation  by  means  of  the  ophthalmoscope,  have  not  been  detailed 
with  that  degree  of  minuteness  vvhich  their  importance  demands.  One  great 
obstacle  in  the  completion  of  such  details,  has  been  the  injurious  effects  fol- 
lowing the  frequent  use  of  such  a  degree  of  concentration  of  light  on  the  parts 
involved  in  disease  as  is  produced  by  the  best  forms  of  the  instrument  for  this 
purpose.  Hence,  at  present  at  least,  it  seems  almost  an  impossibility  to  watch 
the  changes  which  disease  produces  from  day  to  day  in  this  structure. 

Thus  far,  observers  have  been  able  to  detect  signs  of  active  congestion  in 
the  brightness  and  deepening  of  hue  of  the  red  choroid,  increased  size  of  its 
vessels — and  by  the  vessels  of  the  retina  from  sympathy  appearing  more 
numerous.  In  this  stage  of  choroiditis,  the  transparent  media  are  clear  and 
brilliant,  unless  "sometimes  in  the  lens  are  seen  undulating  transverse  and 
transparent  streaks."  In  no  case  of  active  congestion  have  Dr.  Bader  and 
Mr.  Roberts*  been  able  to  observe  "corpuscles  floating  iu  the  vitreous 
humor." 


552  CHOROIDITIS. 

"  In  some  cases  of  active  congestion,"  these  same  observers  state,  that  "  on 
approaching  the  eye  so  as  to  see  not  quite  clearly  the  form  of  the  vessels,  a 
circular  shadow  will  be  seen  upon  the  convexity  of  the  lens,  surrounded  by  a 
luminous  ring,  behind  which  appears  the  illuminated  vitreous  space,  of  a 
brighter  color,  however,  behind  the  luminous  ring,  than  behind  the  greater 
convexity  of  the  lens:  whether  the  lens  is  pushed  slightly  forwards,  or  what 
is  the  cause  of  the  shadow,  we  have  not  been  able  to  determine." 

"  In  the  congested  choroid  of  one  patient  were  seen  quite  white,  irregular, 
sharply  marked  spaces,  in  which  were  scattered  about  little  diffused  effusions 
of  blood.  These  small  apoplexies  may  be  sometimes  seen,  after  blows  upon 
the  eye,  or  an  attack  of  apoplexy  of  the  brain,  as  sharply  marked  dark-red 
flakes,  as  a  mass  of  points  composed  of  blood,  or  oval  patches,  besides  the 
vessels  with  or  without  augmentation  of  the  vessels  of  the  retina." 

When  the  choroid  is  congested,  and  the  retina  appears  to  be  infiltrated 
with  serum,  the  bottom  of  the  eye  presents  "a  yellowish  bright  aspect,"  ana- 
logous to  that  of  the  conjunctiva  when  the  seat  of  slight  congestion  and  cede- 
matous  infiltration. 

Whenever  the  retina  or  the  white  surface  of  the  entrance  of  the  optic  nerve 
exhibits  an  extraordinary  brilliancy — partaking  of  a  greenish  or  bluish  glitter- 
ing, there  exists  the  probability  of  serous  infiltration  •  and  attention  must  be 
given  to  the  parts  around  the  periphery  of  the  optic  nerve.  The  periphery 
being  a  fixed  point,  prevents  the  further  extension  of  the  serous  effusion,  and 
the  infiltrated  or  detached  parts  are  raised  around  and  hang  over  it,  sup- 
posing the  choroid  is  not  pushed  forward  (as  it  may  be  by  the  effusion),  but 
only  the  retina ;  the  wall  hanging  over  the  periphery  has  a  slight  reddish 
appearance,  is  transparent,  and  allows  the  choroid  around  the  entrance  of  the 
optic  nerve  to  be  seen  through  it. 

"  In  six  cases  of  detached  retina  which  have  been  examined,  no  pigment" 
(such  as  may  be  observed  in  the  healthy  state)  "was  seen  upon  the  choroid, 
which  was  of  a  feeble  red  color,  yet  in  these  cases  the  vitreous  humor  was 
full  of  detached  portions  of  pigment. 

"  The  accumulation  of  pigment  in  masses  seems  to  be  one  of  the  first  visi- 
ble symptoms  of  a  diseased  condition  of  the  interior  of  the  eye." 

On  several  occasions,  effusions  of  blood  were  seen  by  Dr.  B.  and  Mr. 
K..,  in  the  entrance  of  the  optic  nerve,  either  without  any  bloodvessels 
about  them,  or  more  frequently  surrounded  by  a  red  gauze,  which  seemed  to 
be  situated  below  the  vessels  coming  from  the  midst  of  the  entrance  of  the 
optic  nerve ;  the  vessels  composing  the  red  gauze  above  mentioned  cannot 
always  be  seen,  or  even  the  trunks  from  which  they  originate,  but  in  some 
cases  vex"y  fine  branches  are  observable,  leaving  the  vessels  at  the  entrance  of 
the  optic  nerve,  and  forming  a  red  gauze  or  network  over  its  surface ;  but  in 
these  cases,  two  layers  are  frequently  to  be  seen — a  superficial  one,  formed  by 
fine  vessels  coming  from  the  entrance  of  the  optic  nerve,  and  a  deep  one 
which  can  only  be  seen  as  a  gauze,  and  is  generally  confined  to  the  surface, 
whereas  the  former  passes  over  upon  the  retina. 

The  double  layer  is  generally  observed  to  be  accompanied  by  a  congested 
state  of  the  choroid,  the  vessels  of  the  retina,  chiefly  the  veins,  being  very 
numerous.  The  appearance  of  the  red  gauze  is  sometimes  simulated  by  the 
choroid  hanging  over  the  entrance  of  the  optic  nerve,  and  often  exists  dis- 
tinctly, without  any  change  visible  in  the  other  blood-carrying  tissues  of  the 
eye. 

In  some  cases,  where  the  patient  is  unable  to  distinguish  more  than  the 
outlines  of  objects  placed  between  him  and  the  light,  you  will  be  able  with 
the  ophthalmoscope  to  perceive  an  irregular  brownish  spot  as  large  as  a  pin's 
head  occupying  the  place  of  the  yellow  spot,  which  is  the  point  opposite 


CHOROIDITIS.  553 

the  mirror  (in  the  normal  eye)  when  the  patient  looks  at  the  aperture  in 
the  centre  of  it.  Such  are  some  of  the  various  chanc:es  produced  in  the 
choroid  or  its  immediate  neighborhood  by  acute  choroiditis.  When  the  in- 
flammation becomes  chronic,  or  other  tissues  are  involved,  other  changes 
are  to  be  observed,  some  of  which,  at  least,  we  shall  be  able  to  enumerate  in 
their  proper  place. — H.] 

Considerable  constitutional  disturbance  attends  acnte  choroiditis.  The 
patient  is  in  a  perpetual  state  of  restlessness,  and  is  greatly  alarmed  for  the 
total  loss  of  sight.  The  pain  entirely  prevents  sleep.  The  head  is  so  tender 
that  it  cannot  be  laid  on  the  pillow.  The  face  is  flushed.  There  is  giddiness 
and  nausea.  The  tongue  is  foul,  the  mouth  parched,  and  there  is  much 
thirst.  The  pulse  is  quick  and  hard.  I  have  known  the  long-continued 
pain  and  want  of  sleep  wear  out  the  patient,  and  thus  lead  to  a  fatal  termi- 
nation. 

One  eye  often  suffers  alone  from  acute  choroiditis.  In  other  cases,  the 
eyes  are  attacked  in  succession ;  very  rarely  together.  In  one  case,  some 
years  after  one  eye  had  been  affected,  I  saw  the  other  become  amaurotic, 
with  irregularly  dilated  pupil,  but  without  pain  or  redness. 

Causes. — 1.  Exposure  to  a  draught  of  cold  air,  while  perspiring.  2.  Over 
use  of  the  eyes  on  minute  objects.  3.  Mental  anxiety,  grief,  and  want  of 
sleep.  4.  The  sudden  suppression  of  some  long-continued  discharge,  such 
as  that  from  haemorrhoids. 

These  are  the  causes  to  which  the  disease  is  oftenest  to  be  traced.  In  one 
woman  whom  I  saw,  it  occurred  after  typhus  fever,  without  any  other  cause 
which  could  be  assigned. 

Treatment. — 1.  Blood  must  be  taken  from  the  arm,  or  from  the  temporal 
artery,  followed  by  cupping  and  leeches.  The  degree  to  which  depletion  is 
carried,  and  the  form  in  which  it  is  employed,  must  be  regulated  by  its  effects 
and  the  constitution  of  the  patient. 

2.  A  dose  of  calomel  should  be  given  at  bedtime,  followed  by  a  purgative 
next  morning.  This  may  be  necessary  more  than  once,  after  which  a  mild 
mercurial  course  ought  to  be  commenced.  Mercury  must  not  be  pushed  too 
far.  It  has  not  the  same  control  over  choroiditis  which  it  has  over  iritis, 
nor  are  the  patients  so  able  to  withstand  its  depressing  effects. 

3.  Opiates  are  necessary,  internally  and  externally,  to  overcome  the  pain. 

4.  The  usual  counter-irritating  means  are  not  to  be  neglected. 

5.  The  various  secretions  ought  to  be  brought  into  as  healthy  a  condition 
as  possible,  especially  those  of  the  liver,  kidneys,  and  skin. 

6.  In  tranquillizing  the  system,  much  advantage  is  obtained  from  the  use 
of  sarsaparilla,  after  which  a  course  of  bitter  tonics  will  be  found  advan- 
tageous. 

T.  Paracentesis  of  the  cornea,  or  of  the  sclerotica,  affords  great  relief  to 
the  pain.  Atrophy  of  the  eye  sometimes  follows  puncturing  the  sclerotica, 
and,  if  vision  is  already  extinct,  is  a  desirable  termination  of  the  disease. 

§  2.  Chronic  Choroiditis. 

Instead  of  occurring  suddenly,  with  severe  pain,  and  perhaps  instantaneous 
blindness,  the  symptoms  in  the  chronic  variety  succeed  each  other  slowly  and 
insidiously.  Iridescent  vision,  and  the  sensation  of  undulating  or  whirling 
circles  of  light,  come  to  be  associated  with  gradual  deterioration  or  even 
abolition  of  vision.  Pain  is  felt  in  and  above  the  eye,  and  in  the  forehead 
and  temple.  Varicose  vessels,  of  a  livid  hue,  appear  on  the  surface  of  the 
sclerotica  and  on  the  iris,  while  glaucoma  commences  its  usual  slow  but  cer- 
tain course  of  disorganization,  accompanied  with  an  irregularly  expanded  or 
distorted  pupil.     The  eyeball  is  hard,  which  is  the  reverse  of  what  happens 


554  CHOROIDITIS. 

in  retinitis,  where  the  cornea  and  sclerotica  are  flexible.     Photopsia  often 
continues,  after  all  perception  of  external  light  is  extinct. 

To  revert  again  to  the  anatomy  of  the  choroid,  while  its  inner  surface  forms 
in  front  the  black  plicated  circle,  called  the  corpus  ciliare  or  ciliary  processes, 
adhering  to  the  zonula  Zinnii  of  the  hyaloid,  it  presents  on  its  outer  surface 
the  whitish  ring  called  orbiculus  ciliaris  or  ciliary  ligament,  now  generally 
recognized  as  a  muscular  structure,  the  anterior  edge  of  which  serves  to  unite 
the  choroid  to  the  sclerotica.  That  both  the  corpus  ciliare  and  the  choroid 
muscle  suffer  in  choroiditis,  can  scarcely  be  doubted.  There  is  even  reason 
to  think,  that  sometimes  the  one,  and  sometimes  the  other,  may  be  the  seat 
of  inflammation,  independently  of  one  another,  or  of  the  rest  of  the  choroid 
coat.  Inflammation  of  the  orbiculus  ciliaris  has  indeed  been  particularly 
described  by  Dr.  Ammon,"  who  mentions  its  being  attended  with  a  vascular 
elevation  of  the  conjunctiva  over  the  junction  of  the  sclerotica  and  cornea,  its 
frequent  connection  with  symptoms  of  aquo-capsulitis,  and  its  leading  occa- 
sionally to  sclerotic  staphyloma.  It  is  by  no  means  probable  that  the  same 
symptoms  will  attend  inflammation  of  the  ciliary  processes  and  that  of  the 
ciliary  ligament,  and  it  is  sufficient  to  show  that  the  observation  of  these 
affections  of  different  portions  of  the  choroid  is  as  yet  only  in  its  infancy, 
that  Dr.  Hasner^  has  lauded  Dr.  Ammon's  description  as  one  of  inflammation 
of  the  corpus  ciliare,  whereas  it  refers  only  to  that  of  the  orbiculus  ciliaris. 

[In  this  form  of  choroiditis,  the  congestion  revealed  by  the  ophthalmo- 
scope will  be  more  passive  in  its  character,  the  membrane  being  partially  or 
completely  affected,  "  of  a  dark  red  color,  the  veins  running  over  it  enlarged, 
numerous,  and  tortuous;  but  few  arteries,  and  those  of  small  diameter,  visi- 
ble ;  the  choroid  itself  covered  by  brownish-red  spots  of  pigment,  in  some 
places  placed  more  thickly  together  than  in  others.  In  the  vitreous  humor 
are  seen  floating  bodies  of  the  same  color  as  the  pigment;  similar  deposits 
are  also  seen  sometimes  upon  the  posterior  surface  of  the  capsule  of  the  lens." 
With  these  will  also  be  associated  the  phenomena  of  glaucoma  and  fluidity  of 
the  vitreous  humor.  The  condition  of  things  presented  by  the  corpus  ciliare 
and  the  orbiculus  ciliaris  cannot  be  detected  by  this  instrument,  from  the 
fact  that  we  cannot  explore  the  interior  of  the  eye  with  it  further  forward 
than  a  little  in  front  of  the  highest  or  lowest  concavity  of  the  vitreous 
space  ;  the  transmission  of  the  rays  of  light  to  any  point  in  front  of  this  being 
cut  ott'by  the  iris — the  diaphragm  of  the  eye. — H.] 

The  subjects  of  chronic  choroiditis,  like  those  of  arthritic  iritis,  are  often 
affected  with  symptoms  of  irregular  gout.  They  have  sufl'ered  from  a  gene- 
rally depressed  state  of  health,  have  a  feeble  pulse,  their  appetite  is  deficient, 
and  they  are  troubled  with  nausea,  flatulence,  and  other  signs  of  gastric 
derangement. 

In  such  sulijects,  depletion  is  rarely  required.  Mild  alterative?  and  tonics, 
long  continued,  seem  most  beneficial.  The  regular  use  of  the  warm  foot-bath, 
with  mustard  or  Cayenne  pepper  infused  in  the  water,  proves  of  service. 


'■  [On  the  means  of  Dingnosing  the  Internal  kunrle.     Vol.  xxx.  p.  240  ;  Berlin,  1S.''.0 :  Zoits- 

Diseases  of  the  Eye.     By  C.  Bader,  M.  D.,  and  chrift  filr  die  Ophthalmologic,  Vol.  ii.  p.  194; 

Branshy  Roberts.     Brit,    and    Foreign    Med.-  Dre.'den,  1832. 

Chir.  Rev.  for  April,  1855,  p.  501.]  '  Entwurf   einer    anatomisohe    Begriindung 

*  Rust's   Magaziu  fiir  die  gesammte  Heil-  der  Augeukrankheiten,  p.  158 ;  Prag,  1847. 


IDIOPATHIC   RETINITIS.  555 

SECTION   XXVIII. — IDIOPATHIC   RETINITIS. 

Si/n. — Ophthalmitis  interna  idiopathica  proprie  sic  dicta,  J3eer. 
Fig.  Beer,  Band  II.  Taf.  I.  Fig.  5. 

It  is  easy  to  understand  that  the  internal  inflammations  of  the  eye,  as  they 
originate  from  causes  which  affect  the  organ  in  very  different  ways,  may  arise ' 
sometimes  in  one  texture,  and  at  other  times  in  another  ;  that  in  one  case  the 
retina  shall  be  first  affected;  in  another,  the  choroid;  in  a  third,  the  iris. 
The  inflammatory  action,  however,  is  seldom,  if  ever,  confined  to  the  part 
first  affected.  We  have  already  seen  how  inflammation,  originating  in  the 
iris,  spreads  to  the  sclerotica,  and  to  the  choroid;  and  how  choroiditis  affects 
the  textures  both  within  and  without  the  choroid.  In  the  same  way,  inflam- 
mation commencing  in  the  retina  is  likely  to  spread  inwards,  to  the  vitreous 
humor,  to  the  capsule  of  the  lens,  and  to  the  lens  itself ;  outwards,  to  the 
choroid  and  iris,  to  the  sclerotica  and  cornea,  and  to  the  conjunctiva.  Thus 
an  inflammation  of  the  whole  eyeball  may  have  a  very  limited  origin. 

Although  the  retina  possesses  a  considerable  degree  of  vascularity,  the  amaz- 
ing fatigue  which  it  sustains  without  injury,  shows  that  it  is  not  very  suscep- 
tible of  inflammation.  It  is  insensible  except  to  light,  and  therefore,  when 
inflamed,  no  pain  is  experienced,  unless  the  inflammation  extends  to  other 
textures  of  the  eye.  As  the  ramifications  of  the  central  artery  of  the  retina 
lie  near  its  concave  surface,  the  exudation  which  may  follow  the  congestive 
stage  of  retinitis,  will  generally  take  place  between  the  retina  and  the  vitre- 
ous body ;  and,  even  when  limited  in  extent,  will  cause  obliteration  of  vision. 
When  lymph  or  pus  is  effused  on  the  convex  surface  of  the  membrane,  the 
pressure  is  likely  to  produce  photopsia.  Should  the  choroid  and  iris  get  in- 
volved in  the  inflammation,  the  ciliary  nerves  being  pressed  upon,  will  cause 
pain,  more  or  less  acute,  in  and  round  the  eye. 

The  morbid  anatomy  of  the  eye  proves  distinctly  that  the  retina  suffers  in 
various  ways  from  inflammation  ;  for  it  sometimes  prevents  the  appearances  of 
greatly  increased  vascularity,  its  surfaces  are  found  loaded  with  lymphatic  or 
with  purulent  exudation,  its  color  is  changed,  it  is  adherent  to  the  choroid 
or  the  hyaloid,  its  tissues  are  hypertrophied  or  atrophied,  loaded  with  calcare- 
ous matter,  &c.* 

The  accounts  given  by  authors,  of  the  symptoms  of  inflammation  of  the 
retina,  are  remarkably  discordant.  This  arises,  in  some  instances,  from  dis- 
eases altogether  different  from  one  another,  except  in  so  far  as  they  speedily 
end  in  loss  of  vision,  being  designated  by  the  name  of  retinitis.  There  seems 
reason  also  to  believe,  that  inflammation  of  the  retina  is  in  some  cases  accom- 
panied by  hyperesthesia  both  of  the  optic  and  of  the  fifth  nerve,  while  in  gen- 
eral no  such  complication  is  present.  When  hypera^sthesia  of  these  nerves 
exists,  the  patient  is  tormented  by  intolerance  of  light,  photopsia,  exquisite 
sensitiveness  of  the  organ  of  vision  to  the  touch  of  the  finger,  and  paroxysms 
of  dreadful  pain,  all  which  symptoms  may  occur,  without  any  retinitis  ;  while, 
on  the  other  hand,  vision  may  be  speedily  extinguished  by  inflammation  of 
the  retina,  without  any  manifestation  of  exalted  sensibility. 

Some  of  the  causes  to  which  retinitis  is  generally  ascribed,  are  rather  such 
as  we  should  judge  likely  to  produce  this  effect,  than  causes  which  have  been 
completely  traced  in  their  operation.  As  a  sequela  of  a  peculiar  variety  of 
remittent  fever,  and  as  a  sympathetic  or  reflex  effect  in  the  one  eye,  from 
traumatic  disorganization  of  the  opposite  eye,  retinitis  occurs  much  more 
markedly  than  from  exposure  of  the  eye  to  vivid  light,  or  from  overworking 
of  the  organ  of  vision.  In  both  the  cases,  however,  now  referred  to,  it  occurs 
only  as  the  commencement  of  a  disease  which  at  last  involves  all  the  tissues 
of  the  eye. 


556  IDIOPATHIC   RETINITIS. 

§  1.  Acute  Idiopathic  Retinitis. 

Symptoms. — 1.  In  the  commencement  of  the  disease,  the  external  appear- 
ances of  inflammation  are  very  slight.  There  may  be  little  or  no  redness,  or 
only  a  trifling  degree  of  zonular  injection  round  the  cornea.  As  the  disease 
advances,  the  redness  round  the  cornea  increases,  and  affects  both  the  con- 
junctival and  the  sclerotic  network. 

2.  In  acute  retinitis,  the  inflammation  is  never  long  confined  to  the  retina, 
but  speedily  spreads  to  the  other  vascular  textures  vrithin  the  eye,  to  the 
choroid,  and  especially  to  the  iris.  The  iris  changes  color,  assuming  most 
frequently  a  greenish  hue,  while  a  deposit  of  pus  takes  place  between  its 
lower  edge  and  the  cornea.  The  nutrition  of  the  lens  being  disturbed  by  the 
implication  of  the  corpus  ciliare  and  zonula  Zinnii,  capsulo-lenticular  cataract 
ensues. 

3.  The  pupil  generally  becomes  contracted ;  but  sometimes  it  is  dilated. 
Its  motions  are  always  performed  slowly  and  imperfectly,  however  great  the 
alternations  of  light  to  which  the  eye  is  exposed.  A  reddish  wreath  is  some- 
times seen  within  the  pupil.     Lymphatic  exudation  glues  it  to  the  capsule. 

4.  If  the  pupil  continues  patent  and  the  lens  clear,  a  yellowish  deposit  is 
sometimes  visible  at  the  bottom  of  the  eye,  fixed,  as  if  lying  on  the  retina,  or 
waving,  as  if  loose  in  the  vitreous  humor. 

5.  The  eyeball,  and  especially  the  cornea,  becomes  flaccid,  yielding  to  the 
slightest  pressure  of  the  finger,  evidently  showing  a  diminution  to  have  taken 
place  of  the  natural  quantity  of  vitreous  fluid. 

6.  Vision  is  speedily  affected.  In  acute  cases,  it  is  abolished  in  the  course 
of  not  many  hours.  Brought  under  the  influence  of  proper  remedies,  it 
returns  slowly,  never  suddenly. 

7.  If  the  disease  is  limited  to  the  retina,  there  may  be  no  pain  in  the  eye. 
The  patient  generally  complains  of  considerable  headache,  and  when  the 
choroid  and  iris  become  implicated,  circumorbital  pain  is  experienced. 

8.  If  vision  is  preserved,  the  patient  complains  greatly  of  muscte  volitantes. 
We  should  a  priori  expect  fixed  muse®,  but  such  rarely  occur. 

Diagnosis. — Not  only  does  retinitis  bear  a  resemblance  in  many  respects 
to  some  of  the  other  ophthalmia?,  but,  as  I  mentioned  when  entering  on  the 
consideration  of  iritis,  a  degree  of  inflammation  of  the  retina  always  accom- 
panies inflammation  of  the  iris.  The  disease,  however,  with  which  retinitis 
has  been  oftenest  confounded,  is  hyperoasthesia  of  the  optic  and  fifth  nerve,  in 
which  there  is  excessive  sensibility  to  light,  with  spasm  of  the  orbicularis  pal- 
pebrarum, pain  in  and  round  the  eye,  and  great  sensitiveness  of  the  eyelids 
and  eyeball  to  the  touch.  Vision,  during  this  affection,  is  almost  null,  because 
the  organ  cannot  be  put  to  use  ;  the  disease  may  continue  for  a  great  length 
of  time  ;  the  recovery  is  generally  sudden  and  complete.  Pure  retinitis,  then, 
and  ocular  hyperesthesia,  are  easily  distinguished.  In  some  cases,  however, 
there  is  reason  to  believe,  that  an  exalted  sensibility  of  the  fifth  nerve  is 
combined  with  inflammation  of  the  retina,  so  that  the  symptoms  are  of  a 
mixed  description.  In  pure  ocular  hypera^sthesia,  there  is  no  redness  of  the 
eye,  the  pupil  is  clear,  the  iris  lively,  the  retina  perfectly  sensible.  That 
photophobia  is  not  to  be  received  as  a  sign  of  inflammation  of  the  retina,  is 
shown  by  what  we  see  in  scrofulous  ophthalmia ;  a  disease  in  which,  though 
the  influx  of  light  is  intolerable,  on  dissection  the  retina  shows  no  appearance 
of  increased  vascularity.^ 

Causes. — Retinitis  sometimes  arises  from  causes  of  very  limited  and  tran- 
sient action. 

It  occasionally  follows  long-continued  straining  of  the  sight  in  the  examina- 
tion of  very  small,  perhaps  microscopical,  objects,  under  a  strong  light  reflected 
into  the  eye,  either  immediately  from  the  object  of  examination,  or  from  a 


IDIOPATHIC   RETINITIS,  55t 

speculum.  In  such  cases,  however,  there  are  commonly  certain  predisposing 
causes,  which  ought  not  to  escape  observation ;  such  as  a  state  of  general 
plethora,  or  a  tendency  to  determination  of  blood  to  the  head. 

Yivid  flashes  of  lightning  sometimes  excite  inflammation  of  the  retina,  which 
has  also  frequently  been  brought  on  by  imprudently  viewing  an  eclipse  of  the 
sun.  Prisoners  long  confined  to  the  darkness  of  a  dungeon,  have  been  seized 
with  inflammation  of  the  retina  on  being  brought  suddenly  forth  into  the  full 
glare  of  day.  Travelling  over  a  tract  of  country  covered  with  snow  has  been 
known  to  produce  the  same  effect.  Saint  Yves  notices  the  case  of  a  man  who 
became  blind  in  consequence  of  going  too  close  to  the  light  and  heat  of  a 
strong  fire,  in  attempting  to  tie  a  string  to  a  fowl  turning  on  the  spit ;  and 
another  of  a  workman  in  the  mint,  who  lost  his  sight  from  the  brilliant  flash- 
ing to  which  he  was  exposed,  while  pouring  metal  into  a  redhot  crucible. 
Both  of  these  accidents  were  probably  owing  to  retinitis.  Several  cases  are 
recorded,  in  which  the  disease  occurred  in  cooks. 

To  blind  one  was,  and  still  is,  in  some  countries,  a  mode  of  punishment. 
The  person  is  compelled  to  look  on  a  concave  mirror  of  polished  steel,  held 
opposite  to  the  sun.  This  will  excite  speedy  inflammation  of  the  retina, 
and  certainly  end  in  a  greater  or  less  degree  of  insensibility  to  light.  Some 
such  method  must  be  employed  in  India  at  this  day,  as  many  of  the  native 
princes,  condemned  to  the  loss  of  sight  by  the  jealousy  of  their  rivals,  but 
suffered  to  live  in  a  state  of  captivity,  are  said  to  have  no  appearance,  at  a 
little  distance,  of  being  blind. 

Prognosis. — The  prognosis  in  retinitis  is  not  unfavorable,  if  a  proper  me- 
thod of  treatment  be  commenced  before  the  pupil  is  much  contracted,  or  the 
power  of  vision  greatly  impaired.  If  vision  seems  already  extinguished,  the 
prognosis  is  extremely  unfavorable.  If  the  pupil  be  once  closed,  even  before 
the  retina  appears  to  have  become  insensible,  there  is  scarcely  any  hope  of 
preserving  sight;  for  even  should  the  pupil  reopen  in  some  degree,  as  it  occa- 
sionally does  on  the  inflammatory  symptoms  abating,  yet  it  remains  small  and 
motionless,  and  the  eye  is  still  blind. 

Treatment. — Complete  rest  of  the  eyes  and  of  the  whole  body,  darkness, 
abstinence,  and  active  depletion,  followed  by  the  rapid  introduction  of  mer- 
cury into  the  system,  are  the  means  to  be  depended  upon  in  retinitis. 

Copious  bloodletting  from  the  arm  is  to  be  immediately  followed  by  a  plen- 
tiful application  of  leeches  round  the  eye.  Should  the  symptoms  not  yield, 
the  jugular  vein  or  temporal  artery  ought  to  be  opened,  and  an  additional 
quantity  of  blood  abstracted. 

Calomel  with  opium  ought  to  be  given  in  frequent  doses,  till  the  mouth  is 
affected. 

Belladonna  is  to  be  applied  in  the  usual  way. 

Should  a  small  quantity  of  matter  be  present  in  the  anterior  chamber,  we 
must  on  no  account  let  ourselves  be  induced  to  open  the  cornea  ;  but  trust 
to  the  sorbefacient  effect  of  the  mercurj',  assisted  by  blisters  behind  the  ears 
or  on  the  back  of  the  neck. 

The  treatment,  then,  of  retinitis  is  essentially  the  same  as  that  formerly 
recommended  for  iritis.  The  same  advantage  will  probably  be  derived  from 
the  substitution  of  iodide  of  potassium  for  mercury,  when  we  are  obliged  to 
intermit  the  latter  medicine  ;  and  the  preparations  of  cinchona  will  be  had 
recourse  to,  should  debility  of  the  patient  indicate  the  use  of  tonics,  in  the 
stage  of  convalescence, 

§  2.  Chronic  Idiopathic  Retinitis. 

Chronic  cases  of  retinitis  not  unfrequently  present  themselves  to  our  ob- 
servation, characterized  by  sluggishness  of  the  pupil,  muscte  volitantes,  ocular 


558  IDIOPATHIC   RETINITIS. 

spectra,  obscurity  of  vision,  dryness  of  the  eyes  and  Schneiderian  membrane, 
followed  after  a  time  by  flexibility  of  the  cornea.  There  is  reason  to  think 
that  the  disease  ends  in  atrophy  of  the  retina  and  optic  nerve.  It  is  probably 
the  most  frequent  cause  of  amaurosis. 

Watchmakers,  jewellers,  and  those  who  spend  a  great  part  of  the  day  and 
night  in  reading  and  writing,  are  apt  to  be  affected  in  this  way ;  also  tailors, 
milliners,  mathematical  instrument  makers,  printers,  and  engravers,  with  many 
other  classes  in  whom  the  eyes  are  excessively  fatigued.  Those  who  indulge 
in  ardent  spirits,  or  who  habituate  themselves  to  the  use  of  tobacco,  are  also, 
frequently  affected  with  chronic  retinitis. 

The  Esquimaux,  inhabiting  Hudson's  Bay,  are  well  aware  of  the  loss  of 
vision  M'hich  arises  from  constantly  viewing  a  country  covered  with  snow. 
They  make  use  of  a  kind  of  preservers,  which  they  term  snow-eyes.  These 
consist  of  two  pieces  of  wood  or  ivory,  so  formed  as  to  fit  the  eyes,  which 
they  completely  cover,  and  are  fastened  behind  the  head.  Each  piece  pre- 
sents a  narrow  slit,  through  which  everything  is  distinctly  seen.'*  This  inven- 
tion preserves  them  from  the  snow-blindness,  which  is  apt  to  be  occasioned 
by  the  strong  reflection  of  the  sun's  rays  ;  and  which,  it  is  probable,  is  the 
effect  of  slow  inflammation  excited  in  the  retina. 

[J.  Spencer  Wells*  tells  us  that  Dr.  Bonders  has  distinguished  a  limited 
effusion  of  blood  between  the  choroid  and  retina,  or  in  the  latter  membrane 
itself,  with  chronic  inflammation,  in  one  case  of  insensibility  of  about  two- 
thirds  of  the  retina.  Mr.  Wells  has  himself  detected,  in  various  forms  of  par- 
tial or  total  amaurosis,  congestion  and  varicosity  of  the  vessels  of  the  retina, 
partial  removal  of  the  pigment  in  patches,  and  exudations  into  the  substance 
of  the  retina,  or  upon  its  surface. 

Dr.  Yan  Trigt^  says  that  it  is  undeniable  that  in  by  far  the  majority  of  cases 
of  blindness  explored  by  him,  morbid  changes  in  the  retina  could  be  distinctly 
recognized.  He  has  detected  strong  i-eflecting  Avhite  spots,  and  strong  re- 
flection generally ;  great  general  vascular  injection ;  change  of  color,  and  an 
opaque  state  of  the  papilla  of  the  optic  nerve  ;  strongly  reflecting  yellow 
streaks,  communicating  together,  which  appeared  to  be  the  choroidal  vessels; 
and,  lastly,  the  retina  bulged  forward,  and  tremulous  in  the  dissolved  vitreous 
body.— IL] 

'Treatment. — Cases  of  chronic  retinitis  are  often  injured  by  stimulant  and 
tonic  treatment,  while,  on  the  other  hand,  they  are  greatly  benefited  by  mode- 
rate and  repeated  depletion.  A  gentle  course  of  mercury  is  also  of  use. 
Counter-irritants  sometimes  seem  hurtful.  The  eyes  must  be  spared,  bad 
habits  abandoned,  and  the  patient,  if  it  be  in  his  power,  should  try  the  effects 
of  country  air  and  exercise.  ^ 


'  Soe  Wnrdrop's  Morbid  Anatomy  of  the  Hu-  eye-piece,  and  that  it  is  long  and  narrow,  while 

man  Eye,  Veil.  ii.  p.  153;    London,  ISIS:    Am-  others  say  that  there  arc  two,  about  a  quarter 

mon's  Klinische  Darstellungen  der  Krankheiten  of  an  inch  long.   This  is  probably  regulated  by 

des  menschlichen  Auges,  Thl.  i.  Taf.  xix.  xx.j  the  fanej'  of  the  wearer. 

Berlin,  1838.  '  [Med.  Times  and  Gazette,  Sept.  10,  1853, 

*  Langenbeek  de  Ketina,  p.  163;  Gottingse,  p.  265.] 

1836.  '  [lieport   on    the  Ophthalmoscope.     By  T. 

^  The  snow-eyes  also  increase  the  powers  of  AVharton    Jones,    British    and    Foreign  Med.- 

vision,  so  that  the  Esquimaux,  when  desirous  of  Chir.  Review,  No.  xxviii.,  Oct.  1854,  p.  549.] 

viewing  anything  at  a  distance,  mechanically  *  On  Retinitis,  consult  Ilocken,  Transactions 

apply  them  to  their  ej'es.     Different  accounts  of  the  Provincial  Medical  and  Surgical  Asso- 

are  given   of  the  slit  or  slits  in  these  instru-  elation,  Vol.  xiii.  p. 241  j    London,  1845. 
ments;  for  some  tell  us  there  is  onlj'  one  in  each 


RETINITIS   FROM   UNDUE   LACTATION.  559 

SECTION  XXIX. — RETINITIS  FROM  UNDUE  LACTATION. 

Syn. — Retinitis  lactantium. 

The  attention  of  practitioners  is  often  called  to  imperfect  vision,  or  what 
the  patients  style  trecd-7iess  of  the  eyes,  in  women  giving  suck.  The  most 
momentous  part  of  the  disease  is  really  a  chronic  inflammatory  state  of  the 
retina.  Almost  all  the  other  tissues  of  the  eye,  however,  may  be  involved, 
so  that  it  might  almost  be  set  down  as  an  ophthalmitis,  were  it  not  much 
more  apt  to  terminate  simply  in  amaurosis,  than  in  any  such  general  disor- 
ganization of  the  organ  of  vision  as  occurs  in  those  inflammations  to  which 
the  name  ophthalmitis  ought  to  be  appropriated.  Mr.  Middlemore  describes' 
the  disease  as  affecting  chiefly  the  edges  of  the  eyelids  and  the  conjunctiva, 
and  designates  it  by  the  name  of  irritable  ophthahnia .  Dr.  Nasse'^  considers 
it  chiefly  as  an  inflammation  of  the  cornea.  Dr.  Ashwell  refers'  to  the  affec- 
tion as  an  amaurosis. 

Symptoms. — The  disease  may  affect  one  eye  only,  but  commonly  both  eyes 
suffer  from  it.  There  is  an  evident  general  irritation  about  the  organs  of 
vision.  The  eyelids  are  somewhat  swollen,  and  their  edges  red.  The  con- 
junctiva, and  especially  the  palpebral  portion  of  it,  is  affected  with  catarrhal 
inflammation,  generally  slight,  but  sufBcient  to  cause  adhesion  of  the  eyelids 
in  the  morning.  There  is  often  some  degree  of  rheumatic  sclerotitis,  with 
stinging  pain  in  the  eyeball  and  orbital  region.  The  redness  of  the  conjunc- 
tiva or  sclerotica  is  rarely  very  considerable.  The  external  i^art  of  the  dis- 
ease is  apt  to  assume  the  form  of  phlyctenular  conjunctivitis ;  then  there  is 
intolerance  of  light;  and  the  cornea  becoming  involved,  presents  a  small 
opaque  deposit  near  its  centre,  vrhich  is  apt  to  fall  into  a  state  of  ulceration. 
The  patient  complains  of  muscse  volitantes,  and  of  such  dimness  of  sight, 
that  even  the  large  letters  of  a  title-page  cannot  be  distinguished.  The  loss 
of  vision  often  proceeds  to  the  length  of  disqualifying  the  patient  from  know- 
ing one  person  from  another.  The  pupil  is  at  first  contracted,  but  after  a 
time  becomes  somewhat  dilated  and  sluggish,  while  the  cornea  and  sclerotica 
are  found  to  yield  too  readily  to  the  pressure  of  the  finger. 

The  pulse  is  small  and  quick.  The  patient  complains  of  debility  and  gene- 
ral ill  health,  and  is  somewhat  emaciated.  Want  of  appetite,  derangement 
of  the  bowels,  rigors,  flushings  in  the  face,  headache,  vertic;o,  a  draa'aing- 
feeling  in  the  back,  and  a  deficiency  of  milk  generally  attend  the  disease. 

Subjects. — It  is  rare  to  find  very  young  women  affected  with  retinitis  from 
undue  lactation.  The  subjects  are  generally  upwards  of  thirty,  who  have 
had  several  children,  and  have  nursed  them  long.  When  they  begin  to  com- 
plain of  their  eyes,  they  have  almost  always  been  nursing  for  some  months, 
perhaps  for  twelve  or  eighteen  ;  but  the  disease  may  also  occur  soon  after 
they  have  commenced  nursing,  or  not  till  they  have  weaned  the  child.  They 
often  state  that  they  have  never  been  robust,  and  that  their  eyes  were  always 
weak  while  nursing.  They  are  often  of  a  scrofulous  or  rheumatic  diathesis, 
and  bear  evident  marks  of  an  impoverished,  as  well  as  irregularly  distributed 
state  of  the  blood.  Is"ot  unfrequently  they  had  suffered,  before  marriage, 
from  chlorosis,  or  been  weakened  by  hemorrhagic  or  leucorrhocal  discharges. 
Fatiguing  themselves  much  with  their  infant,  supporting  it  almost  entirely 
by  their  own  milk,  allowing  it  to  suck  during  the  night  while  they  themselves 
are  asleei),  not  taking  a  sufficiently  digestiljJe  and  nutritive  diet,  and  attempt- 
ing to  keep  up  their  strength  by  alcoholic  drinks,  are  frequent  circumstances 
in  their  case.  Over-working  of  the  eyes  in  sewing  and  the  like,  want  of  rest 
during  the  night,  anxiety  of  mind,  and  other  causes,  often  conspire  with  pro- 
longed or  undue  lactation,  to  produce  the  disease. 


560  CRYSTALLINO-CArSULITIS. 

Prognosis. — Months,  and  even  years,  may  elapse,  with  the  best  care  and 
treatment,  before  the  symptoms  are  overcome,  and  distinct  and  strong  vision 
restored. 

Treatment. — 1,  The  first  thing  to  be  done  is  to  give  up  nursing.  The 
symptoms  are  often  so  urgent,  that  this  must  be  done  at  once,  and  without 
this,  other  things  will  be  of  little  or  no  avail. 

2.  i^otwithstandiug  the  state  of  general  debility,  the  signs  of  local  con- 
gestion, reaction  in  the  organs  of  vision,  and  actual  inflammation  of  the 
retina,  cannot  be  overlooked.  General  bleeding  is  out  of  the  question  ;  but 
the  symptoms  are  often  such  as  vindicate  the  taking  of  blood  from  the  temple 
by  leeches,  or  by  cupping. 

3.  Counter-irritation  by  small  blisters  behind  the  ear,  to  the  temple,  or  on 
the  forehead,  will  be  proper. 

4.  Pledgets,  wrung  out  of  cold  water,  laid  over  the  eyes  and  applied  to 
the  forehead  and  temples,  afford  great  relief. 

5.  The  bowels  having  been  emptied  by  a  laxative,  some  mild  mercurial, 
such  as  blue  pill  or  hydrargyrum  cum  creta,  ought  to  be  administered,  along 
with  the  small  doses  of  sulphate  of  quina,  twice  or  thrice  daily,  till  the  gums 
are  touched. 

6.  The  vision  clearing  under  these  remedies,  the  chief  indication  v/ill  be  to 
restore  tone  to  the  system,  by  the  cautious  use  of  chalybeates  and  other  tonics. 
The  patient  should  adopt  a  mild  nutritious  diet;  but  avoid,  in  general,  wine, 
ale,  and  spirits.  The  bowels  must  be  carefully  regulated,  and  perfect  exemp- 
tion from  fatigue,  hurry,  and  disturbance,  should  be  enjoined. 

7.  The  eyes  must  be  rested,  and  employed  in  no  fatiguing  occui)ation. 
Exercise  out  of  doors,  and  country  air,  are  important  auxiliaries. 

8.  The  external  symptoms  which  so  frequently  attend  the  disease,  require 
the  employment  of  the  means  formerly  recommended  for  ophthalmia  tarsi, 
phlyctenular  conjunctivitis,  and  corneitis.  Many  of  those  symptoms  are  re- 
lieved by  the  use  of  a  collyrium,  containing  extract  of  belladonna  or  sulphate 
of  atropia.  As  the  disease  subsides,  advantage  is  obtained  from  the  diluted 
vinum  opii,  dropped  occasionally  on  the  eye. 


'  Treatise  on  the  Diseases  of  the  Eye,  Vol.  i.        '  Practical  Treatise  on  the  Diseases  peculiar 
p.  297;   Lonflon,  IS.jo.  to  Women,  p.  725;  London,  1814. 

■  Aiumon's    Monatsschrift,  Vol.  iii.  p.  622; 
Leipzig,  ISIO. 


SECTION   XXX. — INFLAMMATION   OF   THE   CRYSTALLINE   CAPSULE   AND   LENS. 

Syn. — Crystallino-capsulitis  et  Lentitis. 

Common  lenticular  cataract,  whether  soft  or  hard,  appears  to  be  a  conse- 
quence of  impeded  or  disturbed  nutrition,  upon  the  causes  of  which  little 
light  has  as  yet  been  thrown  ;  while  opacities  of  the  capsule  are  probably  in  all 
instances  the  result  of  inflammation,  and  thus  resemble  specks  of  the  cornea. 
Capsular  and  capsulo-lenticular  cataracts  generally  present  themselves  to  our 
observation,  after  the  inflammation  in  v.iiich  they  have  originated  has  sub- 
sided ;  but  in  other  cases  we  may  be  fortunate  enough  to  meet  with  the  dis- 
ease in  its  acute  stage.  The  appearances  which  are  then  presented  to 
observation,  have  been  minutely  described  by  Walther,*  and  from  numerous 
opportunities  I  am  enabled  to  verify,  to  a  certain  extent,  the  accuracy  of  his 
description. 

lie  states  that  inflammation  of  the  crystalline  capsule  generally  occurs 
about  the  middle  of  life,  and  in  subjects  of  a  slightly  cachectic  disposition. 


CRYSTALLINO-CAPSULITIS.  561 

This  is  certainly  true,  although  in  more  than  one  instance  of  congenital 
syphilis,  I  have  seen  such  severe  inflammation  of  the  capsule,  that  the  part 
appeared  to  the  naked  eye  completely  loaded  with  red  vessels  ;  a  state  not 
unfrequently  observed  in  the  horse, '^  but  which  I  have  never  seen  in  the  adult 
human  subject. 

The  anterior  hemisphere  of  the  crystalline  capsule  is  frequently  met  with 
in  a  state  of  inflammation,  while  the  posterior  seems  free  from  disease.  As 
both  are  structureless,  and  after  birth  non-vascular,  the  vessels  which  become 
evident  in  disease  must  be  prolongations  over  their  surfaces,  from  the  vessels 
of  neighboring  parts,  or  new  vessels  formed  in  effused  lymph. 

1.  Iiiflammation  of  the  anterior  hemisphere  of  the  capsule  occurs  oftener  in 
light  eyes  than  dark,  and  is  always  accompanied  by  a  slight  change  in  the 
color  of  the  iris  and  form  of  the  pupil,  the  iris  becoming  a  little  darker,  and 
the  pupil  irregular.  The  motions  of  the  iris  are  at  first  lively  and  extensive, 
but  subsequently  become  sluggish  and  limited.  The  pupil  is  generally  smaller 
than  in  the  sound  state,  but  sometimes  it  is  irregularly  dilated.  There 
usually  appears  a  black  or  reddish  rim  of  irregular  breadth  all  around  its 
edge,  caused  by  the  pigmentum  nigrum  of  the  uvea  coming  into  view,  or  by 
vascular  sproutings  from  the  iris. 

Along  with  these  symptoms,  a  number  of  red  vessels  appear  in  the  pupil 
itself,  the  largest  of  which  are  in  some  instances  visible  to  the  naked  eye,  but 
the  greater  .number  distinguishable  only  by  the  aid  of  a  lens  or  the  ophthal- 
mic microscope.  What  at  first  merely  appears  a  red  point,  assumes  under 
the  mici'oscope  the  appearance  of  a  delicate  tissue  of  vessels.  If  a  single 
lens  be  used  for  this  microscopical  examination  of  the  eye,  it  should  be  one 
of  about  -J  inch  focus,  and  the  patient  should  be  so  placed  with  respect  to 
the  light  that  the  parts  within  the  pupil  be  well  illuminated,  and  not  shaded 
by  the  glass,  nor  by  the  head  of  the  observer.  In  order  to  have  the  pupil  as 
large  as  possible,  a  little  solution  of  atropine  may  be  dropped  upon  the 
affected  eye  an  hour  previously,  and  the  other  eye  should  be  closed  during 
the  examination.  In  this  ophthalmia,  the  sensibility  not  being  much  increased, 
the  patient  can  bear  examination  of  the  eye  in  a  strong  light  and  with  a 
dilated  pupil,  without  much  uneasiness. 

The  red  vessels  in  inflammation  of  the  anterior  hemisphere  of  the  capsule, 
constitute  a  vascular  wreath,  observed  at  about  a  quarter  of  a  line's  distance 
from  the  pupillary  edge  of  the  iris  ;  this  wreath  forms  a 
concentric  circle  within  the  pupil,  and  is  observed  to  con-  Fig.  71. 

sist,  not  of  one  or  a  few  vessels  circularly  disposed,  but  of 
a  number  of  vascular  loops.  (Fig.  'Tl,  shows  a  magnified 
view  of  the  appearances.)  To  this  vascular  wreath  there 
run,  in  a  radiated  form,  numerous  vessels  from  the  circum- 
ference of  the  capsule.  Other  vessels  seem  to  extend  from 
the  uvea  ;  but  such  are  not  constantly  present.  It  is  only 
in  cases  whei'e  the  disease  has  lasted  some  considerable  FronTwIi^ther. 
time,  that  they  appear.  In  other  cases,  according  to  Wal- 
ther,  vessels  seem  to  be  prolonged  rather  from  the  capsule  into  the  posterior 
surface  of  the  iris.  Those  which  run  from  the  iris  to  the  capsule  never  arise 
from  the  edge  of  the  pupil,  but  at  a  little  distance  from  it,  on  the  posterior 
surface  of  the  iris,  so  that  nearly  a  line's  breadth  next  the  pupillary  edge  is 
free  from  these  vascular  sproutings. 

From  the  vascular  wreath  already  mentioned,  vessels  spread  towards  the 

centre  of  the  anterior  capsule,  and  there  again  form  clusters  and  loops.    The 

continuation  between  the  vessels  seen  in  different  parts  of  the  pupil,  seems 

interrupted  at  some  points;  yet  there  can  be  little  doubt  of  their  being  con- 

36 


562  CRYSTALLINO-CAPSULITIS. 

tinuous.    From  their  extremely  minute  size,  they  are  distinguished  only  where 
enlarged  and  clustering  together. 

2.  Inflammation  of  the  posterior  hemisphere  of  the  crystalline  capsule  is  a 
much  rarer  disease  than  that  of  the  anterior.     It  is  easily  recognized  by  the 

deep   situation  of  the   opacity  which  it  presents,  and  the 
F'g-  '—  stellated  arrangement  of  the  vessels.     Both  hemispheres 

of  the  capsule  may  be  inflamed  ;  in  which  case,  behind 
the  red  vessels,  seen  in  the  anterior  capsule,  there  appears 
a  network  of  more  delicate  vessels  which  seem  to  be  seated 
in  the  lens  itself.  The  larger  trunks  of  this  network 
evidently  come,  says  Walther,  from  its  posterior  surface, 
directly  forwards,  and  then  divide  into  branches.  (Fig.  72, 
From^vlither.  shows  a  magnified  view  of  the  appearances.)  The  distribu- 
tion of  these  vessels  bears  a  resemblance  to  that  of  the  cen- 
tral artery  of  the  vitreous  humor,  upon  the  posterior  capsule,  in  the  foetus. 

3.  As  the  lens  undoubtedly  derives  its  nourishment  from  the  capsule,  it  is 
not  to  be  wondered  at  that,  when  the  latter  is  inflamed,  enlarged  vessels 
should  sometimes  be  prolonged  into  the  former.  The  existence  of  vessels 
passing  into  the  lens  is  entirely  morbid,  and  is  compared  by  Walther  to  what 
occurs  in  inflammation  of  the  thorax,  when  vessels  are  prolonged  from  the 
pleura  to  the  pseudo-membrane  formed  on  its  surface.  He  says,  that  as  ves- 
sels from  the  anterior  hemisphere  of  the  capsule  shoot  forwards  into  the 
posterior  surface  of  the  iris,  so  they  shoot  backwards  into  the  lens  itself;  and 
that  the  same  holds  good  with  respect  to  the  posterior  hemisphere  of  the 
capsule.  He  says,  that  the  largest  vessels  of  the  inflamed  lens  are  seen  to 
come  from  behind  forwards.  It  would  appear,  also,  that  all  inflammations  of 
the  lens  begin  in  the  capsule  ;  a  fact  which  Walther  considers  as  analogous 
to  the  spread  of  inflammation  of  the  ciliary  processes  or  from  the  iris  to  the 
capsule.  It  is  probable  that  congestion  of  the  vessels  of  the  zonula  Zinnii 
attends  every  case  of  inflammation,  affecting  any  portion  of  the  crystalline 
body. 

At  the  apparent  terminations  of  several  of  the  vessels  in  the  capsule,  there 
are  distinctly  perceived  little  knots  of  a  whitish-gray  semi-transparent  sub- 
stance. This  is  evidently  coagulable  lymph,  and  Walther  considers  its  pres- 
ence as  disclosing  the  manner  in  which  inflammation  of  the  capsule  and  lens 
produces  opacity  of  these  parts.  The  anterior  hemisphere  of  the  capsule, 
where  the  vessels  are  often  very  numerous,  sometimes  assumes  a  peculiar  vel- 
vety or  flocculent  appearance,  and  in  one  or  more  spots  of  its  extent  presents 
a  gray  or  brownish  color.  These  brownish  spots  appear  in  some  instances  to 
be  nothing  more  than  effused  lymph;  but  in  other  cases  they  probably  owe 
their  origin  to  the  iris  having  been  united  to  the  capsule  by  partial  adhesions, 
which  being  separated  either  by  more  extensive  spontaneous  motion  of  the 
iris,  by  mechanical  violence,  or  by  the  sudden  influence  of  belladonna  or  some 
similar  narcotic,  part  of  the  pigment  of  the  iris  has  remained  adherent  to  the 
anterior  surface  of  the  capsule. 

It  is  a  fact  strongly  confirming  the  accuracy  of  Walther's  account  of  inflam- 
mation of  the  crystalline  capsule,  that  in  anterior  capsular  cataract,  the  specks 
or  streaks  generally  radiate  from  the  edge  of  the  anterior  hemisphere  of  the 
capsule  towai'ds  its  centre ;  while  in  posterior  capsular  cataract,  they  evidently 
branch  out  from  the  centre  of  the  posterior  hemisphere,^  following  thus  the 
directions  of  the  vessels  as  represented  by  Walther. 

As  to  the  state  of  the  patient's  vision,  it  is  indistinct  and  confused,  where 
the  disease  is  severe,  particularly  when  the  eye  is  directed  towards  distant 
objects.  Near  objects  are  seen  as  if  through  a  fine  gauze.  This  does  not 
seem  red,  nor  are  objects  tinged  of  that  color,     I  have  seen  the  anterior  cap- 


HYALOIDITIS.  563 

sule  inflamed,  along  with  such  dimness  of  sight  as  led  me  to  suspect  that  there 
was,  or  had  been,  retinitis. 

This  ophthalmia  almoU  always  observes  a  chronic  course.  It  proceeds 
very  slowly,  and  is  attended  with  little  or  no  pain.  When  pain  does  attend 
the  disease,  it  is  seated  at  the  bottom  of  the  orbit,  in  the  forehead,  or  in  the 
crown  of  the  head.  When  the  disease  has  continued  for  some  considerable 
time,  the  vessels  become  varicose  and  remain  so  permanently.  Walther  ob- 
served the  vessels  of  the  lens  in  a  middle-aged  man,  to  remain  in  a  varicose 
state  for  a  whole  year,  without  undergoing  the  least  alteration.  I  have  seen 
this  disease  followed  or  accompanied  by  incomplete  amaurosis,  complicated 
in  one  case  with  tremulous  iris.  Effusion  of  fluid  between  the  lens  and  cap- 
sule, and  dissolution  of  the  former,  are  not  unfrequent  consequences  of  inflam- 
mation of  these  parts  ;  while  in  some  instances,  the  disease  would  appear  to 
go  the  length  of  suppuration,  for  we  must  consider  inflammation  as  the  cause 
of  that  variety  of  cataract  which  is  called  cataracta  cum  bursa  icJiorem  conti- 
nente,  the  opaque  state  of  the  lens  and  capsule  being  complicated  with  the 
presence  of  a  cyst  within  the  capsule,  filled  with  pus. 

The  causes  of  this  ophthalmia  have  not  been  sufficiently  investigated.  In 
one  case  which  came  under  my  care,  it  affected  the  right  eye  of  a  keen  sports- 
man, and  might  perhaps  have  been  connected  with  the  over-excitement  which 
the  eye  must  have  undergone  year  after  year,  at  the  shooting  season.  In 
another  case,  the  patient  blamed  over-working  his  sight  in  gas  light.  He  had 
long  been  affected  with  an  eruption  on  the  head,  which  disappearing,  crystal- 
lino-capsuiitis  occurred,  first  in  one  eye,  and  afterwards  in  the  other. 

Inflammation  of  the  lens  and  capsule  approaches  nearer  to  iritis  than  to 
any  other  ophthalmia.  It  is,  however,  much  less  acute  in  its  character,  and 
greatly  less  under  the  influence  of  treatment. 

Treatment. — Depletion,  counter-irritation,  and  alteratives,  are  the  remedies 
which  suggest  themselves  as  most  likely  to  do  good  in  the  early  stage  of  this 
disease,  and  tonics  in  the  latter  stages.  In  the  acute  stage,  I  have  sometimes 
succeeded  completely  in  curing  inflammation  of  the  anterior  hemisphere  of  the 
capsule.  In  a  case  which  I  treated  lately,  on  the  first  day  of  my  being  called 
in,  two  minute  reddesh  spots  were  seen  projecting  from  behind  the  edge  of 
the  pupil.  Next  day,  there  were  five.  In  the  course  of  a  week  the  symp- 
toms totally  disappeared,  under  the  employment  of  venesection,  leeches,  cal- 
omel with  opium,  and  belladonna.  The  mouth  was  made  very  sore.  In  the 
chronic  stage,  however,  I  must  confess  that  this  ophthalmia  has  in  my  hands 
proved  one  of  the  most  obstinate.  Cases,  generally  mistaken  and  treated  for 
iritis,  have  been  sent  to  me  for  consultation,  in  which  a  long-continued  use  of 
various  remedies,  including  mercury,  had  been  productive  of  no  effect. 


'  Abhandlungen  aus  dem  Gebiete  der  prac-  servees  sur  les  principaus  Animaux  Domesti- 

tiscben    Medicin;    Vol.    i.    p.    53;    Landsbut,  ques,  p.  409 ;  Paris,  1S24. 

1810.  '  Medieo-Cbirurgical  Transactions;   Vol.  iv. 

*  Leblanc,  Traite  des  Maladies  des  Yeux  ob-  PI.  ii.  Fig.  9;  London,  1S13. 


I 


SECTION  XXXI. — INFLAMMATIOX  OF  THE  HYALOID  MEJtBRANE. 

Syn. — Vitreo-capsulitis.     Hyaloiditis. 

The  hyaloid  is  a  very  delicate,  transparent,  homogeneous  membrane,  entirely 
destitute  of  vessels  in  the  adult,  so  that  the  nutrition  of  the  vitreous  humor 
must  be  carried  on  by  the  vessels  of  the  retina  and  of  the  corpus  ciliare.  It 
is  probable  that  the  vessels  described  by  Dr.  Schroeder  van  der  Kolk,  as  run- 
ning backwards  from  the  zonula  Zinnii,  and  forwards  from  the  central  artery 


564  HYALOIDITIS. 

of  the  retini,  over  the  surface  of  the  hyaloid,  were  the  product  of  disease.* 
The  morbid  states  in  which  the  vitreous  humor  is  occasionally  found,  such  as 
synchesis  or  dissolution,  dropsical  increase,  atrophy,  unnatural  viscidity,  change 
of  color,  loss  of  transparency,  and  ossification,  lead  us  to  regard  the  hyaloid 
membrane  as  susceptible  of  inflammation.  A  still  more  convincing  proof  is, 
that  the  vitreous  body  is  sometimes  met  with,  on  dissection,  infiltrated  with 
exudation  corpuscles,  or  with  purulent  matter. 

Case  283. — I  had  under  my  care,  at  the  Glasgow  Eye  Infirmary,  a  young  man  with 
incomplete  amaurosis  in  each  eye.  His  vision  had  failed  suddenly,  about  two  years  before. 
At  that  time  it  was  subject  to  frequent  alternations,  becoming  suddenly  diminished,  and 
as  suddenly  regaining  its  usual  acuteness.  lie  complained  of  headache,  with  painful 
sensations  over  the  body.  He  was  troubled  with  red  spectra  before  the  left  eye,  but  not 
before  the  right.  The  left  eye  was  presbyopic,  but  with  the  right  eye  he  perceived  near 
objects  more  distinctly  than  distant  ones.  Deep  in  the  right  vitreous  humor,  a  spotted 
opaque  appearance  was  observed.  On  dilating  the  pupil  by  belladonna,  it  was  evident 
that  there  were  two  sets  of  opacities  behind  the  lens.  One,  consisting  of  a  central  spot 
with  numerous  opaque  threads  radiating  from  it,  especially  downwards  and  outwards, 
was  situated  exactly  in  the  axis  of  the  eye,  and  a  little  way  behind  the  lens.  The 
other  opaque  spot  was  much  deeper  in  the  eye,  without  any  radii,  and  evidently  moved 
up  and  down  when  the  patient  moved  his  eje.  Each  pupil  possessed  considerable  power 
of  motion,  and  there  was  no  tremulousness  of  cither  iris.  I  considered  the  appearances 
in  the  right  eye  as  indicative  of  previous  inflammation  of  the  vitreous  body. 

In  two  subsequent  cases,  I  have  seen  similar  appearances.  In  one  of  these, 
I  discovered  what  I  considered  the  effects  of  hyaloiditis,  on  directing  the 
light  of  a  gas  jet  through  the  pupil,  with  a  lens.  The  ophthalmoscopes  of 
Helmholtz,^  Coccius,^  and  Follin,*  are  likely  to  assist  in  the  detection  of  the 
effects  of  inflammation,  both  in  the  crystalline  and  in  the  vitreous  body. 

[Dr.  Bader  and  Mr.  Roberts,  from  whose  paper  on  the  application  of  the 
ophthalmoscope,  we  have  already  had  occasion  to  quote,  state  that  "the  most 
frequent  pathological  conditions  of  the  vitreous  met  with,  are  its  fluidity,  in 
diiferent  degrees,  and  its  being  obscured  by  the  so  called  muscse,  or  through 
effusions  into  it.  Fluidity  without  any  substance  floating  in  it"  they  "have 
never  as  yet  met  with  ;  the  degrees  of  fluidity  are  various  and  well  marked, 
and  can  be  best  judged  of,  by  the  facility  with  which  the  bodies  move  about; 
they  are  seen  sometimes  flying  up  only  to  a  certain  height,  and  falling  back 
again ;  often  these  movements  are  confined  to  the  space  which  corresponds 
to  the  posterior  convexity  of  the  lens  ;  often  these  bodies  form  grayish  clouds 
which,  in  consequence  of  the  shock  given  to  the  vitreous  by  any  movement 
of  the  eye,  take  on  a  rotatory  movement,  which  is  confined  to  the  circumfer- 
ence of  the  lens ;  often  the  bodies  are  so  free  that  they  may  be  seen  moving 
in  all  directions,  disappearing  behind  the  iris,  appearing  again — never  being 
quiet." 

"  Numerous  small  muscse  appear  to  interfere  more  with  vision  than  the 
larger  flakes  which  hang  together  and  are  less  numerous — and  the  movements 
of  the  latter  are  generally  very  limited,  simply  from  one  side  to  the  other. 
Black  muscjB  of  the  color  of  the  pigment  deposited  upon  the  choroid,  do  not 
seem  to  affect  the  sight  so  much  as  the  grayish  ones  (due  regard  to  other 
changes  in  the  eye  being  taken  into  consideration).  These  black  bodies 
seem  so  analogous,  in  many  respects,  to  the  pigment  over  the  choroid,  as  to 
at  once  give  rise  to  the  idea  that  an  emigration  takes  place  in  some  way  from 
the  choroid  to  the  vitreous.  We  are  (they  say)  further  led  to  think  this  by 
the  obliteration  of  spots  of  pigment  at  the  same  time  behind  and  over  the 
vessels  of  the  retina,  so  that  one  layer  seems  more  advanced  than  the  other ; 
for  this  to  be  carried  out,  we  must  suppose  an  atrophy  of  portions  of  the 
retina.  Besides  these  sinking  muscffi,  a  fine  grayish  or  black  mass  of  points 
is  often  seen  suspended  through  the  whole  vitreous  ;  these  appearing  in  some 
cases  to  be  like  the  debris  of  larger  bodies,  in  others  quite  uniform." 


IDIOPATHIC   OPHTHALMITIS.  565 

As  to  the  nature  of  these  bodies  to  be  detected  floating  or  existing  in  the 
vitreous  humor,  observers  have  not  yet  arrived  at  a  positive  conclusion. 
Whether  they  are  (as  Dr.  Williams*  observes)  inflammatory  exudations  from 
the  ciliary  body,  retina,  or  choroid,  that  have  become  detached  :  whether 
they  are  the  remains  of  blood  effused  into  the  cavity  of  the  eye,  or  as  is  more 
probable  attributable  sometimes  to  the  one  and  sometimes  to  the  other  of 
these  sources,  is  not  yet  settled.  Future  observations  can  alone  decide  that 
question;  since  in  all  cases  where  these  corpuscles  exist,  the  vitreous  humor  is 
disorganized  and  liquid,  "  I  have,"  he  says,  "thought  that  some  of  them  might 
be  opaque  and  thickened  portions  or  shreds  of  hyaloid  membrane." — H.] 

Ammon  has  remarked,  that  opacity  of  the  posterior  wall  of  the  capsule  is 
very  frequently  the  precursor  of  disease  of  the  vitreous  body  and  of  the  retina, 
or  is  a  consequence  of  it.^ 


'  Bowman's  Lectures  on  the  Parts  concerned  *  De  I'Exploration  de  la  Retine  et  du  Orig- 
in the  Operations  on  the  Eye,  p.  54;  London,  tallin  a  I'aide  d'un  instrument  d'optique,  Me- 
1S49.  Schroeder  van  der  Kolk,  Anatomisch  moires  de  la  Societe  de  Chirurgie,  Tome  iii.  p. 
pathologische  Opmerkingen  over  de  Ontsteking  337;  Paris,  1853. 

van    eenige  inwendige   Deelen  van    het  Oog ;  '  [Braithwaite's  Retrospect,  part  30th  p.  181. 

Amsterdam,  1841.  Am.  Edition. — H.] 

-  BeschreibungeinesAugen-Spiegels;  Berlin,  "^  Amraon's  Zeitschrift  fiir  die  Ophthalmolo- 

1851.  gie;  Vol.  iii.  p.  469;  Dresden,  1833. 

^  Medical  Times  and  Gazette,  Sept.  10, 1853, 
p.  264. 


SECTION  XXXII. — IDIOPATHIC  OPHTHALMITIS. 

St/n. — Ophthalmitis  phlegmonosa.    Phlegmone  bulbi,  Beck.    Phlegmon  oculaire,  Rognetta. 
Fig.  Beer,  Taf.  I.  Fig.  2. 

For  ophthalmia  we  substitute  the  term  ophthalmitis,  when  an  inflammatory 
disease  of  the  eye  affects  almost  all  its  textures.  In  some  varieties  of  oph- 
thalmitis, gradually  one  texture  after  another  becomes  affected,  till  the  whole 
are  involved ;  in  others,  the  disease  is  so  rapid  and  extensive,  that  the  whole 
eyeball  seems  implicated  at  once.  In  many  instances,  not  the  eyeball  alone, 
but  the  ocular  capsule,  the  areolar  tissue  of  the  orbit,  and  the  conjunctiva, 
participate  in  the  inflammation.  This  is  the  case  in  idiopathic,  traumatic, 
and  phlebitic  ophthalmitis,  three  diseases,  which,  though  their  exciting  causes 
be  different,  bear  a  close  resemblance  in  their  symptoms. 

In  all  of  them  the  inflamed  eye  seems  greatly  swollen,  and  is  protruded 
from  the  socket ;  it  suppurates  internally,  and  its  textures  are  thereby  so 
much  changed  that  its  function  is  generally  destroyed. 

The  violence  of  the  pain  has  caused  idiopathic  ophthalmitis  to  be  com- 
pared to  paronychia,  and  even  to  be  called,  though  improperly,  panaris  of 
the  eye. 

Stages. — The  symptoms  have  been  divided  into  three  stages,  viz  :  1st. 
The  stage  of  pure  inflammation,  extending  from  the  beginning  of  the  disease 
till  the  retina  becomes  insensible.  2d.  The  stage  of  the  suppuration  and 
pi'otrusion  of  the  eye.  3d.  The  stage  of  spontaneous  rupture  of  the  eye, 
of  the  ocular  capsule,  or  of  both. 

Symptoms. — 1.  There  is  at  first  only  slight  external  redness  of  the  eye, 
the  conjunctiva  is  rather  oedematous  than  inflamed,  presenting  the  state  which 
has  sometimes  been  termed  serous  or  ivhife  chemosis.  The  aqueous  humor 
seems  turbid,  and  is  sometimes  tinged  with  blood.  The  fundus  oculi  appears 
reddish.     The  inflammation  produces  a  change  in  the  color  of  the  iris ;  the 


566  IDIOPATHIC   OPHTHALMITIS. 

pupil  is  somewhat  contracted,  and  the  disease  may  be  taken  for  iritis.  The 
crystalline  capsule  sometimes  becomes  opaque,  but  in  other  cases  preserves  its 
transparency.  There  is,  in  general,  at  the  bottom  of  the  eye,  and  in  the 
orbit,  severe  pulsative  pain,  exactly  as  in  an  intense  whitlow;  the  pain  extends 
to  the  forehead  and  to  the  temple,  and  is  accompanied  by  a  feeling  of  burn- 
ing heat,  tension,  and  fulness,  as  if  the  eye  could  not  be  contained  within  the 
orbit.  The  patient  complains  greatly  of  intolerance  of  light,  and  is  atfected 
with  a  sensation  of  flaming  and  shining  spectra.  By  and  by,  this  symptom 
totally  subsides,  the  retina  having  become  insensible  from  the  effects  of  the 
inflammation  upon  its  substance,  or  from  the  compression  arising  from  the 
fluids  extravasated  from  the  surrounding  textures,  and  especially  from  the 
capillaries  of  the  choroid. 

2.  The  total  loss  of  sensibility  in  the  retina  may  be  regarded  as  a  sign  of 
internal  suppuration;  but  the  most  striking  symptom  in  the  second  stage,  is 
the  projection  of  the  eye.  One  would  suppose  the  eyeball  to  be  much 
increased  in  size,  but  this  is  an  error ;  for  after  death,  the  eye  which  appeared 
so  much  swollen,  would  be  found  nearly,  if  not  altogether,  of  its  natural 
dimensions.  It  is  pressed  forward  by  an  effusion  into  the  cavity  of  the  ocular 
capsule ;  and  as  in  this  state  it  is  covered  by  the  chemosed  conjunctiva,  while 
the  upper  eyelid  is  much  extended  and  the  lower  everted,  the  eye  presents 
altogether  the  aspect  of  being  greatly  enlarged.  It  is  besides  very  hard  to 
the  touch,  as  if  it  contained  a  considerably  greater  quantity  of  fluid  than  in 
health.  That  it  partly  does  so  is  true ;  but  the  internal  effusion  is  not  the 
only,  nor  the  principal  cause  of  the  excessive  tension  and  apparent  enlarge- 
ment of  the  eyeball.  The  principal  cause  of  these  symptoms,  as  well  as  of 
the  projection  of  the  eye,  is  the  effusion  into  the  intra-orbital  tissues.  The 
projection  of  the  eye  sometimes  appears  early  in  the  disease ;  in  other  cases 
it  occurs  later,  or  even  not  till  the  internal  parts  of  the  eye  and  vision  are 
destroyed.  It  is  necessary  to  observe  that  there  are  differences  in  the  pro- 
gress of  the  disease,  and  in  the  order  in  which  the  symptoms  follow  one 
another. 

In  the  second  stage  of  the  disease,  the  eyeball  becomes  absolutely  fixed, 
the  state  of  tension  and  pain  rendering  all  muscular  contraction  of  the  recti 
difficult  or  impossible.  So  completely  is  the  eye  fixed,  that  we  cannot  even 
press  it  from  side  to  side  in  the  orbit. 

The  conjunctiva  continues  to  swell;  and  what  does  not  occur  except  in  cases 
of  ophthalmitis,  this  membrane,  especially  where  it  lines  the  lower  eyelid,  be- 
comes covered  with  a  layer  of  coagulable  lymph,  which  may  be  detached  like 
a  false  membrane,  and  which  is  gradually  reproduced.  This  appearance  is 
observed  in  idiopathic,  traumatic,  and  phlebitic  cases  of  ophthalmitis,  and 
serves  to  show  the  analogy  which  exists  between  these  three  varieties  of  the 
disease.  If  the  lens  and  its  capsule  have  retained  their  transparency,  we  may 
sometimes  observe  the  vitreous  humor  to  present  a  greenish  color,  resulting 
from  infiltration  of  pus  within  the  hyaloid.  The  iris  is  seen  to  approach  to- 
wards the  cornea,  and  pus  is  deposited  in  the  aqueous  chambers. 

3.  The  whole  eyeball,  as  well  as  the  ocular  capsule,  being  filled  with  pus, 
if  the  patient  survive,  the  disease  passes  into  the  third  stage.  Its  progress 
is  exactly  as  in  whitlow,  and  after  severe  suffering  on  the  part  of  the  patient, 
the  matter  gains  the  surface  and  escapes  externally.  The  rupture  of  the  eye 
or  of  the  ocular  capsule,  is  a  means  of  saving  the  life  of  the  patient,  who  runs 
much  greater  risk  if  the  disease  is  left  to  itself,  and  no  spontaneous  evacua- 
tion of  the  matter  takes  place. 

It  happens  sometimes  that  the  cornea  becomes  infiltrated  with  pus,  or  is 
converted  into  a  slough,  and  gives  way.  This  is  the  only  disease  of  the  eye, 
in  which  I  have  myself  seen  a  distinct  slough  separate  from  the  cornea,  like 


IDIOPATHIC   OPHTHALMITIS.  567 

a  bit  of  white  leather  which  has  been  soaked  in  water.  Mention  is  often 
made  of  sloughing  of  the  cornea ;  but  the  term  is  more  frequently  applied 
when  that  structure  is  destroyed  by  softening  and  ulceration,  than  when  it 
actually  separates  in  a  gangrenous  state,  as  we  sometimes  see  in  ophthalmitis. 
The  suppuration  or  sloughing  of  the  cornea  is  followed  by  evacuation  of  the 
humors,  and  the  eyeball  collapses.  In  other  cases,  it  is  the  sclerotica  and 
tunica  tendinea  which  give  way;  and  this  may  take  place  into  the  cavity 
of  the  ocular  capsule,  which,  opening  in  its  turn  through  the  conjunctiva, 
allows  a  large  quantity  of  matter  to  escape.  Sometimes  it  is  the  capsule  only 
which  bursts,  the  eyeball  remaining  entire;  but  this  looks  so  much  like  a  rup- 
ture of  the  sclerotica,  that  it  is  easy  to  mistake  the  one  for  the  other.  An 
opening  is  seen  through  the  conjunctiva,  giving  issue  to  purulent  matter;  and 
on  introducing  a  probe,  it  seems  to  pass  completely  into  the  cavity  of  the  eye- 
ball, although  it  has  merely  penetrated  into  that  of  the  ocular  capsule.  If 
the  eye  retains  at  all  its  natural  size  and  form,  and  especially  if  it  retains  any 
sensibility  to  light,  the  eyeball  has  not  given  way,  but  only  the  ocular  capsule. 

The  constitutional  symptoms  which  accompany  ophthalmitis,  vary  consider- 
ably, but  in  general  are  very  intense.  The  patient  is  affected  with  rigors, 
anxiety,  want  of  sleep,  delirium,  and  sometimes  convulsions,  especially  when 
the  disease  is  about  to  terminate  fatally.  In  the  beginning,  the  pulse  is  full 
and  strong;  towards  the  end  of  the  disease,  it  is  small,  feeble,  and  very  quick. 

[The  following  exceedingly  interesting  case,  will  serve  to  indicate  the 
various  pathological  changes  to  be  observed  in  cases  of  idiopathic  ophthal- 
mitis by  means  of  the  ophthalmoscope.  It  occurred  in  the  practice  of  Dr. 
Jiiger,  and  has  been  quoted  by  Mr.  Wharton  Jones  in  his  "  Report  on  the 
Ophthalmoscope,"  and  we  give  it  in  full  detail,  as  presenting  one  of  the  most 
complete  histories  of  a  case  observed  by  the  instrument. 

A.  B.,  aged  72,  of  a  robust  frame  but  troubled  with  piles,  has  been  for  the  last  year 
becoming  emaciated,  without  any  particular  cause.  Six  weeks  ago,  had  repeated  attacks 
of  vomiting  of  blood,  which  have  weakened  him  considerably.  One  day,  after  an  attack, 
he  found  on  awakening,  that  his  right  eye  had  become  quite  blind,  so  that  he  could  not 
perceive  the  hand  moving  before  it,  nor  even  the  presence  of  light. 

Being  called  a  few  hours  after,  Dr.  Jllger  found,  on  making  an  ordinary  examina- 
tion, no  perceptible  change  in  the  affected  eye :  but,  by  means  of  the  ophthalmoscope, 
he  discovered  the  interesting  phenomenon  of  a  disturbed  circulation. 

The  media  of  the  eye  were  perfectly  transparent,  although  increased  reflection  from 
the  several  strata  was  remarked.  The  x-etina  appeared  of  a  moderate  yellow-red,  with- 
out perceptible  morbid  alteration. 

The  optic  nerve,  at  its  entrance,  which  had  some  pigment  deposit  at  its  circumference, 
and  was  more  of  a  yellow  color  than  usual,  presented  only  slight  indications  of  blue  spots. 
The  vessels  of  the  retina  were,  on  the  whole,  not  much  enlarged,  especially  the  larger 
trunks.  The  corresponding  arteries  and  veins  were  of  equal  size,  and  both  of  a  dark  red 
color ;  so  that  the  arteries  and  veins  could  be  distinguished  from  each  other  only  by  the 
direction  of  the  stream  of  blood  in  them,  which  could  be  seen  with  great  distinctness. 
Thei'e  was  no  appearance  of  pulsation  (not  even  in  the  arteries),  as  the  walls,  espe- 
cially of  the  larger  vessels,  remained  unchanged;  but  the  circulation  appeared,  accord- 
ing to  the  diameter  of  the  vessels,  as  a  slower  or  quicker,  an  equable  or  interrupted 
(not  rhythmical)  progression  of  an  unequally  red  colored  stream  of  blood. 

In  the  principal  vessels,  the  stream  of  blood,  in  the  extent  of  one-fourth  to  a  whole 
diameter  of  the  vessel,  showed  lighter  and  darker  red  colored  patches,  which,  however, 
by  the  progress  of  the  blood,  were  always  changing,  so  that  the  lighter  patches  became 
smaller,  and  quite  ceased  at  one  place  to  appear  again  at  another.  Then  the  progress  of 
the  blood  appeared  equable,  but  extremely  slow.  In  the  middle  sized  vessels,  the  move- 
ment of  the  blood  was  quicker,  but  frequently  interrupted  for  a  short  time;  the  lighter 
patches  in  the  blood  were  of  a  paler  red ;  these,  as  well  as  the  darker,  were  of  greater 
extent,  as  much  as  two  or  four  times  the  diameter  of  the  vessel.  In  the  finest  vessels 
visible  in  the  optic  nerve,  the  circulation  appeared  most  rapid;  but,  at  the  same  time 
also,  the  most  frequently  disturbed. 

The  very  fine  stream  of  blood  suddenly  appeared  interrupted,  the  dark  red  part  of  the 
blood  drained  away,  and  the  little  vessel,  become  scarcely  visible  on  the  clear  ground, 


568  IDIOPATHIC   OPHTHALMITIS. 

seemed  to  have  assumed  the  color  of  the  optic  nerve ;  by  and  by  shorter  or  longer 
columns  of  red  blood  glided  in  an  interrupted  course  through  the  vessel ;  and,  after  this, 
smaller  aggregations  of  red  corpuscles,  when  suddenly  the  vessel  became  filled  in  its 
whole  extent  with  dark  red  blood,  the  individual  parts  of  which  seemed  rather  to  roll  in 
a  rapid  course  than  to  flow  smoothly.  This  circulation  (which  was  of  equal  velocity  in 
the  corresponding  arteries  and  veins)  gradually  became  visibly  diminished,  stagnation 
occurred  here  and  there,  so  that  at  the  end  of  twenty-four  hours  the  circulation  was 
complety  stopped.  The  retina  had  now  acquired  a  somewhat  darker  red  color  than 
general.     The  diameter  of  all  the  vessels  evidently  increased. 

The  smallest  vessels  were  proportionally  more  gorged  with  blood.  There  were  no 
longer  any  li.nht  patches  in  the  vessels,  or  an  interruption  of  the  uniform  dark  red  color 
of  blood.  The  middle  sized  vessels  showed  here  and  there  a  short  interruption  in  their 
color  for  the  extent  of  half  to  two  diameters.  The  chief  trunks  were,  to  a  greater  extent, 
equally  filled  with  red  blood.  In  the  smallest  and  middle-sized  vessels  there  was  not  the 
slightest  movement,  but  in  the  larger  there  could  still  be  observed,  by  attentive  examina- 
tion, a  diminution  of  the  lighter  patches  in  the  course  of  a  minute  or  two,  and  at  last  a 
disappearance  of  them  in  one  situation,  and  their  reappearance  in  another.  In  such  a 
condition  of  the  circulation,  we  did  not  delay  the  application  of  a  considerable  number 
of  leeches  behind  the  right  ear,  notwithstanding  the  age  and  weakness  of  the  patient.  A 
favorable  effect  manifested  itself  before  the  leeches  had  all  fallen  off;  the  patient  re- 
gained some  sensibility  to  light,  and  could  perceive  the  waving  of  a  hand  before  the  eye; 
the  circulation  of  the  blood  became  partly  re-established — in  the  smaller  vessels  it  was 
pretty  rapid,  in  the  upper  branches  slow,  in  the  lower  still  arrested.  By  and  by  a  strong 
movement  could  be  recognized,  so  that  at  the  end  of  fortj'-eight  hours,  the  stagnation  in 
the  lower  vessels  had  also  ceased,  and  the  circulation  re-established  in  the  same  degree  in 
which  it  Avas  observed  on  the  first  day.  There  was,  however,  no  diminution  in  the 
size  of  the  vessels.  The  patient  had  now  a  more  distinct  perception  of  light,  and  could, 
though  with  difiBculty,  count  the  fingers  of  a  hand  held  before  the  eye,  and  a  little  towards 
the  temple. 

Considering  the  general  condition  of  the  patient,  no  further  abstraction  of  blood  was 
had  recourse  to.  « 

After  twenty-four  hours  more,  the  velocity  of  the  flow  of  blood  was  observed  to  be  again 
diminished,  but  there  was  nowhere  permanent  stagnation ;  the  sight  had  diminished,  and 
some  uniform  dimness  with  increased  reflection,  was  seen  in  the  lens.  On  the  following 
day  various  changes  supervened,  but  only  slowly  and  gradually  ;  and  at  the  eighth  day 
an  evident  difference  in  the  character  of  the  vessels  could  be  for  the  first  time  distin- 
guished. The  veins  retained  their  original  size  and  color,  but  the  arteries  presented  a 
less  diameter,  and  were  no  longer  so  much  gorged  with  blood.  The  circulation  was  con- 
siderably accelerated,  more  so  in  the  larger  than  in  the  smaller  vessels.  The  motion  of 
the  blood,  still  perceptible  by  reason  of  the  difference  of  coloration,  appeared  more 
uniform  and  less  interrupted ;  very  distinct  in  the  larger  and  smaller  veins,  as  well  as  in 
the  larger  arteries,  but  less  perceptible  in  the  smaller  arteries.  The  lighter  and  darker 
patches  in  the  blood  had  increased  in  number,  but  diminished  in  extent,  so  that  the  former 
might  amount  to  from  a  fourth  to  a  half,  the  latter  to  from  a  half  to  the  whole  diameter 
of  the  vessel.  The  opacity  and  reflection  of  the  lens  were  not  increased,  but  the  sight 
not  improved.  On  the  twelfth  day,  the  color  of  the  retina  appeared  lighter  red,  the  size  of 
the  veins  diminished.  The  difference  between  the  arteries  and  veins  in  diameter,  and 
the  lighter  color  of  the  former,  were  more  evident.  The  greatest  diminution  in  width 
was  exhibited  by  the  smallest  veins  and  arteries,  especially  by  the  latter.  The  deficient 
coloration  in  the  blood  no  longer  appeared  so  uniformly  and  sharply  defined,  the  cir- 
culation more  equable  and  rapid,  distinctly  visible  in  the  veins,  less  so  in  the  larger 
arteries,  and  scarcely  at  all  in  the  smaller  arteries.  The  opacity  and  reflection  of  the 
lens  were  somewhat  more  increased,  the  sight  nevertheless  improved,  so  that  the  patient 
could  count  with  accuracy  the  fingers  of  a  hand  held  before  him,  and  recognize  the 
largest  objects  in  the  room.  Three  days  after  this,  the  circulation  could  be  seen  dis- 
tinctly only  in  the  large  veins.  The  lenticular  opacity  had  increased,  the  sight  remained 
unchanged.  On  the  twentieth  day,  on  account  of  the  increased  opacity  of  the  crystalline 
body,  the  circulation  of  the  blood  could  no  longer  be  perceived  with  sufficient  distinctness 
even  in  the  venous  trunks,  and  therefore  further  observation  was  prevented. — H.] 

Prognosis. — Ophthalmitis  has  different  terminations.  A  complete  recovery 
is  extremely  rare.  The  disease  often  terminates  in  amaurosis.  The  eye  pre- 
serves its  natural  form,  or  is  left  somewhat  atrophic ;  the  pupil  is  small  and 
contracted,  the  capsule  of  the  lens  opaque,  and  the  retina  insensible. 

The  disease  may  terminate  in  suppuration  and  rupture  of  the  eye,  of  the 
ocular  capsule,  or  of  both  together.     In  this  case,  the  eye  becomes  shrunk. 


IDIOPATHIC   OPHTHALMITIS.  569 

It  is  in  cases  of  phlebitic  ophthalmitis  that  the  disease  is  most  apt  to  eud 
fatally.  Idiopathic  cases  sometimes  have  this  termination,  which  probaljly 
would  happen  oftener,  were  the  eye  not  to  give  way  spontaneously,  or  be 
opened  artificially. 

The  relief  which  arises  from  the  eye  giving  way  or  being  opened,  resembles 
exactly  what  takes  place  when  a  whitlow  gives  way  or  is  freely  incised.  If 
the  eye  is  not  opened,  the  patient  is  apt  to  fall  into  a  state  of  coma,  from 
which  he  does  not  recover. 

Case  284. — Daniel  Waclellan,  aged  35  years,  -was  admittecl  into  the  Glasgow  Eye  Infir- 
mary, under  the  care  of  Dr.  Rainy,  on  the  7th  June,  1836. 

The  bulbs  of  both  eyes  are  of  an  intense  red,  much  swollen,  and  projecting  far  out  of  the 
sockets,,  but  still  covered  with  the  upper  eyelids.  The  whole  cellular  membrane  round  the 
ej'eis  oedematous;  the  lower  eyelids  swollen  and  everted.  The  irides  have  a  greenish  hue; 
the  pupils  are  irregular,  and  are  not  affected  with  light.  The  right  pupil  is  occupied  by 
an  opaque  lens;  the  left  presents  a  hazy  whiteness.  Has  no  perception  of  light  nor  shade 
with  either  eye.  Thinks  he  has  a  vei-y  slight  perception  Avith  left  eye.  This  disease  com- 
menced about  a  fortnight  ago,  after  an  attack  of  severe  pain  in  side  of  chest,  for  which  he 
was  bled  profusely.  Pain  has  been  frequently  severe  in  the  eyes,  and  is  still  occasionally 
troublesome  above  the  orbits.  Pulse  110,  soft.  Bowels  rather  bound.  Has  been  treated 
with  leeching,  blisters,  scarifications,  purgatives,  and  calomel  and  opium.  Eight  leeches 
to  each  eye.     Eight  grains  of  calomel  and  eight  of  aloes. 

10th.  Swelling  of  left  eye  greatly  diminished,  and  vision  improved.  Swelling  of  right 
continues.     Ten  leeches  to  right  eye. 

12th.  Right  eye  still  much  inflamed.  Leeches  repeated  to  right  eye.  Pill  containing 
2  grains  of  calomel  and  1  of  opium,  morning  and  evening. 

13th.  The  lids  were  carefully  brought  together  by  plasters,  and  a  compress  and  bandage 
applied  over  the  eyes.  The  swelling  of  both  eyes  is  much  diminished  to-day.  '  Solution 
of  4  grains  of  nitrate  of  silver  in  1  ounce  of  water.  Three  of  the  calomel  and  opium  pills 
daily. 

15th.  Mouth  a  little  sore.     Two  pills  daily. 

16th.  Head  to  be  shaved.  Blisters  behind  ears.  Twelve  drops  of  vinum  colchici  at 
bedtime. 

18th.  Complains  of  pain  in  left  eye.     Two  leeches  to  left  upper  eyelid. 

22d.  Pain  in  the  left  eye  was  relieved  on  the  20th.  On  the  morning  of  the  21st,  sud- 
denly became  insensible,  and  expired. 

Ins2^cclion. — The  pia  mater  was  rather  more  vascular  than  usual.  A  considerable  quan- 
tity of  serum  under  the  arachnoid,  and  at  the  base  of  the  brain. 

Right  eye. — The  orbital  cellular  tissue  was  infiltrated  with  serum ;  it  was  indurated,  and 
contained  a  collection  of  purulent  matter,  which  projected  under  the  conjunctiva,  and  com- 
municated, by  an  opening  on  the  under  surface  of  the  sclerotica,  with  the  interior  of  the 
eye.  The  sclerotica  was  greatly  thickened,  and  firmly  adherent  to  the  indurated  cellular 
tissue  around  the  entrance  of  the  optic  nerve.  The  choroid  adhered  firmly  by  its  outer 
surface.  The  inner  surface  of  the  choroid  presented  traces  of  fibrinous  effusion,  and  was 
completely  detached  from  the  retina  by  a  collection  of  purulent  matter,  which  also  extended 
into  the  cells  of  the  vitreous  body,  and  communicated  with  the  external  abscess  through 
the  opening  in  the  sclerotica,  already  mentioned.  The  retina  and  hyaloid  membrane  ad- 
hered firmly,  and  formed  a  whitish  thickened  mass,  inclosing  the  infiltrated  cells  of  the 
vitreous  body,  but  presenting  apertures  of  communication  at  various  points.  The  lens 
was  transparent ;  the  iris  was  adherent  to  the  capsule.  Some  blood  was  effused  in  the 
anterior  chamber,  with  some  traces  of  lymph. 

Left  eye. — The  cellular  tissue  around  this  eye  was  also  indurated,  infiltrated  with  serum, 
and  closely  adherent  to  the  sclerotica,  which  was  much  thickened,  especially  at  the  en- 
trance of  the  optic  nerve.  The  choroid  adhered  firmly  to  the  inner  surface  of  the  sclero- 
tica. Very  little  fluid  was  found  interposed  between  the  choroid  and  retina.  On  turning 
back  the  choroid,  the  retina,  hyaloid  membrane,  and  vitreous  body  were  found  united  into 
a  firm  yellowish  mass,  having  much  the  appearance  of  coagulable  lymph,  and  with  scarcely 
any  traces  of  purulent  matter.  The  ciliary  body  was  of  a  dark  red  color;  the  lens  and 
its  capsule  transparent;   a  slight  effusion  of  blood  in  anterior  chamber. 

Both  lungs  adhered  at  several  points  to  the  pleura  costalis,  but  they  were  chiefly  cel- 
lular adhesions.  The  left  lung  was  collapsed  to  one-third  of  its  ordinary  size.  A  fibrinous 
concretion  was  found  in  the  left  ventricle  of  the  heart,  but  not  firmly  adherent  to  its  inner 
surface. 

Maclellan  was  a  strong  muscular  man.  As  is  noted  in  the  case,  he  had  had 
pleurisy  some  weeks  befoi-e  he  was  seized  with  the  affection  of  his  eyes,  and 


570  IDIOPATHIC   OPHTHALMITIS. 

had  been  bled  for  it.  Whether  he  had  any  inflammation  of  the  vein  which 
had  been  opened,  could  not  be  learnt.  I  place  his  case,  therefore,  under  the 
head  of  idiopathic  ophthalmitis,  although  in  many  respects  it  bears  a  resem- 
blance to  cases  to  be  brought  forward  in  the  next  section,  the  phlebitic  origin 
of  which  cannot  admit  of  a  doubt*  (^)  The  medical  gentleman  who  first  saw 
him  when  he  began  to  complain  of  his  eyes,  considered  the  symptoms  as  in- 
dicative of  inflammation  of  the  brain.  The  patient  complained  of  severe 
pain  in  his  head  ;  he  was  bled  for  this,  and  had  calomel  and  opium.  He  was 
also  seen  by  Dr.  W.  Brown,  before  being  admitted  into  the  Eye  Infirmary. 
Dr.  B.  saw  him  10  or  14  days  after  the  commencement  of  the  ophthalmic 
disease.  Both  pupils  were  then  widely  dilated,  the  one  more  than  the  other, 
and  immovable.  The  retinae  were  insensible  to  a  lighted  candle.  The  pain 
had  subsided.  There  was  considerable  eversion  of  the  lower  eyelids.  Dr.  B. 
proposed  puncturing  between  the  lower  eyelid  and  the  eyeball,  on  the  pre- 
sumption that  matter  was  effused  there. 

Causes. — The  causes  of  idiopathic  ophthalmitis,  as  in  the  above  case,  are 
often  obscure;  slight  injuries,  such  as  a  simple  puncture,  may  produce  the 
disease  in  some  particular  states  of  the  constitution.  There  is  reason  to  be- 
lieve that  ophthalmitis  occurs  as  a  consequence  of  certain  eruptive  fevers, 
such  as  measles,  smallpox,  scarlatina,  and  typhus.  Whether  in  these  cases 
the  disease  arises  from  pus  being  taken  up  by  the  veins  from  some  of  the 
viscera,  can  at  present  be  merely  proposed  as  a  query. 

Treatment. — Ophthalmitis  of  whatever  kind  requires  the  taking  away  of 
blood  by  venesection,  cupping,  and  leeches.  The  vein  at  the  bend  of  the  arm 
should  be  reopened  as  often  as  the  hardness  of  the  pulse  and  the  other  symp- 
toms point  out  the  propriety  of  further  depletion. 

The  chemosed  conjunctiva  ought  to  be  freely  scarified,  and  the  eye  fomented 
with  warm  water. 

Tartrate  of  antimony  has  been  recommended  in  large  doses;  a  solution  of 
6  grains  in  6  ounces  of  water,  to  be  taken  in  tablespoonfuls  every  half  hour. 
I  have  not  tried  this  remedy,  as  it  is  inconsistent  with  the  administration  of 
mercury,  which  I  regard  as  much  more  efficacious.  In  the  only  case  of  oph- 
thalmitis which  I  have  seen  followed  by  a  complete  cure,  the  mouth  had  become 
promptly  affected  by  the  administration  of  calomel  with  opium.  The  prognosis 
in  this  case  was  very  doubtful,  so  much  so  that  I  thought  it  my  duty  to  state 
the  dangerous  situation  of  my  patient  to  his  friends;  but  as  soon  as  the  mer- 
cury had  acted  upon  the  mouth,  the  disease  began  to  give  way,  the  eyeball 
retreated  into  the  orbit,  and  a  perfect  recovery  took  place. 

Abstinence  must  be  enjoined,  and  diluent  drinks  administered.  Cold  com- 
presses should,  at  first,  be  kept  constantly  over  the  eyelids;  but  when  the 
disease  is  more  advanced,  wai-m  fomentations  or  a  warm  poultice,  should  be 
used.  Mustard  baths  of  the  feet,  and  blisters  to  the  neck  or  behind  the  ears, 
are  likely  to  be  useful.  The  eyelids  and  eyebrows  ought  to  be  painted  with 
the  extract  of  belladonna. 

In  the  second  stage,  the  products  of  inflammation  being  pent  up  within  the 
eyeball,  so  that  they  cannot  be  discharged,  paracentesis  of  the  cornea,  so 
as  to  evacuate  the  aqueous  humor,  or  puncturing  of  the  sclerotica,  is  to  be  em- 
ployed. By  puncturing  the  sclerotica  there  is,  perhaps,  very  little  discharged ; 
but  the  tension  is  taken  off",  and  the  danger  of  the  disease  spreading  to  the 
brain  is  set  aside.  The  form  of  the  eye  may  be  preserved  by  these  means, 
and  even  the  life  of  the  patient.  Should  the  disease  still  go  on  to  suppura- 
tion, the  matter  escapes  by  the  aperture  made  in  the  cornea  or  sclerotica,  and 
the  eye  sinks;  or  if  the  wound  in  either  place  has  healed,  it  is  to  be  opened 
again,  and  a  warm  poultice  continued  over  the  eyelids. 

An  important  part  of  the  treatment  consists  in  opening  the  ocular  capsule. 


PHLEBITIC   OPHTHALMITIS.  5T1 

The  eye  being  extremely  bard  and  very  protuberant,  while  an  indistinct  fluc- 
tuation is  felt  around  the  organ,  as  if  from  a  fluid  accumulated  within  the 
cavity  of  the  ocular  capsule,  this  fluid  should  be  evacuated.  For  this  purpose 
we  proceed  somewhat  as  if  we  were  about  to  operate  for  strabismus,  dividing 
the  conjunctiva  at  the  internal  angle  of  the  eye  and  towards  the  lower  eyelid, 
and  then  passing  the  lancet  close  to  the  globe  of  the  eye,  and  between  it  and 
the  lower  internal  wall  of  the  orbit,  so  as  to  avoid  the  internal  and  inferior 
recti  muscles.  This  being  done,  there  is  an  immediate  gush  of  serous  fluid, 
mixed  with  pus ;  the  globe  of  the  eye  falls  back,  and  the  cornea  becomes 
flaccid,  showing  that  the  cause  of  the  excessive  hardness  and  projection  of 
the  eye  existed  behind  it,  and  not  in  the  organ  itself.  In  such  cases,  the 
opening  of  the  capsule  ought  to  be  had  recourse  to  early,  and  not  delayed  till 
the  eye  is  disorganized  or  the  patient  sinking  into  a  state  of  coma.  The  ope- 
ration is  simple,  and  is  likely  to  save  both  the  eye  and  the  life  of  the  patient. 
In  the  third  stage,  the  eye  having  been  emptied  either  spontaneously  or  by 
the  knife,  the  parts  remain  for  a  time  swollen  and  painful;  but  as  the  sup- 
puration goes  on,  the  swelling  of  the  tissues  falls,  and  the  remains  of  the  eye- 
ball shrink.  Some  astringent  fomentation  may  now  be  used.  If  the  patient 
is  much  weakened  from  pain,  fever,  and  the  debilitating  treatment,  mild  nour- 
ishment ought  to  be  given,  with  small  doses  of  sulphate  of  quina. 


'  See  fatal  case,  in  which  ophthalmitis  ac-  ^  [Report   on    the  Ophthalmoscope.     By  T. 

compauied  inflammation  of  the  heart  and  brain;  Wharton  Jones,  F.  R.  S.     British  and  Foreign 

Bowman's  Lectures  on  the  Parts  concerned  in  Med.  Chir.  Review,  Oct.  1854,  p.  5-19. — H.] 
the  Operations  on  the   Eye,  p.   127 ;    London, 
1S19. 


SECTION  XXXm. — PHLEBITIC  OPHTHALMITIS. 

Syn. — PyEemic  ophthalmitis.     Puerperal  ophthalmitis.     Conjunctivitis  muciflua  puerpe- 

rarum,   Waliher. 

Ophthalmitis  from  pyaemia,  or  purulent  infection  of  the  blood,  has  been 
observed  under  a  variety  of  circumstances.  It  is  a  consequence  of  suppura- 
tive inflammation  in  some  part  of  the  venous  system,  and  this  may  be  excited 
in  diff'erent  ways. 

1.  Inflammation  of  a  distant  vein,  produced  by  a  wound,  or  by  tying  the 
vein,  has  been  followed  by  the  usual  constitutional  disturbance  attendant  on 
phlebitis,  and  amongst  other  secondary  effects,  by  disorganizing  inflammation 
of  the  eye. 

2.  Suppurative  inflammation  of  the  uterine  branches  of  the  hypogastric 
veins,  in  puerperal  women,  which,  spreading  to  the  iliac  and  femoral  veins,  is 
apt  to  cause  phlegmasia  dolens,  sometimes  produces  phlebitic  ophthalmitis. 

3.  Phlebitis  produced  in  erysipelas,  or  diffuse  cellular  inflammation,  has 
been  known  to  terminate  in  ophthalmitis.  In  one  case,  I  saw  ophthalmitis 
of  phlebitic  character  arise,  in  consequence  of  a  boil  of  the  opposite  cheek. 

4.  Phlebitis  occurring  in  consequence  of  febrile  diseases,  has  ended  in  the 
same  result. 

I  have  little  doubt  that  this  termination  follows  in  other  cases  of  phlebitis  ; 
but  the  subject  is  comparatively  a  new  one,  and  much  remains  to  be  done  for 
its  complete  elucidation.  In  all  cases  of  ophthalmitis  arising  without  direct 
injury,  we  should  suspect  this  cause.  We  should  examine  carefully  the  different 
limbs,  in  order  that  if  there  be  any  swelling,  hardness,  or  pain,  in  any  of  the 
external  veins,  we  may  detect  it.  We  should  ascertain  also  the  state  of  the 
general  health,  and  the  history  of  the  patient's  previous  ailments,  so  that  if 


572  PHLEBITIC   OPHTHALMITIS. 

phlebitis  had  preceded  the  affection  of  the  eye,  we  may  not  remain  ignorant 
of  so  important  a  circumstance.  In  fatal  cases  of  ophthalmitis,  the  venous 
system  should  undergo  the  most  careful  scrutiny,  when  the  dead  body  comes 
to  be  examined. 

1.  The  two  following  cases  are  illustrations  of  phlebitic  ophthalmitis,  re- 
sulting from  wounds  of  veins  : — 

Case  285. — Mr.  Earle  removed  a  portion  of  a  varicose  vein  of  the  leg.  This  was  fol- 
lowed by  great  constitutional  disturbance,  inflammation  of  the  vein,  deep-seated  abcesses 
in  the  opposite  leg,  in  both  forearms,  and  in  one  of  the  lungs.  The  day  before  death, 
the  cornete  were  observed  to  have  become  opaque  and  their  surface  rough,  the  vessels  of 
the  conjunctivfB  were  injected,  and  the  patient  lay  Avith  his  eyes  constantly  closed.  On 
dissection,  destructive  changes  Avere  found  to  have  taken  place  within  the  globe  of  the 
right  ej'e,  the  crystalline  lens  was  so  soft  as  to  j'ield  to  the  slightest  touch,  the  vitreous 
humor  was  of  a  reddish-yellow  color,  and  red  vessels  were  distinctly  seen  traversing  its 
membrane.  The  retina  was  of  a  deep  red  color.  The  third  nerve  on  the  left  side  was 
evidently  flattened,  and  softer  than  that  on  the  right.  The  fifth  nerve  on  the  right  side 
had  undergone  a  similar  change  to  a  greater  extent. ' 

Case  28G. — A  young  man  had  a  ligature  placed  on  the  left  carotid  artery,  for  an  aneu- 
rismal  disease  of  one  of  its  branches.  Considerable  difficulty  was  experienced  in  passing 
the  needle  round  the  vessel.  Venous  hemorrhage  took  place  during  the  operation,  re- 
curred at  night,  and  occasionally  afterwards,  for  nine  or  ten  days.  On  the  fifth  day  after 
the  operation,  the  patient  had  a  severe  rigor,  succeeded  by  heat  of  skin  and  general 
febrile  symptoms.  These  increased,  the  pulse  rose  to  120,  and  the  constitutional  disturb- 
ance assumed  a  violent  character.  About  the  10th  day,  the  vision  of  the  left  eye  became 
impaired,  and  was  quickly  lost,  the  pupil  was  contracted,  the  iris  immovable,  and  the 
cornea  hazy  ;  eff'usion  took  place  under  the  conjunctiva,  and  the  lids  were  greatly  swollen, 
producing  an  appearance  as  if  the  globes  were  much  protruded.  There  was,  at  the  same 
time,  a  degree  of  deafness,  considerable  stupor,  and  occasionally  slight  delirium.  In  the 
course  of  a  few  days,  the  coats  of  the  eye  sloughed  at  the  upper  part,  and  its  contents 
were  evacuated. 

While  these  changes  were  going  on  in  the  eye,  collections  of  matter  formed,  without 
pain,  in  diff"erent  parts  of  the  body,  on  both  shoulders  above  the  insertion  of  the  deltoid 
muscles,  over  the  sacrum,  &c.  The  constitutional  disturbance  abated,  and  the  collapsed 
eye  healed  over  ;  but  the  patient  never  recovered  his  health.  He  died  five  months  after, 
laboring  under  lumbar  abscess,  and  worn  out  by  hectic.  On  examination  of  the  body,  a 
portion  of  the  jugular  vein,  to  the  extent  of  2  inches,  was  found  wanting  ;  the  upper  and 
lower  ends  next  the  lost  part  being  shrunk,  ligamentous,  and  gradually  lost  in  the  cellular 
substance.  On  opening  the  head,  pus  was  found  efi"used  in  great  quantity  between  the 
tunica  arachnoidea  and  pia  mater,  along  the  base  of  the  brain,  and  the  Avhole  length  of 
the  spinal  chord.    The  intermuscular  cellular  substance  of  the  loins  was  loaded  with  pus. 2 

Mr.  Arnott,  in  his  valuable  paper  on  the  Secondary  Effects  of  Inflamma- 
tion of  the  Veins,3  asks,  whether,  when  we  consider  the  circumstances  of  this 
case,  the  venous  hemorrhage,  constitutional  disturbance,  formation  of  ab- 
scesses, and  appearances  presented  on  dissection,  and  compare  them  with  the 
consequences  which  have  been  observed  to  follow  inflammation  and  suppura- 
tion of  a  vein,  and  the  occurrences  in  Mr.  Earle's  case,  we  can  doubt  that  the 
affection  of  the  eye  arose  from  the  inflammation  of  the  jugular  vein,  and  from 
the  entrance  of  an  inflammatory  secretion,  probably  pus,  into  the  blood. 

2.  A  disease  of  the  eye,  similar  to  that  observed  in  the  two  cases  above 
quoted,  occurring  in  the  puerperal  state,  has  been  described  by  Dr.  Hall  and 
Mr.  Higginbottom,*  under  the  title  of  "  Cases  of  Destructive  Inflammation  of 
the  Eye,  and  of  Suppurative  Inflammation  of  the  Integuments,  occurring  in  the 
Puerperal  State,  and  apparently  from  Constitutional  Causes."  In  all  of  these 
cases,  six  in  number,  the  affection  of  the  eye  took  place  in  from  five  to  deven 
days  after  delivery.  It  was  preceded  and  accompanied  by  serious  indisposi- 
tion, in  every  instance  terminating  fatally  and  under  symptoms  of  extreme 
exhaustion. 

The  affection  of  the  eye  was  characterized  by  redness  of  the  conjunctiva, 
intolerance  of  light,  and  contracted  pupil,  rapidly  followed  by  opacity  of  the 
cornea  and  excessive  chemosis.     In  two  of  the  cases,  the  coats  of  the  eye 


PHLEBITIC   OPHTHALMITIS.  5t3 

gave  way;  and  in  one  of  these,  where  the  process  was  observed,  the  rupture 
took  place  by  ulceration  of  the  coats  round  the  cornea.  In  both  of  these 
cases,  the  collapsed  globe  had  healed  over  previously  to  death.  In  each  in- 
stance, only  one  eye  was  affected,  and  in  five  of  them  it  was  the  left.  In 
the  case  communicated  by  Mr.  Ward,  it  does  not  appear  which  eye  was  the 
seat  of  the  disease. 

With  the  disease  of  the  eye,  there  also  took  place  an  inflammation  of  the 
integuments,  first  observed  on  the  hand,  but  on  careful  examination,  found  in 
the  inferior,  as  well  as  the  superior  extremities,  and  under  which  matter  quickly 
formed.  In  one  case  only,  there  was  no  such  inflammation.  The  authors  of 
the  paper  conjecture,  that  the  morbid  affection  of  the  eye  had  a  constitutional 
origin.  No  examination  after  death  seems  to  have  been  made  in  any  of  the 
cases. 

In  his  comments  on  these  cases,  Mr.  Arnott  seems  to  think  that,  consider- 
ing the  circumstances  under  which  the  affection  of  the  eye  took  place,  its 
characters,  and  the  depositions  of  pus  under  the  integuments  of  the  body, 
and  comparing  these  with  the  known  consequences  of  inflammation  of  veins, 
and  the  frequency  of  inflammation  in  the  veins  of  the  uterus  after  parturition, 
we  may  be  justified  in  attributing  the  disease  of  the  eye  to  inflammation  of 
the  uterine  veins,  and  the  introduction  of  pus  into  the  circulation. 

I  owed  to  Dr.  James  Brown  the  opportunity  of  seeing  the  following  case 
of  puerperal  ophthalmitis,  which  I  had  no  doubt  was  of  the  nature  of  the 
cases  recorded  by  Dr.  Hall  and  Mr.  Higginbottom  : — 

Case  287. — The  patient  was  a  slender  scrofulous  woman,  about  30  years  of  age,  of 
irritable  temperament,  sedentary  habits,  and  melancholy  disposition.  She  had  been  seven 
times  pregnant,  and  the  following  numbers  indicate  the  months  during  which  each  utero- 
gestation  was  continued,  viz :  9,  7,  5,  9,  9,  7,  4.  She  had  formerly  been  subject  to  dis- 
charge from  the  vagina,  probably  leucorrhoeal,  but  not  immediately  before  the  abortion 
of  the  fourth  month,  which  led  to  her  last  illness.  There  was  nothing  remarkable  about 
the  labor.  The  lochial  discharge  was  scanty,  and  did  not  continue  above  a  week,  at  the 
end  of  which  time  she  began  to  complain  of  pain  in  the  back  and  groins,  accompanied 
with  slight  colds  and  heats,  and  little,  if  at  all,  relieved  by  bloodletting  and  purging,  both 
of  which  were  copiously  used.  Some  15  or  18  days  after  delivery,  she  was  seized  with 
vei-y  severe  rigors,  followed  by  great  pain  in  the  head,  back,  and  abdomen ;  the  pain  in 
the  abdomen  being  complained  of  chiefly  on  pressure. 

The  affection  of  the  ej'e,  which,  as  in  the  cases  already  referred  to,  was  the  left,  came 
on  about  28  or  30  diij's  after  the  former  symptoms  had  been  apparently  subdued  by  the 
usual  means,  although  during  all  this  time,  the  general  state  of  the  patient  had  been  by 
no  means  favorable.  The  affection  of  the  eye  was  ushered  in  by  new  rigors,  which  were 
followed  by  a  good  deal  of  fever,  rather  of  a  remittent  type,  and  occasional  feelings  of 
sinking.  The  pulse  continued  from  the  first,  quick,  irritated,  and  by  no  means  strong. 
The  eye  was  highly  inflamed,  the  conjunctiva  much  chemosed,  the  lids  swollen,  and  the 
lower  lid  everted.  There  was  severe  pain  in  the  eye  and  head,  and  excessive  intolerance 
of  light,  so  much  so  that  she  was  obliged  to  keep  her  face  covered  with  a  handkerchief, 
although  the  window  shutters  were  kept  constantly  closed.  At  first  tears  ran  from  the 
eye,  and,  after  a  time,  purulent  matter.  The  cornea  became  opaque,  but  the  eye  did  not 
burst. 

Her  mind  was  all  along  very  desponding.  For  some  days  she  was  slightly  incoherent 
on  coming  out  of  sleep,  but  when  roused  was  sensible  to  the  last.  No  abscess  formed 
near  the  surface  of  any  part  of  the  body.  She  died  about  eight  weeks  after  the  abortion. 
It  is  to  be  regretted  that  neither  the  eye  nor  the  body  was  permitted  to  be  examined. 

Ca&e  288. — On  the  15th  September,  1839,  I  was  requested  to  visit  ^Nlrs.  H.  along  with 
Dr.  Panton.  I  found  her  comatose ;  but  she  could  be  roused  to  put  out  her  tongue, 
and  to  state  that  she  had  pain  in  her  right  temple.  The  right  pupil  was  dilated,  the 
retina  insensible,  and  the  conjunctiva  aflFectcd  with  white  chemosis.  Pulse  150.  1  learned 
she  had  been  delivered  on  the  5th,  that  the  placenta  bad  been  adherent,  and  had  to  be 
separated  by  the  hand;  that  she  had  complained  much  of  headache,  and  had  had  frequent 
and  severe  rigors.     She  died  on  the  IGth. 

On  inspection,  serous  effusion,  but  not  profuse,  was  found  in  the  cavity  of  the  arach- 
noid. There  was  no  effusion  nor  infiltration  in  the  orbital  tissues.  The  eyeball  was 
natural,  except  that  the  retina  was  of  a  reddish  color  on  its  concave  surface. 


5Y4  PHLEBITIC   OPHTHALMITIS. 

The  fundus  of  the  uterus,  where  the  placenta  had  adhered,  was  covered  with  sanioua 
purulent  matter ;  and  several  of  the  veins  proceeding  from  it,  were  filled  with  pus.  Two 
of  them,  as  large  as  writing-quills,  were  completely  filled.* 

Case.  289. — Mr.  Selkirk,  surgeon  at  Newtonshaw,  by  Alloa,  informed  me  of  the  follow- 
ing case.  A  poor  woman  in  Tillicoultry  had  a  child,  and  was  attended  by  a  midwife,  who 
had  some  difficulty  in  removing  the  placenta,  which  she  brought  away  in  pieces  and  at 
difi"erent  times.  Eight  days  after,  Mr.  S.  being  called  in,  found  her  laboring  under 
puerperal  fever  and  insensible.  He  thought  she  would  have  died;  but  contrary  to  all 
expectation,  she  recovered.  lie  then  discovered  that  the  left  eye  had,  while  she  lay 
insensible,  become  enlarged,  and  that  a  fleshy  excrescence  projected  between  the  lids.  The 
eyeball  seemed  much  enlarged,  and  felt  hard,  and  the  cornea  was  projecting  and  opaque. 
The  poor  woman  had  also  phlegmasia  dolens  of  the  right  leg. 

Case  290. — Dr.  Lee  relates,  that  in  a  patient  of  the  British  Lying-in  Hospital,  delivered 
on  the  27th  January,  1832,  obscure  febrile  symptoms  took  place  a  few  days  after,  without 
any  pain  in  the  region  of  the  uterus.  On  the  tenth  day  after  delivery,  there  was  fever, 
with  delirium,  tremoi's  of  the  muscles,  and  a  peculiar  dusky  sallow  complexion ;  the  whole 
of  the  left  lower  extremity  was  swollen,  hot,  tense,  and  shining,  and  there  was  exquisite 
pain  on  pressure  along  the  course  of  the  iliac  vessels  on  the  left  side,  and  down  the  inner 
part  of  the  thigh.  The  conjunctivae  of  both  eyes  suddenly  became  intensely  red  and 
swollen,  and  the  sight  was  much  impaired,  if  not  entirely  lost.  The  right  knee-joint 
became  exquisitely  painful,  and  a  gangrenous  spot  appeared  over  the  sacrum.  Before 
death,  which  took  place  on  the  18th  February,  the  eyes  had  become  enormously  swollen, 
so  that  the  eyelids  could  not  be  closed,  and  vision  was  completely  gone. 

Inspection. — The  coats  of  the  left  common,  external  iliac,  and  femoral  veins,  deep  and 
superficial,  were  all  thickened,  and  their  cavities  plugged  up  with  firm  coagula.  The  same 
was  the  case  with  the  epigastric  vein,  and  circumflexa  ilii.  The  glands  in  the  vicinity  of 
these  veins,  were  enlarged,  red,  and  vascular,  and  closely  adherent  to  the  cellular  mem- 
brane and  outer  surface  of  the  vessels.  The  vena  cava,  to  a  short  distance  above  the 
entrance  of  the  left  common  iliac  vein,  had  its  coats  thickened,  and  a  soft  coagulum  of 
lymph  adhering  to  its  inner  surface.  The  uterine,  vaginal,  gluteal,  and  most  of  the  other 
veins  which  form  the  left  internal  iliac,  were  gorged  with  pus,  and  lined  with  false  mem- 
branes of  a  dark  color.  The  uterine  branches  of  the  right  internal  iliac  vein  were  also 
filled  with  pus  and  lymph;  but  the  inflammation  had  not  extended  beyond  the  entrance 
of  the  trunk  of  this  vessel  into  the  common  iliac ;  and  the  right  common,  external  iliac, 
and  femoral  veins,  were  all  in  a  healthy  condition.  In  the  muscular  coat  of  the  cervix 
uteri,  on  the  left  side,  was  a  cavity  which  contained  about  half  an  ounce  of  purulent  fluid. 
The  veins  proceeding  from  this  part  of  the  cervix  were  filled  with  pus.^ 

The  facts  above  stated  or  referred  to,  show  that  puerperal  ophthalmitis 
may  show  itself,  from  the  third  to  the  thirtieth  day  after  parturition. 

3.  In  the  following  case,  both  eyes  appeared  to  be  affected  with  phlebitic 
ophthalmitis,  in  consequence  of  diffuse  cellular  inflammation  of  the  forearm : — 

Case  291. — Mrs.  L.  aged  GO,  previously  very  healthy,  became  aff'ected  with  whitlow  at 
the  point  of  the  index  finger  of  the  right  hand,  about  the  end  of  November,  1837.  She 
said  she  had  pricked  the  finger,  and  that  it  had  afterwards  been  "poisoned."  She 
described  the  pain  as  shooting  occasionally  from  the  finger  towards  the  shoulder.  The 
finger  was  laid  open,  and  a  few  drops  of  pus  were  discharged.  In  the  course  of  a  few 
days,  it  was  apparent  that  pus  was  lodged  in  the  sheath  of  the  flexor  tendon,  which  was 
opened.  This  was  soon  followed  by  erysipelas  over  the  Avhole  forearm,  ending  in  extensive 
suppuration.  The  forearm  continued  in  a  bad  state  for  more  than  five  weeks.  It  was 
repeatedly  punctured,  and  disorganized  cellular  membrane  was  discharged  by  numerous 
orifices. 

About  the  middle  of  January,  1838,  she  began  to  complain  of  rheumatic  pains  in  seve- 
ral of  her  joints,  but  without  any  swelling.  She  had  never  been  subject  to  rheumatism, 
nor  to  synovitis.  A  few  days  after  this  occurrence,  the  erysipelas  suddenly  subsided,  and 
she  began  to  complain  of  dimness  of  sight,  but  without  any  pain  in  the  eyes.  The  iris  of 
each  eye  appeared  inflamed,  and  the  pupils  were  somewhat  contracted  and  very  hazy. 
In  three  or  four  days  from  the  commencement  of  this  afiFection  of  the  eyes,  there  was  a 
deposition  of  lymph  observable  at  the  lower  part  of  each  anterior  chamber. 

I  visited  ]Mrs.  L.  along  with  Mr.  Maxwell  and  Mr.  Mofi'at,  on  the  2(Jth  of  January. 
Both  eyes  were  almost  completely  amaurotic.  The  capsule  of  each  lens  was  opaque  and 
of  a  greenish  hue.  The  pupils  were  irregular  and  contracted.  These  symptoms  denoted 
the  existence  of  inflammation:  but  their  supervention  had  been  unattended  with  pain,  and 
in  this  respect  the  case  difl"ered  from  ordinary  instances  of  iritis.  Calomel  and  opium 
were  given,  so  as  to  make  the  gums  sore  in  a  few  days;  leeches  and  blisters  were  applied;  ■ 
and  extract  of  belladonna  was  used  externally. 


PHLEBITIC   OPHTHALMITIS.  5*75 

On  the  6th  February,  nine  days  from  the  time  when  the  sight  became  impaired,  the  left 
eye  was  greatly  pi'otruded,  and  the  conjunctiva  so  much  cbemosed  as  to  overlap  the 
greater  part  of  the  cornea.  The  swelling  was  of  a  pale  red  color,  and  covered  Avith  a 
pretty  firm  lymphatic  exudation,  which  peeled  off  in  the  form  of  a  membrane.  The  eye- 
ball was  very  tense.     I  punctured  it  with  a  lancet,  through  the  sclerotica. 

In  about  a  week  the  swelling  bad  fallen,  so  that  the  eye  retreated  into  its  socket,  and 
presented  its  natural  size,  but  the  rheumatic  pains  became  much  aggravated  for  several 
weeks.  Vinum  colchici,  external  rubefacients,  &c.,  were  liberally  used,  with  little  ap- 
parent benefit. 

About  the  beginning  of  April,  the  right  eyeball  became  protruded  in  a  similar  yvaj  as 
the  left  had  been  two  months  before,  but  not  to  the  same  extent.  It  subsided  in  about 
the  same  time,  under  soothing  applications.  The  left  eye  afterwards  became  atrophic. 
Both  remained  totally  amaurotic. 

In  the  month  of  June  and  July,  the  rheumatic  affection  abated  considerably,  and  the 
general  health  improved ;  but  the  patient  felt  so  much  weakness  in  her  back  that  she 
could  not  walk  without  assistance.  Several  of  the  lumbar  vertebrae  appeared  a  little  pro- 
truded. 

In  this  case,  there  were  strong  grounds  for  believing  that  the  disease  of 
the  eyes  was  the  consequence  of  some  morbid  poison,  generated  during  the 
attack  of  diffuse  cellular  inflammation,  and  conveyed  through  the  body  by 
means  of  the  circulation.  A  remarkable  circumstance  was,  the  length  of 
time  which  elapsed  between  the  protrusion  of  the  one  eye  and  that  of  the 
other. 

4.  The  train  of  events  in  the  following  case  was  scarlatina,  phlegmasia 
dolens,  typhus  fever,  phlebitic  ophthalmitis,  and  death : — 

Case  292. — Stewart  Bell,  a  weaver,  aged  23,  was  admitted  into  the  Glasgow  Fever 
Hospital,  on  the  14th  May,  1836,  for  scarlatina,  and  was  dismissed  cured  in  the  course  of 
a  few  days.  He  was  readmitted  on  the  1st  June.  At  his  readmission,  he  complained 
of  acute  pain  in  the  left  thigh  and  leg,  much  increased  by  pressure  on  the  inner  part  of 
the  thigh.  Both  the  leg  and  thigh  were  swollen,  but  of  their  natural  color.  The  left 
arm  was  rigid,  but  not  swollen,  and  pressure  or  motion  produced  slight  uneasiness.  He 
complained  of  pain  in  the  joints.  Pulse  112,  pretty  fii-m.  Tongue  furred,  moist.  Bowels 
loose.  It  was  the  impression  of  Dr.  Cowan,  whose  patient  he  was,  that  he  was  affected 
with  phlegmasia  dolens  from  phlebitis.  He  had  had  several  rigoi's  on  the  24th  May,  fol- 
lowed by  headache,  heat  of  skin,  and  urgent  thirst;  and  on  the  25th,  the  affection  of  the 
limbs  commenced.  He  was  ordered  ^ss.  of  castor  oil,  with  25  drops  of  laudanum;  gr. 
jss.  of  opium  at  bedtime;  and  12  leeches  to  the  thigh. 

2d.  Considerably  relieved  by  the  leeching.  Urine  drawn  off  by  the  catheter.  Thrice 
a-day  2  grains  of  calomel  with  5  grains  of  Dover's  powder. 

5th.  Typhoid  eruption.  Delirium.  (Edema  of  the  eyelids  to  a  great  degree.  Pulse 
100.     Tongue  brown  and  dry. 

7th.  Delirium  continues.  Pulse  100.  Tongue  much  loaded.  Bowels  slow.  Six  grains 
of  calomel,  with  12  of  jalap. 

8th.  Pulse  120.     Powders  continued. 

9th.  Rigidity  of  both  arms.  Delirium  continues.  Pulse  120.  Eyes  much  swollen  and 
protruding.     Twelve  leeches  to  head.     Powders  continued. 

10th.  Sinking.  Pulse  120.  Features  sharp.  During  this  day,  deposition  of  purulent 
matter  was  discovered  in  both  eyes.     Died  in  the  evening. 

11th.  Inspection. — Dura  mater  thickened  ;  and  in  the  course  of  the  longitudinal  sinus, 
a  small,  rough,  irregularly  shaped,  ossified  body,  about  the  size  of  a  split  pea,  was  dis- 
covered. Brain  softer  than  natural.  Lungs  engorged,  and  bronchi  reddened.  No  disease 
in  stomach  or  intestines.  No  trace  of  pus  in  the  veins.  The  eyeballs,  which  had  previ- 
ously been  much  protruded,  had  sunk  nearly  to  their  ordinary  place  in  the  orbits. 

Left  eye.- — The  cellular  and  adipose  tissue  surrounding  the  eyeball,  was  indurated, 
swelled,  and  infiltrated  with  serum.  The  cornea  transparent.  The  sclerotica  reddish, 
soft,  and  thickened,  especially  around  the  entrance  of  the  optic  nerve.  The  anterior 
chamber  contained  a  reddish  fluid,  with  some  white  flaky  matter.  The  iris  was  thin  and 
soft.  It  had  contracted  no  adhesion.  The  choroid  coat  adhered  more  firmly  than  usual 
to  the  sclerotic;  its  inner  surface  presented  some  reddish  spots,  interspersed  with  white 
patches,  apparently  of  lymph,  which  could  not  be  detached  from  it,  and  seemed  incorpo- 
rated with  its  substance.  The  ciliary  body  was  not  materially  changed.  The  pigment 
was  in  some  places  entirely  deficient,  and  in  others  the  remains  of  it  could  be  easily  sepa- 
rated from  the  choroid  ;  no  trace  of  it  was  found  on  the  posterior  surface  of  the  iris,  and 


516  PHLEBITIC   OPHTHALMITIS. 

the  slight  shreds  of  it  which  remained  on  the  ciliary  processes,  were  readily  removed,  so 
as  to  leave  that  structure  of  a  uniform  white  color. 

The  choroid  coat  was  separated  from  the  retina  by  a  considerable  quantity  of  reddish 
fluid,  with  whitish  puriform  flakes,  from  the  entrance  of  the  optic  nerve  forward  to  the 
zonula  Zinnii.     It  flowed  out  on  penetrating  the  choroid. 

The  retina,  thus  detached  from  the  choroid,  was  firmly  united  to  the  hyaloid  membrane, 
and  anteriorly  to  the  zonula  Zinnii ;  so  that  these  textures  formed  a  whitish  thickened 
mass,  inclosing  a  small  quantity  of  a  reddish  fluid,  the  remains  of  the  vitreous  humor. 
The  membranous  lamina  of  the  vitreous  body  had  entirely  disappeared  towards  its  centre. 
The  adhesion  and  thickening  of  the  retina,  zonula  Zinnii,  and  hyaloid,  seemed  to  be  from 
effusion  of  coagulating  lymph.  It  was  most  remarkable  at  the  zonula  Zinnii,  and  greater 
near  the  entrance  of  the  optic  nerve  than  at  the  equator  of  the  eye. 

The  lens  and  both  layers  of  its  capsule  were  transparent. 

Right  eye. — The  appearances  were  exactly  similar,  with  the  following  exceptions:  1. 
There  was  a  thin  lamina  of  lymph  lying  in  the  lower  part  of  the  anterior  chamber,  parallel 
to  the  iris,  and  extending  up  to  the  pupillary  margin.  2.  A  zone  of  the  retina  and  hyaloid 
membrane  in  the  equator  of  the  eye  was  so  slightly  thickened,  and  so  transparent,  that 
the  reddish  fluid  in  the  centre  of  the  vitreous  body  was  distinctly  seen  through  it,  when 
the  light  was  transmitted  through  the  lens.  3.  A  slight  uniform  layer  of  pigment 
remained  on  the  posterior  smooth  zone  of  the  ciliary  body,  and  a  very  distinct  layer  on 
the  posterior  surface  of  the  iris. 

Phlebitis,  attendant  on  typhus  fever,  is  no  doubt  a  rare  event;  but  I  under- 
stood from  Dr.  Cowan,  that  he  had  witnessed  several  cases  of  it.  It  gene- 
rally shows  itself  about  the  period  of  convalescence,  and  not  early  in  the 
disease,  as  it  did  in  Bell.  For  example,  one  patient,  a  man  of  25  years  of 
age,  was  pronounced  convalescent  on  the  15th  May,  had  rigors  on  the  24th, 
and  died  on  the  29th.  Pus  was  found  in  the  left  femoral  vein.  In  two  cases, 
besides  that  of  Bell,  Dr.  Cowan  had  seen  affections  of  the  eyes,  probably  the 
result  of  phlebitis.  In  one  of  these,  the  corneae  ulcerated  on  the  day  of  the 
patient's  death ;  in  the  other,  there  were  purulent  deposition  and  ulceration 
of  the  corner,  on  the  19th  day  of  the  fever. 

There  is  reason  to  believe  that  cases  occur,  which  are  regarded  as  phlebitis 
after  fever,  but  are  really  examples  of  a  fever  like  typhus,  arising  from  phle- 
bitis. "  I  remember  attending  a  case  in  private  practice,"  says  Dr.  Todd, 
"  where  the  pus  showed  itself  in  the  anterior  chamber  of  the  eye.  This  case 
presented  all  the  symptoms  of  typhus  fever ;  and  for  a  day  or  two,  I  viewed 
it  as  such.  I  was  one  day  much  surprised  at  observing  pus  in  the  anterior 
chaml)er,  which  increased  in  quantity  very  rapidly,  and  pus  was  afterwards 
found  in  the  elbow  and  shoulder  joints.  When  we  came  to  examine  this 
patient,  we  found  an  ulcer  in  the  heart,  at  the  base  of  one  of  the  mitral 
valves."'' 

The  reader  is,  doubtless,  acquainted  with  the  fact,  that  phlebitis  is  apt  to 
be  followed  by  what  have  been  termed  jD?«-i//e?«i  deposits  in  different  parts  of 
the  body,  and  that  these  have  generally  been  ascribed  to  the  circulation  of 
pus  in  the  bloodvessels.  The  notion,  however,  that  the  matter  found  in  the 
lungs,  liver,  brain,  cellular  membrane,  and  other  parts,  in  cases  of  phlebitis, 
is  actually  that  which  has  been  carried  through  the  circulation  from  the  vein 
originally  injured  or  inflamed,  is  now  abandoned.  The  matter  found  in  the 
organs  secondarily  inflamed  is  doubtless  secreted  in  these  organs  themselves ; 
and  it  appears  probable,  that  it  is  from  inflammation  of  the  veins  of  these 
parts,  that  the  secondary  affections  arise.  Far  from  regarding  any  mere  de- 
posit of  pus  from  the  general  circulation  as  the  efflcient  cause  of  the  second- 
ary abscesses  which  occur  in  consequence  of  phlebitis,  it  is  the  opinion  of 
recent  inquirers"'  that  the  circulating  pus  acts  only  by  irritating  the  coats  of 
the  capillary  veins  in  different  organs  of  the  body,  and  exciting  them  to 
inflame ;  and  that  these  inflamed  veins  produce  a  circumscribed  suppuration 
around  themselves.  This  is  not  a  conjecture,  but  an  opinion  founded  on 
various  and  accurate  observations. 


PHLEBITIC   OPHTHALMITIS.  517 

To  apply  these  views  to  the  eye,  we  cannot  believe  that  the  same  pus  which 
has  passed  from  the  uterine  veins,  or  from  the  veins  of  the  extremities,  in  cases 
of  phlebitis,  is  deposited  between  the  choroid  and  retina,  or  in  the  aqueous 
chambers  of  the  eye ;  but  that  the  textures  in  the  neighborhood  of  which 
lymph  or  pus  is  found  in  phlebitic  ophthalmitis,  have  themselves  been  excited 
to  inflammation  ;  and  according  to  our  present  knowledge  of  the  subject,  it  is 
a  probable  supposition,  that  the  minutest  veins  of  these  textures  are  the  parts 
in  which  the  circulating  pus  is  first  arrested,  and  in  which  the  irritation  and 
secondary  inflammation  are  first  produced.  Desmarres^  refers,  however,  to 
several  cases  of  phlebitic  ophthalmitis,  in  which  the  ophthalmic  vein  was  found 
on  dissection,  inflamed  and  filled  with  clots. 

The  effects  of  inflammation  of  a  vein  may  be  distinguished  into  primary 
and  secondary,  local  and  remote.  We  must  not  confound  the  several  effects. 
Take,  for  example,  suppurative  inflammation  of  the  veins  of  the  uterus  after 
parturition.  The  ])riniary  efi'ects  are  increased  thickness  of  the  coats  of  the 
affected  veins,  false  membranes  on  their  internal  surface,  gradual  coagulation 
of  their  contents,  deposition  of  ]nis  in  their  cavities,  and  occasionally  entire 
destruction  of  their  texture.  The  secondary  effects  are  abscess  in  the  liver, 
purulent  collections  in  the  chest,  inflammation  and  ulceration  of  the  synovial 
membranes,  and  ophthalmitis.  The  efi'ects  just  now  enumerated  are  also 
remote,  while  the  swelled  leg,  or  phlegmasia  dolens,  is  an  example  of  a  local 
effect ;  being  a  consequence  merely  of  the  obstructed  state  of  the  iliac  and 
femoral  veins,  produced  by  the  original  inflammation  extending  into  these 
vessels.  It  would  be  incorrect,  then,  to  speak  oi phlegmasia  dolens  of  the  eye, 
as  some  have  done,  meaning  thereby  the  secondary  and  remote  inflammation 
of  that  organ,  arising  from  the  circulation  of  purulent  matter. 

Local  symptoms. — Phlebitic  ophthalmitis  presents  the  same  train  of  symp- 
toms which  I  have  enumerated  in  last  section. 

The  disease  begins  slowly  and  insidiously  in  some  cases ;  suddenly  and 
severely,  in  others.  One  eye,  or  both,  may  be  affected.  Sometimes  the  in- 
flammation seems  to  commence  in  the  ocular  conjunctiva ;  at  other  times,  it 
proceeds  from  the  orbital  tissues.  In  many  cases,  the  retina  appears  to  be 
the  focus  of  the  disease. 

Pulsatory  pain  is  felt  in  the  eye  and  orbit,  spreading  to  the  forehead  and 
temple,  and  accompanied  with  a  sensation  of  burning  heat,  tension,  and  ful- 
ness, as  if  the  eye  could  not  be  contained  within  the  orbit. 

The  patient  complains  of  photophobia  and  photopsia.  The  smallest  ray 
of  light  occasions  a  severe  feeling  of  intolerance.  This  symptom  occurs 
chiefly  in  the  commencement ;  it  subsides  as  the  retina  becomes  insensible. 

There  is  swelling  of  the  eye,  the  intra-orbital  tissues,  and  the  eyelids.  The 
eye  wants  only  the  profuse  purulent  discharge,  to  give  it  all  the  external 
characters  of  a  severe  attack  of  purulent  ophthalmia.  The  upper  eyelid  is 
sometimes  so  swollen  as  to  overlap  the  lower.  The  eyeball  is  hard,  and 
incompressible  ;  and  in  consequence  chiefly  of  inflammatory  effusion  into  the 
ocular  capsule,  is  pushed  almost  completely  out  of  the  orbit.  One  unac- 
quainted with  the  disease,  is  led  to  suspect  the  presence  of  an  abscess  or  a 
tumor  behind  the  eye.  From  the  fibrous  texture  of  the  shell  of  the  eyeball, 
we  might  think  it  incapable  of  extension  ;  and,  no  doubt,  it  is  from  its  yield- 
ing so  little,  that  the  severity  of  the  pain  arises  which  attends  ophthalmitis. 
Still  it  does  yield,  and  the  eyeball  is  distended  and  increased  in  volume  and 
contents.  Much  less  so,  however,  than  its  state  of  extreme  protrusion,  and 
its  pressure  against  the  eyelids,  might  lead  us  to  suppose. 

At  first,  the  conjunctiva  is  rather  edematous  than  very  red.     The  aqueous 
humor  is  sanguinolent ;  the  iris  changed  in  color,  and  coated  with  lymph  ; 
the  pupil  contracted ;  the  fundus  oculi  reddish  or  greenish.     There  is  an 
37 


578  PHLEBITIC   OPHTHALMITIS. 

involuntary  fixedness  of  the  eyeball,  the  state  of  pain  and  swelling  rendering 
its  common  movements  impossible. 

Constitutional  symptoms. — The  constitutional  symptoms  which  attend  any 
secondary  phlebitic  disease,  such  as  ophthalmitis,  are  generally  of  a  typhoid 
description  ;  frequent  rigors,  prostration  of  strength,  rapid  feeble  pulse, 
labored  respiration,  emaciation,  insomnia,  anxiety,  low  wandering  delirium, 
attacks  of  vomiting  and  purging,  a  leaden  and  icterous  tint  of  the  skin,  and 
a  brown  parched  tongue. 

Terminations. — Like  the  idiopathic  variety,  phlebitic  ophthalmitis  has  dif- 
ferent terminations. 

1.  A  perfect  recovery  is  extremely  rare.  If  the  patient  survive,  the  func- 
tion and  the  form  of  the  eye  are  generally  destroyed.  It  terminates  in  amau- 
rosis, as  it  did  in  the  case  I  have  related,  where  it  arose  from  erysipelas. 
The  eyeball  may  remain  almost  natural  in  size,  or  it  may  become  atrophic. 
The  capsule  of  the  lens  is  left  opaque,  and  the  pupil  small  and  adherent. 

2.  Phlebitic  ophthalmitis  terminates  in  suppuration  and  rupture  of  the  eye. 
The  cornea  infiltrates  with  pus,  and  becomes  ulcerated  ;  it  bursts,  and  allows 
the  humors  to  escape,  along  with  portions  of  pigment,  and  purulent  matter ; 
sometimes  it  is  affected  with  gangrene,  and  throws  off  a  distinct  slough.  In 
some  cases,  the  sclerotica  points  and  gives  way,  so  that  pus  is  discharged. 
In  other  cases,  the  ocular  capsule  bursts ;  an  event  which  is  apt  to  simulate 
rupture  of  the  eye. 

3.  The  disease  of  the  eye  may  subside  ;  but  the  purulent  infection  of  the 
blood  continuing,  pytemic  inflammation  of  some  other  organ  may  follow,  such 
as  of  the  pleura,  or  the  pericardum.^"  From  this  new  aflection  the  patient 
may,  or  may  not  recover. 

4.  This  disease  terminates  by  death.  This  would  certainly  happen  more 
frequently,  if  the  eye  or  the  ocular  capsule  did  not  give  way  spontaneously. 
The  relaxation  which  results  from  the  bursting  of  the  eye,  or  the  ocular 
capsule,  diminishes  the  violence  of  the  inflammation,  and  the  disease  subsides, 
as  does  a  whitlow  treated  by  a  deep  incision.  On  the  other  hand,  the  inflam- 
matory action,  if  unsubdued,  is  propagated  to  the  brain  or  its  membranes, 
and  ends  in  fatal  coma ;  or  the  patient  sinks  from  typhoid  exhaustion. 

Prognosis. — The  danger  of  the  disease  spreading  to  the  brain,  or  of  the 
patient  sinking,  either  without  any  new  symptoms,  or  after  an  affection  of  the 
synovial  membranes  or  other  organs,  must  render  our  prognosis  always 
extremely  guarded.  According  to  the  intensity  of  the  symptoms,  and  their 
seeming  tendency  to  such  or  such  a  termination,  the  friends  must  be  warned 
of  the  dangerous,  or  very  dangerous,  state  in  which  the  patient  is. 

Treatment. — The  tendency  to  rapid  sinking  forbids  active  depiction  ;  but 
in  other  respects,  the  same  general  line  of  treatment  must  be  followed  as  in 
the  idiopathic  variety.  Colchicum  has  been  recommended  ;  but  I  believe 
calomel  with  opium,  to  be  the  best  internal  remedy.  Leeches,  and  fomenta- 
tions to  the  eye,  are  of  much  service. 


'  Medical  Gazette;  Vol.  ii.  p.  284;  London,  Pan  ton's  inaugural  Essay  on  Uterine  Phlebitis; 

1828.  Glasgow,  1840. 

"  See  case  after  ligature  of  carotid  in  Brasdor's  ^    Medico-chirurgical     Transactions;     Vol. 

method,  by  Colson,    Memoires  de   FAcademie  xxviii.  p.  347 ;  London,  1845.     See  othtr  cases 

Royale  do    Medecine,  Tome  ix.  p.   80,  Paris,  by  Lee,  Ibid.  p.  349;  Ibid.  Vol.  xv.  p.  370:  by 

1841.     The  patient  recovered  with  the  loss  of  M'Whinnie,  Ibid.  Vol.  xxxi.  p.  65:  by  Graves, 

the  eye  which  burst  spontaneously,  and  became  Medical  and  Surgical  Journal,  Vol.  iii.  p.  360; 

atrophic.  London,  1833:    by  Moser,  Amnion's    Monats- 

'  Medico-chirurgical  Transactions;  Vol.  xv.  sehrift.  Vol.  iii.  p.  216  ;  Leipzig,  1840:  by  Weir, 

p.  120:  Ldndon.  1829.  Monthly  Journal  Medical  Science,  Sept.  1847, 

■■  Ibid.  Vol.  xiii.  p.  189;  London,  1825.  p.  209.     In    the  cases  related    by  M'Whinnie 

'  The  details  of  this  case  are  given  in  Dr.  and    Weir,   the    patient   recovered,   with    the 


POSTFEBRILE   OPHTHALMITIS.  519 

affected   eye  atrophic.     The  other  cases  were  '"  See  case  of  phlebitic  ophthalmitis,  conse- 

fatal.  quent  on  amputation,  and  followed  by  pleurisy, 

■■  Medical  Times  and  Gazette,  February,  21,  with  dissection,  by  Bowman :  Lectures  on  the 

1852,  p.  182.  parts  concerned  in  the  Operations  on  the  Eye, 

'  Cruveilhier,  Anatomie  Pathologique,  Tome  p.  12.3;   London,  1849:     Case  after  scarlatina, 

i. ;  Livraison  ii. :     Dictionnaire  de  Medecine  et  followed  by  an  affection  like  rheumatism  and 

de  Chirurgie  Pratiques,  art.  Phlehlte:  Douglas,  by  pericarditis,  by  Porter,  American  Journal  of 

Inaugural  Essay  on  Phlebitis;  Glasgow,  1835.  the  Medical  Sciences,  January,  1845,  p.  85. 

°  Traite  des  Maladies  desYeux,  p.  244;  Paris, 
1847. 


SECTION  XXXIV. — POSTFEBRILE  OPHTHALMITIS. 

Syn. — Ophthalmia  post  febrem. 

The  cases  whence  I  have  drawn  the  following  account  of  post-febrile 
ophthalmitis,  were  the  result  of  an  epidemic  fever,  which  prevailed  in  Glas- 
gow during  the  greater  part  of  1843  and  1844,  supplanting  the  exanthematic 
typhus  to  which  this  town  had  immediately  before  been  subject. 

The  new  fever  was  a  remittent,  often  accompanied  with  jaundice,  its  first 
paroxysm  coming  to  a  crisis  within  seven  days,  a  relapse  happening  almost 
invariably,  the  patient  rarely  suffering  more  than  two  paroxysms,  and  the 
mortality  probably  not  exceeding  2|^  per  cent.  I  am  unable  to  say,  whether 
the  same  species  of  fever  had  ever  before  been  known  in  Glasgow.  At  the 
same  time  that  this  town  suffered  from  it,  it  prevailed  in  Edinburgh,  Dundee, 
and  several  other  places  in  Scotland.  That  it  had  at  different  times  prevailed 
in  Ireland  is  shown  from  the  fact,  that  the  course  observed  by  some  of  the 
Irish  epidemics  corresponds  closely  with  that  of  the  Glasgow  fever ;  while 
the  complete  identity  of  this  fever  with  that  which  prevailed  in  Dublin  in 
1826,  is  proved,  not  only  by  the  correspondence  in  their  general  course,  but 
also  by  the  exact  similarity  of  the  affection  of  the  eyes,  observed  as  a  sequela 
in  both  instances. 

That  the  organs  of  vision  are  apt  to  suffer  from  various  kinds  of  fever,  has 
long  been  observed.  Even  Thucydides  mentions*  in  his  account  of  the  plague 
at  Athens,  which  has  been  supposed  to  have  been  typhus,  that  some  lost  their 
eyes  in  consequence.  Typhus  is  sometimes  followed  by  muscse  volitantes, 
or  even  by  amaurosis,  and  in  some  rare  instances  by  general  ophthalmitis. 
I  have  known  the  disease  called  hay-fever,  to  be  followed  by  intermittent 
ophthalmia  of  iritic  character,  ending  in  amaurosis.  Dr.  Lawrie  informs  me, 
that  remittent  fever  in  India  is  sometimes  followed  by  corneitis  and  sloughing 
of  the  cornefe.  Certainly  no  febrile  disease  with  which  we  were  previously 
acquainted  in  this  country,  was  followed  by  such  an  inflammatory  affection  of 
the  eye  as  that  which  I  am  about  to  describe. 

Symptoms  of  the  remittent  fever. — The  disease  commenced  with  the  usual 
symptoms  of  fevers,  rigors,  headache,  and  sickness.  A  striking  feature  was 
the  frequent  and  excessive  vomiting,  or  straining  to  vomit,  attended  by  pains 
throughout  the  body  resembling  those  of  rheumatism.  There  were  often  no 
premonitory  symptoms,  the  attack  being  very  sudden,  and  marked  by  excessive 
weakness.  One  little  boy  whom  I  saw,  was  seized  in  the  street,  and  fell  down, 
so  that  he  required  to  be  carried  home.  In  some  of  the  cases,  the  disease 
resembled  very  much  sea-sickness  in  its  accession,  both  in  respect  to  the 
prostration  of  strength  by  which  the  vomiting  was  accompanied,  and  the  total 
indifference  of  the  patients  whether  they  lived  or  died. 

The  pulse  was  much  accelerated.  It  often  rose,  the  night  before  the  crisis, 
to  140;  then  fell  at  once  to  84,  or  less.  The  tongue  was  not  much  loaded  ; 
after  a  time,  it  became  brown  and  dry.     Especially  in  the  night,  the  patients 


580  POSTFEBRILE   OPHTHALMITIS. 

were  delirious ;  often  affected  with  subsultus  tendinum ;  could  not  sleep,  tossed 
continually,  and  insisted  on  getting  up. 

Epistaxis  in  some,  and  jaundice  in  others,  were  of  frequent  occurrence. 
When  the  disease  attacked  women  about  the  menstrual  period,  the  discharge 
was  very  copious  ;  and  almost  all  the  women  in  a  state  of  pregnancy  who 
v/ere  seized,  aborted,  if  in  the  early  months,  or  had  premature  labor,  if  far- 
ther advanced.  If  pregnant  women  affected  with  the  fever,  went  the  full  time, 
sometimes  the  child  was  dead,  or  if  born  alive,  the  mother  had  no  milk,  and 
had  a  troublesome  and  lingering  recovery,  while  the  child  generally  died  from 
want  of  support,  or  perhaps  from  being  affected  with  the  fever. 

At  the  height  of  the  disease,  the  symptoms  were  the  same  as  at  the  begin- 
ning, only  of  greater  violence.  Convulsions  were  not  uncommon,  immediately 
before  the  crisis.     Sometimes  they  proved  fatal. 

There  was  no  certain  period  when  the  first  crisis  happened.  The  patient 
was  generally  several  days  ill,  perhaps  five  or  six,  when  a  decided  change  took 
place  by  profuse  perspiration  during  the  night,  generally  preceded  by  a  severe 
rigor.  Next  morning  the  patient  expressed  himself  as  if  in  a  new  world  ; 
the  tongue  had  become  moist,  the  thirst  was  greatly  abated,  and  he  was  free 
from  sickness  and  headache.  In  old  people,  there  was  little  or  no  perspira- 
tion at  the  crisis ;  but  the  change  was  at  once  observed  by  the  more  agreeable 
expression  of  the  countenance,  and  the  manner  of  speaking. 

Some  patients  had  a  very  short  remission  ;  others  had  one  of  considerable 
length.  In  some,  it  lasted  only  for  three  or  four  days  ;  in  others,  for  two  or 
three  weeks.  Very  few  escaped  a  return  of  the  fever.  Whether  they  got  up, 
and  perhaps  went  out  of  doors,  or  confined  themselves  closely  to  bed,  nineteen 
out  of  twenty  relapsed.  Where  the  first  attack  was  mild,  the  second  was  gen- 
erally more  severe,  and  vice  versa.  If  any  improper  freedom  had  been  used 
in  diet  during  the  remission,  the  second  paroxysm  was  generally  more  severe 
than  the  first. 

The  relapse  occurred  with  the  very  same  symptoms  as  the  original  attack. 
The  patient,  whom  the  day  before  we  had  left  to  all  appearance  convalescent, 
we  now  found  again  in  the  height  of  the  fever,  excessively  weak,  his  counte- 
nance often  shrunk  to  such  an  extent  as  to  remind  one  of  the  collapsed  stage 
of  malignant  cholera,  and  his  skin  covered  with  a  clammy  disagreeable  per- 
spiration. 

The  general  duration  of  the  second  attack  was  much  about  that  of  the  first,  the 
second  crisis  taking  place  sometimes  in  two  or  three  days,  but  more  commonly 
not  before  four  or  five.  If  there  were  any  difference  in  the  symptoms  of  the 
first  and  second  attacks,  it  was  in  the  muscular  and  articular  pains  being  of 
greater  severity  in  the  second.  There  was  also  considerable  pain  in  micturi- 
tion. Dysentery  sometimes  attended  the  second  attack,  traceable  not  unfre- 
quently  to  the  use  of  spirits  during  the  remission. 

A  second  or  third  relapse  was  rare  ;  but  some  patients  having  had  the  dis- 
ease, with  its  paroxysmal  character  well  marked,  and  who  therefore  thought 
themselves  secure,  were  seized  with  it  again,  aftev  an  interval,  in  some  in- 
stances, of  several  months,  and  went  through  all  its  stages  a  second  time  ;  a 
circumstance  which,  along  with  others  already  mentioned,  served  to  draw  a 
broad  line  of  distinction  between  this  fever  and  exanthematic  typhus. 

Various  sequel*  were  observed  to  follow  the  fever ;  such  as  pains  in  the 
joints,  want  of  power  in  the  extremities,  oedema  of  the  feet,  enlargement  of 
the  glands  in  the  neck,  boils  in  different  parts  of  the  body,  and  long-continued 
debility.  But  the  most  remarkable  was  the  amaurotic  and  inflammatory  affec- 
tion of  the  eye,  which  is  the  subject  of  the  present  section. 

The  fever  appeared  to  be  highly  contagious.  Where  many  individuals, 
ill-fed  and  ill-clothed,  lived  together  in  small,  dirty,  and  ill-ventilated  apart- 


POSTFEBRILE   OPHTHALMITIS.  581 

meuts,  it  generally  went  throngli  the  whole  of  them,  young  and  old,  in  rapid 
succession. 

The  smallness  of  the  mortality,  compared  with  the  severity  of  the  symptoms 
and  the  debility  left  by  the  disease,  was  a  matter  of  wonder.'' 

Statistics  of  postfehriU  ophthalmitis. — The  following  are  a  few  statistical 
facts,  which  may  be  worthy  of  notice  : — 

From  the  8th  August  till  the  31st  October,  1843,  -when  I  finished  my  quarterly  period 
of  attendance  at  the  Glasgow  Eye  Infirmary,  36  cases  of  postfebrile  ophthalmitis  were 
taken  on  the  list.  During  1843  and  1844,  out  of  1877  patients  admitted,  261  were  affected 
with  this  disease.  The  general  subjects  of  it  were  from  17  to  20  years  of  age  ;  but  it 
spared  neither  young  children,  adults,  nor  old  people.  The  general  character  of  the  dis- 
ease was  partly  amaurotic,  partly  inflammatory.  lu  by  far  the  greater  number  of  cases, 
the  eyes  attacked  had  been  previously  healthy,  but  in  some  instances  they  had  suffered 
from  other  diseases,  and  in  one  case  they  were  already  in  a  great  measure  disorganized. 

Out  of  the  36  cases  which  I  treated  in  August,  September,  and  October,  1843,  27  oc- 
curred in  females,  and  only  9  in  males.  The  following  were  the  ages  of  the  36  patients : 
— Below  ten,  2  ;  from  ten  to  twenty,  17  ;  from  twenty  to  thirty,  9  ;  from  thirty  to  forty, 
2 ;  from  forty  to  fifty,  3  ;  from  fifty  to  sixty,  3.  In  eighteen  of  the  cases,  the  right  eye 
only  was  affected ;  in  ten,  the  left  only  ;  and  in  eight,  both  eyes,  either  together  or  con- 
secutively. The  attack  of  ophthalmitis  occurred  at  various  periods,  from  three  to  sixteen 
weeks  from  the  commencement  of  the  fever.  In  several  cases,  it  came  on  about  two 
weeks  after  convalescence  from  the  relapse,  but  generally  somewhat  later. 

The  very  same  disease  of  the  eye  occurred  after  the  Dublin  epidemic  of  1826,  and  was 
described  by  Mi*.  Hewson,^  Dr.  Reed,^  Dr.  Jacob,^  and  Mr.  Wallace. ^  The  last-mentioned 
author  has  remarked  the  greater  liability  of  the  right  eye  to  be  affected  than  the  left. 
"  Of  forty  cases,"  says  he,  "  which  I  have  noted,  there  were  only  four  who  had  the  dis- 
ease in  the  left  eye,  and  only  two  had  it  in  both."  Out  of  ten  cases  in  which  it  happened 
to  me  to  observe  it  in  the  left  eye,  seven  were  females.  The  attack  is  generally  traced  to 
a  draught  of  cold  air  during  the  night ;  it  is  probably  the  eye  which  is  the  more  exposed, 
which  becomes  affected,  while  that  belonging  to  the  side  on  which  the  patient  rests, 
escapes. 

Dr.  Jacob  has  remarked,  that  the  disease  occurs  much  more  frequently  in  young  than 
in  old  persons.  Of  thirty  cases  in  which  he  noted  the  ages,  three  only  were  above  25. 
He  also  met  with  it  more  frequently  in  females  than  males.  In  the  majority  of  the  cases 
seen  by  him,  the  inflammation  made  its  ai^pearance  within  six  weeks  or  two  months  after 
recovery  from  the  fever ;  in  some  instances,  however,  it  appeared  before  the  patients  left 
the  hospital ;  and  in  others,  not  for  four,  five,  or  even  eight  months. 

My  colleague,  Dr.  A.  Anderson,  in  an  excellent  communication^  on  postfebrile  ophthal- 
mitis, says :  "  There  was  not  always  an  interval  of  time  between  the  end  of  fever  and 
the  onset  of  the  ophthalmia,  and  that  which  usually  occurred  was  of  very  vai'ious  length. 
Thus,  of  135  cases,  the  symptoms  (amaurotic  or  inflammatory)  of  the  affction  of  the  eyes 
began  during  the  fever  or  relapse  in  10 ;  at  once  upon  the  convalescence  in  34  ;  within  a 
fortnight  of  the  convalescence  in  29  ;  within  the  following  month  in  31 ;  within  the  next 
five  or  six  months  in  31." 

Symptoms. — The  character  of  postfebrile  ophthalmitis  appears  to  be,  in  the 
first  instance,  that  of  congestion,  followed  by  inflammation  of  the  external 
parts  of  the  eye,  and  especially  of  the  retina,  producing  great  imperfection  of 
sight.  This  is  succeeded  by  evident  inflammation  of  the  iris  and  sclerotica; 
the  disease  extends  to  the  capsule  of  the  lens,  and  sometimes  to  the  lining 
membrane  of  the  cornea;  there  can  be  little  doubt  but  that  the  choroid  is 
also  implicated,  although  not  to  a  great  degree ;  while  the  conjunctiva  remains 
in  general  but  slightly  affected. 

The  part  which  the  sclerotica  takes  in  the  disease,  is  plain  enough  from  the 
intense  injection  of  the  blood  vessels  which  lie  on  its  surface,  and  are  seen 
running  in  radii  towards  the  cornea.  The  change  of  color  in  the  iris,  the  con- 
tracted state  of  the  pupil,  and  the  tags  of  adhesion  between  the  edge  of  the 
pupil  and  the  capsule  of  the  lens,  show  how  much  the  iris  is  affected.  The 
internal  membrane  of  the  cornea,  and  the  anterior  crystalline  capsule,  espe- 
cially the  latter,  are  extremely  muddy,  showing  their  participation  in  the  in- 
flammation. The  whole  walls  of  the  aqueous  cell  seem,  in  some  cases,  as  if 
coated  with  a  thin  layer  of  lymph,  of  a  yellowish-green  color.     The  great 


582  POSTFEBRILE   OPHTHALMITIS. 

deficiency  of  sight  is  not  explicable  from  the  mere  muddiuess  of  these  parts, 
and  is,  besides,  the  earliest  symptom  of  the  disease,  showing  an  affection  of 
the  retina.  In  some  cases,  an  effusion  of  a  whitish  color  is  seen,  apparently 
on  the  surface  of  the  retina.  In  other  cases,  whitish  and  reddish  flocculi  are 
seen  waving  in  the  vitreous  humor.  At  an  early  period,  the  pupil  is  some- 
times dilated,  and  becomes  contracted  only  after  the  inflammation  has  extended 
to  the  iris.  If  not  promptly  combated  by  the  appropriate  remedies,  the  cor- 
nea, and  sclerotica  become  abnormally  flexible  under  the  pressure  of  the  finger, 
showing  a  deficiency  in  the  quantity  of  vitreous  fluid.  In  one  case,  I  found 
the  cornea  very  flexible  in  the  amaurotic  stage,  before  there  was  any  external 
appearance  of  inflammation.  The  flexibility  of  the  coats  of  the  eye  gradually 
disappears,  and  the  organ  becomes  once  more  natural  in  consistence,  but  not 
till  long  after  the  other  symptoms  have  yielded. 

At  the  commencement,  it  seems  probable  that  the  retina  only  is  inflamed. 
The  irritation  and  injection  speedily  spread  to  the  short  and  long  ciliaris,  to 
the  vessels  of  the  ciliary  process,  and  to  the  sclerotic  network  ;  and  in  propor- 
tion as  these  vessels  become  inflamed,  the  iris,  the  lining  membrane  of  the  cor- 
nea, the  crystalline  capsule,  and  the  hyaloid,  show  signs  of  being  implicated  in 
the  disease. 

The  lachrymation,  in  the  second  period,  is  very  considerable,  and  seems  to 
be  connected,  not  so  much  with  the  state  of  the  conjunctiva,  as  with  that  of 
the  interior  of  the  eye.  The  severe  pain  in  and  round  the  eye,  aggravated 
during  the  night,  is  exactly  similar  to  what  attends  rheumatic  and  syphilitic 
ophthalmia,  and  while  no  doubt  partly  the  effect  of  pressure  exercised  by  the 
inflamed  tissues  upon  the  ciliary  nerves  within  the  eye,  may  be  partly,  perhaps, 
a  direct  neuralgic  affection,  such  as  even  when  there  is  no  evident  inflamma- 
tion present,  we  often  meet  with  in  the  branches  of  the  fifth  nerve  emerging 
from  the  orbit.  It  is,  in  general,  only  after  the  iris  and  sclerotica  have  taken 
part  in  the  disease,  that  the  patient  complains  of  ocular  and  circumorbital 
pain.  So  long  as  the  disease  is  confined  to  the  retina,  there  is  little  or  no  pain. 
Hence  the  patient  is  less  alarmed  than  he  should  be  by  the  mere  dimness  of 
sight,  which,  indeed,  from  only  one  eye  being  generally  affected,  may  scarcely 
attract  his  attention.  Photopsia  is  not  a  symptom  of  which  the  patient  makes 
much  complaint.  Muscfe  volitantes  form  a  constant  symptom,  especially  after 
the  inflammation  has  yielded  and  the  eye  is  becoming  convalescent.  They 
then  seem  so  numerous,  that  one  patient  compared  his  state  of  myodesopia  as 
if  a  sooty  bag  had  been  shaken  before  him. 

Although,  in  by  far  the  greater  number  of  cases,  all  the  textures  of  the  eye 
suffer  in  this  disease,  on  which  account  it  is  designated  as  an  ophthalmitis,  it 
sometimes  happens  that  the  inflammation  is  confined  to  one  or  two  textures 
only.  Thus,  in  one  case,  the  anterior  crystalline  capsule,  and  the  lining  mem- 
brane of  the  cornea  only,  were  affected  with  inflammation. 

The  pulse  varies  from  8-i  to  120.  Frequent  rigors  occur.  The  tongue  is 
genei'ally  clean  and  moist.     The  pain  entirely  prevents  sleep. 

The  affection  of  the  eye  may  be  complicated  with  one  or  more  of  the  other 
sequelee  of  the  fever,  already  mentioned. 

Diagnosis. — The  present  disease  is  much  more  extensive,  in  respect  to  'the 
number  of  textures  affected,  and  much  more  intejisive,  in  so  far  as  the  morbid 
action  which  is  at  work  is  concerned,  than  rheumatic  ophthalmia  or  rheumatic 
iritis,  to  which,  however,  in  many  particulars  it  bears  a  resemblance.  Yet 
along  with  postfebrile  ophthalmitis,  we  have  neither  the  bounding  pulse,  the 
hot  skin,  nor  the  white  and  loaded  tongue,  which  attend  inflammation  of  the 
sclerotica  and  iris  from  mere  exposure  to  cold.  Xeither  is  the  blood  drawn 
from  a  vein  so  buffy.  The  pain  at  last  is  not  less  distressing.  Vision  is  much 
sooner  and  much  more  seriously  involved. 


I 


POSTFEBRILE   OPHTHALMITIS.  583 

Mr.  Wallace  considers  this  affection  of  the  eye  as  bearing  so  very  striking 
a  resemblance  to  syphilitic  ophthalmia,  that  the  one  cannot  be  distinguished 
from  the  other  without  particular  attention  to  the  history  of  the  case.  The 
absence  of  the  tawny-reddish  border  which  surrounds  the  pupillary  margin  of 
the  iris,  and  there  being  no  tubercles  on  the  iris  in  postfebrile  ophthalmitis, 
will  serve  to  distinguish  the  two  diseases. 

The  acuteness  of  the  present  disease  will  discriminate  it  from  scrofulous 
iritis,  to  which,  particularly  in  the  appearance  of  the  lens,  it  bears  consider- 
able resemblance,  as  well  as  in  the  degree  to  which  the  retina  is  affected.  In 
scrofulous  iritis,  however,  the  affection  of  the  retina  is  among  the  latest  symp- 
toms; in  postfebrile  ophthalmitis  it  is  the  earliest. 

In  some  instances,  the  present  disease  bears  a  considerable  resemblance  to 
catarrho-rheumatic  ophthalmia.  Onyx,  so  frequent  in  the  latter  disease,  I 
have  not  witnessed  in  the  former.  In  one  case,  I  observed  a  considerable 
portion  of  the  epithelium  of  the  cornea  exfoliated ;  but  never  the  ulcer  which 
affects  the  proper  substance  of  the  cornea,  and  which  is  so  characteristic  of 
catarrho-rheumatic  ophthalmia. 

The  disease  to  which  postfebrile  ophthalmitis  bears  the  nearest  resemblance, 
is  sympathetic  ophthalmitis ;  which,  as  I  shall  explain  in  a  following  section, 
results  so  frequently  in  the  one  eye,  from  incised  and  lacerated  wounds  of  the 
edge  of  the  cornea  and  sclerotica,  and  consequently  of  the  orbicnlns  ciliaris, 
of  the  opposite  eye.  The  cause  of  the  similarity  is  that,  both  in  sympathetic 
and  in  postfebrile  ophthalmitis,  the  inflammation  commences  in  the  retina, 
advances  to  the  iris,  embraces  all  the  internal  textures  of  the  eyeball,  and 
ends,  if  neglected,  in  opacity  of  the  crystalline,  closure  of  the  pupil,  and 
softening  of  the  globe.  The  slightest  inquiry  into  the  history  of  the  case 
will,  in  either  instance,  elucidate  the  origin  of  the  affection. 

Stages. — Mr.  Wallace  has  described  this  disease  as  presenting  two  stages  ; 
the  first  amaurotic,  and  the  second  inflammatory.  My  own  experience 
entirely  confirms  the  accuracy  of  Mr.  Wallace's  description.  "During  the 
first  stage,"  says  he,  "there  exist  amaurotic  symptoms  alone;  and  in  the 
second  stage,  to  the  amaurotic  symptoms  are  added  the  symptoms  of  inflam- 
mation. The  length  of  time  that  the  amaurotic  symptoms  exist  before  the 
occurrence  of  external  redness,  or  of  the  visible  signs  of  inflammation,  is 
extremely  uncertain,  as  also  the  period  after  fever  at  which  the  amaurotic 
symptoms  commence.  On  many  occasions  the  amaurotic  symptoms,  particu- 
larly a  slight  dimness  of  vision,  with  muscaj  volitantes,  have  commenced  at, 
or  even  before  the  time  of  convalescence  from  fever,  and  yet  the  inflammatory 
stage  has  not  supervened  for  w-eeks  or  even  months  ;  while  on  other  occasions 
the  dimness  of  vision  has  not  commenced  for  several  days,  weeks,  or  even 
months,  after  the  febrile  attack,  and  has  then  been  immediately  followed  by 
the  symptoms  of  inflammation.  It  is  to  be  particularly  observed  that  I  have 
never  seen  a  case  in  which,  upon  strict  inquiry,  amaurotic  symptoms,  more  or 
less  strongly  marked,  have  not  preceded  the  inflammatory  symptoms.  This 
is,  in  fact,  one  of  the  most  remarkable  characters  of  the  disease.  It  is  also 
to  be  noticed,  that  a  similar  distinction  of  symptoms  is  observable  during 
amendment;  for  it  uniformly  happens  that  the  inflammatory  symptoms  subside 
a  longer  or  shorter  time  before  the  amaurotic  symptoms,  and  often  before  they 
are  diminished  in  severity."^ 

Not  a  ^%\\  of  the  cases  which  came  under  my  observation  wore,  not  merely 
at  the  commencement,  but  all  along,  much  more  the  aspect  of  amaurosis  than 
of  ophthalmitis.  In  one  case  which  I  saw,  the  patient  was  suddenly  struck 
blind  of  the  affected  eye.  In  another  case  already  referred  to,  along  with 
the  amaurotic  symptoms,  the  cornea  had  become  flexible ;  and  no  longer  ap- 
prehensive of  inflammation  supervening,  I  had  commenced  the  use  of  quina 
and  blisters,  when  suddenly  pain  and  redness  set  in.     I  met  with  several 


584  POSTFEBRILE    OPHTHALMITIS. 

cases  in  which  for  days  the  i^rincipal  symptoms  were  pain  in  and  round  the 
eye,  and  dimness  of  sight.  In  other  cases  there  was  redness  of  the  eye  from 
the  very  commencement. 

Predisposing  and  exciting  causes. — That  an  opportunity  is  afforded  for  the 
disease  of  the  eye  by  the  fever  is  plain  ;  there  may  even  be  grounds  for  be- 
lieving that  the  fever  has  left  the  circulating  fluids  in  an  altered  state,  favor- 
able for  the  production  of  the  local  complaint.  However  this  may  be,  the 
affection  of  the  eye  is  generally  traceable  to  some  exciting  cause,  and  espe- 
cially to  cold.  Sleeping  in  an  apartment  with  broken  windows,  working  in  a 
cold  damp  shop,  and  washing  the  head  with  cold  water,  were  mentioned  by 
some  of  my  patients  as  exciting  causes.  Using  the  eyes  too  early  in  sewing, 
during  the  convalescence  from  the  fever,  is  another. 

Prognosis. — The  recovery  is  tedious.  In  the  majority  of  cases,  two  months 
of  uniuterrupted  and  careful  treatment  were  necessary  to  effect  a  cure.  That 
the  disease  without  any  treatment  will  wear  itself  out,  is  true ;  but  the  eyes 
will  be  left  useless,  from  the  contracted  and  adherent  state  of  the  pupil,  and 
the  amaurotic  condition  of  the  retina.  If  trifled  with,  the  cure  will  be  imper- 
fect ;  synechia  posterior,  muscas  volitantes,  and  other  irremediable  sequeliB, 
remaining.  Taken  early  and  treated  vigorously,  a  complete  cure  may  be 
prognosticated.  Recovery  is  much  more  speedy  and  complete  in  young  sub- 
jects ;  in  adults,  it  is  more  tedious. 

Treatment.  1.  Depletion. — The  wan  appearance  of  many  of  the  patients, 
the  smallness  of  their  pulse,  and  the  state  of  general  debility  in  which  they 
are,  might  tend  to  deter  from  using  the  lancet.  I  am  satisfied,  however,  that 
we  can  rarely,  with  safety,  dispense  with  this  remedy.  The  blood  drawn  from 
a  vein  is  generally  buffy  ;  but  the  bnSy  coat  peculiar,  not  white  and  coria- 
ceous like  that  of  pneumonic  blood,  not  yellow  and  dark  like  that  in  syphilis 
or  hepatitis,  but  of  a  whitish  semi-transparent  appearance,  like  half-boiled 
white  of  ^^^.  Often  it  is  difficult,  from  syncope  coming  on,  to  obtain  more 
than  a  few  ounces  from  the  arm.  When  this  is  the  case,  recourse  must  be 
had  to  leeches  to  the  temple  and  round  the  eye. 

If  depletion  is  omitted,  the  recovery  is  very  slow  and  uncertain ;  adhesions 
form,  and  cannot  be  got  rid  of,  and  vision  continues  imperfect.  We  must 
not  be  regulated  by  the  pain  alone,  in  taking  away  blood.  Nothing  relieves 
indeed  the  pain  so  strikingly  and  effectually  as  venesection ;  but  the  state  of 
the  eye,  independently  of  the  pain,  demands  bleeding.  We  should  not  even 
wait  "for  the  openly  inflammatory  stage  of  the  disease ;  but  relieve  the  con- 
gestion, on  which  the  amaurotic  symptoms  depend,  by  the  employment  of 
depletion. 

Some  cases,  especially  in  children,  I  have  trusted  to  leeching;  but  in  adults, 
venesection  is  almost  always  necessary.  I  have  not  used  arteriotomy,  nor 
cupping  ;  but  have  no  doubt  of  their  efficacy. 

2.  Purgatives. — The  tongue  being  generally  clean  and  the  bowels  regular, 
there  seems  to  be  little  demand  for  purgatives.  At  the  same  time,  I  have 
found  them  of  considerable  use  in  the  course  of  the  treatment.  Sulphate  of 
magnesia,  castor  oil,  and  compound  powder  of  jalap,  are  those  I  have  most 
employed. 

3.  Mercury. — I  am  decidedly  of  opinion  that  the  safest  and  most  effectual 
plan  of  cure  embraces  the  use  of  calomel  with  opium,  exactly  as  in  the  treat- 
ment of  rheumatic  or  syphilitic  iritis.  This  view  of  the  matter  is  confirmed 
by  the  testimony  of  Mr.  Hewson,  who  seems  to  have  trusted  to  opening  the 
temporal  artery,  and  giving  three  grains  of  calomel  with  half  a  grain  of 
opium,  each  night.  Dr.  Jacob,  also,  found  the  use  of  mercury  so  certain 
and  decisive  in  this  affection  of  the  eye,  that  he  trusted  to  it  almost  exclu- 
sively.    He  gave  two  grains  of  calomel  and  a  quarter  of  a  grain  of  opium, 


COMPOUND   OPHTHALMIA.  585 

thrice  a-day.     The  mouth  should  be  made  sore,  but  not  too  suddenly,  lest  vre 
be  obliged  to  omit  the  medicine  prematurely. 

4.  Belladonna. — Dilatation  of  the  pupil  is  an  essential  part  of  the  treatment. 
This  is  to  be  effected  by  liberally  painting  the  eyelids  and  eyebrow  with  the 
moistened  extract  of  belladonna,  morning  and  evening ;  directing  the  patient 
to  renew  its  activity  from  time  to  time,  by  moistening  it  with  his  finger  dipped 
in  water. 

5.  Counter-irritation. — Considerable  benefit  is  derived  from  blisters  to  the 
temples  and  behind  the  ears,  after  due  employment  of  depletion.  They  aid 
in  removing  the  pain,  lessening  the  inflammation,  and  recalling  the  power  of 
vision. 

6.  Cinchona. — Mr.  "Wallace  has  keenly  advocated  the  supremacy  of  cinchona, 
as  a  cure  for  this  affection  of  the  eye.  He  thinks  it  has  a  specific  influence 
over  the  disease ;  recommends  it  both  when  the  patient  is  weak  and  seems  to 
require  tonics,  and  when  he  is  in  full  health  ;  maintains  the  incurability  of  the 
disease  by  mercury  ;  and  is  decidedly  of  opinion  that  there  must  exist  some 
source  of  error  in  Mr.  Hewson's  account  of  the  cases  cured  by  this  medicine. 

I  have  not  employed  cinchona  bark  in  powder  ;  but  the  trials  I  made  of  sul- 
phate of  quina,  did  not  lead  me  to  form  a  very  high  opinion  of  its  efficacy  in 
this  disease.  Some  of  the  milder  cases  yielded,  indeed,  to  the  combination 
of  calomel  and  quina.  One  case  was  much  benefited  by  quina;  in  another, 
it  acted  very  slowly  and  imperfectly.  On  the  whole,  I  feel  indisposed  to  trust 
to  this  remedy ;  and  on  this  point  I  find  my  views  corroborated  by  the  ex- 
perience of  Dr.  Jacob.  "In  two  cases  which  I  met  with,"  says  he,  "after 
the  inflammation  had  subsided,  and  in  which  vision  was  as  much  impaired  as 
if  no  remedies  had  been  adopted,  bark,  in  powder,  had  been  administered  for 
ten  days.  I  gave  trial  to  the  sulphate  of  quinine  myself  in  four  well-marked 
cases  for  eight  days  ;  but  finding  no  relief  had  recourse  to  mercury,  which  ef- 
fected a  cure  in  the  usual  time." 

I  shall  not  extend  this  section  by  commenting  on  the  advantages  to  be  de- 
rived from  regulating  the  diet  of  the  patient,  and  protecting  him  from  cold  ; 
on  the  utility  of  warm  fomentations,  and  anodyne  frictions  ;  nor  on  the  proba- 
ble effects  of  several  internal  remedies,  which  I  have  not  tried  ;  such  as  tartar 
emetic,  colchicum,  and  turpentine.^ 


'  De  Bello  Peloponnesiaco,  Lib.  ii.  Forms  of  Lues  Venerea,  pp.  34,  109;  London, 

^  On  the  remittent  fever,  consult  Cormack's  1814. 

Natural  History,  Pathology  and  Treatment  of  *  Transactions  of  the  Association,  &c.;  Vol. 

the    Epidemic    Fever,  Ac;    Edinburgh,  1843:  v.  p.  294  ;  Dublin,  1828. 

Warden  on  the  Scotch  Fever  of  1843,  in  London  *  Transactions  of  the  Association,  &,c.;  Vol. 

Medical  Gazette  for  1847.     On  the  Irish  fevers  v.  p.  268. 

of  the  same  type,  consult  Rutty's  History  of  the  '  Medieo-chirurgical  Transactions;  Vol.  xiv. 

Diseases  of  Dublin,  during  forty  years  ;  London,  p.  286;  London,  1828. 

1770  :  Reid  and  O'Brien,  Transactions  of  the  '  London  and  Edinburgh  Monthly  Medical 

Association  of  Fellows  and  Licentiates  of  the  Journal,  October,  1845. 

King  and  Queen's  College  of  Physicians  in  Ire-  ^  Op.  cit.  p.  294. 

land;  Vol.  v.  pp.  266,  512;  Dublin,  1828.  ^  For  a  detailed  account  of  eases  of  postfebrile 

"  Observations  on  the  History  and  Treatment  ophthalmitis,  see  London  Jledical  Gazette,  Nov. 

of  the  Ophthalmia  accompanying  the  Secondary  24,  1843  :  and  Dr.  A.  Anderson's  communication 

above  referred  to. 


SECTION  XXXV. — COMPOUND   OPHTHALMiai. 

Strictly  examined,  few  instances  of  the  ophthalmias  will  be  found  absolutely 
simple.  Many  are  strikingly  compound,  even  from  the  first ;  for  example, 
the  catarrho-rheumatic,  already  described.     In  other  cases,  one  variety  is 


586  TRAUMATIC   OPHTHALMIA. 

grafted  on  another ;  for  instance,  scrofulo-catarrlial  ophthalmia,  beginning  as 
a  slight  puro-mucous  conjunctivitis,  but  soon  manifesting,  in  addition,  the 
signs  of  phlyctenular  ophthalmia.  We  often  meet  with  aphthae  of  the  con- 
junctiva, combined  from  the  commencement  with  blennorrhoeal  inflammation  of 
that  membrane.  Phlyctenular  conjunctivitis  with  scrofulous  iritis,  scrofulous 
corneitis  with  iritis,  arthritic  with  syphilitic  iritis,  traumatic  with  syphilitic  or 
scrofulous  ophthalmia,  and  many  other  compound  ophthalmias,  might  be 
enumerated. 

The  treatment  of  such  diseases  will,  of  course,  consist  in  the  combined  use 
of  the  means  which  are  ascertained  to  be  effectual  in  removing  the  simple 
forms  of  the  ophthalmias.  The  treatment  necessary  for  scrofulous  ophthalmia 
will  be  combined,  therefore,  with  that  for  catarrhal  conjunctivitis,  in  the 
scrofulo-catarrhal  cases;  while  in  the  catarrho-rheumatic  ophthalmia,  the 
remedies  for  rheumatic  inflammation  of  the  sclerotica  will  be  required  along 
with  those  for  blennorrhoeal  inflammation  of  the  conjunctiva  ;  and  soon,  in  any 
other  compound  ophthalmise  which  may  occur. 


SECTION   XXXVI. — TRAU>L\.TIC   OPHTHALMIJE. 

Fig.  Wardrop,  PI.  VI.  Fig.  1.     Dalrymple,  PI.  XII.  Fig.  1. 

It  has  been  explained  in  the  preceding  sections  of  this  chapter,  how  each 
texture  of  the  eye  suffers,  in  its  own  way,  from  inflammation,  excited  without 
any  evident  mechanical  or  chemical  injury  ;  the  conjunctiva  suffering  puro- 
mucous  and  eruptive  diseases  ;  the  sclerotica,  rheumatic  disease  and  ramollis- 
sement ;  the  iris  undergoing  adhesive  inflammation;  the  cornea  losing  its 
transparency,  and  becoming  the  seat  of  purulent  infiltration  and  of  ulceration  ; 
the  choroid  becoming  the  source  of  fibrinous  and  serous  effusions,  and  pro- 
truding through  the  atrophied  sclerotica  ;  the  retina  losing  entirely  its  sensi- 
bility to  light ;  every  texture,  in  fact,  suffering  differently. 

The  inflammation  which  is  excited  by  the  evident  mechanical  or  chemical 
injuries,  the  immediate  effects  of  which  have  been  considered  in  the  first  and 
second  sections  of  Chapter  lY.  and  in  Chapter  XII.,  may  attack  one  or 
several  of  these  textures.  "We  may  have  traumatic  conjunctivitis,  traumatic 
corneitis,  traumatic  iritis,  &c.,  and  it  is  remarkable,  that  traumatic  inflamma- 
tion in  any  of  the  textures  of  the  eye  imitates,  so  to  speak,  the  ophthalmiae 
which  we  have  already  considered.  We  meet  with  puro-mucous  conjunctivitis, 
excited  by  injury,  and  we  often  see  pustular  or  phlyctenular  conjunctivitis, 
brought  on  by  the  same  cause.  Traumatic  iritis  (the  iritis,  for  example, 
which  is  so  apt  to  occur  after  the  operations  for  cataract),  very  closely  resem- 
bles rheumatic  iritis  ;  but  in  certain  subjects  is  nothing  else  than  the  disease 
already  described  as  arthritic  iritis.  The  cornea,  by  traumatic  inflammation, 
is  rendered  opaque,  or  becomes  affected  with  onyx,  or  with  ulceration ;  the 
lens  also  loses  its  transparency  from  the  same  cause,  and  the  retina  its 
sensibility. 

This  observation,  duly  understood,  will  throw  a  great  degree  of  light  on 
the  treatment  of  the  traumatic  ophthalmise.  Puriform  inflammation  of  the 
conjunctiva,  arising  from  injury,  is  to  be  treated,  in  fact,  exactly  as  we  treat 
catarrhal  ophthalmia.  In  traumatic  iritis,  the  three  great  objects,  to  abate 
the  inflammatory  action  by  depletion,  to  oppose  the  contraction  of  the  pupil 
by  belladonna,  and  to  promote  absorption  by  mercury,  are  to  be  followed  out, 
exactly  as  in  rheumatic  or  syphilitic  iritis. 

For  these  reasons,  I  thought  it  proper  to  say  nothing  of  the  traumatic 
ophthalmiae,  till  we  had  finished  the  consideration  of  the  varieties  of  infiam- 


TRAUMATIC   OPHTHALMIA.  587 

matoiy  disease,  which  arc  excited  in  the  different  textures  of  the  eye  by  atmo- 
spheric and  constitutional  causes.  Without  a  knowledge  of  these  varieties 
of  ophthalraice,  we  should  be  but  little  able  to  understand  the  inflammatory 
effects  of  evident  mechanical  and  chemical  injuries  upon  the  several  structures 
combined  in  the  eye  ;  but  with  such  a  knowledge,  both  the  symptoms  and  the 
treatment  of  the  traumatic  ophthalmise  become  perfectly  simple.  The  symp- 
toms vary,  no  doubt,  ad  infinitum,  in  regard  to  severity ;  while  in  one  case,  a 
single  texture,  and  in  other  cases,  several  textures  of  the  eye  will  suffer  ;  still, 
the  invariable  and  peculiar  physical  and  vital  properties  of  each  texture  serve 
to  produce,  under  whatever  circumstances  or  by  whatever  causes  inflammation 
may  be  excited,  the  same  essential  phenomena. 

The  severity  and  the  result  of  the  traumatic  inflammations  of  the  eye  depend 
on  the  textures  implicated,  the  extent  of  parts  injured,  the  nature  of  the 
means  by  which  the  injury  was  inflicted,  mechanical,  for  example,  or  chemical, 
sharp  or  ragged,  the  force  with  which  it  was  applied,  the  constitution  of  the 
patient  and  his  conduct  after  receipt  of  the  injury,  and  the  treatment  pursued. 

In  all  cases  of  injury  of  the  eye,  there  is  a  certain  breach  of  continuity  to 
be  repaired  ;  in  simple  incised  wounds,  nature  often  accomplishes  this  without 
inflammation ;  but  in  contused  and  lacerated  wounds,  in  deeply  penetrating 
punctures,  and  sometimes  even  after  apparently  trivial  and  superficial  injuries, 
we  have  to  contend  with  consequent  irritation,  epiphora,  photophobia,  inflam- 
mation, and  the  consequences  of  inflammation,  as  suppuration,  ulceration,  &c. 
The  general  treatment  consists  in  rest  of  the  eyes  and  of  the  body,  exclusion 
of  light,  low  diet,  purging,  bleeding,  calomel  and  opium  ;  in  slight  cases, 
refrigerants  to  the  eye  ;  in  more  severe  cases,  warm  fomentations  and  dilata- 
tion of  the  pupil. 

Even  a  slight  injury  may  be  followed  by  such  a  complete  inflammation  as 
to  warrant  the  appellation  of  traumatic  ojihthalmitis,  in  which,  as  in  some  of 
the  varieties  of  ophthalmitis  already  described,  the  eye  swells  and  protrudes 
from  the  orbit,  the  lids  are  everted,  and  the  conjunctiva  is  covered  with  a 
lymphatic  exudation,  the  fundus  oculi  reddens,  the  hyaloid  becoming  infiltrated 
with  lymph  or  pus  assumes  a  green  color,  the  cornea  suppurates  or  sloughs, 
the  eye  bursts,  and  ultimately  shrinks  to  a  small  stump.  I  have  known  a 
small  cut  of  the  cornea,  to  produce  ophthalmitis,  ending  in  atrophy  of  the 
eyeball. 

In  every  case  of  traumatic  inflammation,  it  is  necessary  to  pay  great  atten- 
tion to  the  state  of  the  digestive  organs.  It  is  in  vain  to  suppose  that  bleed- 
ing and  salivation  will  remove  an  inflammation  resulting  from  injury,  and 
prevent  suppuration,  if  the  stomach  is  allowed  to  remain  in  a  disordered  state, 
or  the  bowels  left  loaded  with  undigested  food,  or  morbid  secretions.  Under 
such  circumstances,  purgatives  and  alteratives  are  to  be  administered,  till  a 
healthy  condition  of  the  digestive  system  is  attained. 

The  subjects  of  traumatic  inflammation  are  not  unfrequently  far  advanced 
in  years,  unable  to  bear  much  depletion,  and  whose  flagging  powers  of  life  are 
more  likely  to  be  benefited  by  tonic  treatment.  A  favorable  change  in  the  state 
of  the  eye  is  often  obtained  by  improving  the  diet  of  such  patients,  and  put- 
ting them  on  bebeerine  or  quinine. 

Abscess  of  the  cornea  is  one  of  the  most  frequent  consequences  of  traumatic 
inflammation,  and  is  extremely  apt  to  end  in  rupture  of  the  front  of  the  eye, 
leading  to  staphyloma,  partial  or  total.  The  symptom  in  question  is  by 
no  means  very  amenable  to  treatment.  Besides  bringing  the  eye  under  the 
anodyne  and  mydriatic  influence  of  belladonna,  and  exhibiting  one  or  other 
of  the  tonics  above  mentioned,  I  have  witnessed  the  good  effect  of  punc- 
turing the  cornea  near  its  edge,  but  at  a  distance  from  the  part  infiltrated 
with  pus. 


588  ARTIFICIAL  ophthalmias;. 

An  important  general  rule  regarding  the  treatment  of  the  traumatic 
ophthalmiae,  is  that  we  should  be  on  our  guard  against  effects  wliich  are  apt 
to  be  produced,  but  which  may  not  yet  be  present,  and  against  effects  impli- 
cating the  interior  textures  of  the  organ,  although  the  injury  has  been,  or  at 
least  has  appeared  to  be,  merely  superficial.  A  considerable  part  of  our 
treatment  must  be  preventive.  We  must  not  delay  to  take  away  blood,  till 
severe  inflammation,  with  acute  circuraorbital  pain,  sets  in.  We  ouglit  to 
bleed  from  the  moment  of  a  severe  injury.  We  must  not  wait  till  the  pupil  is 
evidently  closing ;  but  apply  belladonna,  and  prevent  it.  We  must  not  wait 
till  the  iris  grows  discolored,  or  lymph  is  effused  into  the  pupil;  but  from  the 
vei'y  first  put  the  patient  on  calomel  and  oi^ium,  if  we  apprehend  from  the 
nature  of  the  injury  that  iritis  is  likely  to  be  the  result.  Our  attention  should 
be  confined,  neither  to  the  texture  immediately  affected  by  the  injury,  nor  to 
that  which  seems  most  inflamed  after  an  injury.  I  have  known  a  minute 
fragment  of  steel  sticking  in  the  cornea,  produce  pretty  severe  iritis  and 
sclerotitis,  with  scarcely  any  perceptible  inflammation  of  the  cornea ;  and 
while  the  iritis  was  properly  enough  treated,  the  cause  remained  overlooked. 

In  some  cases  of  traumatic  ophthalmitis  the  enormous  swelling  of  the 
tissues  surrounding  the  eyeball,  the  effusion  into  the  ocular  capsule,  and  the 
cedeinatous  state  of  the  conjunctiva,  produce  such  pressure  on  the  eyelids  as 
to  cause  them  to  separate  at  their  inner  commissure,  so  that  the  lower  one 
hangs  loose  and  everted.  In  other  cases,  gangrene  and  sloughing  of  part  of 
the  lids  take  place. 

Such  violent  and  general  inflammation  of  the  eye  is  apt  to  result  from 
injuries,  chiefly  in  those  of  a  scrofulous  or  otherwise  unsound  constitution. 

It  is  a  fact  worthy  of  notice,  that  specific  inflammations  of  the  eye,  such  as 
syphilitic  or  arthritic  iritis,  may  be  excited  by  injuries. 

It  is  not  unworthy  of  observation  that,  after  all  the  other  symptoms  of 
severe  inflammation  of  the  eye,  following  mechanical  or  chemical  injuries, 
have  been  removed  by  depletion,  counter-irritation,  mercurialization,  &c.,  a 
very  troublesome  and  obstinate  intolerance  of  light,  with  epiphora,  is  apt  to 
remain,  not  so  much  apparently  from  irritation  arising  from  the  state  of  the 
eye,  as  merely  from  continued  and  now  habitual  excessive  activity  in  the  lids 
and  lachrymal  gland.  In  such  cases,  in  addition  to  the  i*emedies  recommended 
for  epiphora,  I  have  derived  advantage  from  the  internal  use  of  the  extract 
of  stramonium. 


SECTION  XXXVn ARTIFICIAL  OPHTHALMIA. 

Soldiers  have  been  detected  exciting  inflammation  of  the  eyes,  by  the 
introduction  of  different  substances  within  the  conjunctival  sinuses ;  or  already 
affected  with  ophthalmia,  they  sometimes  endeavor  to  aggravate  the  symptoms, 
or  to  prevent  a  cure,  by  the  same  practice  ;  their  object  in  all  this,  being  to 
produce  permanent  injury  to  the  eyes,  or  even  loss  of  sight,  so  as  to  be  dis- 
charged, and  to  obtain  a  higher  pension  than  that  to  which  they  would 
otherwise  be  entitled. 

The  irritants  employed  for  exciting  inflammation  of  the  eyes  by  soldiers 
are  very  various ;  as  corrosive  sublimate,  common  salt,  red  precipitate,  lunar 
caustic,  sulphate  of  copper,  quicklime,  nitric  acid,  cantharides  ointment,  snuff, 
the  juice  and  ashes  of  tobacco,  a  bit  of  woollen  cloth,  &c. 

When  a  suspicion  arises  that  a  number  of  soldiers  together  are  stimulating 
puro-mucous  ophthalmia,  or  endeavoring  to  produce  serious  injuries  of  their 
eyes,  by  the  use  of  irritants,  the  suspicion  will  of  course  be  increased,  if  the 


ARTIFICIAL   OPHTHALMIA.  589 

disease  is  almost  exclusively  confined  to  the  privates  or  non-commissioned 
officers  of  a  regiment,  without  affecting  the  commissioned  officers,  or  the 
women  and  children  ;  also  by  the  circumstance  of  the  inflammation  being 
very  frequently  confined  to  one  eye,  and  that  almost  always  the  right. 

In  many  cases,  it  may  be  possible,  from  the  suddenness  and  character  of 
the  symptoms,  not  only  to  detect  the  factitiousness  of  the  disease,  but  to  dis- 
cover what  particular  substance  had  been  used  to  induce  it ;  or  the  substance 
itself  may  be  found  in  whole  or  in  part.  For  instance,  Mr.  Marshall*  once 
detected  a  patient  in  hospital  for  ophthalmia,  with  a  small  portion  of  black 
muslin  spread  over  the  cornea  of  the  right  eye.  This  man  had  recently  lost 
the  power  of  vision  in  the  left  eye,  probably  from  artificially  excited  inflam- 
mation. 

When  an  acrid  powder,  as  quicklime  or  red  precipitate,  is  employed,  it 
commonly  occasions  a  sloughy  ulcer  in  the  lower  fold  of  the  conjunctiva,  and 
sometimes  particles  of  the  foreign  substance  are  found  adhering  to  that  mem- 
brane. Cantharides,  in  any  form,  suddenly  induce  a  great  degree  of  chemo- 
sis,  with  swelling  of  the  eyelids,  and  most  violent  itching.  A  strong  acid 
produces  instant  disorganization  of  the  conjunctiva,  so  that  it  becomes  white 
and  swollen,  and  is  ready  to  peel  off;  at  the  same  time,  the  cornea  is  whitened, 
and  speedily  sloughs. 

In  one  instance,  the  depth  and  defined  edges  of  the  ulceration  having  led 
the  surgeon  to  suspect  the  application  of  some  acrid  substance  to  the  eye, 
the  soldier  was  searched,  and  a  paper  of  corrosive  sublimate  was  found  in  his 
possession,  with  some  manuscript  directions  for  its  use,  in  which  it  was  recom- 
mended to  put  a  minute  portion  into  the  eye  on  going  to  bed,  to  repeat  it 
every  third  night,  and  to  be  cautious  not  to  put  in  too  much,  lest  the  eye 
should  be  destroyed.  There  was  annexed  to  this  prescription  a  receipt  for 
removing  the  artificial  disease,  consisting  in  a  docoction  of  parsnips  and  leaves 
of  clover,  with  which  the  eye  was  to  be  fomented.^ 

In  the  year  1809,  three  hundred  of  the  men  of  two  regiments  on  duty  at 
Chelmsford  became  affected  with  ophthalmia.  The  healthy  men  of  the  corps 
were  removed  to  another  station,  and  the  sick  remained  in  hospital,  but  under 
military  command.  Information  having  reached  their  commanding  oflicer, 
that  one  of  the  nurses  of  the  hospital  was  in  the  habit  of  going  to  a  drug- 
gist's shop  for  the  purpose  of  purchasing  medicines,  suspicions  were  excited. 
Accommodation  having  been  provided  for  about  24  men,  the  number  con- 
tained in  one  ward,  at  midnight  the  officer  made  his  appearance  in  the  hos- 
pital, the  men  were  roused  from  their  beds,  and  forthwith  marched  in  a  state 
of  nudity  to  the  new  ward.  The  old  ward  was  secured  for  the  night ;  and 
next  day  when  the  beds  were  examined,  a  number  of  small  parcels  of  corro- 
sive sublimate  were  found  concealed.  Means  were  taken  to  prevent  a  supply 
of  this  article,  and  in  a  very  short  time  250  of  the  men  recovered.^ 

To  excite  disease  of  the  palpebrsB,  the  cilia  are  sometimes  extracted,  and 
caustic  applied  to  the  part. 

The  most  effectual  means  of  counteracting  attempts  to  injure  the  eyes  by 
the  application  of  noxious  substances,  is  the  seclusion  of  suspected  individ- 
uals. Handcuffs  are  sometimes  necessary,  or  a  tin  mask  for  the  face,  so 
contrived  as  to  prevent  the  patient's  access  to  his  eyes. 


'  Hints  to  Young  Medical  Officers,  &c.,  p.        ^  Ballingall's  Outlines  of  Lectures  on  Military 
112,-  London,  182S.  Surgery,  p.  437;  Edinburgh,  1833. 

'  Ibid.  p.  581. 


590  SYMPATHETIC   OPHTHALMITIS. 

SECTION  XXX Vni. — REFLEX  OR  SYMPATHETIC   OPHTHALMITIS. 
Syn. — Iritis  sympathetica. 

I  have  now  to  direct  tbe  attention  of  the  reader  to  a  disease,  which,  as  it 
generally  proves,  in  the  long  run,  intractable,  and  as  it  is  the  result,  in  the 
one  eye,  of  a  previous  mechanical  injury,  which  has  already  greatly  impaired 
or  destroyed  the  other,  involves  in  its  treatment  a  heavy  responsibility  on  the 
part  of  the  practitioner.  Whenever  I  see  sympathetic  ophthalmitis,  even  in 
its  first  stage,  I  know  that  I  have  to  contend  with  an  affection  which,  how- 
ever slight  its  present  symptoms  may  be,  is  one  of  the  most  dangerous  inflam- 
mations to  which  the  organ  of  vision  is  exposed. 

The  general  nature  of  the  sympathetic  affection  which  I  am  about  to  illus- 
trate, by  references  to  the  journals  of  the  Glasgow  Eye  Infirmary,  is  inflam- 
mation, commencing  in  the  retina,  but  gradually  involving  the  whole  of  the 
internal  textures  of  the  eyeball,  especially  the  iris,  crystalline,  and  vitreous 
body ;  coming  on,  generally,  in  five  or  six  weeks  after  an  injury  to  the  oppo- 
site eye,  and  terminating,  most  frequently,  in  atrophy  and  total  amaurosis  of 
the  eye  secondarily  affected.  The  one,  also,  which  received  the  original 
injury  generally  ends,  or  has  already  ended,  in  amaurosis  and  softening  of  the 
globe.  It  is  remarkable,  however,  that  the  amaurotic  afftction  of  the  eye 
which  suffers  sympathetically,  is  generally  more  complete  than  that  of  the  eye 
which  had  received  the  injury.  The  retina  of  the  injured  eye  is  sometimes 
tolerably  sentient,  while  that  of  the  other  is  totally  insensible.  ~v 

Case  293. — Henry  Taterson,  aged  25,  admitted  31st  January,  1827.  > 

Two  months  before  bis  admission,  be  struck  the  left  eye  against  a  nail  -which  stood  out 
from  a  door-post.  The  upper  part  of  the  iris  is  no  longer  in  view,  so  that  the  pupil  is 
much  enlarged,  and  shifted  to  behind  upper  edge  of  cornea.  Severe  inflammation  has 
followed  the  accident,  and  has  communicated  itself  to  tbe  right  eye,  which,  indeed,  suflers 
more  at  present  than  the  left.  Both  eyes  exceedingly  irritable  ou  exposure  to  light,  and 
alfected  with  profuse  epiphora.  The  right  pupil  small ;  both  irides  greenish,  and  both 
cornea;  hazy.  Retains  a  degree  of  vision  in  left  eye.  Bowels  very  bound.  Leeches  have 
been  applied  frequently  to  the  temples. 

On  tbe  7th  February,  he  is  reported  as  improving,  but  very  slowly.  The  treatment 
consisted  in  an  emetic,  followed  by  calomel,  opium,  and  tartrate  of  antimony,  with  blisters, 
belladonna  externally,  and  solution  of  nitrate  of  silver  to  tbe  eyes. 

We  find  from  the  subsequent  reports,  that  his  mouth  becomes  sore,  and  the  pain 
diminishes.     Afterwards,  tenderness  of  the  eyes  increases  and  diminishes  by  turns. 

On  the  Gth  April,  he  is  stated  not  to  have  improved  for  the  previous  fortnight.  On  the 
16th,  his  mouth  is  sore,  and  his  eyes  decidedly  improved.  On  the  30th,  mouth  well;  in- 
flammation continues  to  decline ;  vision  of  right  eye  very  much  better. 

On  the  11th  May,  left  lens  is  mentioned  as  in  an  opaque  state,  and  pressing  the  iris 
into  contact  with  the  cornea.     After  this,  paracentesis  corneae  was  twice  performed,  but  1 

with  little  or  no  relief.  I 

About  the  middle  of  June,  the  irritability  of  the  eyes  diminishes.     This  symptom  had  ' 

continued  in  a  very  distressing  degree;  but  on  the  11th  July,  the  report  states  that  he 
can  now  open  his  eyes,  which  he  attributed  very  much  to  steaming  them  with  laudanum. 
On  the  20th,  intolerance  of  light  much  abated,  so  that  the  right  pupil  can  now  be  ob- 
served contracted,  and  filled  with  a  fibrinous  efi'usion. 

August  ISth.  Can  now  distinguish  objects  of  moderate  size.  Inflammation  and  intol- 
erance of  light  continue  to  decline.  This  improvement  took  place  under  the  continued 
use  of  calomel  and  opium,  and  a  decoction  of  elm  bark. 

September  17th.  Inflammation  now  gone;  vision  improves  slowly.  Centre  of  right 
anterior  capsule  opaque.     Pupil  somewhat  contracted  and  adherent. 

November  IGth.     Eight  pupil  as  at  last  report.     Vision  considerably  improved. 

February  25th,  1828.     Vision  improving. 

During  these  12  months,  a  great  variety  of  remedies  were  employed.  The  principal 
were  leeches,  scarifications  of  the  eyelids,  paracentesis  cornea;,  blisters,  tartar  emetic 
eruption,  a  caustic  issue,  purgatives,  calomel  and  opium,  cinchona,  elm  bark,  belladonna 
externally,  solution  of  nitrate  of  silver,  and  vinum  opii  to  the  eyes,  anodyne  fomentations, 


SYMPATHETIC   OPHTnALMITIS.  591 

and  red  precipitate  salve.  Whatever  benefit  arose  from  the  treatment,  was  to  be 
ascribed  chiefly  to  the  leeches,  the  calomel  and  opium,  and  the  anodyne  fomentations. 

We  saw  nothing  more  of  Paterson  till  the  8th  September,  1830,  when  he  was  re- 
admitted, for  the  purpose  of  having  an  artificial  pupil  formed  in  his  right  eye. 

The  report,  at  his  readmission,  states,  that  his  right  pupil  continues  very  small,  iri-egu- 
lar,  filled  with  lymph,  and  attached  to  the  capsule.  Within  the  last  12  months,  his  vision 
has  greatly  declined,  so  that  when  his  back  is  turned  to  the  light  he  can  discern  merely 
the  i-etlection  from  the  face  of  a  person  standing  before  him.  The  iris  is  of  a  green 
color,  but  there  is  no  vascularity  on  the  surface  of  the  eye.  Says  that  upon  catching 
cold,  the  eyes  are  apt  to  become  tender. 

On  the  19th,  I  pei-formed  the  operation  of  incision  with  Maunoir's  scissors.  I  need  not 
describe  the  operation,  nor  the  difficulties  with  which  it  was  attended.  Any  hopes  of  a 
restoration  to  sight  by  the  operation  were  completely  frustrated,  in  consequence  of  a  blow 
which  the  unfortunate  patient  received  on  the  right  eye,  from  a  person  who  was  intoxi- 
cated, on  the  28th  March,  1831.  This  filled  the  aqueous  chambers  with  blood,  and  com- 
pleted the  disorganization  of  the  eye. 

Case  294. — Joseph  Moore,  aged  30,  was  admitted  14th  December,  1884. 

About  three  months  ago,  the  right  cornea  was  cut  by  a  chip  of  cast  steel.  Some  portion 
of  the  humors  escaped.  Violent  inflammation  followed,  which  has  terminated  in  discolo- 
ration of  the  iris,  and  contraction  of  the  pupil  to  a  mere  point,  which  is  occupied  by 
opaque  capsule.     Complete  extinction  of  perception  of  light  in  this  eye. 

About  a  month  after  the  accident,  the  pain,  which  was  at  first  chiefly  confined  to  the 
right  orbit,  extended  to  the  left.  The  left  iris  is  discolored ;  the  pupil  irregular,  con- 
tracted, not  afi"ected  by  light,  and  occupied  by  opaque  capsule,  apparently  adherent  to 
margin  of  iris.  The  opacity  is  less  dense  in  the  centre.  AVith  this  eye  he  can  dis- 
tinguish the  bars  of  the  window,  and  count  the  fingers  interposed  between  him  and  the 
light.  Occasional  circumorbital  pain  on  both  sides.  Severe  pain  in  bulb  of  left  eye, 
especially  at  night. 

Has  been  bled,  and  used  some  mercurial  preparation,  with  temporary  and  partial 
benefit. 

On  his  admission,  he  was  bled  at  the  arm,  leeches  were  applied  to  left  conjunctiva, 
belladonna  extract  was  smeared  round  the  eyes,  and  he  was  ordered  a  pill,  morning  and 
evening,  containing  calomel,  opium,  and  belladonna  leaf,  of  each  a  grain. 

Under  this  treatment,  he  improved  slowly,  but  he  still  complained  of  pain  in  the  ball 

of  his  eyes.     Two  grains  of  belladonna  leaf  were  substituted  for  1  grain.     His  mouth 

became/6ore,  and  the  pain  was  relieved.     It  soon  returned,  and  seems  to  have  been  but 

sli^ltWy  alleviated  by  opium  and  belladonna  internally,  which  made  up  the  chief  part  of 

le  treatment  during  January. 

On  the  5th  Febi'uary,  the  report  states,  that  considerable  improvement  had  taken 
place  in  the  vision  of  the  left  eye.  Gentian,  and  afterwards  quina,  appear  to  have  been 
emploj'ed  on  account  of  general  weakness.     No  further  improvement  is  noticed. 

Case  295. — James  Downie,  aged  25,  was  admitted  5th  January,  1837. 

About  three  months  ago,  his  right  eye  was  wounded  by  a  splinter  of  steel.  It  now 
presents  a  cicatrice  at  the  junction  of  the  cornea  and  sclerotica,  towards  nasal  side  of  eye. 
The  pupil  is  dragged  towards  the  cicatrice,  while  the  portion  of  iris  most  remote  from  the 
cicatrice  appears  on  the  stretch.  There  is  some  opacity  towards  lower  part  of  pupil.  No 
pain.     Vision  of  right  eye  much  impaired. 

About  seven  weeks  ago  the  left  eye  became  affected.  The  iris  is  now  discolored  ;  the 
pupil  conti-acted  and  irregular.  The  form  of  the  eye  is  altered,  the  anterior  part  being 
projected.  The  conjunctival  vessels  are  enlarged,  and  there  is  a  bluish  zone  around  the 
cornea.     Does  not  complain  much  of  pain  in  left  eye  ;  its  vision  seems  nearly  extinct. 

Has  been  bled,  blistered,  and  mercurialized,  and  had  improved  considerably;  but  having 
gone  to  the  country  about  ten  days  ago,  he  became  much  wOrse. 

Leeches  were  applied  to  the  left  upper  eyelid,  and  a  blister  behind  the  ear.  Calomel 
and  opium  were  prescribed,  and  Dover's  powder  at  bedtime.  These  remedies  were  con- 
tinued, along  with  repeated  leeching  and  the  external  use  of  belladonna,  during  the  month 
of  January,  with  little  or  no  eflTect  on  the  eyes.  On  the  1st  February,  the  report  states 
that,  with  his  back  turned  to  the  light,  he  distinguishes  objects  with  the  right  eye,  but 
not  with  the  left.  He  is  put  on  a  solution  of  _::^ij.  of  hydriodate  of  potass  in  5  viij.  of  water, 
a  tablespoonful  thrice  a-day;  and  the  quantity  of  the  hydriodate  is  increased  gradually 
to  ^iv.  There  is  no  notice  of  any  improvement;  but,  on  the  contrary,  the  surface  of  the 
iris  is  stated  to  have  become  vascular,  a  very  unpromising  symptom ;  and  on  the  IGth,  he 
is  ordered  to  be  bled  at  the  arm,  on  account  of  increased  inflammation  of  left  eye.  His 
mouth  does  not  appear  to  have  become  sore.  The  bleeding  at  the  arm  relieves  the  pain 
of  left  eye.  On  account  of  costlveness,  the  calomel  and  opium  pills  are  clianged  for  blue 
pills.     On  the  22d,  his  mouth  is  pretty  sore ;  but  there  is  no  improvement  in  vision,  and 


592  SYMPATHETIC   OPHTHALMITIS. 

the  irides  are  described  as  assuming  a  gilt  green  color.  He  now  complains  of  want  of 
sleep,  and  is  ordered  opium  and  sarsaparilla.  This  last  medicine  appears  to  have  been 
continued  for  nearly  two  months,  but  without  benefit. 

On  the  22d  of  Api'il,  the  sarsaparilla  is  discontinued,  and  he  is  ordered  one-sixteenth  of 
a  grain  of  oxide  of  arsenic  thrice  a-day.  On  the  Uth  May,  the  report  states  that  there  is 
no  change.  The  outer  margin  of  each  iris  is  occupied  by  a  lavender-colored  ring.  The 
left  pupil  is  contracted  and  occupied  by  opaque  capsule. 

Called  21st  August,  1842,  to  inquire  if  an  artificial  pupil  could  be  formed  in  right  eye. 
From  its  atrophied  soft  state,  I  advised  him  against  this.  Both  eyes  atrophic  and  soft, 
but  the  left  more  so  than  the  right.  Perceives  light  and  shade  with  the  right,  but  not 
with  the  left. 

Case  296.— Robert  Finlay,  aged  24,  admitted  5th  July,  1837. 

Last  night,  the  right  cornea  was  penetrated  by  a  screw-driver,  so  as  to  form  an  angular 
flap,  with  the  apex  pointing  downwards  and  inwards,  while  the  extremities  of  the  incision 
are  separated  \>y  a  space  equal  to  the  diameter  of  the  cornea.  Much  blood  is  effused  into 
the  anterior  chamber.  The  iris  appears  to  be  wounded;  the  state  of  the  pupil  cannot  be 
discovered.  Vision  with  this  eye  is  reduced  to  a  mere  perception  of  light.  The  eyelids 
were  brought  together,  and  a  bandage  applied.     Venesection.     Six  grains  of  calomel. 

6th.  Pain  relieved.  As  the  calomel  had  not  purged,  he  was  ordered  3  aloes  and  blue 
pills. 

Augvist  1st.  Wound  cicatrized;  pupil  very  irregular ;  considerable  vascularity  of  eye; 
little  pain.     Blister  behind  right  ear.     CoUyrium  muriatis  hydrargyri. 

5th.  Eye  less  vascular.  Lids  adhere  in  the  morning.  Four  grains  solution  of  nitrate 
of  silver. 

Leeches  were  after  this  applied  twice  to  the  eyelids. 

13th.  Since  yesterday,  an  attack  of  iritis  sympathetica  of  left  eye,  with  pain  beneath 
the  eyebrow  during  the  night.  Upper  edge  of  pupil  appeai-s  tagged  to  capsule.  Ascribes 
this  attack  to  having  read  a  book,  in  small  type,  for  three  or  four  hours  last  night.  Pulse  84. 
Venesection.  Belladonna  to  left  eyebrow  and  upper  eyelid.  Six  grains  of  calomel,  and  1 
grain  of  opium,  at  bedtime,     ^i.  of  sulphas  magnesias  to-morrow  morning. 

14th.  Blood  buify ;  pain  greatlj'  relieved.  Cornea  flexible ;  pupil  tagged  above  and  below. 
Eight  leeches  round  left  eye.  Calomel  and  opium  at  bedtime,  and  salts  to-morrow  mor- 
ning. 

15th.  Pupil  transversely  oblong;  vision  very  dim.  Venesection.  Blister  to  left  side  of 
head.     Four  grains  of  calomel  and  half  a  grain  of  opium,  thrice  a-day. 

16th.  Blood  butTy. 

ITtli.  Pain  of  left  eye  entirely  gone  ;  pupil  still  irregular.  Mouth  not  affected.  Calo- 
mel and  opium  continued. 

19th.  Was  bled  at  the  arm  yesterday;  blood  bufiy.  Eye  much  less  vascular ;  vision 
clearer. 

20th.  Cornea  less  flexible. 

23d.  Pupil  more  regular ;  eye  free  of  vascularity. 

24th.  Two  grains  of  calomel,  and  a  quarter  of  a  grain  of  opium,  daily. 

27th.  Mouth  sore.     Calomel  and  opium  omitted. 

31st.    One  grain  of  sulphas  quiuaj  thrice  a-day. 

Sept.  1st.  Lower  part  of  pupil  more  regular. 

4th.  Very  numerous  minute  whitish  spots,  apparently  on  the  inner  surface  of  left  cornea, 
opposite  lower  edge  of  pupil.     Belladonna  omitted. 

8th.  Calomel  and  opium  resumed. 

12th.  As  the  pupil  contracts  from  the  omission  of  the  belladonna,  vision  becomes  dim- 
mer.    Calomel  and  opium,  morning  and  evening. 

IStli.  Vision  clearer. 

26th.  Calomel  and  opium  stopped. 

27th.  One  grain  of  opium.     Alum  gargle. 

29th.  No  pain  in  right  eye,  unless  when  pressed  with  the  hand.  The  minute  white  spots 
on  inside  of  left  cornea  still  very  numerous.  With  this  eye  reads  a  very  large  type.  Two 
grains  of  extract  of  stramonium  morning  and  evening. 

October  5th.  Was  attacked  last  night  with  violent  pain  in  both  eyes.  At  present  the 
pain  afi"ects  principally  the  left  eye.  Venesection.  To  foment  the  eyes  with  poppy  decoc- 
tion. 

6th.  Left  conjunctiva  this  morning  in  a  highly  chemosed  state.  Venesection.  Four 
grains  of  calomel  and  1  grain  of  opium  at  bedtime,  and  half  these  quantities  in  the  morn- 
ing. 

7th.  A  much  better  night ;  inflammation  greatly  abated. 

10th.  A  recurrence  of  severe  pain  this  morning.     Leeches.     Fomentation. 

13th.  Has  again  had  a  smart  attack  of  p.ain.     Pulse  84,  feeble.     Fomentation. 


SYMPATHETIC   OPHTHALMITIS.  593 

14th.  Mouth  sore.  Calomel  and  opium  omitted.  Alum  gargle.  Blister  behind  left 
ear. 

16th.  No  pain  in  eye.     Mouth  better. 

18th.  Another  attack  of  pain  this  morning.     Five  leeches.     Fomentation. 

21st.    Has  continued  easy  since  the  application  of  the  leeches. 

25th.  Again  seized  with  pain  in  the  forenoon,  accompanied  with  vomiting  in  the  evening. 
Four  leeches.     Fomentation. 

November  8th.  Has  continued  free  from  pain  since  last  report. 

10th.  Some  pain  in  right  eye.  Two  leeches.  Two  grains  of  calomel  and  half  a  grain 
of  opium  at  bedtime. 

December  10th.  At  present  the  right  eye  is  entirely  free  from  inflammation.  Its  cornea 
is  bounded  by  an  irregular  line,  and  is  reduced  to  half  of  its  original  size.  Distinct  per- 
ception of  light  and  shade  with  this  eye.  The  cornea  of  left  eye  is  now  unnaturally  prom- 
inent and  surrounded  by  a  reddish  zone.  The  iris  is  greatly  altered  in  color,  and  is  bul- 
ging forwards,  so  as  to  be  very  nearly  in  contact  with  the  cornea.  The  pupillary  margin 
seems  to  be  adhering  to  the  capsule,  which  is  opaque  in  the  centre.  The  perception  of  light 
is  less,  even  than  in  right  eye.  Some  palpitation  of  the  heart  for  four  or  five  weeks. 
Pulse  110,  rather  sharp. 

Case  297. — Jane  Gartshore,  aged  15,  admitted  30th  April,  1838. 

Six  months  ago,  left  cornea  was  divided,  towards  its  outer  edge,  by  being  struck  against 
the  latch  of  a  door.  The  iris  had  protruded,  as  it  is  now  dragged  towards  the  site  of  the 
wound  and  fixed  there.  What  remains  of  the  pupil  is  occupied  by  opaque  capsule.  Large 
varicose  vessels  run  towards  the  cicatrice.  There  are  also  numerous  red  vessels  on  the 
surface  of  the  iris.     This  eye  retains  the  perception  of  light  and  shade. 

Four  or  five  weeks  after  the  injury,  sympathetic  inflammation  came  on  in  the  right  eye, 
and  the  vision  of  this  eye,  also,  is  now  reduced  to  a  perception  of  light  and  shade.  The 
right  iris  is  of  a  dingy  green  color,  with  numerous  varicose  vessels  running  over  it.  The 
pupil  is  contracted,  irregular,  and  adherent  to  an  opaque  capsule.  Both  irides  are  close 
to  the  corneffi. 

Has  now  no  pain.  It  was  severe  in  the  left  eye,  for  nearly  four  months ;  but  the  right 
eye,  she  says,  has  never  been  afi'ected  with  pain.  General  health  was  previously  good. 
Pulse  120.  Was  twice  bled  at  the  arm ;  applied  leeches  and  blisters ;  and  took  some 
medicine,  which  did  not  afi'ect  her  mouth.  Two  grains  of  calomel  and  half  a  grain  of 
opium,  thrice  a-day. 

May  7th.  Thinks  her  vision  improved. 

Case  2.98.— David  Mill,  an  engineer,  aged  38,  admitted  30th  August,  1838. 

When  residing  in  Edinburgh,  18  months  ago,  and  whilst  chipping  iron,  a  splinter  entered 
right  eye,  at  outer  edge  of  cornea.  He  continued  to  work  for  six  weeks  with  his  right 
eye  tied  up,  when,  the  left  eye  beginning  to  inflame,  he  gave  up  working.  About  two 
months  after  receiving  the  injury,  a  swelling  formed  over  the  wounded  part,  which  swelling 
being  cut  off,  the  splinter  of  iron,  he  says,  was  extracted. 

The  right  pupil  is  dragged  towards  the  cicatrice ;  the  nasal  portion  of  the  iris  is  on  the 
stretch  ;  the  capsule  of  the  lens  is  opaque  ;  the  iris  is  close  to  the  cornea,  and  is  pretty 
natural  in  color.  The  eyeball  is  of  tixe  healthy  consistence,  and  the  cornea  not  more  flex- 
ible than  natui'al.  No  pain  in  right  eye.  With  this  eye  discerns  the  fingers  indistinctly,  and 
sees  a  pen  as  a  long  stalk.     Thinks  vision  of  right  eye  improving. 

About  a  fortnight  before  the  piece  of  iron  was  extracted  from  right  eye,  the  left  began 
to  be  inflamed,  and  has  suffered  severely.  The  iris  is  greenish  ;  the  pupil  is  nearly  natural 
in  size,  but  is  misshapen,  with  its  edge  jagged,  and  fixed  by  adhesions  to  the  capsule. 
Within  the  verge  of  the  pupil,  the  capsule  presents  a  whitish  wreath,  without  any  red 
vessels.  The  whole  of  the  lens  is  hazy,  and  of  a  greenish  hue  ;  consistence  of  eye  natural. 
With  this  eye,  knows  the  Infirmary  card  to  be  printed,  and  reads  a  type  about  three-quarters 
of  an  inch  in  size. 

Was  at  first  affected  with  severe  nocturnal  circumorbital  pain,  for  which  he  applied 
leeches,  but  was  not  bled  at  the  arm.  His  mouth  was  made  sore  with  mercury,  which  re- 
lieved the  pain,  and  improved  his  sight.  Left  eye  has  been  pretty  free  from  redness  till 
within  four  or  five  months  ago.  Within  last  month,  its  power  of  vision  has  declined,  for 
at  that  period  he  could  read  an  ordinary  type.    Pulse  84.     Thirst.    Appetite  deficient. 

A  pill,  every  night,  containing  two  grains  of  calomel  and  half  a  grain  of  opium.  Bel- 
ladonna coUyrium. 

31st.  He  had  no  eruption  on  his  skin.  This  question  was  put,  with  reference  chiefly 
to  syphilis  ;  as  in  one  of  the  cases  previously  treated  at  the  Infirmary,  there  was  some 
reason  to  suspect  a  syphilitic  complication. 

September  4th.  Complains  more  of  photopsia  in  both  eyes,  with  occasional  headache. 
Less  thirst ;  appetite  improved. 

5th.  Still  complains  of  flashes  of  light  in  both  eyes.     Blisters  behind  ears. 
38 


594  SYMPATHETIC   OPHTHALMITIS. 

Gtb.  Vision  of  both  eyes,  he  thinks,  improved.     Mouth  sore.     Pill  omitted. 

11th.  Three  leeches  to  nasal  angle  of  left  eye. 

18th.  Complains  more  of  pain  in  left  eye. 

19th.  Left  eye  relieved.  To  take  20  drops,  thrice  a-day,  of  a  solution  of  15  grains  of 
murias  barytte  in  gss.  of  tincture  of  cinchona. 

20th.  Thinks  vision  of  right  eye  somewhat  improved  since  his  admission.  Sees  the 
large  letters,  which  he  read  at  his  admission,  plainer.     No  visible  change  in  either  eye. 

1.  Kind  of  injuries. — The  injuries  which,  affecting  one  eye,  are  most  apt  to 
excite  sympathetic  inflammation  in  the  other,  are  penetrating  and  lacerating 
wounds,  inflicted  by  cutting  instruments,  or  by  the  forcible  projection  of 
splinters  of  iron  or  stone,  or  the  fragments  of  percussion  caps. 

A  mere  blow  on  the  eye  (for  instance  with  a  stick)  has  been  known  to  im- 
pair the  other  sympathetically.  Mr.  Wharton  Jones  has  communicated  to  me 
the  case  of  a  gentleman  by  whom  he  was  consulted,  to  whom  it  happened  that, 
in  firing  a  gun,  the  percussion  cap  struck  one  eye,  making  its  way  through  the 
lower  lid  and  sticking  in  the  sclerotica,  the  result  of  which  was  internal  in- 
flammation first  of  the  eye  struck,  and  afterwards  of  the  other.  When  Mr. 
Jones  saw  the  patient,  the  eye  which  had  been  wounded  was  soft  and  atrophic, 
and  the  other  was  becoming  so.  On  the  16th  September,  1833,  a  quantity  of  sul- 
phuric acid  was  thrown  maliciously  into  the  left  eye  of  Mary  Macshaffery,  aged 
26  years.  The  consequence  was  destruction  of  the  cornea,  and  union  of  the 
whole  of  the  upper  eyelid  to  the  remains  of  the  eyeball.  About  the  end  of 
December,  she  began  working  in  a  cotton-mill,  her  usual  employment.  This 
produced  a  severe  attack  of  sympathetic  ophthalmitis  of  the  right  eye, 
ending  in  haziness  of  the  cornea,  discoloration  of  the  iris,  immobility  of  the 
pupil,  and  such  deterioration  of  vision,  that  at  her  admission  to  the  Glasgow 
Eye  Infirmary,  she  could  not  make  out  the  letters  on  the  Infirmary  card.  Such 
facts  illustrate  the  diversity  of  injuries  which  may  give  origin  to  sympathetic 
ophthalmitis.  In  general,  however,  it  is  from  penetrating  wounds  that  the 
disease  we  are  now  considering,  takes  its  rise.  Sometimes  the  wound  is  in- 
flicted by  such  an  instrument  as  a  chisel  or  screw-driver,  so  that  there  can  be 
no  suspicion  of  anything  being  lodged  within  the  eye  ;  while,  in  other  in- 
stances, the  suspicion  is  strong,  or  there  is  an  absolute  certainty,  that  a  for- 
eign body  has  passed  through  the  tunics,  and  lies  there  unextracted.  Sym- 
pathetic ophthalmitis  may  occur,  where  the  foreign  body  has  been  extracted 
immediately  after  the  receipt  of  the  injury,  where  it  has  lain  for  weeks  within 
the  eye  and  then  been  extracted,  or  where  it  still  remains  within  the  tunics. 

The  injuries  now  referred  to  are  sudden  and  severe.  They  are  often  at- 
tended by  a  loss  of  part  of  the  humors,  and  by  an  extravasation  of  blood  into 
the  interior  of  the  eye.  The  parts  divided  have  generally  been  the  cornea  and 
iris,  with  a  small  part  of  the  sclerotica  and  choroid.  The  junction,  in  fact,  of 
the  cornea  and  sclerotica,  and  consequently  the  annulus  albidus  of  the  choroid, 
or  ciliary  muscle,  is  the  place  which  has  been  wounded,  in  most  of  the  cases 
which  I  have  seen.  I  think  sympathetic  ophthalmitis  is  more  apt  to  be  ex- 
cited, if  the  wound  has  produced  a  protrusion  of  the  iris,  and  such  a  cicatrice 
of  the  cornea  and  sclerotica  as  keeps  the  portion  of  the  iris  which  had  not 
been  protruded,  perpetually  on  the  stretch.  If  the  wound  has  been  so  exten- 
sive as  to  divide  or  lacerate  the  retina,  sympathetic  inflammation  is  probably 
still  more  apt  to  occur.  The  injury  which  the  lens  suffers  in  such  cases,  and 
the  traumatic  cataract  which  follows,  have  little  or  no  influence  in  causing 
sympathetic  disease.  A  wound  which  implicates  merely  the  cornea  and  lens, 
or  even  a  wound  of  the  cornea^  with  simple  prolapsus  iridis,  is  not  apt  to 
excite  sympathetic  inflammation.  Neither  is  a  simple  puncture  of  the  scle- 
rotica and  annulus  albidus,  even  though  causing  amaurosis,  very  apt  to  pro- 
duce an  affection  of  the  opposite  eye.  I  have  never  known  any  of  the  opera- 
tions for  cataract  bring  on  this  affection  ;  not  even  when,  after  that  of  extrac- 


SYMPATHETIC   OPHTHALMITIS.  595 

tion,  the  iris  protruded,  and  the  cicatrice  which  followed  caused  dragging  of 
the  opposite  side  of  the  iris.  The  cases,  then,  in  which  I  should  particularly 
dread  an  attack  of  reflex  inflammation,  are  those  in  which,  along  with  a  wound 
of  the  cornea,  sclerotica,  and  anterior  edge  of  the  choroid,  there  is  a  loss  of 
part  of  the  vitreous  humor,  and  a  laceration  and  protruvsion  of  the  iris  ; 
especially  if,  about  the  time  of  the  cicatrization  of  the  wound,  the  patient  began 
to  use  the  good  eye  in  earnest,  committed  any  irregularity  in  diet,  overfatigued 
himself,  or  suffered  from  mental  excitement  or  distress. 

2.  Date  of  sympathetic  inflammation. — Were  we  to  judge  of  the  time  which 
generally  elapses  between  an  injury  of  one  eye  and  sympathetic  inflammation 
manifesting  itself  in  the  other,  from  the  six  cases  above  related,  we  should 
say  that  five  weeks  was  the  most  frequent  period.  In  Patterson,  the  sympa- 
thetic affection  came  on  three  months  after  the  injury  ;  in  Moore,  the  period 
was  one  month  ;  in  Downie,  five  weeks  ;  in  Finlay,  five  weeks  ;  in  Gartshore, 
four  or  five  weeks ;  in  Mill,  six  weeks.  In  three  out  of  six  cases,  recorded 
by  Mr.  Lawrence,*  the  period  is  not  mentioned  ;  in  the  other  three,  the  pe- 
riods were  a  few  M'eeks,  five  years,  and  soon  after  six  weeks.  In  two  cases 
recorded  by  Mr.  Wardrop,*  the  periods  were  three  weeks,  and  one  year. 

3.  Subjects. — The  subjects  of  sympathetic  ophthalmitis  have  most  fre- 
quently been,  in  my  experience,  men  employed  in  iron-works.  At  the  time 
when  their  eyes  were  injured,  their  general  strength  was  not  impaired  ;  but 
from  their  habits  of  life,  and  especially  from  their  liberal  use  of  spirits  and 
tobacco,  their  constitutions  were  in  an  artificial  state,  very  unfavorable  for 
throwing  off  any  inflammatory  disease.  It  appeared  to  be  from  this  cause 
that  the  sympathetic  inflammation  sometimes  degenerated  into  the  arthritic 
variety,  and  always  proved  so  intractable.  In  some  of  the  cases  I  have  seen, 
the  disease  was  modified  by  scrofula;  a  modification  scarcely  less  troublesome 
than  the  arthritic.  In  one  of  the  cases  at  the  Eye  Infirmary,  Dr.  Kennedy 
observed  that  the  wounds  made  in  bleeding  the  patient  at  the  bend  of  the  arm 
generally  suppurated ;  which  led  him  to  inquire  whether  a  syphilitic  taint 
might  not  be  present.  The  patient  acknowledged  having  had  some  primary 
syphilitic  symptoms  before  he  received  the  injury  of  his  eye ;  but  he  had  no 
sore  throat  nor  eruption,  and  the  eye,  sympathetically  inflamed,  showed  none 
of  the  peculiar  indications  of  syphilis. 

4.  Exciting  causes. — It  sometimes  happens  that  the  patient  is  unable  to 
specify  any  exciting  cause  for  the  sympathetic  attack ;  but  in  other  instances, 
causes  of  this  kind  are  distinctly  mentioned.  For  example,  in  Finlay,  the 
exciting  cause  was  manifestly  the  reading,  for  three  or  four  hours  together, 
in  a  book  printed  in  a  small  type  ;  and  in  one  of  Mr.  Lawrence's  cases,  the 
eye  had  been  incautiously  worked.  The  wounds  of  the  eye,  which  are  apt  to 
give  rise  to  sympathetic  ophthalmitis,  commonly  take  from  a  month  to  six 
weeks  to  cicatrize.  Whenever  they  are  healed,  the  patients  generally  recom- 
mence their  usual  employments  and  modes  of  life  ;  and  then  it  is  that  the 
exciting  causes  of  the  sympathetic  disease  come  into  play. 

The  same  sort  of  exciting  causes  which  produced  the  first  attack  of  sym- 
pathetic inflammation,  also  bring  on  relapses  when  the  patient  is  recovering; 
and  it  is  generally  by  a  succession  of  relapses  that  vision  is  destroyed. 

5.  Symptoms. — The  local  symptoms  of  the  sympathetic  disease  are  those 
of  retinitis  and  iritis,  passing  into  amaurosis  and  atrophy  of  the  eye.  The 
first  symptom  is  generally  dimness  of  sight.  This  is  rapidly  followed  by 
zonular  redness  around  the  cornea,  dingy  greeness  of  the  iris,  flexibility  of 
the  cornea,  bogginess  of  the  sclerotica,  opacity  of  the  capsule,  greenishness 
of  the  lens,  varicosity  of  the  rectal  vessels  ramifying  over  the  surface  of  the 
eye,  contraction  and  adhesion  of  the  pupil,  puckering  and  bolstering  forwards 
of  the  iris,  and  total  insensibility  of  the  retina.     The  pain  is  very  variable  ; 


596  SYMPATHETIC   OPHTHALMITIS. 

for  in  some  it  is  slight,  as  in  Gavtshore,  who  said  she  had  no  pain  in  the  eye 
sympathetically  affected;  while  in  others  it  is  severe,  as  in  Finlay.  A  throb- 
bing or  heaving  is  felt  behind  the  eyes,  synchronous  with  the  pulse.  Photop- 
sia  is  a  usual  symptom  about  the  commencement  of  the  attack.  In  some, 
there  is  a  great  intolerance  of  Ifght ;  in  others,  there  is  little.  At  length, 
the  shrinking  of  the  eyeball,  and  especially  of  the  cornea,  is  very  remarkable. 
In  one  of  Mr.  Lawrence's  cases,  each  cornea  had  shrunk  to  the  size  and 
figure  of  a  barley-corn  placed  horizontally. 

There  can  be  no  doubt  that  inflammation  of  the  retina  forms  a  chief  part, 
in  all  cases  of  sympathetic  ophthalmitis.  Retinitis  appears  to  occur  first, 
and  added  to  it  is  iritis.  The  early  loss  of  vision  shows  that  the  retina  is 
deeply  implicated  from  the  very  commencement.  The  flexibility  of  the  cor- 
nea, and  softness  of  the  sclerotica,  indicate  the  vitreous  fluid  to  be  lessened 
in  quantity.  The  changes  which  are  visible  in  the  capsule  and  in  the  iris  are 
plain  indications  how  far  these  textures  are  affected. 

Sympathetic  ophthalmitis  is  generally  an  inflammation  of  that  kind  which 
is  called  unhealthy.  It  sometimes  resembles  scrofulous  internal  ophthalmia; 
more  frequently,  it  resembles  arthritic  ophthalmia.  The  symptoms  are  often 
such  that  one  skilled  in  German  ophthalmology,  would  at  once  say,  here  is 
arthritic  iritis.  As  I  have  before  remarked,  if  we  use  the  term  arthritic 
merely  as  a  conventional  one,  to  express  a  certain  variety, of  eye-disease, 
characterized  by  certain  signs,  this  may  be  allowed ;  but  if  by  arthritic  is 
meant  strictly  gouty,  applied  to  the  cases  we  are  now  considering,  the  term 
is  incorrect.  The  subjects  of  sympathetic  ophthalmitis  may  have  some  pecu- 
liarity of  constitution,  produced  by  their  mode  of  life,  and  by  the  nature  of 
the  ingesta  to  which  they  have  habituated  themselves ;  but  there  are  not 
sufficient  grounds  for  supposing  that  they  labor  under  the  gouty  diathesis. 
It  is  more  probable  that  the  particular  textures  of  the  eye  which  are  affected, 
and  the  modes  in  which  these  textures  are  suffering,  produce  the  peculiar 
svmptoms  which  present  themselves  so  strikingly  in  such  cases,  and  which  the 
Germans  call  arthritic. 

Amongst  the  constitutional  symptoms  may  be  mentioned  quickness  of  pulse, 
thirst,  a  marked  bufty  coat  on  the  blood  drawn  from  a  vein,  a  pallid  complex- 
ion, and  obstinate  constipation.  A  degree  of  ill  health,  in  fact,  has  generally 
resulted  from  the  confinement,  want  of  exercise,  and  medical  treatment  neces- 
sary for  the  cure  of  the  original  accident;  and  in  this  debilitated  state  the 
patient  is  attacked  by  the  sympathetic  disease. 

6.  Ratio  symptomatum. — The  fact,  that  disease  in  one  eye  is  liable  to  be 
followed  by  similar  disease  in  the  other,  has  long  attracted  attention.  Inflam- 
mation, cataract,  and  amaurosis,  have  especially  been  observed  to"  occur  in 
this  way,  from  what  is  termed  a  consensus  oculorum. 

A  little  girl,  who  was  an  out-patient  at  the  Glasgow  Eye  Infirmary,  pre- 
sented a  curious  instance  of  the  tendency  to  symmetrical  disease  of  the  two 
eyes.  She  was  affected  with  trichiasis,  xeroma  of  the  palpebral  conjunctiva, 
and  thickening  and  opacity  of  the  cornea.  At  her  admission,  and  for  sevei'al 
years  after,  the  symptoms  were  confined  to  the  left  side,  the  right  eye  being 
perfectly  well.  But,  by  and  by,  the  same  set  of  symptoms  began  to  show 
themselves  in  the  right  eye,  only  in  a  less  degree.  The  corresponding  eye- 
lashes were  inverted,  the  corresponding  part  of  the  conjunctiva  became  dry, 
and  the  corresponding  portion  of  the  cornea  opaque. 

Two  patients,  attending  the  Eye  Infirmary  about  the  same  time  as  the 
child  whose  case  I  have  just  noticed,  afforded  instances  of  sympathetic  amau- 
rosis, and  oscillation  of  the  eyeball.  In  one  of  these  patients,  the  left  eye 
was  destroyed  by  a  blow ;  and  eight  days  after,  the  right  eye  was  found  to 
be  affected  with  oscillation,  and  a  great  degree  of  dimness  of  sight,  but  with- 


SYMPATHETIC   OPHTHALMITIS.  591 

out  inflammation.  Less  was  known  of  the  other  patient's  history,  as  the 
injury  which  destroyed  the  sight  of  his  left  eye,  and  produced  almost  a  com- 
plete absorption  of  the  iris,  occurred  in  childhood ;  but  he  afforded  another 
example  of  sympathetic  oscillation  and  amaurosis. 

Dr.  Albers  relates''  the  case  of  a  countryman,  who,  in  a  scuffle  with  his 
brother,  was  struck  with  a  pitchfork  in  the  right  eye,  whereby  the  cornea  and 
iris  were  seriously  injured.  The  wound  healed  in  such  a  way  that  the  sight 
was  not  entirely  lost.  In  three  days  after  the  injury,  the  patient  observed 
diminution  in  the  vision  of  the  left  eye,  and  an  opacity  was  discernible  within 
the  pupil.  The  opacity  increased  so  rapidly,  that  in  eight  days  there  were 
all  the  signs  of  a  fully  formed  cataract.  Half  a  year  afterwards,  he  was  ope- 
rated on"  by  Professor  Jung,  of  Marburg,  but  unsuccessfully,  the  patient 
remaining  completely  blind.  Albers  asks,  if  this  case  does  not  go  to  prove 
a  decussation  of  the  optic  nerves,  to  which  Himly  replies  in  the  negative. 
For  suppose  (says  he),  that  the  cataract,  the  sudden  formation  of  which  is 
very  remarkable,  was  really  a  consequence  of  the  injury,  and  not  only  so,  but 
that  the  injury  was  the  sole  cause  of  the  cataract,  and  did  not  operate  merely 
in  exciting  a  tendency  already  existing  to  opacity,  we  find  similar  appearances 
of  consensus  frequently  in  the  corresponding  teeth  of  the  two  sides,  where 
no  such  decussation  or  nervous  communication  can  be  brought  forward  in 
explanation. 

ISTotwithstanding  this  objection  of  Himley,  it  is  generally  acknowledged 
that  those  organs  of  the  body  are  most  apt  to  affect  others,  or  in  their  turn 
to  be  affected  sympathetically,  in  which  the  nervous  system  is  most  developed; 
that  there  are  no  organs  between  which  a  sympathy  in  different  states  of 
disease  exists  so  remarkably  as  the  two  eyes  ;  and  that  there  are  no  organs 
in  which  the  nervous  system  is  more  developed,  none  in  which  the  nerves  of 
the  opposite  sides  are  connected  in  the  same  intimate  way. 

In  the  cases  now  under  our  consideration,  it  is  not  improbable  that  the 
bloodvessels  on  the  side  of  the  injured  eye,  being  in  the  state  of  congestion 
which  attends  inflammation,  communicate  to  those  of  the  opposite  side,  with 
which  they  have  connections  within  the  cranium,  a  disposition  to  the  same 
state  in  which  they  themselves  are.  The  ciliary  nerves  also  of  the  injured 
eye,  may  be  the  means  of  conveying  to  the  third  and  fifth  nerves,  an  irrita- 
tion which  may  be  reflected  from  the  brain  to  the  same  nerves  on  the  oppo- 
site side.  I  think,  however,  that  the  chief  medium  through  which  sympa- 
thetic ophthalmitis  is  excited,  is  the  union  of  the  optic  nerves.  The 
researches  of  modern  anatomists  have  tended  only  to  confirm  the  conjecture 
of  Newton,*  that  the  optic  nerve  of  the  one  eye,  proceeding  backwards  and 
meeting  the  optic  nerve  of  the  other  eye,  the  two  mingle  their  fibres,  and 
partially  decussate.  It  is  extremely  probable  that  the  retina  of  the  injured 
eye  is  in  a  state  of  inflammation,  which  is  propagated  along  the  correspond- 
ing optic  nerve  to  the  chiasma,  and  that  thence  the  irritation  which  gives  rise 
to  inflammation,  is  reflected  to  the  retina  of  the  opposite  eye,  along  its  optic 
nerve. 

7.  Diagnosis. — The  history  of  the  case  will,  in  general,  be  sufficient  to 
prevent  any  difficulty  in  the  diagnosis.  Sympathetic  ophthalmitis  may  be 
complicated  with  scrofula,  and  assume  a  good  deal  of  the  scrofulous  charac- 
ter; or  it  maybe  complicated  with  syphilis,  which  an  examination  of  the 
patient's  skin  and  throat,  and  an  inquiry  into  his  previous  health,  will  serve 
to  elucidate.  These  complications,  as  well  as  the  arthritic,  will  no  doubt 
render  the  symptoms  more  severe ;  but  they  will  scarcely  influence  the  line  of 
treatment  to  be  followed. 

8.  Prognosis. — The  prognosis  is  so  unfavorable,  that  it  is  our  duty  to 
guard  the  patient  who  has  suffered  any  severe  injury  of  one  eye,  against  the 


598  SYMPATHETIC   OPHTHALMITIS. 

exciting  causes  of  sympathetic  ophthalmitis,  from  the  very  first.  When  this 
disease  is  actually  present,  even  the  most  active  treatment  is  generally  inef- 
fectual. I  have  very  seldom  seen  an  eye  recover  from  sympathetic  oph- 
thalmitis. Renewed  attacks  have  generally  terminated  by  extinguishing 
vision. 

9.  Treatment. — Rest,  antiphlogistic  means,  the  internal  use  of  mercury, 
and  the  external  application  of  belladonna,  are  the  principal  points  of  the 
treatment.  These  means,  we  have  abundant  proof,  are  not  very  successful. 
Still,  to  relinquish  these  remedies  would  be  wrong. 

A  little  boy,  at  the  Glasgow  Eye  Infirmary,  after  his  mouth  was  made  sore 
by  mercury,  was  much  benefited  by  iodide  of  potassium. 

The  only  case  in  which  I  have  witnessed  a  complete  cure  of  sympathetic 
ophthalmitis,  was  the  result,  in  the  right  eye,  of  the  left  being  punctured, 
close  to  the  edge  of  the  cornea,  with  a  packing-needle,  the  pupil  being  perma- 
nently dragged  towards  the  wound.  After  depletion  and  mercury  had  been 
pretty  extensively  employed.  I  put  the  patient  on  the  combined  use  of  calo- 
mel and  sulphate  of  quina,  and  had  the  satisfaction  of  seeing  the  symptoms 
yield  entirely  to  this  plan  of  treatment. 

I  have  found  the  inhalation  of  the  vapor  of  sulphuric  ether  to  alleviate,  in 
a  marked  manner,  the  symptoms  of  sympathetic  ophthalmitis. 

There  is  a  disease,  Mr.  Wardrop  informs  us,*  frequent  in  the  eye  of  the 
horse,  having  the  appearance  of  a  specific  inflammation,  whicli  usually  first 
affects  one-  eye,  and  then  the  other,  and  sooaer  or  later  destroys  vision.  It  is 
known  to  farriers,  that,  if  the  eye  first  affected  suppurates  and  sinks  in  the 
orbit,  the  disease  does  not  attack  the  other,  or  subsides  if  it  had  commenced 
in  it.  They  therefore  adopt  the  practice  of  destroying  the  diseased  eye,  in 
order  to  save  the  other.  They  do  this  rudely,  by  putting  lime  between  the 
eyelids,  or  thrusting  a  nail  into  the  eyeball,  so  as  to  excite  violent  inflamma- 
tion and  suppuration.  Mr.  Wardrop  has  frequently  succeeded  in  saving  one 
eye  of  the  horse  by  adopting  this  practice ;  but  he  destroyed  the  eye  by 
making  an  incision  in  the  cornea,  and  discharging  through  it  the  lens  and 
vitreous  humor.  "In  some  diseases  of  the  human  eye,"  says  he,  "where  the 
disease  makes  a  similar  progress,  first  affecting  one  eye  and  then  the  other 
with  complete  blindness,  the  practice  so  successful  in  animals  might,  by  judi- 
cious discrimination,  be  beneficially  adopted." 

The  practice  thus  hinted  at  by  Mr.  Wardrop,  has  actually  been  adopted, 
though  with  a  somewhat  different  view,  by  Mr.  Barton,  of  Manchester,  in 
cases  of  injury  of  the  eye  with  the  fragments  of  percussion  caps.  The 
reader  will  find  an  account  of  Mr.  Barton's  mode  of  treating  such  cases  at 
page  415. 

Mr.  Croraptom  states,^  that  in  one  of  the  cases  which  he  witnessed  under 
Mr.  Barton's  care,  the  vision  of  the  uninjured  eye  was  nearly  lost  from 
sympathetic  inflammation,  and  adds  that  he  thinks  it  most  likely  that  the 
other  cases  would  have  terminated  similarly,  if  the  plan  of  laying  open  the 
injured  eye  had  not  been  adopted.  Mr.  Barton,  it  is  true,  opens  the  injured 
eye,  with  the  view  of  extracting  the  fragment  of  the  cap,  on  the  presence  of 
which  he  considers  the  sympathetic  inflammation  to  depend.  lie  not  only 
opens  the  cornea,  but  cuts  away  a  large  flap  of  it.  He  then  applies  a  poul- 
tice, and  Avaits  till  the  fragment  is  discharged.  In  the  cases  published  by 
Mr.  Crompton,  this  practice  appears  to  have  not  only  relieved  the  patients 
of  the  pain  they  were  suffering  in  the  injured  eye,  but  to  have  arrested  the 
reflex  disease  which  threatened  the  other.  This,  then  affords  good  ground 
for  following  a  similar  plan,  not  only  in  cases  where  we  have  reason  to  be- 
lieve that  some  foreign  body  is  lodged  within  the  eye,  but  even  in  other 
cases,  where  the  one  eye  being  disorganized  and  deprived  of  sight,  the  other 


INTERMITTENT  OPHTHALMIA.  599 

eye  seems  likely  to  be  destroyed  by  sympathetic  inflammation.  Where  there 
is  a  suspicion  that  some  foreign  body  is  lodged  within  the  injured  eye,  there 
can  be  no  question  that  Mr.  Barton's  practice  ought  to  be  adopted  ;  but  even 
in  other  cases,  why  should  we  hesitate  to  lay  open  an  eye  in  which  vision  is 
extinguished,  if  the  operation  affords  a  reasonable  hope  of  our  being  thereby 
able  to  save  the  other  V 


'   Treatise   on    the  Diseases  of  the  Ej'e,  p.  '  Op.  cit. ;  Vol.  ii.  p.  139. 

147;  London,  1833.  ^  London  Medical  Gazette;  "Vol.  xxi.  p.  175. 

^  Morbid  Anatomy  of  the  Human  Eye  ;  Vol.  '  See    cases     of   sympathetic   ophthalmitis, 

i.  p.  117;  Vol.  ii.  p.  140;  London,  1818,  1819.  treated  by  incision  of  the  injured  eye;  French 

'  Himly  und    Schmidt's    Ophthalmologische  translation  of  this  Work,  p.  xxi.;  Paris,  1844; 

Bibliotheli ;  Vol.  ii.  No.  3,  p.  169  ;  Jena,  1804.  Association  Medical  Journal,  May  13,  1853,  p. 

*  Opticks;  query  15,  411. 


SECTION  XXXIX. — INTERMITTENT  OPHTHALMI.a;. 

At  the  period  when  I  sent  to  the  press  the  earlier  editions  of  this  work, 
although  sevei'al  interesting  cases  had  been  recorded  of  ophthalmia  recurring 
in  the  same  individual  after  longer  or  shorter  intervals  of  time,  yet  I  did  not 
think  there  was  sufficient  ground  to  admit  the  existence  of  any  disease  of 
this  kind  so  regularly  periodic  in  its  accession,  as  to  warrant  the  appellation 
of  intermittent  ophthalmia.'^  Although  I  have  since  seen  cause  to  change  my 
opinion,  the  following  remarks  are  still  appropriate  : — 

The  pain  which  attends  many  of  the  ophthalmite  is  undoubtedly  subject  to 
regular  nocturnal  exacerbations  ;  but  this  does  not  entitle  these  diseases  to 
the  appellation  of  intermittent.  By  an  intermittent  or  periodical  ophthalmia, 
I  should  understand  one  which  recurred  with  considerable  regularity  at  inter- 
vals of  days,  weeks,  or  months,  and  apparently  not  from  accident,  but  from 
concatenation  with  the  revolutions  of  time  ;  Avhereas,  if  we  examine  the  gene- 
rality of  cases  recorded  as  of  this  kind,  we  shall  find  that  they  are  nothing 
more  than  instances  of  some  particular  ophthalmia  recurring  more  or  less 
frequently  in  the  same  individual,  in  consequence  of  his  repeatedly  exposing 
himself  to  the  same,  or  to  some  similar  exciting  cause.  Phlyctenular  oph- 
thalmia, being  that  which  is  most  apt  to  be  renewed  on  slight  exposures,  will 
also  frequently  appear  to  be  periodic;  rheumatic,  catarrho-rheumatic,  and 
catarrhal  may  also,  from  their  ready  occurrence  in  eyes  once  affected  with 
them,  seem  intermittent.  I  have  frequently  treated  patients  who,  at  inter- 
vals of  three  or  four  months,  or  once  a  year,  and  nearly  about  the  same 
season  for  several  successive  years,  had  suffered  an  attack  of  rheumatic  iritis ; 
but  in  every  case  of  this  kind,  I  have  been  able  to  trace  the  return  of  the 
disease  to  some  new  imprudence.  In  arthritic  inflammation  of  the  eyes,  there 
may  also  appear  to  be  a  periodic  tendency  ;  for  every  attack  leaves  the  eyes 
worse  than  before,  and  with  a  strong  disposition  to  suffer  again  from  renewed 
causes  of  excitement. 

These  remarks  will  be  confirmed  by  a  perusal  of  the  narratives  of  Dr. 
Curry  and  Dr.  Bostock,  both  of  whom  had  suffered  from  repeated  attacks  of 
severe  ophthalmite.*^  Some  other  cases,  published  as  illustrations  of  inter- 
mittent ophthalmia,  seem  to  have  been  rather  instances  of  neuralgia,  attended, 
as  this  disease  often  is,  with  inflammation  of  some  of  the  texture  of  the  eye.^ 

The  following  case  first  induced  me  to  change  my  opinion  regarding  the 
non-existence  of  intermittent  ophthalmioe. 

Case  299. — A  gentleman  came  from  a  distance,  to  consult  me,  in  July,  1835.  His  age 
was  24,  and  he  stated  that  he  had  been  troubled  with  scrofulous  ophthalmia  till  he  was 
10.     After  that  age,  he  remained  free  from  ophthalmia  till  within  ten  months  of  the 


600  INTERMITTENT   OPHTHALMIA. 

period  when  he  consulted  me.  For  these  ten  months,  the  conjunctiva  had  been  affected 
■with  considerable  redness,  and  this  symptom  presented  exacerbations  of  a  distinctly- 
periodic  character.  The  redness  was  of  a  carmine  hue,  and  differed  from  that  of  any 
ordinary  ophthalmia.  The  eyes  were  never  entirely  free  from  redness;  but  regularly, 
every  six  or  seven  days,  there  was  an  exacerbation,  first  in  the  one  eye,  and  then  in  the 
other.  A  patch  of  redness  was  first  observed  on  one  of  the  conjunctivae,  the  redness 
spread  rapidly  till  the  whole  membrane  was  affected,  and  then  the  other  eye  underwent 
the  same  process.  Some  swelling  of  the  conjunctivae  attended  these  attacks,  along  with 
a  degree  of  heat  and  pain  in  the  eyes.  There  were  no  rigors,  nor  headache.  There  was 
not  much  intolerance  of  light.  The  bloodvessels  of  the  conjunctiva3  showed  a  tendency 
to  pass  over  the  edge  of  the  cornete.  There  were  no  phlyctenulae,  and  no  increased  dis- 
charge from  the  conjunctivae.  The  scleroticre  appeared  neither  thickened  nor  thinned. 
There  was  no  affection  of  the  cornea?,  except  some  minute  specks  of  opacity  at  the  edge 
of  the  right  one.  There  was  no  disease  in  either  iris,  and  the  vision  was  perfect.  The 
attacks  came  to  a  crisis  in  about  36  hours  from  their  commencement,  the  redness  after 
this  gradually  decreasing  till  the  eyes  recovered  something  like  their  proper  color,  and 
the  wJiole  process  occupying  generally  six  or  seven  days.  There  seemed,  the  patient 
remarked,  to  be  some  cause  residing  in  the  eye  itself,  which  produced  inflammation,  ex- 
clusive of  any  external  irritant,  and  whicli  no  care  could  counteract;  for  when  the  eyes 
were  at  the  palest,  he  was  sensible  of  a  slight  pricking  sensation,  the  certain  forerunner 
of  another  attack.     Thus  matters  had  gone  on  for  ten  months. 

The  remedies  which  had  been  tried,  were  leeches  round  the  eyes ;  mercury,  sulphate 
of  quina,  and  arsenic,  internally ;  along  with  solution  of  nitrate  of  silver,  solution  of 
sulphate  of  zinc,  and  vinum  opii,  externally :  all  without  effect.  Venesection  was  now 
had  recourse  to,  and  seemed  to  do  good  for  some  time,  Vmt  the  benefit  was  only  temporary. 

The  patient  again  consulted  me  in  March,  1838.  His  disease  had  continued  with  little 
change.  Perhaps  the  intervals  between  the  exacerbations  were  a  little  longer,  approach- 
ing nearer  to  seven  than  to  six  days.  There  was  now  a  remarkable  increase  of  the  opacity 
formerly  observed  at  the  edge  of  the  cornea.  On  each  cornea  there  was  now  a  sort  of 
arcus,  deficient  above,  but  occupying  to  a  considerable  breadth  the  rest  of  the  circumfer- 
ence. These  rings  were  of  a  peculiar  yellowish-white  color,  so  as  to  resemble  pus  or  bone 
in  appearance.     They  had  been  increasing  for  18  months. 

The  patient  had  consulted  several  of  the  most  eminent  surgeons  and  oculists  in  these 
countries,  but  without  deriving  any  benefit  from  their  prescriptions.  He  had  been  cupped 
by  the  advice  of  one,  and  was  using  steel  by  the  advice  of  another.  My  friend  Dr. 
Staberoh,  of  Berlin,  saw  him  along  with  me,  and  recommended  a  trial  of  iodine  internally, 
with  a  tartar  emetic  eruption  on  the  nape  of  the  neck.  The  patient  wrote  to  me,  some 
time  after,  to  say  that  these  remedies  had  likewise  been  fruitless. 

On  the  10th  of  July,  1839,  bis  medical  attendant  wrote  to  me,  that  the  disease  con- 
tinued to  make  progress. 

Such  was  the  first  case  of  distinct  intermittent  ophthalmia  which  came 
under  my  observation.  It  corresponds  with  the  cases  seen  by  Benedict,  in  ■ 
affecting  only  the  external  parts  of  the  eye,  and  in  manifesting  the  symptoms 
of  a  taraxis.*  Its  type  is  se.xtan  or  septan.  It  corresponds  with  the  disease 
described  by  Staub^as  a  congestion  rather  than  an  ophthalmia.  This  author 
would  call  it  a  local  intermittent  fever. 

Case  300. — A  gentleman,  about  50,  consulted  me  in  December,  1838.  Both  his  con- 
junctivae presented  a  very  considerable  redness,  rather  of  a  livid  hue,  and  neither  dis- 
tinctly reticular  nor  zonular.  The  conjunctivae  looked  as  if  they  were  dyed  red,  rather 
than  inflamed.  The  redness  was  less  on  the  upper  half  of  the  eyeballs  than  on  the  lower 
half,  but  the  chief  redness  was  on  the  temporal  side.  There  was  not  much  thickening  of 
the  conjunctivoe,  and  no  chemosis.  There  was  no  morbid  secretion ;  no  gluing  of  the 
eyelids  in  the  morning.  There  was  no  pain  in  the  eyes,  nor  feeling  of  sand.  A  narrow 
■white  ring  was  observable  between  the  sclerotica  and  cornea.  The  cornea,  iris,  and  pupil 
of  each  eye  were  natural ;  and  the  vision  perfectly  good.  The  patient  complained  of  a 
feeling  of  coldness  in  his  eyes,  which  he  relieved  by  heating  them  at  the  fire ;  a  practice 
his  medical  attendants  used  to  laugh  at.  They  felt  better,  however,  and  the  redness  al- 
waj's  diminished,  when  he  passed  into  the  open  air.  They  became  weak,  if,  after  coming 
within  doors,  he  used  them  in  reading  for  half  an  hour,  and  the  redness  then  increased. 
Gas  light  was  pleasing,  not  painful  to  them.  They  showed  alternations  of  better  and 
worse,  but  the  exacerbations  were  not  regular.  If  there  was  any  intermittence,  it  was 
daily ;  the  relief  being  experienced  when  the  patient  was  out  of  doors  in  the  forenoon. 
TVinds,  even  the  east  wind,  did  not  hurt  his  eyes. 

The  ophthalmia  was  of  two  months'  standing.     The  patient  had  been  long  subject  to 


DISEASES   CONSEQUENT   TO   THE   OPHTHALMIA.  601 

neuralgic  pains  in  the  chest,  back,  and  sides.  Pulse  66.  He  felt  no  rigors,  but  rather  a 
pleasing  heat  of  skin.  His  skin  was  dry,  and  he  perspired  ■with  difficulty,  except  on 
taking  exercise. 

In  this  case,  diaphoretics  and  colchicum  had  been  tried,  with  various  local  applications ; 
but  without  any  effect. 

I  understood  the  patient  continued  in  the  same  state  five  months  after  I 
saw  him.  From  the  peculiar  appearance  of  the  eyes,  I  considered  the  disease 
to  be  essentially  the  same  as  that  which  existed  in  the  preceding  case,  although 
the  intermittent  character  was  but  obscurely  declared. 

Case  301. — A  lady  of  rank,  who  each  summer,  for  two  years,  had  taken  large  doses 
of  sulphate  of  quina  for  hay-fever,  became  suddenly  affected  with  dimness  of  sight  in 
the  right  eye,  followed  by  external  appearances  of  inflammation.  When  she  came  under 
my  care,  in  May,  1842,  the  attack  of  inflammation  involved  chiefly  the  retina,  iris,  and 
anterior  crystalline  capsule.  The  pupil  was  contracted  and  irregular,  the  iris  was  dis- 
colored, and  its  edge  appeared  thinned,  and  was  studded  with  minute  reddish  points. 
These  symptoms,  as  well  as  the  dimness  of  sight,  yielded  to  leeching,  calomel  with  opium, 
and  belladonna.  After  being  some  short  time  under  my  care,  I  discovered  that  the  dis- 
ease suffered  a  distinct  exacerbation  every  seventh  day.  Each  paroxysm  began  with 
slight  redness  and  oedema  of  the  conjunctiva,  followed  by  more  or  less  pain  in  the  eye, 
generally  nocturnal,  and  by  an  increased  dimness  of  sight.  These  symptoms  went  on 
increasing  for  two  days,  and  then  subsided  till  the  seventh  day,  when  they  regularly 
returned,  often  with  a  slight  rigor.  These  relapses  were  in  a  great  measure  warded  off 
by  small  doses  of  sulphate  of  quina. 

In  December,  the  same  set  of  symptoms  occurred  in  the  left  eye,  with  tags  of  the  pupil- 
lary margin  to  the  capsule,  and  were  overcome  by  the  same  remedies  as  had  before  been 
used  for  the  right  eye.  On  the  tenth  day  of  the  treatment,  the  tags  gave  way,  and  the 
eye  was  free  from  redness,  and  seemed  perfectly  well.  Next  day,  the  patient  had  a  rigor, 
followed  by  pain  in  the  eye,  with  redness  and  slight  oedema,  and  the  pupil  again  showed 
itself  irregular  and  contracted.  By  means  of  the  calomel  with  opium,  and  the  belladonna, 
the  eye  was  again  restored,  and  the  patient  was  put  on  sulphate  of  quina,  previously  to 
leaving  Glasgow. 

Two  years  afterwards  I  was  sorry  to  learn  that  the  disease  had  returned,  and  had 
ended  in  amaurosis. 

This  case  was  evidently  one  of  chronic  intermittent  ophthalmia,  of  iritic 
character,  and  septan  type. 


'  The  frequently  recurring  inflammation  of  by  John  Bostock,  M.  D.;  Ibid.  Vol.  s.  p.  161; 

the    eye  of  the_  horse,  which  at  last  ends  in  London,  1819. 

moon-blindness,  was  formerly  supposed   to   be  ^  See  Hueter,  Grafe  und  Walther's  Journal 

periodic,  and  to  be  governed  by  the  changes  of  der  Chirurgie  und  Augenheilkunde  ;  Vol.  xii. 

the  moon.  p.  271  ;  Vol.  xiii.  p.  93  ;  Berlin,  1828,  1829. 

*  History  of  a  case  of  Remitting  Ophthalmia,  *  Benedict's  Handbuch  der  praktischen  Au- 

and  its    successful  Treatment   by  Opium  ;    by  genheilkunde  ;  Vol.  ii.  p.  6  ;  Leipzig,  1823. 

James  Curry,  M.  D.;  Medico-Chirurgical  Trans-  '  Zeitschrift  fiir  die    Ophthalmologie  ;    Vol. 

actions,  Vol.  iii.  p.  348;  London,  1812:  Case  iv.  p.  371 ;  Heidelberg,  1835. 
of  a  Periodical  Affection  of  the  Eyes  and  Chest; 


CHAPTER  XIV. 

DISEASES  CONSEQUENT  TO  THE  OPHTHALMIA. 

Some  of  the  consequences  of  the  ophthalmite  are  direct ;  others,  remote. 
Onyx,  for  example,  or  effusion  of  matter  within  the  cornea,  is  a  direct  conse- 
quence of  severe  inflammation  of  the  exterior  textures  of  the  eye  ;  hernia  of 
the  iris  is  a  remote  consequence,  which  cannot  take  place  till  the  cornea  is 
penetrated  by  ulceration ;  while  staphyloma  of  the  iris  and  cornea  is  still 
more  remote,  never  occurring  till  the  process  of  cicatrization  has  formed  a 
pseudo-cornea  over  the  iris,  exposed  by  partial  or  total  destruction  of  the 


602  ONYX. 

natural  cornea,  and,  in  many  cases,  not  for  a  considerable  number  of  weeks 
or  months  after  such  a  formation  is  effected. 

In  all  the  cases  falling  under  the  head  of  Diseases  consequent  to  the  oph- 
tlialmice,  it  is  a  question  of  importance,  Is  the  ophthalmia  subdued  ?  If  not, 
then  the  remedies  which  are  indicated  in  the  particular  species  of  ophthalmia 
still  present,  however  long  it  may  have  continued,  and  however  much  neglected 
or  mistreated,  are,  in  all  probability,  the  most  likely  means  to  remove  also  the 
consequences  which  the  ophthalmia  has  produced.  If,  on  the  other  hand,  all 
active  symptoms  are  gone,  and  merely  certain  sequelce  remain,  it  is  often 
necessary  to  try  some  mode  of  treatment  totally  different  from  what  might 
have  been  pursued  with  advantage,  had  the  disease  still  existed  in  the  inflam- 
matory stage.  To  recur  again  to  onyx  and  staphyloma,  as  illustrations,  we 
have  frequent  opportunities  of  witnessing  the  complete  dispersion  of  the 
former  by  the  employment  of  proper  antiphlogistic  means,  while  the  latter  is 
totally  beyond  the  influence  of  any  such  mode  of  treatment. 

It  is  worthy  of  notice,  that  certain  of  the  consequences  of  the  ophthalmias 
are  occasionally  to  be  regarded  as  causes  as  well  as  effects ;  a  fact  analogous 
to  what  is  observed  with  regard  to  other  organs.  Thus  tubercles  in  the  lungs 
are  both  excited  by  inflammation,  and  in  their  turn  are  the  cause  of  inflam- 
matory attacks.  Granular  conjunctiva,  an  effect  of  conjunctivitis,  is  a  cause 
of  corneitis. 


SECTION  I. — ONYX,  OR  ABSCESS  OP  THE  CORNEA. 

'Om^,  the  nail.     Syn. — Unguis.     Lunula. 

Fhj.  Wardrop,  PI.  VI.  Fig.  1.    Demours,  PI.  XXIV.  Figs.  1,  2.  PI.  XXIX.  Figs.  1,  2.  PL  XXX. 
Fig.  1.     Aramon,  Thl.  I.  Taf.  II.  Fig.  18. 

The  term  onyx  signifies  a  deposition  of  pus  in  the  spongy  substance,  or  be- 
tween the  lamellfe  of  the  cornea.  Such  an  abscess  must  always  be  attended 
by  partial  destruction  of  the  interlamellar  substance.  It  generally  makes  its 
appearance  at  the  lower  edge  of  the  cornea;  and  however  small,  may  easily  be 
distinguished  from  commencing  hypopium,  or  abscess  of  the  anterior  chamber, 
by  its  exact  similarity  in  form  to  the  white  spot  seen  at  the  root  of  the  nails. 
Even  when  the  quantity  of  pus  is  more  considerable,  an  onyx  may  be  known 
by  its  superior  limit  being  convex,  and  by  its  remaining  unchanged  in  form  and 
situation,  whatever  be  the  position  of  the  patient's  head;  whereas,  when  the 
patient  has  been  for  some  time  at  rest  in  the  erect  position,  hypopium  presents 
a  horizontal  limit  superiorly,  although  this  form  may  be  somewhat  changed, 
by  the  matter  gravitating  to  one  or  other  side,  according  to  the  direction  in 
which  the  head  is  placed. 

Although  the  lower  edge  of  the  cornea  is  by  far  the  most  frequent  seat  of 
incipient  onyx,  it  sometimes  happens  that  pus  is  collected  in  a  circumscribed 
spot  over  the  pupil,  or  at  any  other  part  of  the  cornea,  while,  in  other  cases, 
we  see  onyx  commencing  perhaps  above  the  centre  of  the  cornea,  and  diffusing 
itself  irregularly  over  a  large  extent.  This  is  particularly  the  case  with  onyx 
originating  in  a  scrofulous  phlyctenula,  or  following  smallpox.  Such  an 
onyx  is  apt,  instead  of  bursting  through  the  exterior  lamella,  to  infiltrate  a 
considerable  portion  of  the  substance  of  the  cornea.  After  a  time  the  matter 
is  generally  absorbed,  and  the  corneal  substance  which  was  separated  by  its 
presence,  comes  together  again,  adheres  by  means  of  effused  lymph,  and 
presents  a  peculiar  variety  of  albugo,  which  seldom  entirely  disappears. 

Onyx  takes  place  most  frequently  in  acute  and  neglected  cases  of  the  puro- 
mucous  ophthalmiiB,  and  especially  in  the  ophthalmia  of  new-born  children. 


ONYX.  603 

It  occurs  not  unfrequently  in  catarrho-rheuniatic,  variolous,  and  traumatic 
ophthalmia;  occasionally  in  phlyctenular  ophthalmia;  rarely  in  any  of  the 
others. 

Under  the  use  of  the  remedies  most  applicable  to  the  particular  ophthalmia 
in  which  it  originates,  incipient  onyx  is  often  removed  by  absorption,  in  the 
course  of  a  few  days,  or  even  in  a  few  hours.  But,  in  neglected  cases,  more 
and  more  matter  is  effused,  so  as  to  extend  over  the  cornea,  or  mount  gradu- 
ally from  its  lower  edge  till  it  covers  the  yjupil,  separating  the  lamellro,  or 
perhaps  rather  infiltrating  the  substance  of  the  cornea,  till  at  length  this  part 
of  the  eye  is  completely  put  on  the  stretch,  and  looks  like  an  abscess  ready  to 
burst.  As  the  onyx  increases,  the  pupil  uniformly  contracts  and  becomes 
filled  with  lymph.  The  pain  of  the  eye  and  head  is  at  the  same  time  severely 
aggravated.  At  length  it  sometimes  happens,  although  very  rarely,  that  the 
posterior  lamellte  of  the  cornea  give  way,  and  the  matter  falls  into  the  anterior 
chamber,  so  as  to  form  a  spurious  hypopiura.  This  event  is  sometimes 
supposed  to  have  taken  place  when,  in  fact,  onyx  is  combined,  as  in  cases  of 
catarrho-rheumatic  and  traumatic  ophthalmice  it  not  unfrequenly  is,  with  true 
hypopium.  Much  more  frequently  ulceration  commences  on  the  external 
surface  of  the  cornea,  and  over  the  middle  of  the  onyx ;  in  the  progress  of 
ulceration,  the  cavity  containing  the  pus  is  opened,  and  the  matter  is  slowly 
evacuated.  Not  unfrequently  the  ulcer  which  has  served  to  open  the  onyx, 
goes  on  to  penetrate  completely  through  the  cornea,  so  that  the  aqueous 
humor  is  discharged,  the  iris  falls  forward  into  contact  with  the  ulcerated 
cornea,  adhesion  between  them  ensues,  and  the  case  ends  in  partial  staphy- 
loma. If  a  great  part  of  the  cornea  is  destroyed,  the  staphyloma  will  be 
total.  The  result,  however,  of  the  bursting  of  an  onyx  externally,  is  not 
always  so  unfortunate.  It  sometimes  happens  that,  as  soon  as  its  contents 
are  discharged,  the  inflammation  begins  to  subside  ;  the  pupil  clears  ;  and 
although  some  degree  of  leucoma  is  always  left,  it  may  be  very  limited,  so 
that  a  fair  degree  of  vision  shall  be  preserved. 

Treatment. — The  remedies  most  likely  to  subdue  the  ophthalmia  in  which 
the  onyx  has  originated,  must  be  carefully  employed.  Bleeding,  nauscants, 
purgatives,  counter-iiTitation,  and  mercurialization,  besides  their  antiphlo- 
gistic powers,  frequently  appear  to  act  favorably,  by  promoting  the  absorp- 
tion of  the  purulent  effusion  in  these  abscesses  of  the  cornea.  Belladonna 
ought  to  be  used  to  obviate  contraction  of  the  pupil.  Warm  anodyne  fomen- 
tations are  of  great  use. 

Ought  abscesses  of  the  cornea  to  be  evacuated  by  the  knife  ?  All  agree  that 
this  ought  never  to  be  ventured  on  when  they  are  small  ;  that  is  to  say,  when, 
having  commenced  at  the  lower  edge  of  the  cornea,  they  have  perhaps  not 
mounted  higher  than  opposite  to  the  lower  edge  of  the  pupil,  in  its  medium 
state  of  dilatation.  Larger  onyces  than  this,  I  have  repeatedly  opened  with 
the  lancet ;  and  in  every  case  in  which  I  have  done  so,  so  much  of  the  cornea 
was  destroyed  that  staphyloma  was  the  result.  I  have,  on  the  other  hand, 
left  onyces  untouched,  although  they  were  so  extensive  as  to  cover  the  pupil 
completely,  and  have  sometimes  had  the  satisfaction  of  witnessing  an  almost 
perfect  recovery  of  the  eye.  The  following  is  a  case  which  I  treated  on  this 
plan  : — 

Case  302. — John  Ferrie,  aged  47,  was  admitted  at  the  Glasgow  Eye  Infirmary,  22d 
May,  1826,  on  account  of  catarrho-rheumatic  oplithalmia  of  the  left  eye,  with  which  he 
had  been  affected  for  about  three  weeks.  For  eight  days  he  had  had  severe  orbital  pain 
during  the  night.  There  was  an  onyx,  extending  from  the  lower  edge  of  the  cornea  so 
high  as  to  cover  the  pupil,  and  over  the  middle  of  the  onyx  there  was  a  small  ulcer.  The 
conjunctiva  and  sclerotica  were  very  vascular.  Vinum  opii  was  dropped  upon  the  eye, 
and  extract  of  belladonna  smeared  on  the  eyebrow  and  lids.  He  was  ordered  to  rub  the 
forehead  and  temple  every  night  with  tincture  of  opium,  to  bathe  his  feet  in  hot  water,  and 


604  HYPOPIUM. 

to  take  two  grains  of  calomel  with  one  of  opium,  on  going  to  bed.  On  the  24th,  he  felt 
the  eye  better,  although  there  was  not  much  evident  change  in  its  appearance.  The  iris 
was  discolored,  and  there  was  a  lymphatic  effusion  into  the  pupil.  He  was  ordered  to 
take  the  calomel  and  opium  morning  and  evening,  to  apply  a  blister  to  the  nape  of  the 
neck,  and  to  continue  the  other  remedies.  On  the  27th,  the  mouth  was  affected,  but  the 
onyx  had  increased.  Eight  leeches  were  applied  to  the  left  temple  ;  the  morning  dose  of 
calomel  and  opium  was  omitted.  On  the  31st,  the  pupil  appeared  to  be  contracting.  On 
the  2d  of  June,  the  upper  part  of  the  cornea  was  observed  to  be  nebulous,  and  the  eye 
felt  more  uneasy.  The  nitras  argenti  solution  was  applied  in  the  place  of  the  vinum  opii. 
By  the  5th,  the  exterior  laminte  of  the  cornea  had  given  way,  and  a  considerable  quantity 
of  matter  had  been  discharged  from  the  onyx.  The  pupil  was  still  more  contracted.  He 
complained  of  a  feeling  of  sand  in  the  eye.  He  was  oi'dered  an  aqueous  solution  of  ex- 
tract of  belladonna  as  a  collyrium.  On  the  7th,  the  blisler  was  reapplied.  By  the  9th, 
the  aqueous  humor  had  evacu.ated  itself,  and  the  iris  fallen  forward  into  contact  with  the 
cornea.  The  matter  of  the  onyx  had  almost  entirely  disappeared,  and  he  said  he  saw  a 
little  better.  On  the  12th,  the  pupil,  still  in  contact  with  the  cornea,  appeared  clearer, 
and  vision  was  more  distinct.  On  the  14th,  a  little  aqueous  humor  was  present  between 
the  upper  part  of  the  iris  and  the  cornea ;  the  ulcer  of  the  cornea  was  covered  with 
lymph  ;  and  all  the  pus  gone.  On  the  2Gth,  the  pupil  was  considerably  larger  and  clear; 
more  aqueous  humor  was  present  between  the  iris  and  the  cornea.  By  the  80th,  the  pupil 
was  clear,  and  of  considerable  size.  A  minute  adhesion  between  the  slight  leucoma  on 
the  cornea  and  the  lower  edge  of  the  pupil  was  observed  when  the  eye  was  examined  lat- 
erally.    The  vision  of  the  eye  was  good. 

In  this  instance,  then,  I  left  the  abscess  of  the  cornea  to  itself,  and  certainly 
no  case  could  have  been  more  alarming?  in  its  progress,  nor  more  unexpectedly 
favorable  in  its  results.  The  causes  of  such  success  I  have  endeavored  to  ex- 
plain at  page  504. 

When  the  abscess,  however,  does  not  incline  to  open  of  itself,  but  appears 
about  to  involve  the  whole  cornea,  an  artificial  exit  must  be  afforded  to  the 
matter,  were  it  merely  to  save  the  patient  from  the  continuance  of  the  violent 
pain  which  attends  this  symptom.  The  incision  may  be  made  conveniently 
with  the  iris-knife,  and  ought  to  comprehend  only  the  external  laminae  of  the 
cornea.  No  pus  is  in  general  discharged  at  the  moment  of  making  the  inci- 
sion ;  but  it  forms,  in  the  course  of  some  minutes,  a  small  drop,  which  may 
be  wiped  away  from  the  cornea.  The  operation,  in  most  cases,  requires  to 
be  several  times  repeated,  before  the  onyx  is  entirely  evacuated,  and  ought  to 
be  held  out  to  the  patient  more  as  a  palliative  for  the  pain,  than  as  a  means  of 
saving  the  sight,  which,  in  such  circumstances,  is  generally  lost. 

The  effect  of  evacuating  the  aqueous  humor,  by  puncturing  the  healthy  part 
of  the  cornea  in  the  early  stages  of  onyx,  does  not  appear  to  be  ascertained. 
It  would,  at  least  for  a  time,  relieve  the  tension  which  attends  severe  inflam- 
mation of  the  eye  ;  and  as  onyx  makes  its  appearance  only  in  severe  cases,  it 
might  have  a  good  effect  upon  this  dangerous  symptom.  To  trust,  however, 
almost  solely  to  this,  or  to  any  other  local  means,  without  assiduously  com- 
bating by  general  remedies,  the  ophthalmia  in  which  the  onyx  has  originated, 
would  be  highly  improper. 

a\Ir.  Guthrie's  plan  of  dividing  the  whole  thickness  of  the  cornea,  in  cases 
of  onyx,  I  have  already  explained  at  page  504. 


SECTION    n. — HYPOPIUM. 

Hypopium,  from  Itro,  under,  and  trvov,  pus.  Syn. — Occulus  purulentus.  Das  Eiterauge,  Ger. 

Fig.  Demours,  PI.  XXX.  Figs.  2,  3.  PI.  XXXI.  Fig.  1.  Ammon,  Thl.  I.  Taf.  VIII.  Fig.  3.  Dai- 
ry tuple,  PI.  XVIII.  Figs.  2,  3.     Sichel,  PI.  IX.  Figs.  5,  6. 

Hypopium  is  a  much  rarer  disease  than  onyx.     We  distinguish  two  varieties 
of  it ;  the  true,  and  the  spurious. 

1.  By  true  hypopium  is  meant  a  collection  of  pus  or  of  puro-lymph  in  the 


HYPOPIUM.  605 

chambers  of  the  aqueous  humor,  and  most  frequently  in  the  anterior  chamber, 
secreted  by  the  lining  membrane  of  the  cornea,  the  iris,  the  capsule  of  the 
lens,  or  the  ciliary  processes.  The  most  frequent  sources  appear  to  be  the  iris 
and  the  cornea.  The  purulent  matter  is  observed  first  at  the  bottom  of  the 
anterior  chamber,  and  is  thereby  easily  distinguished  from  the  curd-like  effu- 
sion of  coagulable  lymph,  which  occasionally  occurs  in  iritis,  and  drops  down 
from  the  pupil  in  a  considerable  mass.  So  long  as  the  patient  remains  at  rest 
in  the  erect  position,  the  superior  limit  of  the  matter  in  true  hypopium  con- 
stantly presents  a  horizontal  line.  In  some  cases  it  is  seen  to  shift  its  posi- 
tion, on  inclination  of  the  head  from  side  to  side  ;  while,  in  other  instances, 
it  is  so  thick  and  glutinous,  that  it  undergoes  no  change  of  this  kind.  It 
may  increase  gradually  till  it  not  merely  covers  the  pupil,  but  fills  the  anterior 
chamber.  If  the  case  be  neglected,  the  cornea  is  rendered  unnaturally  promi- 
nent, and  its  substance  becoming  infiltrated  with  pus,  it  presents  exactly  the 
appearance  of  an  abscess.  At  last,  under  almost  insupportable  pain,  the  cor- 
nea gives  way  ;  the  pain  now  ceases  ;  the  iris,  falling  forward,  adheres  to  the 
remains  of  the  cornea  ;  and  staphyloma  generally  ensues. 

It  is  rare  to  meet  with  true  hypopium,  uncombined  with  some  affection  of 
the  cornea  ;  and  this  disease  never  proceeds  to  such  a  degree  as  to  burst  ex- 
ternally, unless  complicated  with  onyx.  Most  frequently  the  collection  of  pus 
remains  nearly  the  same  in  quantity,  not  only  for  days,  but  weeks  ;  during 
which  time  the  iris  becomes  more  and  more  inflamed,  its  motions  more  and 
more  impeded,  and  at  last,  if  the  matter  be  absorbed,  the  pupil  is  found  to  be 
obliterated.  When  onyx  or  ulcer  of  the  corneals  present  along  with  true  hy- 
po])iura,  there  is  much  danger  of  the  cornea  being  destroyed,  and  the  case 
ending  in  staphyloma.  This  combination  occurs  not  unfrequently  in  severe 
catarrho-rheumatic  ophthalmia.  In  the  ophthalmia  occurring  from  injuries 
with  the  stalks  or  ears  of  wheat  during  harvest,  I  have  repeatedly  seen  onyx 
with  hypopium. 

2.  The  name  spurious  hypopium  is  applied  to  a  collection  of  pus  in  the 
anterior  chamber,  arising  from  the  bursting  of  an  abscess  of  the  iris  or  of  the 
cornea  into  that  cavity.  Abscess  of  the  iris  I  have  described  at  pages  524 
and  528,  and  abscess  of  the  cornea  in  the  last  section.  Hypopium  of  this 
sort  seldom,  if  ever,  reaches  so  high  as  the  lower  edge  of  the  pupil.  When 
onyx,  however,  exists  along  with  spurious  hypopium,  and  bursts  into  the  an- 
terior chamber,  this  cavity  may  become  completely  filled  with  pus. 

Treatment. — The  remarks  in  last  section,  on  the  treatment  of  onyx,  apply, 
with  little  variation,  to  that  of  hypopium.  The  inflammation  must  be  com- 
bated by  the  appropriate  means,  and  in  its  subsidence  we  must  chiefly  trust 
for  the  removal  of  the  purulent  effusion.  Bleeding,  calomel  with  opium,  and 
belladonna,  will  be  necessary;  and  advantage  may,  in  general,  be  reaped  from 
the  use  of  warm  emollient  fomentations,  such  as  infusion  of  mallow  leaves  and 
flowers. 

The  giving  exit  to  the  matter  of  hypopium,  by  an  incision  of  the  cornea, 
is  advisable,  if  the  chambers  appear  filled;  for  we  can  never  depend,  in  such 
a  case  on  absorption;  while  by  delay  we  should  risk  the  bursting  and  complete 
destruction  of  the  eye.  Under  such  circumstances,  we  must  regard  the  opening 
of  the  cornea  as  nothing  more  than  a  means  of  freeing  the  patient  from  exces- 
sive pain,  and  of  preserving  such  a  form  of  the  eyeball  as  may  afterwards  per- 
mit the  application  of  an  artificial  eye.^ 

When  the  hypopium  does  not  amount  to  such  a  quantity  of  matter  as  to 
fill  the  chambers  of  the  eye,  and  especially  when  severe  inflammation  of  the 
iris  is  present,  opening  the  cornea  might  appear  likely  to  aggravate  the  inflam- 
mation, increase  the  secretion  of  purulent  matter,  and  expose  the  eye  to  pro- 
trusion of  the  iris.     Notwithstanding  these  apparent  objections,  Mr.  Wardrop 


606  ULCERS   OF   THE   CORNEA. 

has  recommended  evacuation  of  the  aqueous  humor,  as  a  remedy  of  much  ser- 
vice, in  the  early  stages  of  hypopium;  and  in  cases  of  iritis,  and  of  ulcer  of 
the  cornea,  combined  with  hypopium,  we  have  the  testimony  of  Dr.  Monteath^ 
in  favor  of  still  greater  interference. 

Dr.  Monteath  recommends  an  incision,  two  or  three  lines  long,  to  be  made 
with  the  iris-knife.  This  extent  is  necessary,  from  the  purulent  exudation 
being  thick  and  adherent,  so  that  it  will  not  flow  out,  but  requires  to  be  ex- 
tracted by  forceps,  or  a  small  blunt  hook.  Dr.  M.  mentions,  that,  after  open- 
ing the  cornea,  and  laying  hold  of  a  small  filament  of  the  matter,  he  has  often 
been  able  to  extract  the  whole  in  a  mass,  which,  examined  through  the  cornea, 
had  every  appearance  of  pus;  but,  when  extracted,  was  found  in  all  respects 
similar  to  the  exudation  of  puriform  lymph,  on  the  surface  of  an  inflamed 
pleura  or  peritoneum.  lie  observes,  that  when  the  hypopium  is  considerable, 
the  operation,  repeated  again  and  again  if  necessary,  checks  the  suppuration 
and  ulceration  of  the  internal  surface  of  the  cornea,  which  invariably  take 
place  when  the  collection  mounts  as  high  as  the  centre  of  the  pupil,  and  which 
is  so  apt  to  end  in  bursting  of  the  cornea  and  destruction  of  the  eye. 

In  cases  of  hypopium,  Mr.  Guthrie  follows  a  similar  plan  to  that  which  he 
recommends  in  onyx;  namely,  a  free  division  of  the  cornea,  after  which  the 
eye  is  to  be  kept  padded. 


'  Bklloo,  Exercitationum  Anatomico-chirur-         ^  Glasgow  Medical  Journal;  Vol.  ii.  p.  122; 
gicarum  decas;  Exerc.  vii.  De  Oculo  Purulento;     Glasgr)w,  182'J. 
Lugduni  liatavoruin,  1704. 


SECTION  III. — ULCERS,  FOSSULA,  HERNIA,  AND  FISTULA  OF  THE  CORNEA;   AND 

HERNIA  OF  THE  IRIS. 

Fig.  AYardrop,  PI.  Y.  Figs.  1,  2.  PI.  X.  Fig.  1.     Dalrjraple,  PL  XIV.  Figs.  1,2, 
Sichel,  PI.  VII.  Figs.  2,  3. 

1.  There  are  two  distinct  varieties  of  ulcer  of  the  cornea,  the  superficial 
and  the  deep. 

The  former  generally  extends  over  a  considerable  portion  of  the  surface  of 
the  cornea,  and  often  appears  to  involve  little  more  than  its  epithelium  or  con- 
junctival covering.  The  deep  ulcer  is  commonly  much  less  extensive ;  but 
affects  the  proper  substance  of  the  cornea,  and  often  penetrates  comijletely 
through  it,  so  as  to  open  the  anterior  chamber,  and  give  exit  to  the  aqueous 
humor.  The  superficial  ulcer  sometimes  arises  from  slight  mechanical  or 
chemical  injuries.  It  occurs  much  more  frequently  in  the  catarrho-rheumatic 
than  in  any  other  of  the  ophthalmias.  The  deep  ulcer  of  the  cornea  is  gene- 
rally the  result  of  the  bursting  of  a  scrofulous  phlyctenula,  or  the  giving  way 
of  an  onyx  externally. 

The  superficial  ulcer  of  the  cornea  discharges  only  a  thin  clear  matter ;  its 
surface  is  slightly  rough;  its  edges  are,  in  general,  very  irregular,  and  so  little 
raised  above  the  level  of  the  ulcer  that,  in  many  cases,  the  surface  of  the  cor- 
nea appears  merly  as  if  abraded.  Not  unfrequently  we  may  observe  an  ulcer 
of  this  kind  spreading  from  day  to  day  at  one  part  of  its  edge,  and  cicatrizing 
at  another  part.  The  cicatrice  which  follows  such  an  ulcer,  is  grayish  or 
bluish-white,  and  semi-transparent.  It  eventually  clears.  Sometimes  the 
appearance  of  the  ulcer  is  as  if  a  portion  of  the  cornea  had  been  sliced  olf. 
It  may  continue  so  for  weeks  or  months,  constituting  what  has  been  called  an 
asthenic  ulcer,  or  incorrectly,  a  transparent  cicatrice;  but  at  length,  becoming 


ULCERS   OF   THE   CORNEA.  GOT 

covered  by  an  opaque  fibro-albuminous  exudation,  it  undergoes  a  real  process 
of  cicatrization.^ 

Tlie  deep  ulcer  is  small  and  circular;  and  by  penetrating  the  lamina3  of  the 
cornea  one  after  the  other,  but  the  deep-seated  larainse  less  extensively  than 
the  superficial,  comes  to  present  a  funnel-shape.  Its  surface  is  usually  ragged 
and  covered  with  a  sloughy-like  matter  which  assumes  a  white  color,  if  touch- 
ed by  any  lotion  or  other  preparation  containing  sugar  of  lead.  The  same 
happens  to  the  superficial  ulcer,  which  becomes  covered  by  an  opaque  cica- 
trice, in  consequence  of  the  use  of  saturnine  applications.  Hence  in  every 
case  of  ulcer  of  the  cornea,  these  applications  are  totally  inadmissible.  The 
deep  ulcer  is  apt  to  become  covered  with  red  vessels  before  it  heals  up,  es- 
pecially if  it  be  the  result  of  any  chemical  injury.  Deep  scrofulous  ulcer  is 
sometimes  attended  with  onyx.  I  have  also  seen,  in  such  cases,  a  deposition 
of  puriform  lymph  into  the  anterior  chamber  from  the  lining  membrane  of  the 
cornea.     (See  Case  2t9). 

I  have  already  (p.  43 T)  had  occasion  to  speak  of  troughing  ulcer,  as  it 
has  been  termed,  at  the  edge  of  the  cornea,  the  consequence  of  chemosis  in 
the  puro-mucous  ophthalmice.  I  may  mention  that  I  have  occasionally  met 
with  an  obstinate  variety  of  ulcer,  in  the  same  situation,  which,  creeping 
slowly  on,  one  portion  of  it  sometimes  cicatrizing  while  another  was  spread- 
ing, has  at  length  formed  a  deep  trench  round  a  great  part  of  the  edge  of 
the  cornea.  This  variety  of  ulcer  occurs  in  old  subjects ;  is  attended  by 
severe  pain  in  the  branches  of  the  fifth  nerve  round  the  orbit ;  and  if  it  does 
not  destroy  vision  by  penetrating  the  cornea,  is  very  apt  to  do  so  by  exciting 
inflammation  of  the  iris  and  closure  of  the  pupil. 

A  deep  ulcer,  when  healing,  sometimes  appears  for  a  time  as  a  transparent 
fossnla  in  the  cornea ;  but  generally  this  fills  up,  and  is  converted  into  an 
opaque  cicatrice,  the  centre  of  which  may  still  be  somewhat  depressed,  or  be 
on  a  level  with  the  surface  of  the  cornea,  or  be  slightly  elevated.  It  presents 
a  yellowish-white  color,  while  the  circumference  is  more  of  a  grayish-white. 
Such  a  cicatrice  or  leucoma  seldom  admits  of  being  completely  absorbed. 
•  Solutions  of  saline  substances  to  the  eye,  when  the  cornea  is  affected  with 
ulceration,  are  exceedingly  apt  to  cause  an  opaque  cicatrice.  The  salts,  such 
as  nitrate  of  silver,  acetate  of  lead,  and  the  like,  are  decomposed  by  the 
tears  and  the  mucus  of  the  conjunctiva ;  and  their  bases  being  precipitated 
in  an  insoluble  state  on  the  ulcerated  surface,  become  incorporated  with  the 
cicatrice.  Such  applications,  therefore,  should  always  be  avoided  as  much 
as  possible. 

2.  There  is  one  peculiar  appearance  of  the  cornea,  which  must  not  be 
confounded  with  the  ulcers  above  described ;  namely,  that  state  of  it  which 
follows  the  absorption  of  a  phlyctenula.  The  result  of  such  absorption  is  a 
small /oss?</a,  still  smoother  and  more  transparent  than  the  similar  appear- 
ance which  sometimes  occurs  in  cases  of  deep  ulcer,  being,  in  fact,  covered 
by  the  epithelium,  which  has  fallen  down  into  the  little  dimple  formed  by  the 
removal  of  the  contents  of  the  phlyctenula. 

3.  Occasionally  it  happens,  that  the  progress  of  a  deep  ulcer  is  arrested 
by  the  lining  membrane  of  the  cornea,  or  that  this  membrane,  after  having 
been  penetrated  by  the  ulcer,  heals  up;  but  in  either  case,  being  unable  by 
itself  to  support  the  aqueous  humor,  it  is  protruded  through  the  ulcer  in  the 
form  of  a  vesicle,  constituting  what  is  termed  hernia  of  the  cornea.  The 
patient  whose  eye  is  in  this  state,  or  presents  a  transparent  dimple  in  the 
cornea,  ought  to  guard  against  touching  it  roughly,  and  avoid  all  violent 
exertions.  On  blowing  the  nose,  or  straining  at  stool,  the  cornea  is  very  apt 
to  give  way,  with  a  sensation  of  a  sort  of  snap  in  the  eye,  and  a  gush  of 
water  from  it.     A  young  lad  had  been  under  my  care  for  gonorrheal  ophthal- 


608  ULCERS   OF   THE   CORNEA. 

mia;  he  had  a  deep  ulcer  of  the  cornea;  it  healed,  and  left  a  transparent 
dimple.  About  twelve  months  afterwards,  on  striking  his  eye  suddenly  with 
the  thumb,  the  dimple  gave  way,  and  a  myocephalon  took  place. 

Protrusion  of  the  lining  membrane  of  the  cornea  sometimes  takes  place  to 
a  very  great  extent,  assuming  a  conical  form,  and  rising  so  far  above  the 
natural  level  of  the  cornea  as  with  difficulty  to  be  covered  by  the  eyelids.  In 
this  case,  we  are  obliged  to  remove  it  with  the  scissors,  or  destroy  it  by  the 
application  of  lunar  caustic ;  and  what  is  very  remarkable,  such  a  protrusion 
is  apt  to  return  again  and  again,  even  in  the  course  of  a  few  days  after  we 
have  completely  removed  the  preceding  one,  till  at  length  the  cicatrized  cornea 
attains  a  sufficient  degree  of  firmness. 

4.  When  an  ulcer  fairly  penetrates  the  cornea,  the  aqueous  humor  is  sud- 
denly discharged,  the  iris  falls  forward,  and  but  too 
often  becoming  engaged  in  the  ulcer,  protrudes 
through  it,  forming  a  small  black  point  like  the  head 
of  a  fly,  whence  the  name,  myocephalon,  which  is  be- 
stowed on  this  hernia  of  the  iris.  The  bit  of  iris 
which  protrudes,  speedily  adheres  to  the  edges  of  the 
ulcer,  and  as  the  inflammation  subsides,  contracts, 
and  becomes  covered  by  an  opaque  cicatrice.  But 
should  the  inflammation  of  the  eye  increase  after  this 
accident,  so  that  more  of  the  cornea  is  destroyed,  and 

more  of  the  iris  protruded,  the  latter,  covered  by  a 
pseudo-cornea,  is  very  apt  to  form  a  staphyloma. 

5.  Artificial  wounds  of  the  cornea,  such  as  the  section  made  for  extraction 
of  the  cataract,  sometimes  remain  long  open,  and  threaten  to  become  callous 
and  fistulous.  A  perforating  ulcer  of  the  centre  of  the  cornea  may  fall  into 
a  similar  state,  and  allow  the  aqueous  humor  to  drain  away  for  a  number  of 
days.  These  may  be  considered  as  instances  o^  fistula  of  the  cornea;  but 
the  most  remarkable  affection  of  this  sort  occurs  in  the  manner  described  at 
page  396. 

Both  kinds  of  ulcer  of  the  cornea,  but  especially  the  deep,  are  usually 
attended  by  much  intolerance  of  light,  and  a  gush  of  burning  tears  on  open- 
ing the  eyelids. 

The  subjects  of  ulcer  of  the  cornea,  and  especially  of  the  deep  ulcer,  are 
rarely  robust  or  in  a  good  state  of  general  health.  On  the  contrary,  they  fre- 
quently present  the  indubitable  signs  of  great  weakness,  sometimes  even  of 
inanition.  In  emaciated  infants,  particularly,  I  have  repeatedly  seen  the  cornea 
of  one  or  both  eyes  become  thin  and  prominent,  and  give  way,  without  much, 
and  even  without  any  apparent  inflammation.  The  wasted  state  of  the  body  in 
such  subjects  arose  from  various  causes,  as  chronic  diarrhoea,  cough  following 
measles,  hydrocephalus,  and  syphilis.  In  1832, 1  saw  several  instances  of  the 
same  destructive  ulceration  of  the  cornea,  occurring  after  malignant  cholera. 
[We  remember  having  seen  some  years  ago,  a  case  of  sloughing  of  both  cornese, 
which  occurred  a  week  before  death  in  a  patient,  with  Bright's  disease  of  the 
kidney,  who  had  been  treated  for  his  dropsical  symptoms  in  real  old  fashioned 
style,  in  the  country,  without  any  investigation,  as  to  their  cause.  Purgation 
and  ptyalism  had  been  pushed  to  an  extreme  degree,  and  the  poor  fellow's 
death  was  evidently  hastened  by  the  treatment  he  had  received. — H.]  I 
have  sometimes  been  led  to  compare  such  eyes  to  those  of  the  dogs  in 
Magendie's  experiments,  which  being  fed,  or  rather  starved,  on  white  sugar 
and"  distilled  water,  died  from  exhaustion,  their  death  being  preceded  by 
perfoi-ating  ulcer  of  the  cornea  and  evacuation  of  the  humors.^  A  similar 
state  of  the  cornea,  along  with  anaesthesia  of  the  eye,  eyelids  and  face,  some- 
times arises  from  diseases  of  the  fifth  nerve. 


ULCERS   OF  THE   CORNEA.  609 

Treatment. — In  all  cases,  we  endeavor  to  check  the  ulcerative  process,  by 
the  measures  best  fitted  for  subduing  the  particular  ophthalmia  in  which  the 
ulcer  has  taken  its  origin.  The  girl,  whose  case  I  have  related  at  page  484, 
was  in  a  state  of  great  debility  from  over-depletion.  Within  24  hours,  tonic 
treatment  arrested  the  progress  of  a  deep  ulcer  on  the  cornea.  In  chronic 
superficial  ulcer,  which  often  proves  very  tedious,  calomel,  given  so  as  to 
affect  the  mouth,  is  sometimes  necessary.  In  almost  all  cases  of  ulcerated 
cornea,  counter-irritation  is  useful.  As  the  inflamed  state  of  the  eye  abates, 
the  patient  finds  the  pain  greatly  relieved.  We  now  observe  the  ulcer  losing 
its  purulent  appearance  and  clearing,  while  its  edges  become  smooth  and 
begin  to  contract. 

"  Some  chronic  ulcers  of  the  cornea  will  heal,"  observes  Mr.  Bowman,  "in 
the  most  gradual  manner,  without  the  formation  of  any  vessels  in  their  vicinity ;" 
but,  "  if  any  ulcer  exists,  having  to  heal  by  a  slow  and  gradual  process,  we 
usually  find,  in  the  interval  between  it  and  the  neighboring  vessels,  a  grayish 
half-transparent  tract,  distinguishable  from  the  healthy  cornea ;  and  in  this 
there  is  soon  developed  a  series  of  vessels,  which  presently  declare  themselves 
as  arteries,  capillaries,  and  veins,  carrying  the  blood  in  a  circuit  through  and 

about  the  seat  of  reparative  action Thus  is  the  cornea  made  dull  and 

useless  for  a  time,  by  the  introduction  of  a  structure  destructive  of  its  trans- 
parency, in  order  that  its  integrity  may  be  restored  according  to  the  natural 
laws  of  growth.  When  its  restoration  is  somewhat  advanced,  and  less  blood 
is  required,  these  vessels  dwindle  ;  their  coats,  which  are  at  best  imperfectly 
organized,  soon  disappear,  and  the  cornea  becomes  once  more  permeable  to 
light.  "^ 

Ko  remedy,  in  my  experience,  has  proved  more  beneficial  in  ulcers  of  the 
cornea  than  belladonna.  I  do  not  at  present  refer  to  its  dilatation  of  the  pupil, 
although  this  effect  is  also  of  high  importance,  but  to  its  anodyne  effect  on  the 
eye,  whereby  a  healing  action  appears  to  be  induced  in  the  ulcerated  part, 
leading  to  its  speedy  cicatrization.  I  regard  it  as  an  essential  part  of  the 
treatment  in  all  cases  of  deep,  and  even  in  the  more  serious  cases  of  superficial, 
ulcer  of  the  cornea,  to  employ  extract  of  belladonna,  or  solution  of  atropine. 
If  artificial  dilatation  of  the  pupil  is  neglected,  the  iris,  even  when  the  ulcer 
is  yet  far  from  penetrating  into  the  anterior  chamber,  may  advance  into 
contact  with  the  cornea,  and  become  adherent.  The  good  effects  of  belladonna 
in  freeing  the  iris,  even  after  it  had  become  involved  in  an  ulcer  of  the  cornea, 
is  well  illustrated  by  the  case  of  James  Tassie,  which  I  have  related  at  page 
484.  I  have  repeatedly  witnessed  the  same  happy  result,  under  similar 
circumstances. 

It  frequently  happens,  that  the  ulcer  itself  is  a  principal  cause  of  prolonging 
the  inflammation  of  the  eye,  while  the  flow  of  tears  and  the  motions  of  the 
eyelids,  constantly  irritating  the  ulcer,  keep  it  from  healing.  In  such  a  case, 
there  is  one  method  of  treatment  eminently  useful,  and  that  is  the  coating  of 
the  ulcer  in  such  a  way  that  it  shall,  for  a  time  at  least,  become  insensible.* 
This  is  effected  by  the  application  of  lunar  caustic,  in  solution  or  in  substance, 
which  so  coats  the  surface  of  the  ulcer  as  to  render  it  able,  for  a  time,  to 
withstand  the  friction  of  the  eyelids  and  irritation  of  the  tears.  In  the  interval 
of  rest,  the  healing  process  is  allowed  to' go  on;  and  before  the  thin  slough  is 
thrown  off,  which  is  formed  by  the  application  of  the  caustic,  the  ulcer  has 
contracted.  Were  we  to  leave  the  case  here,  the  ulcer  would,  in  all  likeli- 
hood, again  spread,  and  might  penetrate  the  cornea.  As  soon,  then,  as  we 
observe  a  renewal  of  pain  and  lachrymation,  and  that  the  edges  of  the  ulcer 
are  again  assuming  a  jagged  and  elevated  appearance,  the  caustic  should  be 
reapplied. 

In  cases  of  superficial  ulcer,  the  best  mode  of  applying  the  caustic  is  to 
39 


610  ULCERS   OF   THE   CORNEA. 

I 

touch  the  diseased  surface  with  a  camel-hair  pencil,  dipped  in  a  solution  of 
from  4  to  10  grains  of  the  nitrate  of  silver  in  an  ounce  of  distilled  water. 

The  deep  ulcer  is  better  managed,  in  general,  by  sharpening  a  pencil  of 
caustic,  and  touching  the  diseased  surface  with  it  for  an  instant.  During 
this  application,  the  upper  lid  is  to  be  kept  elevated;  and  before  it  is  allowed 
to  fall,  a  little  water  is  to  be  dropped  upon  the  cornea  from  a  camel-hair 
pencil. 

This  use  of  caustic  must  be  gone  about  cautiously,  and  had  recourse  to  only 
when  the  ulcer  betrays  no  disposition  to  heal  under  the  influence  of  the  reme- 
dies above  recommended.  Were  it  employed  in  every  case  of  ulcer  of  the 
cornea,  and  in  every  stage,  incalculable  injury  would  no  doubt  often  be  done. 
Dr.  Jacob  has  made  an  observation  on  the  subject,  worthy  of  consideration. 
Speaking  of  the  application  of  the  nitrate  of  silver  to  ulcers  of  the  cornea,  he 
says,  "When  applied  to  such  ulcers,  either  in  solution  or  substance,  it  either 
adheres  to,  or  becomes  entangled  in,  the  flocculent  surface  ;  and  if  this  surface 
be  not  a  slough  and  completely  cast  ofl',  the  nitrate  of  silver,  rendered  black 
or  brown  by  exposure,  becomes  permanently  fixed  as  the  ulcer  heals,  and  con- 
stitutes an  indelible  dark  speck.  "^ 

The  caustic  is  to  be  applied  in  the  way  above  described,  if  hernia  of  the 
cornea  be  present,  or  if  the  cornea  be  penetrated,  and  hernia  of  the  iris  has 
taken  place.  The  extract  of  belladonna  being  painted  on  the  eyelids  and 
eyebrow,  or  the  solution  of  atropine  dropped  on  the  conjunctiva,  the  pupil 
in  the  course  of  half  an  hour  will  probably  be  dilated,  in  cases  where  central 
perforation  of  the  cornea  has  happened  within  a  few  hours  ;  we  then  touch  the 
ulcer  with  the  caustic  pencil,  and  continue  the  use  of  the  belladonna  or 
atropine.  If  the  iris  does  not  retire  under  the  action  of  the  belladonna,  the 
application  of  the  solid  caustic  arrests  the  prolapsus.  Adhesion  takes  place 
between  the  edges  of  the  ulcer  and  the  iris ;  the  tumor  shrinks,  and  by  and 
by  is  covered  with  a  solid  cicatrice.  The  caustic  does  not  destroy  the  iris, 
but  merely  makes  it  contract.  In  fistula  of  the  cornea  also,  after  snipping  off 
the  projecting  portion  of  conjunctiva,  the  opening  is  to  be  touched  freely 
with  the  lunar  caustic  pencil.  When  a  hernia  of  the  cornea  or  of  the  iris 
projects  much,  it  may  also  be  removed  with  the  scissors,  and  then  the  caustic 
applied.  If  the  surface  of  the  ulcer,  or  the  piece  of  protruding  substance,  be 
just  whitened  by  the  action  of  the  nitras  argenti,  it  is,  in  general,  enough. 
We  ought  never  to  continue  the  contact,  so  as  to  cause  a  slough  of  any  con- 
siderable thickness. 

When  there  is  a  deep  ulcer  over  the  pupil,  it  has  been  thought  advisable 
to  evacuate  the  aqueous  humor,  and  to  touch  the  ulcer  with  the  solution  of 
lunar  caustic.  In  such  cases,  originating  in  traumatic  or  in  scrofulous 
ophthalmia,  I  have  found  great  advantage  from  puncturing  the  cornea  near 
its  edge.     Dr.  Monteath  has  recommended  a  somewhat  different  practice. 

"  A  deep  scrofulous  ulcer  of  the  cornea,"  says  he,  "  nearly  penetrating  into 
the  anterior  chamber,  at  which  stage  there  is  almost  always  pretty  acute  in- 
flammation, assuming  the  vascular  character,  is  very  apt  to  induce  iritis,  and 
secretion  of  pus  into  the  anterior  chamber,  forming  hypopion.  This  is  a  state 
of  considerable  danger  to  vision,  particularly  if  the  ulcer  be  nearly  opposite  to 
the  pupil;  but  wherever  it  may  be  situated,  I  hardly  ever  fail  to  excite  a 
healing  action  in  the  ulcer,  and  to  give  an  immediate  check  to  the  hypopion 
and  inflammation  of  the  iris,  by  the  following  treatment.  The  first  and  most 
important  step  is,  to  perforate  the  remaining  layer,  or  layers,  of  the  cornea,  at 
the  bottom  of  the  ulcer,  with  an  iris-knife,  and  allow  the  aqueous  humor  to 
flow  out,  and  the  anterior  chamber  to  collapse.  The  second,  is  to  give  a  full 
dose  of  calomel  and  opium  each  night,  till  the  mouth  is,  in  the  slightest  degree, 
affected.     The  very  first  night  after  the  puncture,  the  patient  sleeps  soundly, 


OPACITIES   OP   THE   CORNEA.  611 

whicli  he  had  been  prevented  from  doing  for  several  previous  nights  by  violent 
supra-orbital  and  hemicranial  pain.  In  a  day  or  two  after  this  trifling  ope- 
ration, the  ulcer  is  completely  filled  with  coagulable  lymph,  which  even  over- 
laps its  border  so  as  to  put  on  the  appearance,  to  an  inexperienced  surgeon, 
of  the  ulcer  being  ranch  increased  in  size,  whereas,  it  is  the  most  favorable 
circumstance  that  could  happen,  because  the  redundant  lymph  is  removed  by 
absorption  in  a  very  few  days.  In  proportion  as  the  lymph,  deposited  in  the 
ulcer,  becomes  organized,  the  integrity  and  natural  size  of  the  anterior  cham- 
ber are  restored.  From  the  combined  eflFects  of  the  evacuation  of  the  aqueous 
humor,  and  of  the  mercury,  th^  iritis  is  rapidly  removed,  and  the  case  now 
requires  merely  the  ordinary  treatment  for  scrofulous  ophthalmia,  attended 
with  an  ulcer  on  the  cornea,  which  is  one  of  the  most  common  occurrences 
in  ophthalmic  practice.'"^ 

When  we  meet  with  an  ulcer  which  has  been  touched  with  acetate  of  lead 
in  solution,  a  remedy  often  recommended  by  ignorant  people  for  inflamed 
eyes,  we  ought  with  the  small  silver  spatula  to  endeavor  to  remove  the  white 
deposit  adhering  to  the  surface  of  the  ulcer,  lest  it  become  indelibly  incorpo- 
rated with  the  cicatrice,  forming  a  peculiar  chalk-like  speck,  which  may  never 
afterwards  be  capable  of  being  removed  either  by  absorption  or  operation. 
This  attempt,  however,  must  be  made  with  great  caution,  lest  we  cause  a  large 
opacity  of  a  different  character,  viz.,  from  additional  loss  of  substance  of  the 
cornea. 

Prognosis. — In  all  cases  of  deep  ulcer,  we  ought  to  forewarn  the  patient  of 
the  opacity  of  the  cicatrice,  and  the  consequent  deformity,  and,  it  may  be, 
abridgment,  or  even  loss,  of  sight.  Even  when  the  ulcer  is  superficial,  it  is 
proper  to  pronounce  a  cautious  prognosis;  for,  though  the  epithelium  is 
commonly  regenerated  in  such  a  way  that  the  transparency  of  the  cornea  is 
not  impaired,  this  is  by  no  means  always  the  case. 


'  Desraarres,   Annales   d'Oculistique ;    Tome  ^  Lectures  on    the    Parts   concerned   in    the 

ix.  p.  98;  Bruxelles,  1843.  Operations  on  the  Eye,  p.  31;  London,  1849. 

^  Memoire  sur  les  Proprietes  nutritives  des  'Scarpa,  Trattato  delle  prineipali   Malattie 

Substances  qui  ne  contiennent  pas  d'Azote,  p.  degli  Occhi;  Vol.  i.  p.  280  ;  Pa  via,  1846. 

7;  Paris,  1816.     See  Case  of  Ulcerated  Cornea,  'Dublin  Hospital  Reports;  Vol.  v.  p.  367  J 

from  Inanition,  by  Joseph  Brown,  M.D.,  Edin-  Dublin,  1830. 

burgh  Journal  of  Medical  Science;  Vol.  iii.  p.  ^  Glasgow  Medical  Journal;  Vol.  ii.  p.  133; 

218;  Edinburgh,  1827:  Cases  from  Acute  Hy-  Glasgow,  1829. 
drocephalus  and  other  causes,  by  Stober,  Lon- 
don Medical  Gazette,  July  7,  1843,  p.  543. 


SECTION  IV. — OPACITIES  OR  SPECKS  OF  THE  CORNEA — NEBULA — ALBUGO — 

LEUCOMA. 

Fig.  Wardrop,  PI.  IL  Fig.  3.  PI.  VIL  Figs.  1-3.     Dalrymple,  PI.  II.  Figs.  5,  6.  PI.  III.  Fig.  1. 
PI.  XIV.  Figs.  3,  5,^6.    PI.  XV.  Fig.  1.     PI.  XVL  Fig.  1-6.     Sichel,  PI.  VII,  Fig.  4. 

Opacities  or  specks  of  the  cornea  are  distinguished  by  different  names, 
according  to  the  degree  of  density  they  present,  and  the  manner  in  which 
they  originate. 

1.  Nebula  is  the  slightest  degree.  It  resides  most  frequently  in  the  super- 
ficial layers  of  the  cornea  ;  occasionally  it  has  its  seat  in  the  lining  membrane ; 
rarely  in  the  proper  substance  of  the  cornea.  A  general  nebulous  state  of 
the  cornea  is  supposed  to  be  sometimes  the  consequence  of  pressure  merely, 
from  preternatural  increase  of  the  aqueous  humor.  In  some  cases,  it  appears 
to  be  the  result  of  serous  effusion  into  the  substance  of  the  cornea ;  in  others, 
to  arise  from  fibrin  effused  on  the  internal  surface  of  its  lining  membrane,  or 


612  OPACITIES   OF  THE   CORNEA. 

deposited  between  its  proper  substance  and  either  its  lining  membrane  or  its 
anterior  elastic  lamina.  Nebula  includes  only  those  opacities  of  the  cornea 
which  are  cloudy  or  hazy.  In  general,  this  kind  of  speck  is  also  extensive 
and  undefined,  becoming  less  and  less  opaque  towards  its  edges,  and  often 
affecting  the  whole  cornea. 

Nebula  is  a  frequent  consequence  of  puro-mucous  ophthalmia,  but  its  most 
common  cause  is  scrofulous  corneitis.  The  inflammation  produced  by  in- 
verted or  supernumerary  eyelashes,  or  inverted  eyelids,  and  that  arising  from 
sarcomatous  or  granular  conjunctiva,  are  also  abundant  sources  of  nebula. 
Depending  on  the  latter  causes,  this  opaci^  will  require  for  its  removal  the 
cure  of  the  disease  of  the  eyelid,  and  will  not  be  at  all  benefited  by  any  reme- 
dies directed  against  the  state  of  the  cornea  merely.  Whenever  we  find  the 
upper  half  of  the  cornea  nebulous,  and  especially  nebulous  and  vascular,  we 
may  suspect  the  conjunctiva  of  the  upper  eyelid  to  be  granular. 

2.  Whenever  the  effusion  of  lymph  into  any  part  of  the  cornea  is  so  dense 
as  to  present  a  pearly  appearance,  the  name  of  nebula  is  changed  for  that  of 
albugo. 

This  sort  of  speck  has  most  frequently  its  seat  immediately  under  the  an- 
terior elastic  lamina  of  the  cornea.  The  lymph  effused  forms  an  opaque  spot, 
generally  circular  or  oval,  more  dense  usually  in  the  centre  than  towards  the 
circumference,  but  in  some  rare  cases  presenting  the  appearance  of  a  ring. 

The  common  source  of  albugo  is  a  phlyctenula  on  the  cornea,  which  has 
receded  without  bursting.  Like  every  other  abscess,  these  minute  ones  may 
be  regarded  as  cavities  formed  by  the  exudation  of  coagulable  lymph,  and 
containing  pus.  The  sphere  of  lymph  which  surrounds  the  pus,  appears  to 
be  formed  for  the  purpose  of  limiting  the  extent  of  the  disease.  When  the 
phlyctenula  disappears  without  bursting,  the  contained  matter  being  ab- 
sorbed, the  sphere  of  lymph  remains  for  a  lime,  or,  it  may  be,  forms  a  perma- 
nent speck. 

Another  occasion  of  albugo  is  when  the  pus  of  an  onyx  is  either  absorbed, 
or  evacuated  by  the  knife.  Onyx  or  abscess  of  the  cornea  is  always  attended 
by  more  or  less  lymphatic  effusion  ;  and  after  the  pus  is  dispersed,  the 
laminae  of  the  cornea  which  were  separated  by  its  presence  are  reunited  by 
a  process  of  adhesion,  which  cannot  be  accomplished  without  a  new  secretion 
of  lymph. 

Albugo  may  sometimes  be  observed  with  numerous  red  vessels  running 
into  it  from  the  conjunctiva,  and  is  extremely  apt,  when  this  is  the  case,  to 
spread,  and  to  push  across  the  cornea.  This  vascular  albugo  is  occasionally 
very  obstinate.  It  is  always  somewhat,  and  not  unfrequently  much  and 
abruptly,  elevated  above  the  level  of  the  cornea.  The  conjunctiva  corneas, 
under  which  the  red  vessels  run,  is  much  thickened.  In  some  cases,  these 
vessels  are  so  numerous  as  to  make  the  all)ugo  appear  red,  with  patches  of 
white  in  the  interstices.  We  meet  with  this  variety  of  albugo  in  scrofulous 
adults,  and  sometimes  in  children.  The  shrinking  and  disappearance  of  the 
red  vessels  which  feed  it,  afford  ground  to  believe  that  the  albugo  will  cease 
to  spread ;  but  it  is  rarely  the  case  that  the  speck  itself  totally  disappears. 
It  is  sometimes  destroyed  by  spontaneous  ulceration. 

3.  A  third  sort  of  speck  is  called  leucoma,  and  is  always  the  result  of 
cicatrization.  A  loss  of  substance  in  the  cornea  by  ulceration,  and  a  partial 
filling  up  of  that  loss  by  granulation,  always  precedes  the  foi'mation  of 
•leucoma,  which  indeed  is  synonymous  with  opaque  cicatrice.  It  is  not  a  very 
uncommon  occurrence  for  the  epithelium  covering  a  leucoma  to  be  loose, 
from  the  interposition  of  a  fluid  between  it  and  the  proper  substance  of  the 
cornea. 

When  the  history  of  the  case  is  unknown,  it  may  not  be  possible  to  dis- 


OPACITIES   OF   THE   CORNEA.  613 

tinguish  between  an  albugo  and  a  leucoma.  In  general,  leucoma  has  a  con- 
tracted and  circumscribed  appearance ;  albugo  one  more  difl'used.  Albugo 
is  rarely,  but  leucoma  often,  depressed  at  its  centre,  and  frequently  combined 
with  partial  adhesion  of  the  iris  to  the  cornea. 

Prognosis  and  treatment. — All  the  three  kinds  of  speck,  nebula,  albugo,  and 
leucoma,  have  a  natural  tendency  to  disperse,  as  soon  as  the  disease  which  has 
given  rise  to  them,  subsides  or  is  removed ;  and  that  whether  they  depend  on 
primary  inflammation  spreading  to  the  cornea,  or  secondary  inflammation  of 
that  part,  arising  from  the  irritation  of  inverted  eyelashes  or  granular  con- 
junctiva. We  must,  then,  in  every  case,  endeavor  to  remove  the  ophthalmia, 
or  the  mechanical  irritation  on  which  the  opacity  depends,  assured  that  if  we 
succeed  in  this,  nature,  by  the  process  of  absorption,  will  sooner  or  later 
accomplish  the  whole  amount  of  recovery  which  is  possible.  In  children  and 
young  persons,  many  very  dense  and  extensive  opacities  are  removed  in  the 
natural  progress  of  growth,  which  would  be  quite  irremovable  in  adult  life. 

Demours'  is  of  opinion  that  the  cornea  grows  from  its  circumference  ;  and 
relates,  in  support  of  this  idea,  the  case  of  a  child,  who,  at  the  age  of  six 
months,  had  an  inflammation  of  the  eye,  followed  by  abscess  of  the  cornea, 
evacuation  of  the  aqueous  humor  and  adhesion  of  the  iris  to  the  cornea,  near 
its  edge.  At  the  age  of  eight  years,  this  adhesion  was  at  the  distance  of  a 
line  only  from  the  centre  of  the  cornea,  whence  it  follows  that  the  growth  of 
the  cornea  had  taken  place  between  the  adhesion  and  the  edge  of  the  scle- 
rotica.    (See  Case  169.) 

Leucomata  clear  at  the  circumference,  and  shrink  towards  the  centre.  If 
a  leucoma  be  attended  with  adhesion  of  the  iris  to  the  internal  surface  of  the 
cornea,  in  proportion  as  the  clearing  of  the  circumferential  portion  of  the 
cornea  proceeds,  the  iris  comes  into  view,  lying  in  close  contact  with  the 
cornea ;  and  as  the  growth  of  the  latter  goes  on  from  circumference  to 
centre,  the  iris  is  apt  to  give  way  here  and  there,  so  that  light  penetrates 
through  the  torn  places  and  reaches  the  interior  of  the  eye,  vision  in  some 
measure  improving  from  this  cause. 

"We  are  able,  by  various  applications,  to  hasten  the  action  of  the  absorb- 
ents in  the  removal  of  specks,  especially  if  the  applications  in  question  be 
employed  at  the  proper  time.  If  we  commence  their  use  too  soon,  that  is  to 
say,  before  the  cause  of  the  opacity  be  subdued,  we  shall  often,  not  merely 
torment  the  patient  unnecessarily,  but  actually  impede  the  cure.  For  instance, 
in  a  case  of  opacity,  arising  from  scrofulous  corneitis,  and  still  attended  by 
considerable  vascularity,  were  the  practitioner  forthwith  to  attack  the  eye 
with  stimulating  powders,  and  solutions  of  irritating  or  caustic  substances, 
not  only  would  he  fail  in  effecting  his  object,  but,  by  exasperating  the  disease, 
run  a  great  chance  of  rendering  his  patient  blind.  But  if  he  began  by  com- 
bating the  inflammation  still  lingering  in  the  eye,  and  that  chiefly  by  consti- 
tutional remedies,  not  merely  would  he  witness  the  dispersion  of  the  redness, 
but  he  would  find  the  coi'nea  begin  to  clear,  and  day  after  day  a  little  more 
of  the  effused  lymph  being  removed,  the  patient's  vision  would  proportion- 
ably  improve. 

It  may  be  remarked  that,  in  general,  the  internal  and  constitutional  reme- 
dies which  do  good  in  specks  of  the  cornea,  are  those  which  operate  in  re- 
moving the  ophthalmias  in  which  the  opacities  have  originated  ;  and  the  same 
observation  holds  good  in  regard  to  the  local  remedies  also.  At  the  same 
time,  there  are  both  general  and  local  means  peculiarly  adapted  for  hasten- 
ing the  absorption  of  opaque  depositions  in  the  cornea.  The  exhibition  of 
an  emetic  every  three  or  four  days,  and  a  gentle  course  of  mercury,  are 
general  remedies  of  this  kind.  Some  opacities  yield,  only  under  the  influence 
of  country  air  and  generous  diet. 


614  OPACITIES   OP   THE   CORNEA. 

Most  of  the  applications  used  for  dispersing  opacities  of  the  cornea,  act 
simply  as  stimulants.  Neither  nitrate  of  silver,  nor  any  of  the  innumerable 
substances,  soluble  and  insoluble,  applied  for  the  cure  of  S}>ecks,  act  by  caus- 
ing any  slough  or  destruction  of  the  opaque  substance,  nor  by  eating  it  away, 
as  the  vulgar  suppose ;  whether  they  act  mechanically  or  chemically,  or  in 
any  other  way,  they  simply  excite  such  irritation  as  causes  the  capillaries  to 
become  turgid,  and  as  the  increased  vascularity  subsides,  such  increased 
activity  in  the  absorbents  as  serves  to  carry  off  the  opaque  matter  deposited 
in  the  cornea. 

One,  however,  of  the  means  used  for  the  cure  of  specks,  may  perhaps  act 
difiTerently ;  and  that  is,  the  vapor  of  hydrocyanic  acid,  on  the  supposed 
influences  of  which  I  may  refer  to  what  I  have  said  at  page  429.  I  have 
witnessed  good  effects  from  its  use  in  many  cases  of  speck,  especially  in  nebula 
consequent  to  corneitis ;  in  leucoma,  combined  with  vesication  of  the  cornea, 
or  watery  effusion  under  the  epithelium ;  and  in  vascular  albugo.  In  this 
last  affection,  the  action  of  the  vapor  causes  the  vessels  to  shrink,  after  which 
the  speck  ulcerates  and  disappears. 

When  we  find  that  the  process  of  clearing  has  begun,  we  may  often  greatly 
assist  it  by  such  means  as  the  following  :  Yinum  opii,  pure  or  diluted ;  a 
solution  of  from  2  to  10  grains  of  lunar  caustic,  or  from  1  to  2  grains  of 
corrosive  sublimate,  in  an  ounce  of  distilled  water ;  red  precipitate  salve,  of 
various  strengths ;  a  finely  levigated  powder,  consisting  of  from  half  a  drachm 
to  a  drachm  of  red  precipitate  to  an  ounce  of  white  sugar.  The  powder  is 
to  be  blown  into  the  eye  with  a  quill ;  the  salve  is  to  be  introduced  behind 
the  upper  lid,  and  rubbed  on  the  cornea  by  moving  the  lid  with  the  finger  in 
various  directions  ;  the  fluids  may  either  be  dropped  in  by  means  of  a  camel- 
hair  pencil,  or  injected  over  the  surface  of  the  eye  with  a  syringe.  One  only 
of  these  applications  is,  in  ordinary  cases,  used  daily ;  but  when  the  eye  is 
less  sensitive  to  stimulants  than  common,  one  of  them  may  be  applied  in  the 
morning  and  the  other  at  bedtime. 

Besides  the  substances  above  enumerated,  many  others  have  been  celebrated 
for  removing  specks  ;  but  in  none  of  them  is  there  any  specific  virtue.  Mead 
recommended  equal  parts  of  pounded  glass  and  white  sugar-candy,  levigated 
into  an  impalpable  powder,  which  he  thought  wore  off  the  speck  by  its  incid- 
ing  quality.-  Solutions  of  sulphate  of  zinc,  sulphate  or  ammoniuret  of  copper, 
carbonate  of  potass,  or  sulphate  of  cadmium ;  iodide  of  potassium,  in  solution, 
or  in  salve  ;  creasote,  the  bile  of  various  animals,  especially  of  the  gadus  lota 
and  motella  fluviatilis,  bears'  grease,  and  the  juice  of  the  gryllus  domesticus ; 
walnut  oil,  and  oil  of  lemon  peel ;  have  all  had  their  advocates. 

The  solution  of  lunar  caustic  is  regarded  by  many  as  specific  for  those 
specks  which  are  removable  by  excited  absorption,  so  that  they  keep  this 
solution  ready  by  them  for  all  such  cases.  Dr.  Ryan  recommends^  an  oint- 
ment of  1  drachm  of  nitrate  of  silver  to  1  ounce  of  axunge,  as  more  efficacious 
and  less  painful  than  a  ten-grains'  solution.  It  will  be  found  advantageous, 
however,  to  change  the  stimulant,  after  it  has  been  continued  for  some  time. 

In  all  our  endeavors  to  remove  opacities  of  the  cornea,  it  is  necessary  to 
bear  in  mind,  that  the  points  of  importance  are  the  period  of  the  disease  at 
which  stimulants  are  likely  to  prove  useful,  and  the  regular  and  frequent 
employment  of  the  stimulating  substance  or  substances  selected. 

There  are  few  cases  of  speck  which  are  not  benefited  by  counter-irritation 
behind  the  ear,  or  on  the  back  of  the  neck,  and  by  occasional  scarification  of 
the  palpebral  conjunctiva. 

I  have  often  found  vascular  albugo  intractable,  unless  the  vessels  running 
into  the  speck  were  divided,  and  the  gums  affected  by  mercury.  The  best 
mode  of  dividing  the  fasciculus  of  vessels  is  to  lay  hold  of  a  fold  of  the  con- 


OPACITIES   OF   THE   CORNEA.  615 

junctiva  witli  a  small  pair  of  toothed  forceps,  and  snip  it  through  with  the 
scissors.  If  the  enlarged  vessels  have  escaped  division  in  this  way,  a  small 
hook  may  now  be  easily  introduced  beneath  them,  so  as  to  raise  them  within 
grasp  of  the  scissors.  In  children,  this  plan  is  generally  impracticable,  on 
account  of  their  resistance  and  the  smallness  of  their  palpebral  aperture. 
Considerable  bleeding  follows  the  operation,  and  ought  to  be  encouraged  by 
warm  fomentations.  Besides  the  vapor  of  hydrocyanic  acid,  a  strong  salve 
of  nitrate  of  silver,  or  of  i*ed  precipitate,  proves  highly  useful  in  vascular 
albugo. 

Passing  a  cataract-knife  through  a  leucoma,  without  dividing  the  whole 
thickness  of  the  cornea,  is  a  practice  recommended  by  Dr.  Holscher,*  as 
serving  to  excite  absorption. 

The  vulgar  have  a  notion  that  specks  can  be  removed  by  operation,  but  by 
medical  men  this  has  generally  been  regarded  as  impossible.  Mead,  indeed, 
speaks*  of  paring  specks  every  day  with  a  knife  ;  and  Darwin^  of  trephining 
them  ;  while  Dieffenbach^  has  actually  cut  out  a  leucoma  from  the  centre  of 
the  cornea,  and  brought  the  edges  of  the  incision  together  with  sutures. 
Notwithstanding  these  authorities,  any  attempt  to  operate  on  specks  of  the 
cornea  has  generally  been  deemed  unsafe  or  impracticable,  except  when  the 
opacity  has  been  merely  a  crust  of  oxide  or  carbonate  of  lead  deposited  on 
the  surface  of  an  ulcer  of  the  cornea,  or  an  earthy  deposit  limited  to  its  ante- 
rior elastic  lamina.  In  consequence  of  a  solution  of  acetas  plumbi  being 
employed  as  a  collyrium,  it  sometimes  happens  that  a  whitish  crust  remains 
after  the  ulcer  is  cicatrized,  which  I  have  repeatedly  succeeded  in  detaching 
with  the  sharp  point  of  a  probe,  leaving  the  cornea  beneath  nebulous,  but 
susceptible  of  clearing  completely  under  the  continued  application  of  vinum 
opii.  Two  cases  are  related  by  Mr.  Bowman,  in  which  the  equator  of  each 
cornea  was  covered  by  a  baud  of  brownish  opacity,  sufficient  to  hide  the  pupil 
from  view.  In  one  of  the  cases,  the  opacity  was  finely  mottled  over  with 
dots.  In  both  cases,  the  cornece  beyond  the  opacpie  transverse  bands,  were 
perfectly  clear.  The  epithelium  being  detached,  in  the  one  case  by  Mr.  Bow- 
man, and  in  the  other  by  Mr.  Dixon,  so  as  to  expose  the  opaque  film,  this  was 
then  sliced  or  broken  ofi"  in  small  flakes,  exposing  the  clear  cornea.  The  pain 
attending  the  operations  was  great,  but  the  subsequent  inflammation  slight. 
The  epithelium  was  regenerated  without  any  return  of  opacity,  and  vision 
restored  by  the  operations.  On  analysis,  the  film  was  found  to  consist  of  the 
same  ingredients  as  ordinary  bone;  namely,  phosphates  of  lime  and  magnesia, 
with  a  proportion  of  carbonate  of  lime.^ 

Attempts  have  been  made  by  Rosas,  Gulz,  Malgaigne,  and  others,  to  dis- 
sect or  shave  off  opacities  of  the  cornea,  which  probably  had  their  seat  deeper 
than  the  anterior  elastic  lamina.  M.  Malgaigne  was  led  to  adopt  this  prac- 
tice from  having  found,  in  numerous  dissections,  that  specks  of  the  cornea 
occupied  in  general  only  the  superficial  laminae,  and  that  in  brutes  nearly  half 
the  thickness  of  the  cornea  might  be  pared  away,  and  yet  a  transparent  cica- 
trice ensue.  Before  attempting  an  operation  which  must  be  attended  with  so 
much  danger,  as  removing  any  considerable  thickness  of  the  cornea,  the  sur- 
geon should  assure  himself  that  there  is,  for  the  case  before  him,  no  other 
method  by  which  vision  might  be  restored  with  less  risk ;  for  example,  by 
dilating  the  pupil  by  belladonna,  or  by  the  formation  of  an  artificial  pupil ; 
that  there  is  no  anterior  synechia,  of  such  extent  as  might  frustrate  the  result  of 
the  operation  ;  that  the  pupil  is  not  closed  ;  and  that  the  retina  is  tolerably 
sound.  If  the  whole  cornea  is  affected  with  opacity,  the  removal  of  the 
external  lamina3  ought  to  be  confined  to  a  central  portion,  about  the  size  of 
the  pupil ;  and  it  may  be  well  to  commence  the  operation,  by  circumscribing 
the  part  to  be  removed,  by  a  circular  incision. 


616  VASCULO-NEBULOUS   CORNEA. 

The  instruments  used  on  one  occasion  by  Dr.  Gulz,  in  excising  the  opaque 
layers  of  the  cornea,  were  the  cataract-knife,  with  double  cutting-edge,  of 
Rosas,  and  the  pyramidal  knife  of  Beer,  together  with  a  small  toothed-forceps 
and  a  delicate  pair  of  scissors.  The  manipulations  consisted  in  repeated  and 
progressive  introductions  of  the  knife,  through  and  beneath  the  external  lay- 
ers, until  the  transparent  part  of  the  cornea  was  at  length  reached,  and  ex- 
posed to  the  extent  of  a  line  and  a  half  in  diameter.  The  after-treatment 
consisted  in  the  application  of  plasters  over  the  eyelids,  to  prevent  their 
motion ;  and  the  application  of  cold  or  iced  water,  to  obviate  excessive  reaction. 

In  one  of  M.  Malgaigne's  successful  cases,  even  the  slope  left  by  the  re- 
moval of  the  opaque  laminae  was  ultimately  obliterated  ;  and  more  than  two 
years  after  the  operation,  the  cornea  continued  smooth  and  clear,  and  the  vision 
such  that  the  patient,  a  girl  of  18,  was  engaged  in  needle-work  from  morning 
till  night,  without  the  eye  seeming  to  suflFer.^ 

In  many  cases  of  indelible  opacities  of  the  cornea,  the  simple  plan  of  drop- 
ping upon  the  eye,  every  second  day,  the  solution  of  sulphate  of  atropia,  or 
a  watery  infusion  of  extract  of  belladonna,  suffices,  by  dilating  the  pupil,  to 
improve  the  vision  so  as  to  allow  the  patient  to  walk  about,  to  pursue  his  or- 
dinary business,  or  even  to  read.  Under  such  circumstances,  any  such  hazardous 
operation  as  excision  of  the  opaque  layers  of  the  cornea,  should  never  be  at- 
tempted. It  will  often  happen,  on  proceeding  to  such  excision,  that  the  whole 
thickness  of  the  cornea  will  be  found  to  be  pervaded  by  the  opaque  deposition, 
so  that  the  operation  will  require  to  be  abandoned. 

[Acupuncturation  has  been  proposed  for  the  removal  of  corneal  opacities, 
and  has  been  employed  by  M.  De  la  Flor,  by  means  of  needles,  previously 
dipped  in  hydrocyanic  acid.*"  Dr.  D.  Taviguot"  attempted  to  remove  a  cen- 
tral albugo  in  a  young  girl  of  19,  by  means  of  electro-puncture,  having  pre- 
viously employed  simple  acupuncturation  to  accustom  her  eye  in  some  measure 
to  the  treatment.  The  electro-puncture  was  then  used  on  four  different  oc- 
casions, for  some  minutes  each  time,  but  the  remedy  was  such  a  severe  one, 
that  the  patient,  after  a  fourth  sitting,  refused  to  submit  to  it  any  longer, 
although  it  was  evident  that  two  thirds  of  the  deposit  had  been  removed  by 
it— H.]  

'  Traite  des  Maladies  des  Yeux ;  Tome  i.  p.  ^  Amnion's  Zeitschrift  fiir  die  Ophthalmolo- 

54;  Paris,    1S18.  gie  ;  Vol.  i.  p.  177;  Dresden,  1831. 

"  Medical  Works  of  Richard  Mead,  M.  D.  p.  '  Lectures  on  the  Parts  concerned  in  the  Ope- 

538;  London, 1762.  rations  on  the  Eye,  p.  117;  London,  1849. 

'  Transactions  of  the  Association  of  Fellows  '  On  excision  of   opaque  layers  of   the  cor- 

and  Licentiates  of  the  King  and  Queen's  Col-  nea,  consult  Hamilton,  London  and  Edinburgh 

lege  of  Physicians  in  Ireland ;  Vol.  iv.  p.  256 ;  ISIonthly  Journal  of  Medical  Science,  March, 

Dublin,  1824.  1844,  p.  198:    Ibid.    July  1844,  p.  626:    An- 

'  Revue  Ophthalinologique  de  la   Litterature  nales    d'Oculistique;    Tome    ix.    pp.    95,  180; 

Medicale  de  I'Annee,  1842,  p.  163;  Bruxelles,  Bruxelles,  1843:  Ibid.  Tome  xiii.  p.  211 ;  Brux- 

1843.  elles,  1845. 

'  Op.  cit.p.  539.  '"  [Wilde's  Report,  Dub.  Quarterly,  p.  486.] 

"  Zoonomia;  Vol.iii.  p.  71 ;  London,  1801.  "  [Bull,  de  Therap. ;   Juillet,  54,  p.  49.] 


SECTION  V. — PANNUS,  OR  VASCULO-NEBULOUS  CORNEA. 
Fhj.  Beer,  Band  I.  Taf.  IIL  Fig.  3.  Band  IL  Taf  IV.  Fig.  3.  Wardrop,Pl.  II.  Fig.3.Pl.  VIL  Fig.  1. 

By  pannus  is  understood  a  vascular  state  of  the  cornea,  with  thickening  of 
its  epithelium,  the  result  of  chronic  inflammation. 

There  are  three  varieties  of  the  disease  :  The  first  is  the  consequence  of 
corneitis,  and  to  this  the  name  pannus,  from  the  cornea  presenting  absolutely 
an  appearance  like  a  piece  of  red  cloth,  is  generally  confined  ;  the  second, 
more  frequently  denominated  vasculo-nebulous  cornea,  is  the  result  of  granular 


GRANULAR   CONJUNCTIVA.  611 

conjunctiva ;  the  third,  which  is  often  combined  with  xeroma,  arises  from  the 
irritation  of  inverted  eyelashes  or  eyelids.  T\\q  first  variety  is  idioi)atliic  ;  the 
second  and  third  are  entirely  symptomatic.  In  the  first  variety,  the  internal 
surface  of  the  eyelids  is  smooth  and  natural ;  in  the  second,  rough  and  sarco- 
matous ;  in  the  third,  the  eyelids  or  the  cilia,  by  their  distortion,  rub  on  the 
cornea. 

The  prolongation  of  bloodvessels  over  or  into  the  cornea  is  always  attended 
with  molecular  changes  in  its  substance,  and  often  with  more  or  less  efl'usion 
of  lymph,  so  that  its  lustre  is  destroyed  and  it  is  rendered  semi-opaque.  In 
the  first  variety  of  pannus,  the  bloodvessels  are  derived  from  those  of  the 
sclerotica,  as  well  as  from  those  of  the  conjunctiva ;  in  the  second  and  tldrd 
varieties,  the  conjunctiva  is  the  chief  source  of  the  abnormal  vascularity  of 
the  cornea.  Although  the  vessels  from  the  conjunctiva  have  much  the  ap- 
pearance of  being  covered  only  by  hypertrophied  epithelium,  it  is  most  proba- 
IdIc  that  they  lie  under  the  anterior  elastic  lamina.  When  the  sclerotic  or 
deep-seated  conjunctival  network  is  the  source  of  the  prolonged  vessels,  they 
evidently  pass  beneath  this  lamina,  and  often  pervade  the  whole  lamellated 
tissue  of  the  cornea  to  such  a  degree  as  to  render  it  almost  impervious  to 
light. 

Mr.  Bowman  observes,  that  "the  vessels  are  to  be  regarded  as  originally  a 
result  of  diseased  action,  not  as  themselves  the  disease.  They  are  developed," 
says  he,  "  under  the  salutary  or  conservative  law  of  the  organism,  to  enable  a 
part  of  feeble  vitality  to  sustain  a  morbid  action  to  which  it  has  become  sub- 
ject, and  under  which  its  vitality  would  otherwise  sink.  It  is  true  that  their 
presence  marks  the  existence  of  disease,  and  is  to  a  certain  degree  an  index 
of  its  extent;  but  we  must  be  on  our  guard  against  imagining  that  it  consti- 
tutes its  essence.  Unless  the  vessels  had  been  developed,  the  diseased  pro- 
cess would  long  ago  have  terminated  by  the  total  destruction  of  the  tissue. 
.  .  .We  may  even  go  further,  and  maintain  that  these  adventitious  vessels  are 
necessary  to  a  cure,  and  to  their  own  removal.  .  .  .  For  as  the  morbid  products 
(including  the  vessels)  laid  down  in  the  cornea,  require  for  their  existence  a 
certain  accession  of  new  material,  in  the  way  of  continuous  nutrition,  so  they 
cannot  be  removed  unless  means  are  found  for  the  absorption  and  removal  of 
the  old  material  of  which  they  are  composed,  and  these  means  are  mainly  the 
vascular  channels.^ 

The  first  variety  of  pannus  or  vasculo-nebulous  cornea  is  curable  by  the 
remedies  for  corneitis.  The  second  yields  only  when  a  cure  is  effected  of  the 
granular  conjunctiva,  on  which  it  depends.  The  third  requires  evulsion  of  the 
offending  cilia,  or  a  radical  cure  of  the  trichiasis  or  entropium  whence  it  takes 
its  rise. 

In  the  second  variety,  and  only  in  it,  a  plan  of  inoculating  the  conjunctiva 
with  blennorrhoeal  fluid  has  been  proposed,  as  I  shall  explain  in  the  next  sec- 
tion. 


*  Lectures  on  the  Parts  concerned  in  the  Operations  on  the  Eye,  p.  32;  London,  1849. 


SECTION  VI. — GRANULAR  CONJUNCTIVA. 

Syn_ — Trachoma.  Pladarotes.     Aspritiulo,    Celsiis.     Scabrities  oculorum,  Pliny.     Palpe- 
brarum asperitudo,  Marcellus.     Hypertrophy  of  conjunctival  villi. 

Fig.  MuUer,  Taf.  I.  II.     Eble,  Taf.  IIL  Dalrymple,  PI.  XL  Figs.  5,  6.     Sichel,  PI.  II.  Figs,  3, 4, 

PI.  III.  Figs.  1,  3. 

In  treating  of  the  puro-mucous  ophthalmiiE,  I  have  repeatedly  had  occasion 
to  refer  to  a  thickened,  fleshy,  and  rough  state  of  the  lining  membrane  of  the 


618  GRANULAR   CONJUNCTIVA, 

lids  and  especially  of  the  upper  lid  known  by  the  name  of  granular  conjunc- 
tiva,^ and  which  is  so  frequent  and  troublesome  a  sequela  of  those  ophthalmia?. 
At  page  451,  I  have  made  some  remarks  on  the  sense  in  which  the  term  gran- 
ular is  to  be  taken,  and  on  the  impropriety  of  calling  the  prominences  of  the 
conjunctiva  which  exist  in  this  disease,  gramdations.  The  prominences  in 
question  are  doubtless  the  villi  or  papillae  of  the  palpebral  conjunctiva,  along 
with  its  glandular  elements,  hypertrophied  and  altered  by  chronic  inflamma- 
tion. In  the  normal  state,  the  villi  are  visible  under  the  microscope,  although 
the  conjunctiva  is  not  injected;  in  a  well  injected  preparation,  they  are  visible 
to  the  naked  eye.  They  exist  chiefly  on  that  portion  of  the  membrane  which 
Hues  the  tarsi  f  while  the  muciparous  glands  are  most  abundant  where  the  con- 
junctiva is  about  to  be  reflected  from  the  eyelids  to  the  eyeball.  The  promi- 
nences then,  which  constitute  the  disease  now  before  us,  appear  to  be  in  gene- 
ral nothing  more  than  these,  the  natural  structures  of  the  muco-cutaneous 
membrane  of  the  eye,  enlarged  from  inflammation. 

Symptoms. — The  granular  prominences  vary  in  different  cases.     In  some, 

they  are  exceedingly  numerous,  slightly  raised 

Fig-  "4-  above  the  level  of  the  conjunctiva,  and  give  to 

the  inside  of  the  lids  an  appearance  somewhat 

like  that  of  a  piece  of  shagreen  (Fig.  74);  in 

others   the   grains   are  comparatively  few,    but 

prominent,  very  vascular,  soft,  apt  to  bleed,  and 

often  as  large  as  hemp-seeds.     The  seat  of  the 

granular  degeneration  is  the  internal  surface  of 

tarsi,  and  chiefly  of  the  upper  tarsus.     The  rest 

of  the  conjunctiva  may  present  a  red  and  swollen 

appearance,  but  is  not  really  granular.    Yery  often 

there  is  a  row  of  insulated  pale  and  hard  granules,  at  or  beyond  the  posterior 

edge  of  the  upper  tarsus. 

In  the  angle  of  reflection  between  the  lower  eyelid  and  the  eyeball,  we  not 
unfrequently  observe  a  row  of  bodies  of  a  rounded  form  and  somewhat  vesi- 
cular appearance.  These  are  dift'erent  from  enlarged  papillae,  and  consist,  I 
presume,  in  the  muciparous  glands  described  by  Krause,^  enlarged  by  chronic 
inflammation.* 

I  have  already  (p.  2GT)  spoken  of  warts  of  the  conjunctiva,  which  appear 
to  rise  from  the  irritation  of  a  diseased  secretion,  resembling  in  this  respect 
warts  within  the  prepuce.  They  are  altogether  different  from  the  prominen- 
ces in  granular  conjunctiva;  although,  on  examining  the  latter  with  the  micro- 
scope, I  have  sometimes  detected  fungiform  vegetations  sprouting  from  their 
apices,  and  giving  them  a  warty  appearance.  The  common  warts  of  the  con- 
junctiva are  very  different;  their  exuberant  growth  and  segregated  disposition 
readily  distinguishing  them  from  granular  conjunctiva.  Besides,  they  spring 
from  the  ocular  conjunctiva,  the  semilunar  membrane,  and  the  caruncula  lachry- 
malis,  much  oftener  than  from  the  inside  of  the  eyelids. 

After  granular  conjunctiva  has  undergone  treatment,  the  internal  surface 
of  the  eyelid  often  presents  hard  irregular  ridges  and  depressions,  somewhat 
resembling  cicatrices.  This  appearance  is  sometimes  attributed  to  the  action 
of  the  remedies  employed  for  the  cure  of  the  granular  conjunctiva.  It  seems 
to  be  the  result  of  an  atrophy  of  the  papillary  structure.* 

The  conjunctiva  in  the  granular  state  secretes  an  inordinate  quantity  of 
mucus,  which,  on  any  additional  irritation  of  the  system,  as  from  the  use  of 
spirituous  liquors,  or  any  local  irritation,  as  from  cold  affecting  the  eyes,  is 
apt  to  become  again  puriform.  "When  this  is  the  case,  the  contagious  power 
of  the  original  ophthalmia  returns. 

Rubbing  against  the  cornea,  the  granular  lids  keep  this  part  in  a  state  of 


GRANULAR   CONJUNCTIVA.  619 

constant  irritation,  so  that  it  becomes  vascular  and  nebulous,  particularly  in 
its  upper  half.  Should  the  case  be  neglected,  great  thickening  of  the  epithe- 
lium of  the  cornea,  with  roughness  and  total  opacity,  may  be  the  result.  The 
cornea  assumes  somewhat  of  a  greenish  hue ;  viewed  through  a  magnifying- 
glass,  it  is  seen  to  be  dotted  over  with  minute  depressions ;  and  it  is  covered 
with  prolongations  of  the  bloodvessels  emerging  from  the  recti.  Though 
the  vasculo-nebulous  state  of  the  cornea  is  owing,  in  a  great  measure,  to  the 
granular  condition  of  the  eyelids,  it  would  be  erroneous  to  ascribe  it  entirely 
to  this  cause.  It  is,  no  doubt,  partly  an  immediate  result  of  the  same  inflam- 
mation, which  has  ended  in  hypertrophy  of  the  papilla  of  the  palpebral  con- 
junctiva. From  time  to  time  small  phlyctenulae  form  on  the  upper  half  of  the 
cornea,  break,  and  leave  little  pits  or  ulcers,  thus  adding  to  the  irritation  which 
attends  the  disease,  as  well  as  in  causing  opacity  of  the  cornea. 

Along  with  granular  conjunctiva,  the  constitution  scarcely  ever  fails  to  be- 
come affected,  the  patient  suffering  from  hectic  fever,  with  paleness,  emacia- 
tion and  almost  a  scorbutic  state  of  the  system.  The  frequent  febrile  attacks 
are  always  followed  by  increased  redness,  swelling,  and  roughness  of  the  con- 
junctiva. Under  such  cii'cumstances,  it  is  vain  to  attempt  the  cure  of  the 
local  affection,  unless  the  constitutional  ailment  is  removed.  When  it  is 
found  impossible  to  effect  this,  the  patient  is  apt  to  fall  into  phthisis  pulmo- 
nalis. 

Causes. — Granular  conjunctiva  may  result  from  any  of  the  puro-mucous 
ophthalmite.  It  is  by  no  means  peculiar  to  the  contagious  inflammations  of 
the  conjunctiva,  but  often  arises  from  the  mere  catarrhal.  A  question  of  some 
importance  is,  whether  this  affection  is  a  result  simply  of  the  puro-mucous 
inflammations  of  the  conjunctiva,  of  these  diseases  being  neglected,  or  of 
improper  applications  being  made  to  the  eye  in  these  and  in  other  ophthal- 
miae.  Mr.  Lawrence"  inclines  much  to  the  last  view.  He  describes  granular 
conjunctiva  as  the  effect  of  strong  applications  of  nitrate  of  silver,  in  salve 
or  in  solution,  and  says  it  "  almost  deserves  to  be  named,  from  its  exciting 
cause,  lunar  caustic  ophthalmia."  An  ophthalmia  may  no  doubt  be  produced 
by  such  applications,  and  end  in  granular  conjunctiva;  but  I  believe  neglect 
of  proper  treatment,  and  especially  of  depletion,  general  and  local,  in  the 
early  stage  of  the  puro-mucous  ophthalmise,  is  the  most  frequent  cause  of 
this  affection.  We  see  it  arise  from  catarrhal  ophthalmia,  where  no  applica- 
tion of  any  sort  has  been  made  to  the  conjunctiva. 

Prognosis. — Although  by  sufficient  clothing,  proper  diet,  restriction  from 
intemperance,  good  air,  and  judicious  medical  treatment,  the  sarcomatous  state 
of  the  lids  and  opacity  of  the  cornea,  may,  in  general,  be  lessened  or  removed, 
and  vision  restored ;  yet,  if  the  patient  be  of  intemperate  habits,  be  ill-fed, 
or  be  insufficiently  protected  from  cold  winds  or  damp  cold  weather,  relapses 
will  almost  certainly  take  place,  attended  by  renewed  inflammation  of  the 
conjunctiva  and  puriform  discharge,  so  that  at  last,  especially  in  scrofulous 
subjects,  the  disease  may  prove  incurable.  Attempts  to  hurry  the  cure,  by 
the  too  liberal  use  of  local  means,  often  throw  the  disease  back,  and  bring  on 
phlyctenulae  on  the  cornea. 

Treatment.  1.  Local  depletion. — If  the  conjunctiva  is  very  vascular  and 
sarcomatous,  a  few  leeches  are,  from  time  to  time,  to  be  applied  to  the  ex- 
ternal surface  of  the  eyelids,  or  over  the  nasal  vein.  Advantage  is  also 
obtained  from  everting  first  the  lower  eyelid,  and  then  the  upper,  and  scari- 
fying the  conjunctiva  in  the  manner  directed  at  page  425.  If  the  membrane 
generally  is  not  much  thickened,  each  granular  prominence  ought  to  be 
divided  by  a  crucial  incision,  or  the  membrane  cross-hatched  by  slight  touches 
of  the  lancet. 

2,  Astringents. — Many  different  substances  of  this  class,  the  local  action 


620  GRANULAR   CONJUNCTIVA. 

of  which  on  the  animal  tissues  depends  on  their  affinity  for  albumen  and  fibrin, 
have  been  emploj^ed  in  the  treatment  of  granular  conjunctiva,  the  chief  being 
alum,  borax,  sulphate  of  zinc,  and  acetate  of  lead. 

Mr.  Lawrence  recommends^  the  liquor  aluminis  compositus,  which  at  first 
is  to  be  used  in  a  diluted  state.  Each  fluid  ounce  of  this  preparation  contains 
about  eight  grains  of  alum,  and  as  many  of  sulphate  of  zinc.  The  method  of 
applying  this  and  similar  astringents  in  the  fluid  form,  is  to  pencil  them  on 
the  diseased  membrane  with  a  camel-hair  brush. 

M.  Chassignac  uses  a  crayon  of  borax  or  sulphate  of  zinc.  The  borax  he 
employs  in  its  native  state,  only  cut  into  the  form  of  a  cylinder.  As  it  is  but 
little  soluble,  he  leaves  it  in  contact  with  the  conjunctiva  for  a  few  moments, 
and  it  has  the  effect  of  slightly  whitening  the  surface  without  producing  any 
scar.  Sulphate  of  zinc  he  employs  also  in  the  form  of  a  crayon,  but  mixed 
with  variable  proportions  of  powdered  gum  arable.  A  paste  being  made  of 
the  two  substances,  it  is  rolled  into  the  shape  of  a  crayon,  to  be  applied  in 
the  same  way  as  the  borax.* 

Mr.  Tyrrell  and  others  have  chiefly  used  the  undiluted  liquor  diacetatis 
plumbi;  a  solution  consisting  of  one  part  of  water  to  1.5  of  the  crystallized 
salt.  9 

M.  Buys  introduced  the  neutral  acetate  or  sugar  of  lead,  in  the  state  of  an 
impalpable  powder,  Avhich  he  applied  over  the  diseased  surface  with  a  minia- 
ture pencil,  and  allowed  to  dissolve  in  the  tears.  The  immediate  effect  is  to 
cause  strong  contraction  of  the  ciiseased  tissue ;  the  granular  prominences 
shrink;  and  the  membrane  appears  smooth  and  uniform.  After  replacing  the 
eyelid,  the  salt  assumes  a  white  shining  appearance,  and  it  is  often  a  very 
long  time  before  it  becomes  detached.  It  is  to  be  applied  at  intervals  of  five 
or  six  days,  till  the  cure  is  accomplished.  It  is  stated  that  in  this  mode  of 
treating  granular  conjunctiva  no  insoluble  precipitation  is  met  with,  even  in 
cases  where  ulcers  exist  on  the  cornea,^"  v/hich  is  scarcely  credible. 

[An  astringent  wash  of  sulphate  of  zinc  and  common  table-salt,  in  rose- 
water  of  the  strength  of  ten  or  twelve  grains  of  each  salt  to  the  ounce,  will 
be  found  to  be  an  excellent  application  in  the  management  of  granular  con- 
junctiva, in  connection  with  its  treatment  by  escharotics. — H.] 

3.  Escharotics. — The  escharotics  most  frequently  used,  have  been  nitrate 
of  silver  and  sulphate  of  copper.  A  day  or  two  after  leeching  or  scarifica- 
tion, the  lids  being  everted,  and  dried  from  the  gleety  mucus  with  which  they 
may  be  covered,  the  lunar  caustic  pencil  is  to  be  brought  into  a  single  rapid 
contact  with  the  granular  prominences.  Before  allowing  the  lids  to  be  re- 
placed, a  little  warm  water  is  to  be  squirted  over  the  surface  which  has  been 
touched  with  the  caustic. 

It  is  advantageous,  after  a  time,  to  change  the  lunar  caustic  for  the  sulphate 
of  copper,  which  may  be  more  liberally  applied  to  the  diseased  surface,  and  a 
smooth  wedge  of  it  pushed  up  occasionally  behind  the  everted  tarsus  into  the 
upper  sinus  of  the  conjunctiva. 

[A  very  convenient  method  of  applying  the  sulphate  of  copper,  and  which 
will  sometimes  prove  to  be  the  only  one  available,  as  in  cases  of  chronic 
ophthalmia  attended  with  great  tension  of  the  orbicularis,  softening  of  the 
tarsal  cartilage,  or  disease  of  the  ciliarly  follicles,  precluding  the  possibility  of 
eversion  of  the  lid,  is  that  recommended  by  Mr.  Wilde."  It  consists  in,  first 
of  all,  slightly  lifting  the  lid  (the  upper  lid)  off  the  globe,  "  by  drawing  the 
integument  upward  against  the  brow,  in  the  usual  manner,  and  then  the 
piece  of  bluestone  may  be  inserted  underneath  the  lid,  towards  the  internal 
side,  as  high  up  as  possible,  and  held  a  little  out  from  the  eye,  so  that  it  does 
not  touch  the  surface  of  the  ball.  It  is  then  to  be  drawn  downwards  and 
outwards  towards  the  external  angle."     This  way  of  using  the  sulphate  of 


GRANULAR  CONJUNCTIVA.  621 

copper  we  have  often  found  very  convenient.  Caution  should  always  be 
observed  in  drawing  it  from  the  one  canthus  to  the  other,  so  as  not  to  allow 
the  surface  of  the  copper  opposite  to  that  which  is  in  contact  with  the  lid  to 
touch  the  cornea,  for,  should  it  do  so,  an  abrasion  of  its  epithelial  covering- 
would  be  produced,  and  more  or  less  opacity  of  its  substance  ensue.  This 
can  readily  be  avoided  by  drawing  the  crayon  towards  you,  so  as  to  make  the 
lid  stretch  itself  over  it  as  you  pass  it  downwards  and  outwards  to  the  external 
angle. 

The  crayon  of  bluestone  requires  some  care  in  its  preparation.  A  large 
and  perfect  crystal  of  the  salt  should  be  selected.  This  is  to  be  filed  and 
rubbed  down  to  about  the  size  and  form  as  Mr.  Wilde  describes  it  of  the 
spade  of  cards,  and  of  about  the  eighth  of  an  inch  in  thickness  at  its  shank, 
which  is  to  be  securely  fastened  iu  a  quill  or  porte  crayon.  The  whole 
of  the  crayon  thus  prepared  should  be  kept  always  smooth  and  even  by  fre- 
quently rubbing  the  surfaces  and  edges  on  a  wet  cloth.  This  we  believe  to 
be  the  proper  condition  in  which  sulphate  of  copper  should  be  applied  for 
granular  disease  of  the  lids.  M.  Desraarres  uses  quite  a  rough  crude  crystal 
of  the  salt,  and  thinks  that  advantage  is  to  be  derived  from  the  additional 
irritation  produced  by  its  application  in  such  a  condition. 

But  we  feel  satisfied,  after  having  carefully  watched  its  effects  in  M. 
Desmarres'  own  hands,  at  his  clinique,  and  after  having  given  it  a  full  trial 
at  the  Wills  Hospital,  that  such  is  not  the  result  of  its  application  in  this 
manner.  On  the  contrary,  we  feel  assured  that,  in  the  majority  of  cases,  at 
least,  the  irritation  will  only  impede  the  salutary  effect  of  the  escharotic,  and 
not  unfrequently  serve  to  keep  up  the  diseased  action  in  the  part. 

Dr.  Ilays^^  speaks  very  highly  of  the  use  of  iodide  of  zinc,  in  the  treatment 
of  this  troublesome  affection.  He  says:  "  Some  years  ago,  we  were  led,  by 
the  favorable  reports  of  the  efficacy  of  the  iodide  of  zinc  iu  reducing  enlarge- 
ment of  the  tonsils,  to  try  this  application  in  a  case  of  greatly  thickened 
conjunctiva  of  long  standing,  which  had  proved  rebellious  to  various  reme- 
dies. The  result  was  so  satisfactory  that  we  have  since  employed  it  in  a  few 
similar  cases,  and  our  experience  thus  far  authorizes  us  to  recommend  this 
remedy  to  the  attention  of  the  profession." — H.] 

Alternately,  every  two  or  three  days,  local  depletion  and  one  or  other  of 
the  escharotics  is  to  be  employed,  while  warm  fomentations,  as  the  bichloride 
of  mercury  collyrium,  are  to  be  used  thrice  daily,  and  the  red  precipitate,  or 
diluted  citrine,  ointment  applied  to  the  edges  of  the  eyelids  at  bedtime. 

Besides  lunar  caustic  and  sulphate  of  copper,  in  the  solid  state,  the  appli- 
cation of  these  substances,  and  of  other  escharotics  and  stimulants  to  the 
granular  surface,  in  solution,  or  in  ointment,  is  useful ;  and  especially,  red 
precipitate  salve,  and  vinum  opii.  These  assist  in  clearing  the  cornea,  as 
well  as  repressing  the  sarcomatous  state  of  the  conjunctiva,  A  proper  re- 
medy, which  I  have  known  do  good,  is  the  expressed  juice  of  the  holcus 
avenaceus. 

4.  Counter-irritation. — During  the  employment  of  the  other  means  of  cure, 
advantage  is  derived  from  blisters  kept  open  behind  the  ears,  or  on  the  nape 
of  the  neck. 

Under  this  head,  may  be  mentioned  the  plan  of  pencilling  the  external 
surface  of  the  lids  every  five  or  six  days,  with  solid  lunar  caustic. 

5.  Sorbefacients. — Much  advantage  is  obtained  in  many  cases  of  granular 
conjunctiva,  by  putting  the  patient  on  the  internal  use  of  iodide  of  potas- 
sium. 

Rubbing  the  external  surface  of  the  lids,  for  some  minutes  night  and  morn- 
ing, with  mercurial  ointment,  or  with  red  precipitate  salve,  is  found  useful,  in 
reducing  the  hypertrophy  of  the  diseased  tissue. 


622  GRANULAR   CONJUNCTIVA. 

6.  Tonics. — The  cure  is  greatly  promoted  by  attention  to  the  dietetical  ad- 
juvants mentioned  under  the  head  of  the  prognosis,  and  by  the  administration 
of  tonifs,  especially  chalybeates,  and  the  sulphate  of  quina.  Soldiers,  after 
being  discharged  from  the  army,  are  often  cured  of  granular  conjunctiva,  in 
consequence  of  their  going  into  the  country,  and  there  continuing  the  very 
same  plan  of  treatment  which  had  proved  unsuccessful  in  a  military  hospital. 

'J.  Excision. — When  granular  conjunctiva  has  proceeded  to  a  great  degree 
of  exuberance,  and  continued  for  perhaps  many  months,  notwithstanding  a 
careful  trial  of  other  plans  of  treatment,  recourse  may  be  had  to  a  more 
speedy  method  of  removal,  namely  by  the  knife. ^'^  The  eyelid  to  be  operated 
on  is  to  be  everted  as  completely  as  possible,  and  the  hypertrophied  papillae, 
at  least  the  most  prominent  of  them,  shaved  off  by  means  of  a  small  and  very 
sharp  lancet-shaped  knife,  or  dissected  away  with  the  scissors. 

In  performing  the  operation,  it  is  necessary  to  beware  of  removing  more 
than  the  mere  granular  layer.  If  more  than  this  is  taken  away,  hard  and  ir- 
regular cicatrices  are  left  on  the  internal  surface  of  the  lids,  the  effects  of  which 
on  the  cornea  may  be  scarcely,  if  at  all,  less  prejudicial  than  those  of  the  morbid 
structure  which  has  been  removed. 

8.  Inoculation. — The  idea  of  curing  granular  conjunctiva,  by  exciting  in 
the  diseased  membrane  the  inflammatory  action  of  an  acute  attack  of  purulent 
ophthalmia,  to  be  treated  by  venesection  and  other  remedies,  was  first  sug- 
gested by  my  friend,  the  late  Dr.  Henry  Walker," 

The  method  of  exciting  such  an  inflammation,  adopted  by  Professor  Jiiger 
and  Dr.  Piringer,  is  to  inoculate  the  conjunctiva  with  matter  taken  from  the 
eye  of  a  child  affected  with  mild  ophthalmia  neonatorum.  The  matter  is  ap- 
plied to  the  inside  of  the  lids,  with  a  miniature  pencil,  and  in  a  few  hours  pro- 
duces its  effect.  The  inflammation  thus  excited  is  to  be  treated  like  an  ordi- 
nary attack  of  purulent  conjunctivitis  ;  and  although  the  practice  does  by  no 
means  appear  a  very  safe  one,  it  is  undeniable,  that  cures  have  in  this  way 
been  effected,  of  the  hypertrophied  state  of  the  conjunctiva,  with  the  vasculo- 
nebulous  condition  of  the  cornea  depending  on  it.  For  a  full  account  of  this 
practice,  I  refer  the  reader  to  a  paper  by  Dr.  Hamilton,  in  the  "  London  and 
Edinburgh  Monthly  Journal  of  Medical  Science"  for  July,  1843.  I  shall 
only  add,  that  there  are  important  contra-indications  to  the  practice ;  one  of 
which  is  the  existence  of  scrofula,  rheumatism,  or  any  other  dyscrasia. 


'  "Hie  affectus  etiam    sycosis  seu  pafpebra         "  London  Medical  Gazette,  July,  11, 1845,  p. 

ficosa  dicitur,  quia  interna  palpebra?  superficies  444. 
ficus    discissi    ad     instar     granulosa    evadit."         ''  lb.  p.  446. 
Plenck,  De  Morbis  Oculorum,  p.  30  ;  Viennae,         *  Lancet,  June  7,  1845,  p.  654. 
1777.  "  PracticalWork  on  the  Diseases  of  the  Eye; 

*  Soenimerring's    Abbildungen  des   men?ch-  Vol.  i.  p.  1.34;  London,  1840. 
lichen  Auges;  Tab.   ii.   fig.  14;  Frankfurt  am         '°  Annates  d'Oculistique  ;  Tome  xxi.  p.  293. 
Main,  1801.  "  [See  Mr.  AVilde's  valuable  Report  on  the 

'  Encyclopedie  Anatomiquc;  Tome  v.  p. 585;  Progressof  Ophthalmic  Surgery,  Dub.  Quarterly 

Paris,  1845.  Journal,  Vol.  v.  p.  479,  for  1848.— II.] 

'  See  Eble  iiber  den  Bau  unddie  Krankheiten         "  [See  American  edition  of  Lawrence,  by  Dr. 

der  Bindehaut  des  Auges,  Taf.  3.  fig.  13,  Wien,  Hays,  containing   much  valuable   information 

1828.  on  the  subject  by  the  Editor.— H.] 

'  On  the  palhological  anatomy  of  granular  '^  Sir  William  Read's  Short  but  Exact  Ac- 
conjunctiva,  consult  Thiry,  Annales  d'Oculis-  count  of  all  the  Diseases  incident  to  the  Eyes,  p. 
tique.  Tome  xxi. p.  108;  Bruxelles,  1849:  Hai-  96;  London,  1706. 

rion,  lb.  Tome  xsiii.  p.  109  ;  A^il,  lb.  Tome  xxiv.         ' '  Edinburgh  Medical  and  Surgical  Journal, 

p.  231 ;  Bruxelles,  1850.  January,  1811,  p.  1. 


CONJUNCTIVAL   XEROMA.  623 


SECTION  Vn. — CONJUNCTIVAL   XEROMA   OR   XEROPnTHALMIA.^ 

Syn. — Xerosis  conjunctivjB.     Cuticular  conjunctiva.     Uebei'hilutung  der  Conjunctiva, 
Ger.     Atrophy  of  Conjunctiva.     Symblepharon  posterius,  ^mmow. 

Fig.  Ammon,  Thl.  I.  Taf.  I.  Figs.  16,  18—21. 

Case  SOB. — Agnes  Mackinnon,  aged  26,  applied  at  the  Glasgow  Eye  Infirmary  on  the 
26th  of  March,  1833,  under  the  following  circumstances  :  — 

The  conjunctiva  of  both  eyes  was  red,  and  had  evidently  suiFered  from  long-continued 
inflammation.  The  right  conjunctiva  especially  was  of  a  dark  red  color,  and,  where  it 
passed  from  the  lower  eyelid  to  the  eyeball,  of  an  olive  hue,  from  the  frequent  use  of  ni- 
trate of  silver  solution. 

The  left  conjunctiva  had  the  appearance  as  if  it  were  skinned  over,  being  in  many  places 
of  a  whitish  color,  and  on  the  inside  of  the  upper  lid  looking  as  if  it  had  suffered  cica- 
trization. It  was  altogether  drier  than  natural,  and  seemed  almost  destitute  of  its  proper 
mucous  secretion.  The  patient  said  that  this  eye  watered  much  less  than  the  right.  At 
the  nasal  extremity  of  the  left  lower  lid,  there  was  a  tendency  to  symblepharon  ;  the  con- 
junctiva, when  the  patient  turned  the  eye  upwards  and  outwards,  forming  a  frenum  which 
prevented  the  free  motion  of  the  ej'e.  There  was  a  slight  inversion  of  the  left  eyelids, 
with  some  inverted  eyelashes  rubbing  on  the  surface  of  the  eyeball.  Numerous  red  ves- 
sels were  observed  winding  over  the  left  cornea. 

She  said  she  had  been  subject  to  attacks  of  ophthalmia  for  eight  years  ;  the  first  attack 
being  in  the  left  eye,  in  consequence  of  a  stroke  with  a  shuttle.  The  conjunctivas  were 
never  scarified,  nor  rubbed  with  solid  caustic  ;  and  she  never  had  any  operation  performed 
for  the  inverted  state  of  the  lids,  except  evulsion  of  the  faulty  eyelashes. 

The  inverted  eyelashes  were  removed,  and  she  was  ordered  to  bathe  the  ej^es  thrice  a- 
day  with  a  tepid  solution  of  10  grains  of  muriate  of  ammonia  and  20  grains  of  gum  arable, 
in  8  ouQces  of  water. 

The  above  is  an  example  of  an  atropliic  state  of  the  conjunctiva,  the  result 
of  long-continued  and  ill-treated  inflammation  of  that  membrane.  It  has  been 
described  by  Mr.  Travers,  under  the  name  of  cuticidar  conjunctiva.  He  men- 
tions,^ that  he  had  seen  cases  of  this  conversion  of  the  conjunctiva  into  a  ru- 
gous and  opaque  skin,  go  the  length  of  knitting  the  lids  close  to  the  globe 
and  obliterating  the  palpebral  sinuses.  While  he  places  it  among  the  sequelae 
of  chronic  inflammation  of  the  conjunctiva,  he  considers  it  as  immediately  de- 
pending on  an  obliteration  of  the  lachrymal  ducts ;  a  view  of  tlie  subject 
previously  taken  by  Schmidt,  who  describes^  the  disease  under  the  name  of 
xerophthalmos. 

A  more  complete  account  of  this  diseased  state  of  the  conjunctiva,  we  owe 
to  Dr.  Ammon,  of  Dresden.  He  acknowledges  that  the  first  case  which  he 
had  an  opportunity  of  examining,  was  pointed  out  to  his  attention  by  Pro- 
fessor Jiiger,  of  Erlangen  ;  who,  in  one  of  his  clinical  reports  had  spoken  of 
the  affection  under  the  name  of   Ueherhdutimg  der  Conjunctiva. 

The  principal  symptoms  of  conjunctival  xeroma  may  be  gathered  from  the 
case  of  Makinnon,  as  above  related.  I  may  add,  however,  a  few  remarks, 
embodying  what  seems  most  interesting  in  Dr.  Ammon's  paper.* 

Symptoms. — Although,  in  general,  the  conjunctiva  presents  a  dark  red 
color,  and  has  a  thickened,  rugous,  and  dusky  appearance,  it  is  sometimes 
whiter,  and  less  vascular  than  natural.  Even  in  the  cases  in  which  it  is  red, 
it  bleeds  much  less  than  its  color  might  seem  to  promise,  if  we  divide  it  with 
the  lancet,  with  the  view  of  taking  away  blood.  It  is  always  drier  than  in 
the  healthy  state,  and  looks  as  if  it  were  skinned  over.  The  caruncula  lachry- 
raalis  has  a  dry,  smooth,  flat  appearance  ;  is  sometimes  whiter  than  natural ; 
and  is  often  so  much  shrunk  as  to  be  scarcely  recognizable.  In  some  instances, 
however,  I  have  seen  the  caruncula  hypertrophied,  and  secreting  purulent 
flakes,  which  lay  in  the  lower  sinus  of  the  conjunctiva.  The  puncta  are 
generally  contracted,  or  closed ;  sometimes,  however,  dilated  and  paralyzed. 
The  cornea  is  dull  and    nebulous,  with  red  vessels  running  over  it.     The 


624  CONJUNCTIVAL   XEROMA. 

eyelashes  are  few  and  dwarfish,  and  there  is  generally  some  degree  of  trichiasis 
or  of  eutropium.  Not  unfrequently  the  conjunctiva  is  observed  to  fall  into 
folds,  around  and  especially  above  the  cornea.  The  conjunctiva  often  presents 
frtena,  which  bind  the  lids  unnaturally  to  the  eyeball,  and  the  fissura  palpe- 
brarum is  shortened.  In  a  more  advanced  stage,  the  conjunctiva  is  greatly 
contracted,  so  that  its  sinuses  are  nearly  obliterated,  and  the  membrane  is 
continued  almost  directly  from  the  margin  of  the  lids  over  the  surface  of  the 
eye.  This  state  has  been  called  by  Ammon  Symhlepharon  posterius.^  If  the 
conjunctiva  is  touched  with  the  finger,  it  betrays  scarcely  any  sensibility. 
The  Meibomian  secretion  is  less  than  natural,  or  altogether  wanting.  The 
lids  move  incompletely,  and  with  pain.  The  patient  finds  it  difficult  to  open 
the  eye,  and  complains  of  its  feeling  dry  and  gritty.  If  he  is  excited  to  weep, 
no  tears  flow,  but  the  eye  becomes  red  and  painful,  while  no  such  effect  is 
produced  in  the  sound  eye.  The  sight  is  weak ;  but  becomes  somewhat 
stronger  and  clearer,  if  the  patient  wets  his  eye  with  saliva,  or  anoints  it 
with  a  little  oil  or  lard. 

Causes. — We  generally  find,  that  long-continued  inflammation  of  the  con- 
junctiva, has  preceded  conjunctival  xeroma.  "When  sudden,  it  arises  plainly 
from  the  action  of  escharotic  substances  on  the  conjunctiva,  such  as  quicklime. 
Whether  the  cause  acts  suddenly  or  slowly,  it  seems  indubitable,  both  from 
the  aspect  of  the  membrane  and  the  other  symptoms,  that  the  structure  of  the 
conjunctiva  is  so  altered,  that  its  power  of  secreting  epithelium  or  mucus  is 
partially  or  entirely  lost.  The  kind  of  inflammation  most  apt  to  lead  to  this 
change,  is  the  scrofulo-catarrhal ;  but  it  may  also  follow  any  chronic  conjunc- 
tivitis, scrofulous,  catarrhal,  or  contagious.  Dr.  Amraon  suggests,  that  gran- 
ular conjunctiva  subsiding,  the  membrane  is  disposed  to  fall  into  xeroma.  The 
one  is  an  hypertrophy,  the  other  an  atrophy,  of  the  mucous  tissue.  I  am  inclined 
to  think,  that  the  most  frequent  origin  of  the  disease  is  either  a  totally  neglected 
scrofulo-catarrhal  ophthalmia,  or  one  treated  only  with  stimulants,  such  as 
red  precipitate  salve,  nitrate  of  silver  salve,  and  the  like.  Instead  of  abating 
the  conjunctival  inflammations  by  proper  soothing  and  emollient  applications, 
and  by  the  local  detraction  of  blood,  it  has  unfortunately  become  a  too  com- 
mon practice  to  use  only  stimulants  and  escharotics,  and  some  of  these  so 
strong  that  they  probably  destroy  the  mucous  texture  of  the  membrane  to 
which  they  are  applied ;  an  effect  followed,  after  some  time,  by  the  conversion 
of  the  conjunctiva  into  a  mere  cuticular  covering.  Saturnine  applications 
are,  probably,  in  many  cases,  the  cause  of  xeroma  ;  for  if  the  least  excoriation 
exists  on  the  conjunctiva,  the  lead,  precipitated  by  the  muriatic  acid  which 
exists  in  the  tears  and  conjunctival  mucus,  instantly  fixes  on  the  excoriated 
spot,  renders  it  white  and  dry,  and  continues  long  or  permanently  adherent 
to  it.  Not  unfrequently,  we  observe,  in  xeroma,  numerous  opaque  spots  on 
the  cornea,  apparently  depositions  of  lime  or  lead. 

I  do  not  deny,  however,  that  inflammation  alone  may  destroy  the  power  of 
the  conjunctiva  to  secrete  its  natural  epithelium.  We  see  the  mucous  mem- 
brane of  the  tongue  partially  changed  in  a  similar  way,  independently  of  any 
astringent  or  escharotic  applications,  so  that  it  presents  numerous  white, 
skinny,  unalterable  patches. 

Dr.  Ammon,  finding  xeroma  often  attended  by  entropium,  has  come  to 
the  conclusion  that  the  operation  of  removing  a  fold  of  skin  for  the  cure  of 
the  latter,  may  often  be  the  cause  of  the  former,  the  excision  being  made  too 
deep,  and  the  consequent  inflammation  extending  to  the  lachrymal  ducts.  But 
it  is  a  sufficient  answer  to  this  notion,  that  we  meet  (as  in  Mackinnon)  with 
this  disease  of  the  conjunctiva  in  subjects  who  have  never  undergone  any  such 
operation,  and  even  in  some  who  have  had  no  inversion  of  the  eyelids.  That 
the  lachrymal  ducts  are  sometimes  closed  in  xeroma,  I  do  not  mean  to  deny ; 


ANCHYLOBLEPHARON  AND   SYMBLEPH ARON,  625 

on  the  contrary,  I  think  there  is  good  ground  for  believing  that  lachrymal  and 
conjunctival  xeroma  are  often  conjoined  ;  but  may  not  the  same  chronic 
mismanaged  inflammation,  or  the  same  violent  escharotic  applications  Mhich 
destroy  the  secreting  pores  of  the  conjunctiva,  close  also  the  mouths  of  the 
lachrymal  ducts  ?  Would  mere  closure  of  these  ducts,  with  an  otherwise  healthy 
conjunctiva,  give  rise  to  the  disease  now  under  our  consideration  ?  I  believe 
not ;  and  Dr.  Ammon  seems  inclined  to  the  same  opinion.  It  is  the  mucus 
of  the  conjunctiva,  and  not  the  tears,  which,  under  ordinary  circumstances, 
keeps  the  eye  moist  and  the  cornea  pellucid.  The  moisture  of  the  eye  and 
the  clearness  of  the  cornea  are  preserved,  even  after  the  lachrymal  gland  is 
extirpated.  But  let  the  conjunctiva  be  deprived  of  its  secreting  faculty, 
not  merely  does  the  patient  complain  of  a  feeling  of  dryness  in  the  eye,  and 
move  it  with  difficulty  ;  but  the  membrane  looks  like  the  skin  on  the  back  of 
the  hand  ;  and  the  cornea,  no  longer  guarded  against  the  effects  of  air,  dust, 
and  light,  becomes  opaque.  In  one  case  which  fell  under  my  observation, 
the  epithelium  of  the  cornea  presented  an  appearance  as  if  it  had  been  a  piece 
of  silk  paper  laid  on  the  surface  of  the  eye. 

Prognosis. — The  prognosis  in  conjunctival  xeroma  is  bad.  If  the  disease 
is  not  checked,  blindness  will  be  the  result,  from  the  cornea  becoming  dry 
and  opaque. 

Treatment. — Dr.  Ammon  found  cold  applications  hurtful  in  this  disease. 
Tepid  ones  should  be  used,  and  ought  to  bear  some  resemblance,  in  physical 
and  chemical  properties,  to  the  secretion  which  the  eye  has  lost,  and  which 
there  is  little  hope  of  its  recovering.  The  patient  sees  better  when  the  sur- 
face of  the  cornea  is  moistened  with  some  such  collyrium  as  that  recommended 
(page  122)  for  lachrymal  xeroma.  Mr.  Cadenhead,  of  Aberdeen,  communi- 
cated to  me  a  case  of  xeroma,  in  which  the  cornese  appeared  dry,  shrunk, 
and  opaque,  till  a  little  prepared  lard  was  daily  applied  to  the  eyes,  on  which 
they  regained  their  transparency  so  much  as  to  enable  the  patient  to  wander 
through  the  town,  to  examine  small  objects  which  might  be  met  with  in  shop- 
windows,  and  even  to  read  large  print.  Mr.  Taylor,  of  London,  has  recom- 
mended^ glycerine  for  the  same  purpose,  frequently  employed  through  the 
course  of  the  day;  it  both  serves  to  restore  a  degree  of  transparency  to  the 
cornea,  and  relieves  the  disti'essing  sensations  of  heat  and  dryness.  If  the 
conjunctiva,  be  very  red,  local  bloodletting  will  afford  considerable  relief. 
The  general  health  is  carefully  to  be  attended  to  ;  not  neglecting  the  trichiasis, 
entropium,  and  other  occasional  local  attendants  on  this  affection  of  the  con- 
junctiva. Any  small  portion  of  the  conjunctiva  bulbi,  falling  into  a  fold  as 
the  eye  is  moved,  and  causing  irritation,  may  with  propriety  be  snipped  away, 
Dividing  the  conjunctival  frena  is  of  no  use. 


'  For  Lachrymal  Xeroma  or  Xerophthalmia,  p.  fi5 ;  Dresden,  18.30;  Vol.  ii.  pp.  381,  412; 

see  page  121.  Dresden,  1832. 

^  Synopsis  of  the  Diseases   of  the   Eye,  p.  "  lb.;   Vol.   iii.    Taf.   iv.   Fig.  4;   Dresden, 

120:  London,  1820.  1833. 

'  Ueber  die  Krankheiten  des  Thranenorgans,  °  Edinburgh  Medical  and  Surgical  Journal; 

p.  55;  Wiec,  1803.  Vol.  Ixxxi.  p.  33;  Edinburgh,  1854. 

*  Zeitschrift  fiir  die  Ophthalmologic ;  Vol.  i. 


SECTION  Vin. — ANCHYLOBLEPHARON  AND  SYMBLEPHARON. 
Fig.  Ammon,  Thi.  IL  Taf.  VL  Figs.  1-14.     Walton,  Figs.  15,  13,  14. 

A  union  of  the  edges  of  the  eyelids,  anchylohlepharon,  and  a  union  of  the 
eyelids  to  the  globe  of  the  eye,  symblepharon,  are  two  diseased  states  which 
occur  separately  or  together. 
40 


626  ANCHYLOBLEPHAEON  AND   SYMBLEPHARON. 

The  edges  of  the  lids  may  unite  in  their  whole  length,  or  only  in  part  of 
tiieir  extent,  and  that  generally  at  their  temporal  extremity.  It  is  rarely  the 
case  that  there  is  not  an  opening  left  at  their  nasal  angle.  Symblepharon 
mav  also  be  complete  or  incomplete ;  the  front  of  the  eyeball  being  united  with 
the  whole  of  one  or  of  both  eyelids,  or  a  similar  connection  existing  only  in  a 
small  extent.  These  modifications  have  considerable  influence  upon  the 
prognosis  and  method  of  cure ;  less,  however,  than  the  following.  In  some 
cases,  the  injured  edges  of  the  eyelids,  or  the  surfaces  of  the  eyeball  and  eye- 
lids in  a  partially  ulcerated  or  sloughy  state,  being  left  in  apposition,  a  firm 
and  unyielding  cicatrice  joins  together  the  structures  which  were  formerly 
free.  In  other  cases,  the  injury  being  more  superficial,  coagulable  lymph  is 
effused  between  the  two  edges  or  two  surfaces,  and,  becoming  organized, 
forms  the  morbid  connection.  When  the  lids  are  united  in  such  a  manner,  a 
whitish,  uninterrupted,  firm  membrane  obliterates  their  natural  opening;  and 
when  the  eyeball  is  adherent  to  one  or  both  lids  in  this  way,  the  organized 

coagulable  lymph  presents  itself  in  bands  of 
Fig-  75.  almost  tendinous  texture,  stretching  from  the 

one  surface  to  the  other  (Fig.  75).  Some- 
times there  is  only  one  insulated  band  of  ad- 
hesion, behind  which  the  probe  may  be  passed. 
These  bands  may  be  compared,  in  some  re- 
spects, to  the  partial  adhesions  so  frequently 
met  with  between  the  pleura  which  covers 
the  lungs  and  that  which  lines  the  chest ;  but 
in  one  respect  they  are  essentially  different ; 
namely,  that  as  the  pleura  is  a  serous  mem- 
brane, adhesions  in  the  thorax  may  take 
place  even  upon  slight  inflammation,  whereas 
the  conjunctiva,  following  the  laws  to  which 
all  mucous  membranes  are  subject,  never  ad- 
heres in  the  manner  described,  so  long  as  it  continues  entire.  Were  mucous 
membranes  subject  to  the  same  conditions  as  serous  membranes  in  this  respect, 
the  dangers  to  wliich  life  is  exposed  would  be  greatly  increased,  as  adhesions 
between  the  opposite  sides  of  all  the  hollow  viscera  w'ould  be  continually 
taking  place.  Nature  has  therefore  provided  that  no  mucous  membrane  can 
become  adherent,  so  long  as  its  surface  continues  entire ;  and  accordingly  we 
find  that,  till  it  is  wounded,  or  becomes  excoriated,  ulcerated,  or  partially 
destroyed  by  sloughing,  the  eyeball  never  contracts  adhesions  to  the  eyelids. 
I  have  seen  few  cases  of  symblepharon  in  which  the  cornea  was  not  more  or 
less  involved.  It  is  the  lower  half  of  the  cornea  which  is  most  apt  to  suffer. 
In  a  case  which  came  under  my  care,  an  upper  segment  of  eacli  cornea 
remained  free  and  transparent,  more  than  the  lower  half  of  each  being  incor- 
porated with  the  lower  eyelid,  in  consequence  of  a  burn.  The  pupils  being 
obliterated,  I  formed  an  artificial  pupil  in  each  eye,  by  separating  the  iris 
from  the  choroid,  behind  the  upper  portion  of  the  cornea. 

Causes. — Anchyloblepharon  and  symblepharon  are  chiefly  owing  to  such 
traumatic  inflammations  as  arise  from  burns,  or  from  the  influence  of  such 
substances  as  produce  an  escharotic  effect;  although  any  ophthalmia,  pro- 
ductive of  excoriation  or  ulceration,  may  give  rise  to  these  consequences. 
They  occur  most  frequently  in  those  whose  eyes  have  been  injured,  and  partial 
sloughing  produced,  by  hot  pieces  of  metal,  boiling  fluids,  concentrated  acids, 
or  quicklime.  Wounds  penetrating  through  one  or  other  of  the  eyelids  into 
the  eyeball  are  apt  to  give  rise  to  partial  symblepharon. 

Case  304. — I  saw  a  lad  at  the  Glasgow  Eye  Infirmary,  whose  left  eye,  along  with  the 
edges  of  the  left  eyelids,  had  sloughed  in  consequence  of  a  burn  from  melted  iron,  a  piece 


ANCHYLOBLEPHARON   AND   SYMBLEPHARON.  627 

of  which,  when  he  applied  at  the  infirmarj',  was  found  moulded  in  the  lower  fold  of  the 
conjunctiva.  The  destruction  of  the  eyeball,  and  partially  of  the  eyelids,  was  followed 
by  symblepharon,  and  almost  complete  anchyloblepharon,  the  only  part  of  the  eyelids 
which  was  open,  being  at  the  temporal  angle,  where,  through  an  interstice  about  a  line 
long,  the  tears  distilled. 

Prognosis. — The  prognosis  is  various,  and  depends  upon  the  possibility  of 
completely  separating  the  morbid  adhesions,  the  chance  of  preventing  them 
from  returning,  and  the  apparent  or  presumed  state  of  the  cornea. 

The  operation  for  anchyloblepharon  can  be  performed  with  a  reasonable 
hope  of  success  only  when  it  is  not  complicated  with  symblepharon ;  or  if  the 
latter  be  present,  when  it  is  inconsiderable  in  extent,  and  does  not  involve  the 
cornea.  There  are  various  means  of  ascertaining  the  facts.  One  is,  to  take 
hold  of  a  fold  of  the  upper  eyelid,  and  drawing  it  from  the  eyeball,  desire  the 
patient  to  move  the  eye  as  much  as  he  can  from  side  to  side,  and  as  if  he  were 
opening  and  shutting  his  eyes.  By  this  means  we  are  likely,  not  merely  to 
discover  the  existence,  but  to  ascertain  pretty  correctly  the  extent,  of  any 
adhesion  between  the  eyeball  and  eyelids.  A  second  means  is  the  introduc- 
tion of  a  small  probe  at  the  nasal  angle  of  the  lids.  If  there  be  no  symble- 
pharon, the  probe  passes  on  with  ease  to  the  temporal  angle;  whereas,  when 
adhesion  exists,  the  opposition  to  the  point  of  the  instrument  informs  us  of  the 
situation  and  extent  of  the  morbid  connection.  A  good  deal  may  be  ascer- 
tained, also*,  by  observing  the  degree  of  sensibility  to  light  which  remains.  If 
the  patient  with  anchjdoblepharon  be  able  to  distinguish  various  gradations  of 
light,  it  is  probable  that  no  morbid  adhesion  involves  the  cornea,  and  that  this 
part  remains  transparent.  If  he  distinguishes  only  the  more  considerable 
changes  of  light,  while  the  slighter  gradations  escape  him,  we  must  operate 
in  a  degree  of  uncertainty  regarding  the  state  of  the  cornea.  It  may  not  be 
adherent,  but  is,  perhaps,  in  some  measure  opaque.  If  there  is  no  sensibility 
to  light,  we  may  conclude,  either  that  the  adhesion  extends  to  the  whole  sur- 
face of  the  cornea,  and  probably  includes  even  a  considerable  portion  more  of 
the  surface  of  the  eyeball,  or  at  least  that  the  cornea,  by  the  same  inflammation 
which  produced  the  anchyloblepharon,  has  been  rendered  completely  opaque; 
and  that  therefore  the  great  object  of  an  operation,  namely,  the  restoration  of 
sight,  cannot  be  obtained. 

We  will,  of  course,  recommend  the  patient  to  undergo  an  operation  when  the 
case  appears  to  be  a  simple  anchyloblepharon,  and  we  judge  that  the  surface 
of  the  eyeball  has  either  not  suffered  at  all,  or  has  suffered  but  little  from  the 
inflammation  in  which  the  anchyloblepharon  has  originated.  On  the  contrary, 
when  the  sensibility  to  light  is  extremely  indistinct  or  altogether  wanting,  or 
even  though  the  sensibility  to  light  be  considerable,  if  the  eyeball  feels  to  the 
finger  through  the  eyelid,  larger  or  smaller,  harder  or  softer  than  natural,  or 
quite  irregular  on  its  surface,  we  will  be  cautious  in  recommending  any  opera- 
tion, as  the  patient  would  thank  us  but  little  if  we  merely  brought  into  view 
a  useless  and  destroyed  eye,  which  had  formerly  been  concealed. 

There  is  one  reason,  however,  which  may  sometimes  lead  us  to  operate  for 
symblepharon,  altogether  independently  of  any  hope  of  restoring  sight.  If 
the  one  eye  is  sound  and  the  other  afiTected  with  this  morbid  union,  the  patient, 
on  attempting  to  look  from  side  to  side,  experiences  a  feeling  of  dragging  in 
the  eye  affected  with  symblepharon,  which  restrains,  in  some  measure,  the  exer- 
cise even  of  the  sound  eye.  To  relieve  this,  and  with  no  view  of  restoring  the 
sight,  I  have  been  solicited  to  separate  the  eyeball  from  morbid  connections 
with  the  eyelids. 

When  the  vision  of  the  eye  affected  with  symblepharon  is  good,  the  patient 
is  apt  to  complain  of  diplopia,  when  he  turns  the  eye  so  that  he  puts  the  ad- 
hesion on  the  stretch ;  and  on  this  account  he  is  sometimes  desirous  of  sub- 
mitting to  an  operation. 


628  ANCHYLOBLEPHARON  AND   SYMBLEPHARON. 

We  sometimes  meet  with  symblepharon  combined  with  staphyloma ;  and 
here  we  are  obliged  to  operate  without  any  reference  to  restoration  of  vision, 
which  in  such  circumstances  is  out  of  the  question.  The  lids,  bound  down  to 
the  cornea,  resist  the  growing  staphyloma,  and  thereby  cause  a  great  degree 
of  pain,  which  we  relieve  for  a  time  by  puncturing  any  part  of  the  eye  which 
is  in  view;  but  the  puncture  soon  closes,  the  staphyloma  again  presses  against 
the  lids,  the  pain  and  fever  return,  and  to  give  permanent  relief  we  are  forced, 
first,  to  operate  for  the  symblepharon,  and  then  immediately  to  remove  the 
staphyloma.  It  would  appear  that,  in  cases  of  this  kind,  a  fistulous  communi- 
cation sometimes  forms  between  the  staphyloma  and  the  areolar  tissue  of  the 
upper  eyelid,  so  that,  from  time  to  time,  the  eyelid  becomes  greatly  distended 
and  the  whole  organ  painful.  On  puncturing  the  swelling,  a  large  quantity 
of  what  seems  aqueous  humor  is  discharged.  This  relieves  the  patient  till  the 
fluid  again  accumulates ;  but  permanent  relief  can  be  obtained  only  by  ex- 
posing the  front  of  the  eye,  and  excising  it.  In  cases  like  this,  it  is  sometimes 
doubtful  whether  the  fluid  accumulated  in  the  upper  eyelid,  is  not  derived 
rather  from  the  lachrymal  gland  than  from  the  interior  of  the  eye,  the  symble- 
pharon preventing  the  tears  from  escaping. 

Treatment. — 1.  The  operation  for  anchylohlepharon  requires  to  be  per- 
formed somewhat  differently,  according  as  the  eyelids  are  ixnited  immediately 
or  through  the  medium  of  a  pseudo-membrane.  If  they  are  united  immediately, 
and  there  is  no  sufficient  aperture  at  their  nasal  extremity  for  introducing  a 
small  grooved  director,  the  assistant  takes  hold  of  the  upper  lid  between  his 
finger  and  thumb,  so  as  to  form  a  vertical  fold,  which  he  raises  as  much  as 
possible  from  the  eyeball,  while  the  operator,  with  his  left  hand,  does  the  same 
to  the  lower  lid.  With  a  scalpel  the  operator  now  divides  the  fold  which  is 
thus  formed,  by  a  transverse  incision  to  the  extent  of  2  or  3  lines,  exactly  in 
the  course  of  the  natural  opening  of  the  lids.  Through  the  incision  thus  made, 
the  director  being  passed  and  run  along  to  the  inner  angle  of  the  lids,  the 
nasal  portion  of  the  anchyloblepharon  is  to  be  divided  on  the  director,  which 
is  then  to  be  shifted  so  as  to  allow  the  temporal  portion  to  be  treated  in  the 
same  way.  After  the  central  opening  is  made  in  the  manner  described,  the 
rest  of  the  operation  may  be  i)erformed  with  scissors.  If  the  lids  present  a 
considerable  opening  at  their  inner  angle,  the  director  is  at  once  introduced 
through  this  and  the  anchyloblepharon  divided. 

When  the  edges  of  the  lids  are  united  by  pseudo-membrane,  we  perform, 
first  of  all,  an  operation  similar  to  the  above,  only  that  we  make  the  incision 
close  to  the  edge  of  the  lower  eyelid,  leaving  the  whole  of  the  pseudo-mem- 
brane attached  to  the  upper;  then  laying  hold  of  the  membrane  with  forceps, 
we  remove  it  with  the  scissors. 

The  success  of  the  operation  depends  upon  our  preventing  reunion  of  the 
separated  lids,  or  in  other  words,  upon  their  edges  becoming  quickly  skinned 
over.  To  secure  this,  Mr.  Walton  suggests,*  that  the  surfaces,  being  well  dried, 
should  be  touched  with  collodion. 

Dr.  Schindler  relates'^  a  case  which  he  cured  by  embracing  the  anchyloble- 
pharon in  two  ligatures,  which  made  their  way  through  by  the  third  day. 

2.  When  a  case  of  symblepharon  ])vesenis  itself  uncomplicated  with  anchy- 
loblepharon, it  is  not  difficult  to  determine  whether  we  can  undertake  an  ope- 
ration with  hopes  of  success.  We  see  distinctly  in  what  condition  the  cornea 
is,  and  can  judge  what  are  likely  to  be  the  effects  of  dividing  the  morbid  ad- 
hesions. When  the  symblepharon  is  insulated,  so  that  we  can  pass  a  probe 
round  it,  a  cure  is  always  accomplished  by  operation.  When  the  adhesion  is 
continued  back  to  the  angle  of  reflection  of  the  conjunctiva,  the  result  of  an 
operation  is  uncertain.  When  the  adhesion  is  very  extensive,  interference  is 
useless 


ANCHYLOBLEPHARON  AND   SYMBLEPHARON.  629 

Considerable  as  is  the  liability  of  anchyloblepharon  to  recur  after  opera- 
tion, here  it  seems  impossible  to  prevent,  at  least  to  a  certain  extent,  the 
gradual  readherence  of  the  divided  parts.  "We  need  not  expect,  therefore, 
to  perform  the  operation,  without  the  reappearance  of  some  bands  of  adhe- 
sion, which  will  require  to  be  removed  by  a  second  operation,  except  where 
the  symblepharon  is  a  mere  insulated  tag.  When  this  is  the  case,  the  adhe- 
sion may  be  clipped  through  with  scissors,  or  divided  by  the  application  of  a 
ligatui'e. 

Case  305. — Hildanus  records  a  case  of  partial  union  of  the  upper  eyelid  to  the  eyeball, 
the  consequence  of  a  wound  through  the  eyelid  with  a  sword,  which  at  the  same  tinae 
touched  the  cornea  and  deprived  the  eye  of  sight.  The  patient  was  afraid  of  allowing  the 
adhesion  to  be  divided  with  the  knife,  lest  the  eye  should  be  opened  and  the  humors  evac- 
uated. As  a  probe  could  be  passed  behind  the  symblepharon,  Hildanus  surrounded  it 
with  a  silk  thread,  to  which  he  appended  a  small  leaden  weight.  The  symblepharon  was 
divided  by  the  pressure  of  the  thread,  between  the  eighth  and  ninth  day.' 

If  the  union  be  immediate,  the  assistant  draws  the  upper  eyelid  upwards, 
and  from  the  eyeball  as  much  as  possible,  while  the  operator  draws  the  lower 
eyelid  downwards,  in  order  that  the  united  places  being  brought  into  view  in 
their  whole  extent,  and  put  on  the  stretch,  may  be  the  more  easily  and  accu- 
rately divided.  This  is  to  be  accomplished  with  a  small  scalpel.  The  front 
of  the  union  is  always  the  firmest  part,  the  interior  being  the  looser.  During 
the  separation  we  must  avoid  injuring  the  cartilages  of  the  eyelids  on  the  one 
hand,  and  the  sclerotica  and  cornea  on  the  other.  The  divided  surfaces  must 
be  smeared  frequently  with  tutty  ointment,  and  the  tendency  to  reunion  pre- 
vented, as  much  as  possible,  by  daily  tearing  through,  with  the  point  of  a  probe, 
any  false  membrane  which  may  appear  to  be  forming. 

If  the  symblepharon  exists  through  the  medium  of  bands  of  organized  co- 
agulable  lymph,  after  putting  the  parts  on  the  stretch,  as  in  the  last  case,  we 
must  endeavor  to  cut  away  the  bands  close  to  the  eyeball,  and  then,  laying  hold 
of  them  with  forceps,  dissect  them  from  the  eyelids.  After  this  is  finished, 
following  the  suggestion  of  Mr.  Wilde,*  the  edges  of  the  divided  conjunctiva, 
on  the  lid  and  on  the  globe,  ought  severally  to  be  brought  together  by  sutures. 
This  seems  the  most  effectual  mode  of  preventing  a  relapse  ;  and  as  Mr.  Wal- 
ton remarks,^  if  there  is  not  a  sufficiency  of  conjunctiva  in  the  band  of  adhe- 
sion to  allow  the  edges  of  the  wound  to  be  so  approximated,  little  is  to  be 
hoped  from  the  operation. 

The  following  method  has  been  communicated  to  me  by  Mr.  Hunt,  of  Man- 
chester. Instead  of  dissecting  away  the  adhesion,  Mr.  H.  makes  a  puncture 
through  it ;  and  by  passing  a  probe  through  the  wound  every  day,  he  prevents 
its  closure.  This  is  to  be  done  till  there  is  no  more  suppm-ation  at  any  part 
of  the  edges  of  the  wound,  which  is  now  become  callous.  A  knife  is  then  to 
be  introduced  through  the  opening,  and  the  remaining  adhesion  cut  across. 

M.  Petrequin  proposes  to  pass  a  double  ligature  through  the  adhesion,  tying 
the  one  towards  the  eyelids  loosely,  but  that  towards  the  eyeball  firmly,  so  as 
speedily  to  cut  through  the  band,  and  leave  a  surface  ready  to  cicatrize.  As 
soon  as  this  is  accomplished,  the  remaining  ligature  is  tightened,  and,  dropping 
off,  leaves  a  second  surface  to  heal  by  cicatrization.^ 

In  the  following  case,  a  peculiar  method  of  operating  was  followed  by  M. 
Blandin  : — 

Case  306. — Inconsequence  of  extensive  ulceration  of  the  conjunctiva  of  the  eyeball  and 
lower  lid,  from  a  burn,  the  cartilage  of  the  lid  was  destroyed,  adhesions  formed  between 
the  globe  and  the  lid,  and  the  lower  half  of  the  cornea  was  covered  by  a  cicatrice.  M. 
Blandin  dissected  the  cicatrice  from  above  downwards,  so  as  to  remove  the  adhesion  of  the 
eyelid  to  the  eyeball ;  and  turning  the  dense  cicatrice  inwards,  converted  it  into  a  sub- 
stitute for  the  palpebral  mucous  membrane,  and  thus  prevented  a  new  adhesion  from  taking 
place.     The  cicatrice  was  in  fact  doubled  in,  like  a  hem,  and  retained  in  position  by  the 


630  SYNECHIA. 

glover's  suture,  while  the  two  extremities  of  the  thread  were  carried  horizontally  right  and 
left,  and  fixed  to  the  temples,  so  as  to  keep  the  border  of  the  lid  free  from  the  coi-nea,  and 
assist  in  obviating  any  faulty  cicatrization.  The  sutures  were  removed  on  the  fourth  day. 
Three  weeks  after  the  operation,  the  eye  had  quite  recovered  its  mobility,  and  could  be 
directed  towards  any  object,  while  the  eyelids  had  a  rounded  border,  and  though  rather 
short,  could  be  approached,  without  difficulty,  to  the  upper  lid,  so  as  to  eflFectually  defend 
the  eye  from  the  action  of  light.'' 

Araraon  and  Dieffenbach  have  each  invented  an  operation  for  symble- 
pharon. 

In  Ammon's  operation,  nothing  is  done,  in  the  first  instance,  to  the  symble- 
pharon  ;  but,  by  two  incisions  meeting  at  an  acute  angle,  the  adherent  lid  is 
divided  in  its  whole  thickness,  so  as  to  form  a  triangular  flap,  having  as  its 
basis  the  edge  of  the  lid,  and  including  the  symblepharon.  Over  this  trian- 
gular flap  the  two  remaining  portions  of  the  lid  are  then  stretched,  and  brought 
together  by  the  twisted  suture.  They  unite  to  one  another,  but  not  to  the 
subjacent  flap,  on  the  inside  of  which  is  the  symblepharon.  At  the  end  of 
fifteen  or  twenty  days,  when  the  union  is  consolidated,  the  second  part  of  the 
operation  is  performed ;  Avhich  consists  in  dissecting  out  the  triangular  flap, 
which  has  been  left  adherent  to  the  globe  of  the  eye.  After  each  operative 
proceeding,  compresses  wrung  out  of  iced  water  are  to  be  applied  over  the 
eye,  to  moderate  inflammation.^ 

Dieff"enbach's  method  consists  in  folding  in  the  eyelid,  so  that  its  cutaneous 
surface  is  brought  into  contact  with  the  globe  of  the  eye  after  the  morbid 
union  is  divided.  If  it  is  the  lower  sinus  of  the  conjunctiva,  for  instance, 
which  is  affected,  he  makes  an  incision  from  the  inner  angle  of  the  eye  along 
by  the  side  of  the  nose,  and  another,  likewise  vertical,  from  the  outer  angle  to 
the  lower  outer  edge  of  the  orbit.  He  then  detaches  the  lid  from  the  globe 
of  the  eye,  by  dividing  the  symblepharon,  and  shaves  off  the  cilia.  He  next 
folds  in  the  quadrilateral  flap  upon  itself,  so  as  to  produce  a  complete  entro- 
pium,  and  fi.xes  it  by  sutures  ;  four  are  generally  required.  They  are  sup- 
ported by  strips  of  adhesive  plaster,  and  the  parts  are  covered  by  a  fomenta- 
tion. When  the  globe  of  the  eye  is  once  cicatrized,  the  artificial  entropium 
is  to  be  removed,  and  the  flap  fixed  again  in  its  original  situation  by  sutures.^ 

It  may  be  doubted  whether  the  deformity  which  must  result  from  such 
operations,  will  not  counterbalance  the  gain  to  be  obtained  from  the  cui'e  of 
the  symblepharon. 


^  Operative    Ophthalmic    Surgery,    p.    129  ;  '  Op.  cit.  p.  123. 

London,  1853.  *  Revue  Ophthalmologique  de  la  Litterature 

"  Ammon's  Zeitschrift  fiir  die  Ophthalmolo-  Medicale  de  I'Annee  1842,  p.  57 ;   Bruxelles, 

gie  ;  Vol.  V.  p.  59  ;  Heidelberg.  1836.  1843. 

'  Guilhelmi  Fabricii  Hild.nni  Opera  Omnia;  ''  Quoted  from  the  Gazette  Medieale  de  Paris 

p.  502  ;  Francofurti  ad  Ma?num,  1646.  pour  1846,  in  Walton,  Op.  cit.  p.  123. 

*  Dublin  Quarterly  Journal  of  Medical  Sci-  '  Op.  cit.;  iii.  p.  258;  Dresden,  1833. 

ence,  February,  1847,  p,  233.  °  Operative  Chirurgiej  Vol.  i,  p.  482  j  Leip- 
zig, 1845. 


SECTION  IX. — SYNECHIA. 

2uv6;^6(a,  conlinuily,  from  irvvix_<»j  I  f^old  together. 

The  term  synechia  is  employed  to  signify  any  morbid  adhesion  of  the  iris. 
When  the  adhesion  is  to  the  cornea,  it  is  termed  synechia  anterior.  (Fig, 
65,  p.  4V7).  This  may  result  from  a  penetrating  wound  of  the  cornea,  from 
ulcerative  inflammation  of  that  part,  ending  in  perforation  of  the  anterior 
chamber,  and  escape  of  the  aqueous  humor ;  and  even  from  inflammation  of 


OBLITERATION   OF   THE   PUPIL.  631 

the  cornea  or  iris,  without  any  perforation  of  the  former.  When  the  adhe- 
sion is  to  the  capsule  of  the  crystalline  lens,  it  is  termed  synechia  posterior. 
(Figs.  68  and  69,  p.  524.)     This  is  a  frequent  consequence  of  iritis. 

In  synechia  anterior  of  limited  extent,  the  adhesion  may  sometimes  be 
separated  by  means  of  a  needle  introduced  through  the  cornea,  or  the  adher- 
ent part  may  be  cut  across,  as  I  shall  explain  more  fully  under  the  head  of 
Artificial  jmpil. 

In  synechia  posterior,  even  when  apparently  the  whole  circumference  of 
the  contracted  pupil  is  embraced  in  the  adhesion,  it  sometimes  happens  in 
the  course  of  months,  or  years,  that  a  minute  portion  of  the  edge  of  the  pupil 
becomes  free,  and  a  restoration  to  vision  unexpectedly  takes  place. ^  In  the 
case  of  an  old  man  about  whom  I  was  consulted,  a  separation  of  this  kind, 
seemed  to  have  happened  to  the  whole  circumference  of  the  pupil,  twenty 
years  after  the  iritis  which  closed  that  aperture.  It  is  probable  the  vitreous 
humor  having  dissolved,  the  lens,  enclosed  in  its  capsule,  had  fallen  down 
behind  the  iris,  as  after  the  patient's  vision  was  suddenly  restored,  the  pupil 
appeared  somewhat  dilated,  and  the  iris  tremulous. 

Laceration  or  absorption  of  the  iris  near  its  great  circumference  is  another 
phenomenon  which  we  occasionally  witness,  especially  in  anterior  synechia. 
The  iris  is  on  the  stretch,  and  gives  way  or  is  absorbed,  at  one  or  more  points, 
so  that  vision  is  improved.  According  to  the  number  of  holes  which  have 
been  formed,  vision  is  sometimes  rendered  double,  or  triple. 


'  Siemerling's  merkwurdiger  Fall  einer  viel-     Blindheit  eines  92  jahrigen  Greises;   Berlin, 
jahrigen   von    der  Natur   zweimal   gehobenen     1818. 


SECTION  X. — OBLITERATION  OF  THE  PUPIL. 
Syn. — Phthisis  pupillse. 

It  has  been  fully  explained,  in  the  19th  and  following  sections  of  the  pre- 
ceding chapter,  that  from  inflammation  of  the  iris  the  pupil  is  apt  to  become 
narrowed,  misshapen,  fixed,  and  filled  with  coagulable  lymph ;  a  state  of  parts  to 
which  the  terms  atresia^  iridis,  and  synizesis"^  have  been  applied.  Under  these 
circumstances,  the  capsule,  within  the  verge  of  the  contracted  pupil,  is  either 
opaque  or  covered  with  opaque  deposition,  and  to  this  the  whole  of  the  pupil- 
lary margin  of  the  iris  is  in  general  firmly  adherent,  although  not  unfrequently 
a  small  part  of  it  is  free.  The  texture  of  the  iris,  in  such  cases,  is  apt  to  be 
so  softened  by  inflammation,  as  to  tear,  if  laid  hold  of  by  a  hook  or  other 
instrument.  An  important  fact,  observed  by  Mr.  Bowman,  is  that,  in  syni- 
zesis,  generally  "the  body  of  the  lens  retains  its  transparency,  and  the  cap- 
sule remains  perfectly  clear,  except  within  the  area  of  the  pupil. "^ 

Through  the  thin  web  of  lymph,  which  occupies  the  contracted  pupil,  a 
very  considerable  share  of  vision  may  be  enjoyed. 

The  use  of  belladonna  in  cases  of  closure  of  the  pupil,  ought  not  to  be 
hastily  abandoned,  especially  if  any  portion  of  the  pupillary  margin  remains 
free.  The  filtered  aqueous  solution  of  belladonna,  or  the  solution  of  atropine, 
dropped  upon  the  conjunctiva  once  or  twice  a  day,  and  continued  for  several 
months,  is  often  followed  by  some  degree  of  dilatation  of  the  pupil,  and  con- 
siderable improvement  in  vision.  The  internal  and  long-continued  use  of 
iodine  also  appears  to  be  useful. 

Dr.  Lorch  relates*  an  interesting  case  of  synizesis,  accompanied  by  three 
separate  protrusions  of  the  iris  through  as  many  ulcers  of  the  cornea.     The 


632  OPACITIES   OP   THE   HYALOID   MEMBRANE. 

closure  of  the  pupil  was  complete,  and  the  eye  thereby  deprived  of  sight.  As 
the  prolapsed  portions  of  the  iris  shrunk  and  the  ulcers  healed,  the  pupil 
opened,  and  vision  was  restored. 

Woolhouse  attempted  with  a  needle,  introduced  through  the  sclerotica,  to 
divide  the  whitish  fibres  which  bind  down  the  iris,  and  to  open  up  the  closed 
pupil;  an  operation  which  he  termed  diceresis.^  The  want  of  success  attend- 
ant on  such  attempts,  probably  led  Cheselden  to  the  idea  of  forming  an  arti- 
ficial pupil.  Woolhouse  was  afraid  to  touch  the  uvea  or  the  iris  with  the 
needle.  Cheselden  freely  divided  these  parts,  and  his  boldness  and  ingenuity 
were  crowned  with  success. 


*  From  tt,  negative,  and  ^nfau,  I  perforate.  *  Aminon's  Zeitschrift   fiir  die  Ophthalmol- 

"^  Ivvi^riTtt,  from  a-uvi^u>,  [close.  ogie  ;  Vol.  v.  p.  40:  Heidelberg,  1835. 

'  Medical    Times  aud    Gazette,  January   3,         '  Mauchart,  De  Pupillaj  Phthisi  ac  Synizesi; 
1852,  p.  12.  Halleri  Disputationes  Chirurgieaa  Selectaj;  Vol. 

i.  p.  4fi8  ;  Lausannaj,  1755. 


SECTION   XI. — CATARACTS,    OR   SPECKS   OF   THE   CRYSTALLINE   CAPSULE 

AND   LENS. 

The  origin  of  these  sequelae  of  the  ophthalmite  has  been  fully  explained  in 
those  sections  of  the  last  chapter,  which  treat  of  iritis  and  inflammation 
of  the  crystalline  lens  and  capsule.  When  they  are  limited  to  the  area  of  the 
contracted  pupil,  an  extension  of  the  pupil  by  belladonna  or  by  operation, 
or  the  formation  of  an  artificial  pupil,  may  restore  vision.  When  they  extend 
to  the  whole  breadth  of  the  lenticular  body,  only  its  removal  by  operation  can 
be  of  any  avail. 


SECTION   XII. — OPACITIES   OP   THE   HYALOID   MEMBRANE. 

I  have  seen  three  or  four  cases  of  opacities,  which  I  judged  to  be  the  effects 
of  inflammation  on  the  vitreous  tissue.  They  were  generally  striated,  or 
ramose,  and  presented  a  funnel  shape.  In  one  case,  I  was  surprised  to  find 
the  patient  able  to  read  with  the  affected  eye. 

Caution  is  requisite  in  concluding  on  the  seat  of  opacities,  which  appear  to 
lie  deep  in  the  eye.  I  lately  operated  on  a  patient  who,  for  a  time,  presented 
a  funnel-shaped  striated  opacity,  apparently  at  a  considerable  depth  l)ehind 
the  lens  of  each  eye.  The  case  ended  in  lenticular  cataract.  There  was 
nothing  peculiar  in  the  appearances  of  the  extracted  lenses ;  the  deep-seated 
opacity  was  no  longer  visible  after  the  patient  recovered,  and  she  saw  perfectly. 
The  apparent  depth  of  the  striated  opacity  must  have  been  an  optical  decep- 
tion, attributable  to  the  effect  of  the  lens,  the  aqueous  humor,  and  the  cornea. 


SECTION  Xm. — SYNCHYSIS,    OR  DISSOLUTION  OP  THE   VITREOUS   HUMOR. 

2vy^v(ri;,  commixtion,  from  a-vyxya,  I  pour  together. 

Disorganization  aud  solution  of  the  hyaloid  tissue  follows  various  inflam- 
matory diseases  of  the  eye,  and  especially  those  of  the  choroid  and  iris.  This 
state  of  the  vitreous  body  is  totally  incurable,  and  comes  sooner  or  later  to 
be  accompanied  by  amaurosis.  When  the  vitreous  body  is  dissolved,  it  by  no 
means  follows  that  the  eye  becomes  soft  or  boggy ;  on  the  contrary,  it  often 


ATROPHY   OF   THE   EYE.  633 

feels  harder  tlian  natural,  owing  to  a  superabundant  quantity  of  fluid  occupy- 
ing tbe  place  of  the  vitreous  humor. 

M.  Desniarres^  has  given  the  name  of  sparhling  syncliysis  {synchysis  etince- 
lant)  to  that  condition  of  the  eye  in  which  minute,  glancing  crystals  of  choles- 
teriu  are  seen  moving  up  and  down  within  it ;  a  phenomenon  which  had  been 
observed  by  Parfait-Landrau,^  Dr.  Jacobj^*  and  myself;*  and  which  seems  oft- 
enest  to  be  the  result  of  the  breaking  up  of  a  traumatic  lenticular  cataract, 
but  to  the  existence  of  which,  dissolution  of  the  vitreous  humor  is  not  essen- 
tial. M.  Malgaigne^  was  the  first  to  suggest  that  the  particles  in  question 
consisted  of  cholesterin ;  a  view  of  the  matter  which  was  confirmed  by  the 
analysis  of  Professor  Aldridge,  in  a  case  operated  on  by  Mr.  Wilde."^ 


'  Annales  d'Oculistique,  Noveinbre,  1845;  p.  *  Edinburgh  Medical  and  Surgical  Journal; 

220.  July,  1845  ;  p.  73. 

*  llevue  M6dicale;  Tome  iv.  p.  203;  Paris,  '  Annales  d'Oculistique,  Novembre,  1845;  p. 

1828.  223. 

'  Dublin  Medical  Press,  January  25,  1843 :  ^  Dublin     Quarterly    Journal     of    Medical 

Ibid,  December  11,  1844.  Science;  May,  1848;  p.  498. 


SECTION   XIV. — ATROPHY   OP   THE   EYE. 

Syn. — Phthisis  oculi. 

Fuj.  Beer,  Band  II.  Taf.  II.  Fig.  7.    Demours,  PI.  LXI.  Fig.  1.    Ammon,  Thl.  I.  Taf.  I.  Figs.  24, 25. 

Certain  severe  or  long-continued  ophthalmise,  occurring  in  childhood,  are 
apt  to  impede  the  growth  of  the  eye,  so  that  it  remains  through  life  less  than 
the  average  size ;  or,  attacking  the  adult,  they  are  followed  by  abnormal 
absorption,  or  imperfect  regeneration  of  the  contents  of  the  eyeball,  and  a 
shrinking  of  its  coats.  We  often  see  the  cornea,  and  sometimes  the  whole 
eyeball,  continue  dwarfish,  after  the  scrofulous  varieties  of  ophthalmia,  and 
after  inflammation,  excited  by  injuries  of  the  eye,  in  scrofulous  subjects.  I 
have  seen  the  eye  shrink  to  less  than  half  its  size  from  Egyptian  ophthalmia, 
the  pupil  remaining  open,  though  not  larger  than  a  pin-hole,  and  the  cornea 
greatly  contracted,  yet  still  clear.  The  person  saw  none  with  the  eye  in  this 
state.  In  cases  of  syphilitic  iritis  it  sometimes  happens,  that  after  mercury 
has  caused  the  absorption  of  effused  lymph,  or  of  those  tubercles  which  rise 
upon  the  surface  of  the  iris,  there  follows,  in  consequence  of  the  altered  state 
of  the  internal  parts  of  the  eye,  such  a  degree  of  absorption  as  produces  flac- 
cidity  and  wasting  of  the  bulb,  which,  under  these  circumstances,  assumes  a 
square  form,  being  depressed  opposite  to  the  insertion  of  the  four  recti  muscles, 
while  the  pupil  closes,  the  cornea  shrinks  and  becomes  opaque,  and  the  eye 
sinks  back  in  the  orbit.  In  such  cases  the  atrophy  extends  to  the  optic  nerve, 
and  may  sometimes  be  traced,  on  dissection,  involving  the  opposite  tractus 
opticus  as  far  as  the  corpora  quadrigemina.*  Arthritic  iritis  is  also  frequently 
followed  by  atrophy  of  the  eye. 

Flexibility  of  the  cornea,  or  of  the  sclerotica,  is  one  of  the  surest  signs  of 
the  presence  or  of  the  previous  existence  of  retinitis,  and  is  evidently  owing 
to  a  diminution  in  the  contents  of  the  eyeball,  and  chiefly  of  the  vitreous 
humor.  When  the  retinitis  is  recent,  the  eyeball  may  regain  its  natural 
consistence,  under  the  influence  of  appropriate  treatment.  (See  p.  559.) 
When  the  internal  inflammations  of  the  eye  are  neglected,  along  with  total 
amaurosis  and  flexible  cornea,  the  case  is  apt  to  end  in  complete  absorption  of 
the  vitreous  humor;  while  the  retina,  having  become  opaque,  comes  into 


634  STAPHYLOMA   UVE^, 

view,  being  folded  together  into  the  form  of  a  cord  or  narow  funnel,  stretch- 
ing directly  forwards  from  the  optic  nerves  to  the  posterior  edge  of  the 
suspensory  ligament  of  the  crystalline.  A  watery  effusion  takes  place,  in 
such  circumstances,  between  the  choroid  and  the  coarcted  retina.  If  the  lens 
is  opaque  and  is  artificially  removed,  the  retina  comes  into  view  in  this  state. 
Generally,  however,  the  pupil  is  contracted  and  adherent.  On  dissecting 
such  eyes,  the  choroid  is  sometimes  found  partially  ossified.  Along  with  con- 
tracted pupil  it  is  not  uncommon  to  find,  in  atrophied  eyes,  the  lens  partially 
ossified.  Several  specimens  of  coarcted  retina,  ossified  choroid,  and  ossified 
lens,  in  atrophied  eyes,  I  have  now  before  me. 

It  is  not  in  scrofulous  subjects  alone  that  traumatic  ophthalmia  is  liable  to 
be  followed  by  atroi)hy.  Nor  is  it  necessary  that  the  injuries  should  be  severe 
to  produce  this  effect.  Even  the  wound  produced  by  the  introduction  of  a 
couching-needle,  is  sometimes  followed  by  such  inflammation  as  destroys  the 
secreting  powers  of  the  eye,  so  that  the  regeneration  of  the  humors  is  impeded, 
and  the  organ  shrinks. 

In  all  degrees  of  atrophy  of  the  eye  the  prognosis  is  unfavorable.  Even 
where  there  is  as  yet  no  apparent  diminution  in  the  size  of  the  eye,  if  the  cor- 
nea or  sclerotica  be  more  than  naturally  flexible  (a  symptom  denoting  an 
atrophic  tendency),  we  generally  find,  on  careful  examination,  that  the  retina 
is  imperfectly  sensible.  Operations  upon  such  eyes,  and  still  more  upon  those 
which  have  shrunk  below  their  natural  size,  generally  fail  to  produce  any  benefit. 
The  same  holds  with  regard  to  cougenitally  dwarfish  eyes  affected  with  cataract. 

Atrophy  of  the  eye  is  often  attended  with  chronic  inflammation,  and  with 
neuralgia  of  the  ocular  branches  of  the  fifth  nerve  ;  symptoms  which  are  much 
relieved  by  the  internal  use  of  belladonna  or  of  aconite. 


»  Cloquet,  Pathologic  Chirurgicale,  p.  132,  pi.  x.  Figs.  4,  5,  6 ;  Paris,  1831, 


SECTION   XV. — STAPHYLOMA. 


From  <TTa'pv\ti,  a  grape. 


Various  protrusions,  generally  from  the  front  of  the  eye,  arising  from  mor- 
bid changes  in  the  texture,  and  a  yielding  of  its  coats,  have  recevied  the  name 
of  staphyloma,  from  the  resemblance  they  occasionally  bear  to  a  grape. 

§  1.   Staphyloma  Uvece,  or  Iridoncosis. 
Iridoncus,  or  iridoncosis,  from  "pif,  iris,  and  oyxoj,  tumor. 

Those  conversant  with  diseases  of  the  eye  must  have  observed  the  peculiar 
state  of  the  iris  consequent  to  iritis,  which  Professor  Jager,  of  Vienna,  desig- 
nates by  the  name  of  staphyloma  iridis,  and  for  which  Dr.  Klemmer  proposes^ 
that  of  iridoncosis.  The  anterior  surface  of  the  iris,  in  the  diseased  condition  _ 
to  which  these  names  are  applied,  has  at  one  or  more  spots  lost  its  natural 
color,  having  become  blackish,  or  even  presenting  a  hue  so  deeply  black  that 
we  might  suspect  the  iris  to  have  been  absorbed  at  the  part  affected,  or  a 
piece  of  it  cut  out  for  the  formation  of  an  artificial  pupil.  (Fig.  76.) 

Jiiger's  pathology  of  this  state  of  the  iris  is  very  different  from  that  of 
Klemmer.  Both  are  agreed  that  it  is  one  of  the  sequelae  of  chronic,  and  gen- 
erally of  some  specific,  iritis.     Syphilitic  iritis  is  the  most  frequent  cause. 


STAPHYLOMA   OP   THE   IRIS.  635 

One  of  the  most  remarkable  cases  I  have  seen,  was  the  result  of  ophthalmia, 
after  smallpox  in  a  child  three  months  old.     In  con- 
sequence of  inflammation  Jiiger  thinks  the  iris  loses 
its  natural  firmness  of  texture,  and  becomes  pi'eter- 
naturally  adhei'ent  to  the  subjacent  uvea.     Next,  he 
believes  the  aqueous  humor  of  the  posterior  chamber 
presses  the  uvea  forwards  through  the  attenuated  iris, 
and  that  thus  the  staphyloma  iridis  is  formed.    Staphy- 
loma uvece  would  be  a  more  correct  appellation,  and 
would  serve  to  distinguish  this  affection  from  a  pro- 
trusion of  the  iris  through  the  cornea.     Jager  has 
not  himself  published  on  the  subject ;  but  in  the  ac- 
count of  his  doctrine  furnished  by  Dr.  Froriep,''  and  (From  Kiemmer.) 
referred  to  by  Kiemmer,  no  notice  is  taken  of  the  in- 
fluence which  a  contracted  and  adherent  state  of  the  pupil  is  likely  to  have  in 
promoting  the  pressure  forwards  of  the  uvea  by  the  aqueous  humor,  in  con- 
sequence of  this  fluid  not   being   permitted  to  flow  in  what   is   generally 
regarded   its  natural  course,  namely,  through  the  pupil  into  the  anterior 
chamber. 

That  in  such  cases  as  Jiiger  designates  by  the  name  of  staphyloma  iridis, 
the  iris  is  not  actually  absorbed  in  its  whole  thickness,  is  proved  by  the  want 
of  sight,  and  by  the  fact  that,  under  the  circumstances  in  question,  he  has 
formed  an  artificial  pupil  with  success. 

Kiemmer  proposes  iridoncus  or  iridoncosis  as  an  appropriate  name  for  this 
sequela  of  iritis,  which  he  contends  is  not  a  thinning,  but  a  thickening,  of  the 
iris  ;  not  a  shining  through  of  the  uvea,  but  a  deposition  of  coagulable  lymph 
in  the  parenchyma  of  the  iris.  The  proofs  he  gives  of  this  opinion  are  incom- 
plete ;  and  no  less  so  is  his  refutation  of  Jager's  doctrine  on  the  subject.  For 
anything  yet  established,  each  of  these  conditions  of  the  iris  may  occasionally 
occur.  Which  is  the  more  frequent,  and  by  what  marks  they  are  to  be  dis- 
tinguished, must  be  left  for  future  inquirers  to  determine,  and  especially  for 
those  who  shall  have  opportunities  of  dissecting  eyes  affected  with  the  conse- 
quences of  iritis. 

Sometimes  the  black  discoloration  exists  in  small  insulated  points;  in  other 
instances  the  whole  iris  is  affected,  except  towards  the  pupil,  where  the  iris 
generally  preserves  its  natural  texture.  Sometimes  the  black  color  forms  a 
narrow  ring  close  to  the  great  circumference  of  the  iris ;  in  other  cases  it  pre- 
sents a  triangular  form,  the  basis  of  the  triangle  being  turned  towards  the 
ciliary,  and  the  apex  towards  the  pupillary,  margin  of  the  iris.  The  surface 
of  the  affected  part  may  be  uniform  or  bossulated;  it  often  presents  a  striated 
appearance,  from  the  vessels  or  nerves  passing  through  it;  the  color  is  not 
always  black,  but  is  sometimes  gray  or  bluish  white,  or  blackish  blue. 

Kiemmer  relates  only  one  dissection,  and  that  of  the  eye  of  an  ox. 

§  2.   Staphyloma  of  the  Iris,  or  Staphyloma  racemosum. 

From  racemus,  a  bunch  of  graces. 
Fig.  Beer,  Band  II.  Taf.  I.  Figs.  1,  3,  4.     Dalrymple,  PI.  X,  Figs.  6,  5. 

A  poi'tion  of  iris  protruding  through  a  wound  of  the  cornea,  as,  for  instance, 
the  incision  made  for  the  extraction  of  cataract,  is  sometimes  styled  a  staphy- 
loma iridis;  but,  in  general,  this  term  is  reserved  to  protrusions  arising  from 
partial  or  general  destruction  of  the  cornea  by  abscess  and  ulceration.  From 
whatever  cause  it  may  arise,  the  appropriate  name  for  such  a  protrusion  would 
be  staphyloma  iridis  per  corneam.     There  may  be  a  single  protrusion  of  this 


636 


STAPHYLOMA   OT   THE   CORNEA   AND   IRIS, 


Fig.  77. 


f'^"^!^^ 


(From  Beer.) 


kiud,  formed  of  a  portion  only  of  the  iris,  or  of  the  whole  iris,  with  the  pupil 

closed ;  or  there  may  be  several  protrusions, 
for  it  sometimes  happens  that  the  cornea  is 
perforated  by  ulceration,  not  in  one  point 
alone,  but  in  many;  and  that  through  the 
openings  thus  formed,  the  iris,  protruding, 
gives  rise  to  an  appearance  somewhat  like 
a  brambleberry,  or  a  cluster  of  berries 
(Fig.  *I7),  whence  the  name  staphyloma 
racemosum.  Dr.  Hasner's  view  of  the  for- 
mation of  a  staphyloma  racemosum,  em- 
bracing thus  the  whole  extent  of  the  de- 
stroyed cornea,  is  somewhat  different.  He 
thinks  that  there  are  formed  fibres  which 
stretch  from  one  edge  of  the  ulcerated  cor- 
nea to  the  other,  and  progressively  form  a  network,  in  the  interstices  of  which 
the  protrusions  of  the  ii'is  take  place.^  The  protrusions  of  the  iris  generally 
present  a  dark,  or  even  black  color,  and  a  smooth  glistening  surface.  One 
or  more  of  them  occasionally  give  way,  and  allow  the  aqueous  humor  by  which 
they  have  been  over-distended  to  escape.  The  staphyloma  consequently  be- 
comes flat,  and  may  disappear  altogether,  the  cornea  cicatrizing  over  the 
seat  of  the  former  protrusion.  It  sometimes  happens  that  this  sort  of  sta- 
phyloma meets  with  an  accidental  cure,  a  blow  bringing  on  inflammation, 
which  ends  in  atrophy  of  the  eye.  In  other  cases,  the  staphyloma  of  the  iris 
degenerates  into  staphyloma  of  the  cornea  and  iris  ;  the  exposed  iris  becoming 
covered  by  an  effusion'of  lymph,  which  is  gradually  converted  into  a  cicatrice, 
or  pseudo-cornea,  so  that  the  front  of  the  eye  assumes  a  white,  opaque  appear- 
ance, but  still  presents  an  unnatural  projection. 

Prognosis  and  treatment. — If  any  considerable  portion  of  the  cornea  be  in 
a  natural  state,  it  may  be  possible  to  form  an  artificial  pupil  behind  that  por- 
tion, after  the  staphyloma  of  the  iris  is  removed,  which  is  sometimes  effected 
by  puncturing  the  individual  protrusions  with  the  point  of  a  cataract  needle, 
and  touching  them  with  a  pointed  pencil  of  lunar  caustic.  If  more  consider- 
able, they  may  be  snipped  off",  and  the  place  touched  in  the  same  way.  When 
the  whole  cornea  is  affected,  nothing  can  restore  vision.  The  staphyloma  may 
be  punctured  occasionally ;  but  it  is  better  to  remove  it  entirely  by  the  knife, 
exactly  as  a  total  staphyloma  of  the  cornea  and  iris  is  removed,  which  will  be 
followed  by  a  flat  and  opaque  cicatrice,  or  pseudo-cornea. 

§  3.   Staphyloma  of  the  Cornea  and  Iris. 

Fig.  "Wardrop,  PI.  VIII.  Figs.  3,  2.  PI.  IX.  Fig.  3.  Beer,  Band  II.  Taf.  II.  Figs.  4,  5.  Detnours, 
PI.  LX.  PI.  LXI.  Fig.  1.  Ammon,  Thl.  I.  Taf.  V.  Figs.  7,  8,  9,  11—16.  Dalrymple,  Pi.  XI. 
Figs.  1,  2,  4.   PI.  XVI.  Fig.  5. 

A  staphylo77ia  coniece  et  iridis,  as  it  is  technically  termed,  is  a  cicatrice, 
spread  over  the  iris  and  adhering  to  it,  occupying  the  place  and  presenting 
somewhat  of  the  form  of  the  cornea,  but  totally  opaque.  This  cicatrice  is 
generally  much  thicker  and  denser  than  the  natural  cornea;  often,  indeed,  as 
firm  as  cartilage,  and  perhaps  the  tenth  of  an  inch  thick.  A  staphj^loma  of 
the  cornea  and  iris  is  not  so  much,  what  it  was  once  supposed,  a  degeneration 
of  the  old  cornea;  not  so  much  an  opaque  and  thickened  state  of  those  textures 
which  were  formerly  thin  and  transparent,  as  a  new  and  morbid  product,  oc- 
cupying the  place  of  that  portion  of  the  cornea  which  has  been  destroyed  by 
abscess  and  ulceration.  If  an  onyx  gives  way,  and  the  cornea  is  perforated, 
with  no  extensive  ulceration  round  the  perforation,  partial  staphyloma  will 
probably  be  the  result.     If  around  the  perforation,  even  when  it  is  small, 


STAPHYLOMA   OF   THE   CORNEA   AND   IRIS.  63t 

there  is  extensive  and  deep  ulceration  of  the  cornea,  so  that  it  is  much  thinned, 
total  staphyloma  will  generally  ensue.  If  the  whole  thickness,  and  almost  the 
whole  extent,  of  the  cornea  are  destroyed  by  abscess  and  ulceration,  still  more 
certainly  will  total  staphyloma  be  the  consequence. 

To  the  inner  surface  of  the  cicatrice  or  pseudo-cornea,  the  iris  is  always 
adherent.  A  mere  opacity  of  the  cornea,  in  consequence  of  inflammation, 
never  produces  staphyloma.  The  iris,  as  has  been  explained  in  a  preceding 
section,  sometimes  forms  adhesions  to  the  internal  surface  of  the  cornea,  from 
inflammation ;  but  neither  does  this  anterior  synechia,  as  it  is  termed,  ever  end 
in  staphyloma,  unless  the  cornea  has  been  at  least  partially  destroyed,  and  has 
actually  given  way.  It  is  not  adhesion  of  the  iris  to  the  cornea,  but  it  is  a 
covering  up  of  the  exposed  iris  by  a  new  tissue  altogether,  which  lays  the 
foundation  for  staphyloma,  and  constitutes  an  essential  character  of  the  disease. 
This  is  a  point  which  has  been  illustrated  in  a  masterly  manner,  and  established 
beyond  controversy,  by  Mr.  Wharton  Jones.* 

This  kind  of  staphyloma  is  styled  jof«tm/  or  total,  according  as  it  involves  a 
portion  only,  or  the  whole  extent  of  the  cornea  and  iris.  The  most  evident 
symptom  is  an  opaque  projection  in  the  situation  of  the  cornea,  generally  of 
a  white  color,  but  sometimes  bluish  or  greenish.  If  the  destruction  of  the 
cornea  and  consequent  protrusion  of  the  iris  have  been  limited,  the  staphyloma 
is  generally  partial ;  if  the  whole  or  greater  part  of  the  cornea  has  been  de- 
stroyed, the  whole  iris,  no  longer,  supported  in  front,  is  pushed  forwards  along 
with  the  lens,  and  the  staphyloma  is  total.  In  partial  staphyloma,  the  pro- 
truded iris  is  covered  with  a  cicatrice,  continuous  with  the  portion  of  the  old 
cornea  which  remains,  and  which  preserves  its  transparency.  In  total  staphy- 
loma, the  iris  being  protruded  in  the  form  of  a  round  tumor,  is  gradually 
invested  by  an  opaque  cicatrice,  embracing  the  whole  extent  of  the  natural 
cornea. 

The  doctrine  of  staphyloma  is  beset  with  exceptions.  Even  when  the  cor- 
nea has  been  partially  destroyed,  and  actually  given  way,  the  case  does  not 
necessarily  terminate  in  staphyloma,  partial  or  total  ;  but  a  mere  leucoma, 
with  synechia  anterior,  may  be  the  result.  It  would  likewise  be  erroneous  to 
suppose  that  total  staphyloma  requires  the  whole,  or  even  the  greater  part, 
of  the  cornea  to  be  destroyed  before  it  can  take  place  ;  although,  no  doubt, 
this  is  generally  the  case. 

Case  307. — A  young  lady  was  seized  'with  smallpox,  ■when  at  school  in  Edinburgh. 
She  was  brought  to  me  with  both  cornece  perforated  in  their  centre  by  an  ulcer,  through 
which  there  was  a  protrusion  of  the  iris,  not  bigger  than  the  head  of  a  fly ;  the  rest  of 
the  cornea  being  clear  and  allowing  the  ii-is  to  be  distinctly  seen.  I  hesitated  not  to 
assure  myself  that,  after  the  ulcers  should  heal,  I  should  be  able  to  form  an  artificial 
pupil  in  one  eye,  if  not  in  both.  The  ulcers  gradually  closed,  a  white  dense  substance 
forming  the  cicatrice  in  each  ;  but  scarcely  was  the  cicatrization  complete,  when  the  iris 
and  cornea,  now  in  contact  with  one  another  in  all  their  extent,  began  to  be  elevated,  and 
in  each  eye  formed  a  total  spherical  staphyloma,  so  prominent  in  the  left  eye  that  the 
lids  with  difficulty  closed  over  it. 

The  relative  size  of  the  portion  of  each  cornea  destroyed  by  ulceration  was  about  one- 
fifth  of  its  whole  diameter. 

I  attributed  the  staphylomatous  protrusion,  partly  to  the  complete  closure  of  the  pupil 
in  each  eye,  and  partly  to  the  close  approximation  of  the  whole  iris  to  the  cornea,  and 
consequent  obliteration  of  the  anterior  chamber.  There  was  no  visible  effusion  of  lymph, 
gluing  the  iris  and  cornea  together ;  but  gradually  as  they  protruded,  the  cornea  grew 
dim,  so  that  the  iris  could  no  longer  be  seen.  No  doubt,  lymph  must  have  been  effused, 
and  connected  the  two  structures.  After  a  time,  the  centre  of  the  staphyloma  of  the 
left  eye  began  to  grow  thin  from  distension. 

On  dissecting  such  a  staphyloma  as  occurred  in  the  case  now  related,  we 
should  expect  a  different  anatomical  structure  from  what  occurs  in  comnion 
staphylomata  of  the  cornea  and  iris.     We  should  expect  to  find  a  consider- 


638 


STAPHYLOMA   OF   THE   CORNEA  AND   IRIS. 


able  portion  both  of  the  anterior  and  posterior  elastic  laminte  entire,  with  the 
natural  lamellated  tissue  distended,  but  not  destroyed,  except  in  the  centre  of 
the  protrusion,  where  ulceration  had  at  first  taken  place:  whereas,  a  common 
staphyloma,  as  Mr.  Bowman  has  shown,'^  consists  of  a  dense  and  irregular 
interweaving  of  white  and  yellow  fibrous  tissue,  the  meshes  of  the  tissues 
being  large,  unequal,  and  open  on  all  sides;  the  anterior  surface  formed  by 
a  thick  coat  of  epithelium  resembling  cuticle,  but  without  either  anterior  or 
posterior  elastic  lamina. 

Causes. — Smallpox  being  extremely  apt  to  produce  extensive  onyx,  ending 
in  ulceration  and  bursting  of  the  cornea  and  protrusion  of  the  iris,  staphy- 
loma was  a  much  more  frequent  occurrence,  before  the  general  introduction 
of  vaccination  than  it  is  at  present.  The  ophthalmia  of  new-born  children, 
the  contagious  or  Egyptian,  the  gonorrhoeal,  and  severe  scrofulous  and 
traumatic  ophthalmijB,  are  the  most  common  causes  of  staphyloma  at  the 
present  day. 

1.  Partial  staphyloma  of  the  cornea  and  iris,  generally  the  result  of  an 

onyx  of  limited  extent,  which,  having  burst, 
^'g-  "^-  has  given  rise  to  perforation  of  the  cornea, 

occupies,  in  nine  cases  out  of  ten,  the  lower 
part  of  the  cornea.  (Fig.  78.)  It  is  gener- 
ally of  a  white  color,  the  pseudo-cornea  thick 
and  dense,  and  less  liable  to  expand  than  in 
total  staphyloma.  In  those  cases  where  it 
does  not  cover  nor  involve  the  pupil,  the 
patient  is  able  to  see,  with  more  or  less  dis- 
tinctness, objects  placed  above  him,  or  on  a 
level  with  his  eye ;  but  he  is  generally  af- 
fected with  epiphora,  and  painful  sensibility 
of  the  organ.  In  more  unfortunate  cases, 
the  whole  edge  of  the  pupil  is  adherent  to 
the  internal  surface  of  the  opaque  projection,  and  the  patient  can  recover  a 
degree  of  vision  but  by  the  formation  of  a  lateral  artificial  pupil.  It  some- 
times happens,  however,  that  a  partial  staphyloma,  occupying  the  centre  of 
the  cornea,  and  involving  the  whole  edge  of  the  pupil,  contracts  in  time  to 
such  a  degree,  that  the  iris  at  one  or  more  places  gives  way,  or  is  torn  from 
the  choroid,  so  that  one  or  more  false  pupils  are  formed,  through  which  the 
patient  obtains  some  accession  of  vision.  In  other  cases,  central  partial 
staphyloma,  not  being  completely  consolidated,  goes  on  projecting  more  and 
more,  and  ends  at  last  in  total  staphyloma. 

Diagnosis. — Leucoma  and  anterior  synechia  are  sometimes  mistaken  for 
partial  staphyloma,  although  by  careful  examination  of  the  eye  this  error 
may  always  be  avoided.  To  the  whole  extent  of  the  protuberent  part  of  a 
partial  staphyloma,  the  iris  is  adherent,  so  that  the  anterior  chamber  is  much 
diminished  in  size  ;  in  simple  leucoma,  the  iris  is  not  at  all  adherent  to  the 
cornea,  while  in  synechia,  though  there  is  an  opacity  of  the  cornea,  to  the 
internal  surface  of  which  the  iris  is  adherent,  there  is  no  unnatural  elevation 
or  protrusion.  In  partial  staphyloma,  the  whole  cornea  partakes  in  some 
measure  of  a  conical  form,  the  termination  of  the  cone  being  at  the  centre  of 
the  staphyloma ;  whereas,  in  leucoma  and  synechia,  the  general  spherical  form 
of  the  cornea  remains  unaltered,  the  opaque  spot  being  rarely  raised  above 
the  level  of  the  cornea,  and  not  unfrequently  depressed. 

Treatment. — A  small  partial  staphyloma,  which  is  white  and  dense,  with 
the  pupil  partially  or  entirely  open,  and  which  shows  no  disposition  to  inci'ease, 
ought  not  to  be  interfered  with.  The  formation  of  an  artificial  pupil  in  such 
an  eye  may  be  called  for,  when  the  opposite  eye  is  blind. 


STAPHYLOMA   OP   THE   CORNEA  AND   IRIS.  639 

The  degree  of  vision  which  a  partially  staphylomatous  eye  often  possesses, 
may  readily  be  lost,  either  by  inattention,  or  by  injudicious  attempts  to  remove 
or  lessen  the  disease.  When  such  an  eye  is  injured  or  attacked  by  inflamma- 
tion, and  neglected,  the  tumor  is  apt  to  increase  in  size  till  it  projects  from 
between  the  eyelids,  so  that  it  is  constantly  irritated  by  contact  with  their 
edges,  the  eyelashes,  and  foreign  bodies.  In  these  circumstances,  the  patient 
ought  to  submit  to  such  treatment,  as,  if  carefully  conducted,  is  likely  not 
only  to  improve  very  materially  the  form  of  the  eye  by  lessening  the  staphy- 
loma, but  to  save  the  remaining  sight.  He  must  be  informed,  however,  that 
notwithstanding  the  removal  of  the  partial  staphyloma,  it  will  be'  impossible 
for  him  to  recover  the  transparency  of  the  cornea  in  the  part  affected.  After  . 
the  most  successful  treatment,  a  very  visible,  white,  but  flat,  cicatrice  will 
remain. 

If  the  apex  of  a  partial  staphyloma,  being  dense  and  white,  stands  out  so 
prominently  that  it  impedes  the  ready  closure  of  the  eyelids,  or  prevents  the 
application  of  an  artificial  eye,  it  may  be  shaved  off  to  a  level  with  the  rest  of 
the  staphyloma,  by  means  of  the  cataract-knife. 

By  means  of  a  gradual,  moderate,  and  repeated  inflammatory  process,  cases 
of  partial  staphyloma,  in  which  the  pupil  is  partially  or  entirely  open,  can 
sometimes  be  improved,  without  endangering  the  general  form  of  the  eye,  or 
the  remaining  degree  of  vision.  The  inflammation  is  to  be  excited  by  the 
cautious  use  of  escharotics,  continued  till  such  contraction  and  firm  cohesion 
are  produced  in  the  pseudo-corneal  tissue,  that  it  shall  be  able  to  resist  the 
pressure  of  the  aqueous  humor.  The  eyelids  being  held  widely  apart,  the 
apex  of  the  staphyloma  is  to  be  touched  with  a  pointed  pencil  of  caustic  pot- 
ash, or  of  nitrate  of  silver.  Before  allowing  the  lids  to  close,  the  surface  of 
the  staphyloma  is  to  be  washed  with  a  large  camel-hair  pencil  dipped  in  oil. 
The  part  touched  with  the  escharotic  forms  a  small  eschar,  which  drops  off  in 
the  course  of  some  days,  leaving  an  ulcer,  which,  as  it  cicatrizes,  produces  a 
degree  of  shrinking  and  flattening  of  the  staphylomatous  tissue.  The  caustic 
is  not  to  be  repeated,  till  this  process  of  reparation  seems  completely  to  have 
terminated.  Months  require  to  elapse,  before  any  attempt  should  be  made  to 
form  an  artificial  pupil,  under  such  circumstances. 

When,  either  from  closure  of  the  pupil,  or  from  the  partial  staphyloma  being 
situated  over  it  and  involving  it,  no  vision  exists,  we  must  direct  our  atten- 
tion to  the  diminution  of  the  staphyloma,  and  removal  of  the  pain  and  irri- 
tation by  which  its  increase  in  size  is  attended  ;  and  determine  whether,  by  an 
operation  for  artificial  pupil,  we  are  likely  to  gain  for  the  patient  some  restora- 
tion of  sight.  Under  such  circumstances,  a  similar  use  of  escharotics  may  be 
adopted,  as  in  cases  where  the  pupil  is  open  ;  but  it  is  particularly  recom- 
mended by  Roser,^  on  the  authority  of  Beer  and  Steinberg,  that  we  should 
endeavor  to  re-establish  the  communication  between  the  anterior  and  posterior 
chambers.  This  is  to  be  done,  either  by  forming  an  artificial  pupil,  or  Ijy 
separating  the  adhering  portion  of  the  iris  from  the  cornea,  so  as  to  restore 
the  pupil ;  an  operation  which  may  be  called  abscission. 

2.  Total  staphyloma  of  the  cornea  and  iris,  although  it  may  occasionally  pre- 
sent a  form  somewhat  conical,  is  generally  hemispherical.  (Fig.  79.)  It  often, 
however,  from  dilatation,  approaches  to  a  globular  form. 

Beer  distinguished  two  varieties  of  total  staphyloma,  a  spherical  and  a  co7i- 
ical;  and  was  of  opinion,  that  in  the  spherical  the  anterior  chamber  was  abol- 
ished, while  the  posterior  continued  to  exist;  but  that  in  the  conical,  both 
chambers  were  obliterated.  This  distinction  is  ill  founded  ;  for  on  excising  a 
spherical  staphyloma,  it  is  not  uncommon  to  find  the  crystalline  in  an  opaque 
state,  adhering  to  the  iris  and  pseudo-cornea,  so  that  there  is  no  aqueous 
chamber.    In  general,  no  doubt,  the  crystalline  is  not  so  adherent;  but  a  large 


640 


STAPHYLOMA  OF  THE  CORNEA  AND  IRIS. 


Fig.  79. 


quantity  of  aqueous  fluid   is  lodged  between  it  and  the  internal  surface  of 

the  staphyloma.  Sometimes  the  crystalline  is 
transparent ;  often  it  is  not  seen  at  all,  having 
probably  become  detached  and  sunk  into  the 
vitreous  humor.  Various  opinions  have  been 
formed  of  the  nature  of  the  disease  described 
by  Beer,  under  the  name  of  total  conical  staphy- 
loma ;  some  supposing  it  to  be  the  result  of 
corneitis,  others  ascribing  it  to  choroiditis.'' 
It  seems  most  likely  that  it  is  nothing  else 
than  a  highly  inflamed  state  of  the  cornea. 
This  view  of  the  matter  is  confirmed  by  the 
statement  of  Beer,  that  the  tumor  never  en- 
larges, nor  becomes  so  thin  that  it  bursts,  as  is 
often  the  case  with  spherical  staphyloma  ;  that  its  apex  sometimes  ulcerates,  at 
which  time  the  tumor  is  covered  with  red  vessels  from  the  sclerotica  and  conjunc- 
tiva; and  that  great  part  of  the  tumor  may  be  destroyed  by  the  process  of  ulcera- 
tion, which  is  attended  by  much  pain,  and  renders  the  opposite  eye  weak.  All 
this  we  see  occasionally  in  bad  cases  of  corneitis. 

The  size  attained  by  a  total  staphyloma  depends  much  on  the  degree  of 
activity  possessed  by  the  source  of  the  aqueous  humor,  residing  in  the  poste- 
rior chamber.  The  less  this  source  has  suffered  from  the  preceding  inflamma- 
tion, the  greater  will  be  the  quantity  of  aqueous  humor  secreted,  and  the 
greater  consequently  the  expansion  of  the  united  iris  and  pseudo-cornea.  Al- 
though at  first  extremely  thick  and  very  tough,  so  as  almost  to  resist  division 
with  the  knife,  we  not  unfrequently  see  a  total  staphyloma  become  in  time  so 
thin  and  transparent,  from  distension  and  interstitial  absorption,  that  the  pa- 
tient is  able  to  distinguish  a  number  of  objects  around  him,  and  fondly  de- 
ceives himself  into  a  hope  of  complete  recovery  of  sight  from  the  operator. 
This  appearance  is  the  forerunner  of  the  bursting  of  the  staphyloma,  which  is 
followed  by  a  sinking  away  of  the  tumor  for  a  day  or  two,  but  is  soon  suc- 
ceeded by  its  reappearance  in  its  former  shape,  and  with  its  former  dimensions. 
When  a  total  staphyloma  attains  a  large  size,  the  iris,  unable  to  expand  to 
the  same  degree  as  the  pseudo-cornea,  and  its  texture  much  more  frail,  sepa- 
rates from  the  choroid,  and  becomes  torn  into  shreds,  so  that  when  we  examine 
the  internal  surface  of  such  a  staphyloma,  after  death,  or  after  it  has  been  re- 
moved by  an  operation,  we  find  the  iris  which  adheres  to  the  pseudo-cornea, 
broken  and  reticulated  (Fig.  80)  ;  whereas  the  internal  surface  of  a  staphy- 
loma which  has  not  reached  a  great  size,  exhibits  the  iris  still  entire.^  (Fig-  81.) 


Fig.  80. 


Fig.  81. 


(From  Beer.) 


(From  Beer.) 


Total  staphyloma,  altogether  neglected,  sometimes  reaches  a  prodigious 
size,  and  involves  the  sclerotica  and  choroid,  as  well  as  the  cornea  and  iris. 
The  whole  eyeball  is  in  this  case  greatly  expanded  ;  and  the  sclerotica  being 
much  attenuated,  permits  the  choroid  to  shine  through  it,  while  the  eye  as- 
sumes a  deep  blue  color. 

Prevention When  we  see  an  eye  destroyed  by  total  abscess  and  ulceration 


STAPHYLOMA   OF   THE   CORNEA   AND   IRIS.  641 

of  the  cornea,  as  we  often  do  from  ophthalmia  neonatorum,  we  readily  foretell 
the  probability  of  the  case  ending  in  total  staphyloma.  The  question  has 
been  agitated,  Is  there  no  method  of  preventing  this  termination  ?  Now,  it 
sometimes  happens,  that  although  the  cornea  is  entirely  destroyed  in  purulent 
or  some  other  ophthalmia,  staphyloma  does  not  result,  but  the  cicatrice  which 
forms  in  the  place  of  the  cornea,  continues  flat,  and  the  eye  becomes  atrophic. 
Mr.  Jones  conjectures,  that  in  such  cases,  the  lens  has  escaped  through  the 
ulcerated  cornea  ;  and  proposes  as  a  probable  means  of  preventing  staphyloma, 
the  removal  of  the  lens,  before  the  process  of  cicatrization  has  commenced. 
For  this  purpose  it  will  sometimes  be  necessary  to  make  an  incision  through 
the  iris,  as  the  pupil  is  generally  closed  in  those  cases  where  the  cornea  has 
been  destroyed  by  suppuration.  Mr.  Jones  conceives  that  the  supply  of 
aqueous  humor  in  the  still  existing  posterior  chamber  keeps  up  the  distension 
of  the  iris,  on  the  surface  of  which  the  pseudo-cornea  is  moulded  in  the  form 
of  a  round  prominence.  To  break  in  upon  the  integrity  of  the  posterior 
chamber,  therefore,  he  would  extract  the  lens  ;  a  proposal  which  he  puts  in 
practice  in  the  following  case  : — 

Case  308. — A  man,  about  22,  came  to  Mr.  Jones,  laboring  under  the  eflFects  of  severe 
purulent  ophthalmia  of  both  ej'es.  In  the  right  eye,  the  cornea  being  destroyed,  and  the 
pupil  closed,  the  iris  protruded  and  was  distended  with  aqueous  humor.  The  left  eye  had 
also  suffered  very  much  ;  there  was  a  penetrating  ulcer,  jirolapsus  iridis,  and  consequently 
distortion  and  contraction  of  the  pupil.  Both  eyes  were  still  affected  with  the  inflamma- 
tion, and  it  was  very  doubtful  whether  the  left  eye  could  be  prevented  from  getting  Avorse, 
especially  as  it  was  evidently  kept  in  a  state  of  additional  irritation  from  the  presence  of 
the  staphyloma  in  the  right.  By  an  incision  with  a  Beer's  cataract-knife  through  the 
protruding  and  distended  iris,  the  lens  was  extracted.  Severe  reaction  followed  ;  less  per- 
haps in  consequence  of  the  operation,  than  from  the  patient  not  being  in  a  situation  to 
take  proper  care  of  himself.  The  iris  did  not  again  become  distended  ;  on  the  contrary, 
the  eye  shrunk,  and  irritation  being  thus  removed,  the  left  eye  progressively  improved,  as 
far  as  the  organic  changes  it  had  undergone  allowed,  and  further  than  had  been  hoped 
for,  sufficient  vision  being  preserved  to  enable  the  patient  to  resume  employment  as  a 
porter. 

Laying  hold  of  the  exposed  iris  with  the  forceps,  and  removing  it  from  the 
eye,  is  another  means,  which  would  have  the  effect  of  preventing  the  forma- 
tion of  staphyloma.  If  this  were  done,  the  pseudo-cornea  would  be  formed 
on  the  surface  of  the  crystalline  lens,  and  thus  a  better  form  of  the  eye  be 
preserved,  than  if  the  lens  were  removed. 

Prognosis. — There  is  no  possibility  of  restoring  sight  to  the  patient  affected 
with  total  staphyloma,  even  in  cases  where  there  may  be  reason  to  suppose 
the  lens,  vitreous  humor,  and  retina  to  be  sound.  All  that  we  can  do  in  the 
way  of  relief  is  to  remove  a  tumor  which  is  extremely  unsightly,  and  fre- 
quently very  painful.  If  a  staphjdomatous  eye  receive  a  blow,  it  is  ap^  to 
burst,  in  consequence  of  which,  blood  and  water  are  discharged,  the  wound 
heals,  and  sometimes  the  tumor  shrinks,  and  never  returns.  Projecting  be- 
yond the  eyelids,  a  staphyloma  keeps  up  constant  irritation,  and  renders  the 
opposite  eye  unfit  for  exertion.  Attacked  by  catarrhal  or  by  traumatic  in- 
flammation, a  staphylomatous  eye  is  apt  to  become  gangrenous,  and  the  tu- 
mor to  slough  ;  thus  undergoing  a  painful  natural  cure.  It  is  proper,  there- 
fore, to  remove  as  soon  as  possible,  every  considerable  total  staphyloma.  This 
affords  the  patient  a  great  degree  of  relief,  and  enables  him  to  use  the  opposite 
eye  with  freedom. 

Treatment. — Many  proposals  have  beenmadefor  removing  total  staphyloma 
without  excision.  The  api)lication  of  the  muriate  of  antimony  has  been  par- 
ticularly tried,  in  consequence  of  the  recommendation  of  Richter.  [Mr.  Tyr- 
rell advocates  the  careful  application  of  the  solid  nitrate  of  silver,  or  the  hy- 
drate of  potassa,  to  effect  the  reduction  of  a  partial  staphyloma,  and  states 
that  he  has  succeeded  so  far  as  to  enable  him  to  make  subsequently  an  artificial 
41 


642  STAPHYLOMA   OP   THE   CORNEA  AND   IBIS. 

pupil.  "The  effect,"  be  says,  "has  been  the  separation  of  a  small  slough  ; 
but  previously  to  such  separation,  a  deposit  of  fibrin  beneath,  by  which  the 
deeper  part  has  become  more  solid  and  strengthened. "  The  danger  of  excessive 
inflammatory  action  consequent  on  such  applications  should  we  think  deter  the 
surgeon  from  a  resort  to  any  such  procedure. — H.]  It  was  also  supposed 
that  by  mere  incision  of  the  staphyloma,  passing  a  thread  through  it,  or  ex- 
cising a  small  part  of  it,  so  that  the  eye  was  kept  open  for  a  time,  a  cure  could 
be  accomplished.^  All  these  have  been  found  to  fail.  Incision  is  merely  a 
palliative  ;  the  seton  is  tedious,  and  not  to  be  depended  on  ;  escharotics  are 
apt  to  excite  the  eye  into  a  state  of  violent  inflammation.  Beer,  on  the  other 
hand,  mentions  that  he  had  removed  216  staphylomata  by  operation,  and  that 
in  not  a  single  instance  had  any  dangerous  accident  followed." 

Operation. — It  is  of  great  importance  to  presciwe  the  lens  and  vitreous  hu- 
mor in  this  operation.  If  the  patient,  being  a  child,  cries  and  struggles  much, 
these  textures  are  forced  out  of  the  eye  and  lost.  It  is  proper,  therefore,  to 
put  children  under  chloroform  when  about  to  have  a  staphyloma  excised. 
[Many  surgeons  recommend  that  the  capsule  should  be  lacerated  and  the  lens 
discharged  before  the  operation  for  staphyloma  can  be  considered  complete. 
We,  however,  perfectly  accord  with  the  author  on  the  propriety  of  allowing 
these  structures  to  remain  entire.  The  importance  of  this,  by  preventing  the 
evacuation  of  the  vitreous  humor  for  a  time,  at  least,  is  illustrated  by  a  case 
operated  on  by  Professor  Jiiger,  where  the  capsule  was  not  touched.  Mr. 
Brodhurst,  on  whose  authority  we  cite  the  case,  says,  that  "  cicatrization,  how- 
ever, proceeded  and  the  capsule  played  the  part  of  the  cornea,  so  that  a  very 
fair  degree  of  sight  was  enjoyed.  All  parties,"  he  continued,  "were  pleased, 
for  the  case  advanced  favorably  and  with  a  probable  issue  totally  opposed  to 
that  usually  observed  ;  for  cicatrization  appeared  to  be  now  almost  complete. 
However,  the  capsule  of  the  lens  was  a  poor  substitute  for  the  cornea,  and 
little  able  to  resist  pressure.  Having  dropped  a  needle  on  the  floor,  the  girl 
immediately  stooped  to  search  for  it,  and  straining  her  eye  to  compass  so 
small  an  object,  out  flew  the  lens." — H.] 

The  operation  consists,  first,  in  the  formation  of  a  flap  with  the  knife  ;  and 
secondly,  in  the  removal  of  the  flap  with  the  scissors. 

While  the  asistant  keeps  the  upper  eyelid  raised,  a  pretty  large  sharp  hook 
is  passed  through  and  through  the  staphyloma,  or  it  is  transfixed  with  a  small 
curved  needle,  carrying  a  waxed  linen  thread.  In  the  hand  which  does  not 
hold  the  hook  or  ligature,  the  surgeon  takes  the  staphyloma-knife,  which  is 
nothing  more  than  the  cataract-knife  enlarged.  With  the  cutting  edge  di- 
rected upwards,  the  staphyloma  is  penetrated  at  its  temporal  edge,  close  to  its 
ba^s,  and  at  such  a  distance  below  its  transverse  diameter,  that  two-thirds  of 
the  tumor  shall  be  included  in  the  incision  to  be  made  with  the  knife.  The 
point  of  the  knife  being  directed  perpendicularly  into  the  edge  of  the  staphy- 
loma, till  the  operator  is  pretty  confident  that  he  has  penetrated  the  pseudo- 
cornea,  its  handle  is  then  to  be  carried  back  till  the  instrument  assumes  a  po- 
sition parallel  to  the  basis  of  the  staphyloma.  The  knife  is  now  to  be  carried 
onwards  till  it  reaches  the  point  of  exit,  which  ought  to  be  in  a  horizontal  line 
with  the  point  of  entrance.  The  flap  is  completed  by  the  progressive  motion 
of  the  knife,  till  it  cuts  itself  out.  The  operation  is  instantly  to  be  finished, 
by  dividing  with  the  curved  scissors  that  part  of  the  circumference  of  the 
staphyloma  which  is  yet  entire,  and  in  connection  with  the  sclerotica.  At 
the  same  moment,  the  assistant  lets  fall  the  upper  lid,  which  must  not  again 
be  raised  for  eight  or  ten  days. 

During  the  whole  operation,  and  especially  towards  the  end,  care  must  be 
taken  that  the  eyeball  is  not  irregularly  and  forcibly  pressed  or  dragged,  as 
this  might  really  give  i-ise  to  the  escape  of  the  lens  and  vitreous  humor. 
Frequently  no  trace  of  lens  is  seen  ;  it  seems  either  to  have  been  removed  by 


STAPHYLOMA   OF   THE   CORNEA   AND   IRIS.  643 

absorption,  or  sunk  out  of  view  into  the  dissolved  vitreous  humor.  Often  it 
is  impossible  to  avoid  the  loss  of  the  lens,  or,  if  the  lens  is  wanting,  of  part  of 
the  vitreous  humor,  either  from  adhesion  between  the  capsule  of  the  lens  and 
the  iris,  so  that  the  knife  passes  behind  the  lens  and  through  the  vitreous  hu- 
mor ;  or  from  a  dissolved  state  of  the  hyaloid  membrane,  frequently  attendant 
on  total  staphyloma. 

[In  operating  for  conical  staphyloma  where  the  cornea  alone  is  involved, 
Mr.  Wilde  passes  a  thread  through  the  base  of  the  cone,  so  that  after  the 
projecting  portion  has  been  removed,  the  lips  of  the  wound  can  be  brought 
together,  and  the  escape  of  the  vitreous  humor  effectually  prevented. — H.] 

If  the  sclerotica  has  taken  a  considerable  share  in  the  disease,  and  there  is 
a  number  of  dark  blue  protuberances  round  the  staphylomatous  cornea 
{staphyloma  sderoticce  racemosum) ,  rather  than  confine  the  operation  to  the 
removal  of  the  cornea  and  iris  merely,  it  is  better  to  take  away  the  anterior 
third  of  the  eyeball ;  an  operation  which,  though  occasionally  followed  by 
shrinking  of  the  remains  of  the  eye  to  a  very  small  size,  in  general  leaves  it 
sufficiently  large  to  support  an  artificial  eye. 

After  the  operation  for  staphyloma,  the  eye  is  to  be  covered  with  a  spread 
pledget  and  compresses  of  lint,  supported  by  a  double-headed  roller,  whicli 
is  to  be  applied  first  of  all  several  times  round  the  head  and  over  the  eye, 
and  then  over  the  crown  of  the  head  and  under  the  chin,  so  as  to  prevent  the 
dressings  from  slipping,  and  the  lids  from  moving.  [The  dressing  described 
at  p.  148,  will  be  found  to  answer  an  admirable  purpose  in  these  cases. — H.] 
On  examining  the  eye  some  eight  or  ten  days  after  the  operation,  we  find  the 
gap  in  the  front  of  the  eye  consideral)]y  contracted,  and  occupied  by  a  grayish 
semitrausparent  eflTusion  of  lymph,  which  gradually  becomes  opaque,  and  at 
last  is  converted  into  a  firm  cicatrice,  with  bluish  or  brownish  streaks,  occupy- 
ing the  place  of  the  staphylomatous  cornea.  As  to  the  form  of  the  eyeball, 
if  the  lens  and  vitreous  humor  have  been  preserved,  it  has  lost  only  the  pro- 
jection of  the  cornea ;  in  other  cases,  it  is  more  or  less  sunk,  and  generally 
assumes  a  somewhat  square  shape,  from  the  action  of  the  recti.  After  com- 
plete recovery  from  the  operation,  an  artificial  eye  may  be  worn,  by  which  a 
high  degree  of  illusion  may  be  produced. 

Some  blood  is  generally  discharged  at  the  moment  of  the  operation  ;  but 
occasionally  it  happens,  especially  where  the  disease  has  extended  backwards, 
so  as  to  involve  the  sclerotica  and  choroid,  that  either  immediately,  or  some 
hours  after  the  operation,  a  more  considerable  hjemorrhage  takes  place,  both 
from  the  eye  and  into  its  cavity.  A  bloody  dark-colored  mass,  of  consider- 
able consistence,  protrudes  to  such  an  extent  from  the  wound,  that  it  is 
impossible  for  the  patient  to  keep  the  eyelids  shut.  The  eyeball  is  painfully 
distended,  while  the  conjunctiva  and  lids  become  greatly  ecchymosed.  The 
haemorrhage  into  the  eye  gives  rise  in  some  cases  to  agonizing  pain,  causes 
vomiting,  and  may  even  bring  on  convulsions.  Under  such  circumstances, 
we  ought  to  cut  away  with  the  scissors  the  protruding  substance,  which  per- 
haps is  in  some  cases  the  hyaloid  membrane  injected  with  blood,  but  in  other 
eases  is  nothing  more  than  a  clot,  hanging  from  the  front  of  the  eye.  After 
this  is  done,  the  bleeding  ceases,  and  the  pain  abates.  If  we  do  not  remove 
the  protruding  mass,  but  leave  it  to  itself,  it  dies  away  in  the  course  of  a  few 
days.  The  eye,  thus  affected  with  haemorrhage,  is  apt  to  shrink  below  the 
usual  size  of  a  staphylomatous  eye  after  operation.  In  this  state,  it  does  not 
answer  so  well  for  the  application  of  a  glass  eye,  and  therefore  all  causes 
likely  to  occasion  haemorrhage  ought  to  be  guarded  against. 

It  occasionally  happens  that  the  opening  into  the  eye,  formed  by  the  removal 
of  the  staphyloma,  is  long  of  closing,  no  pseudo-cornea  nor  lymphatic  effusion 
being  present  when  we  open  the  lids  on  the  eighth  or  tenth  day,  and  even  for 
weeks  the  clear  humors  lying  uncovered  behind  the  gap  in  the  front  of  the 


644 


STAPHYLOMA  OF  THE  CHOROID  AND  SCLEROTICA. 


t« 


eye.  At  length,  however,  the  aperture  contracts  and  cicatrizes.  Fungous 
granulations  sometimes  sprout  from  the  aperture,  requiring  the  use  of  lunar 
caustic.  If  the  eye  is  not  kept  shut  after  the  operation,  the  lens  may  come 
forward  and  protrude  through  the  wound.  When  this  is  the  case,  the  lens 
should  be  removed,  and  the  eye  kept  closed  till  the  cicatrice  is  formed. 

Yioleut  inflammation  {oplitliahnitis  phJegmonosa)  sometimes  supervenes  to 
the  operation  for  staphyloma,  ending  in  suppuration  both  within  the  eyeball 
and  in  the  orbital  cellular  membrane.  This  must  be  combated  by  a  strict 
antiphlogistic  plan  of  treatment;  opiates  will  be  required  to  abate  the  severity 
of  the  pain,  a  poultice  is  to  be  laid  over  the  eye,  and  any  abscess  which  may 
form  is  immediately  opened  with  the  lancet. 


§4. 


Fig.  DemourF,  PI.  LXIII.  Fij 
VII.  Figs.  6,  6,  7. 


Taf. 


Staphyloma  of  the  Choroid  aiid  Sclerotica. 

I.     Amnion,  Thl.  I.  Taf.  IV.  Fig.  21.  Taf.  V.  Figs.  17-20. 
Dalrymple,  PI.  XX.  Fig.  6.  PI.  XXIV,  Figs.  6,  6. 

This  kind  of  staphyloma,  called  indifferently  sclerotic  or  choroid  staphyloma, 
is  a  frequent  consequence  of  scrofulous  sclerotitis;  it  originates  also  in  chronic 
choroiditis,  syjjhilitic  iritis,  and  occasionally  in  other  ophthalmia?.  It  is  often 
the  result  of  injury,  especially  of  penetrating  wounds  of  the  sclerotica  and 
choroid.  It  is  either  jtjar/m/  or  total.  In  the  former,  sometimes  a  single 
limited  spot  of  the  sclerotica,  lined  generally,  we  have  reason  to  believe,  by 
the  adhering  choroid,  stands  abruptly  elevated  above  the  level  of  the  eye,  and 
of  a  dark  blue  color.  When  a  circle  more  or  less  complete,  of  such  protru- 
sions surround  the  cornea,  the  corpus  ciliare  is  regarded  as  the  part  princi- 
pally implicated  in  the  disease,  which  is  therefore  called  staphyloma  corporis 
ciliaris,  or  staphyloma  scleroticce  aniudare.  The  anterior  half  of  the  sclerotica 
is  the  part  generally  afi'ected  {staphyloma  scleroticoi  anticum)  ;  but  in  some 
rare  cases  (see  p.  5U5),  a  staphyloma  scleroticce  posticum  has  been  met  with, 
on  dissection.  A  general  sclerotico-choroid  staphyloma  is  not  unfrequent,  in 
which  the  whole  eyel)all  is  dilated,  and  of  a  dark  blue  color.  In  such  cases 
the  cornea  is  sometimes  semi-transparent,  and  the  aqueous  chambers  abnor- 
mally expanded.  In  other  cases,  a  specimen  of  which  I  have  now  before  me, 
no  limit  is  discernible  externally  between  the  sclerotica  and  the  cornea ;  the 
latter  being  opaque,  with  the  iris  adherent  to  its  inner  surface,  the  pupil 
closed,  the  lens  hanging  by  a  pedicle  of  lymph  from  the  closed  pupil,  the 
ciliary  body  entire,  but  greatly  expanded. 

In  every  case  of  choroid  staphyloma,  the  dilated  portion  of  the  sclerotica 

is  greatly  thinned  ;  the  choroid  also  is 
thinned  ;  and,  in  general,  the  two  are  ab- 
normally adherent.  The  disease  is  always 
attended  with  dropsy  of  the  eye;  and  to 
the  water  accumulated  beneath  the  at- 
tenuated tunics,  is  the  blue  color  of  the 
tumor  to  be  attributed. 

The  appearance  of  the  annular  variety 
of  this  staphyloma  is  represented  in  Fig. 
66,  p.  505;  and  that  of  the  total,  with 
the  cornea  semi-opaque,  in  Fig.  67, 
p.  507.  A  partial  choroid  staphyloma 
resulting  from  an  injury  is  represented  in 
Fig.  58,  p.  401,  and  the  annexed  figure 
(Fig.  82)  represents  a  general  choroid  sta- 
phyloma in  a  patient  of  mine,  also  origi- 
nating in  traumatic  inflammation,  with  the 
fibres  of  the  sclerotica  in  a  remarkable  manner  separated,  and,  as  it  were, 


Fig.  82 


VARICOSITY   OF   THE   VESSELS   OF   THE   EYE.  645 

unravelled.  The  front  of  the  sclerotica  was  in  this  case  pretty  entire,  but 
covered  with  numerous  varicose  vessels.  The  cornea  in  neither  of  these  last 
two  cases  was  involved  in  the  staphylomatous  degeneration. 

A  choroid  staphyloma,  having  often  somewhat  of  a  malignant  air,  is  apt  to 
be  taken  for  a  melanotic  affection.  In  choroid  staphyloma,  whether  general 
or  partial,  the  cornea  does  not  suffer  any  diminution  of  size,  but  is  often  ex- 
panded ;  but  in  melanosis,  the  cornea,  when  the  protrusion  is  on  one  side  of 
the  eye,  which  is  generally  the  case,  becomes  deformed,  flattened,  and  shrunk. 
A  puncture,  however,  will  at  once  decide  the  diagnosis ;  for  if  the  case  is  one 
of  choroid  staphyloma,  a  puncture  discharges  immediately  a  large  quantity  of 
watery  fluid,  and  the  tumor  becomes  flaccid ;  but  if  it  is  one  of  melanosis,  a 
black  semi-solid  substance  protrudes,  without  any  diminution  in  the  size  of 
the  eye. 

Choroid  staphyloma  often  results  from  syphilitic  inflammation,  and  some- 
times yields  to  mercury.  It  generally  occupies  the  temporal  side  of  the  eye- 
ball in  such  cases,  and  raises  the  edge  of  the  cornea  much  above  its  natural 
level.  Under  the  use  of  iodide  of  potassium,  I  have  known  such  a  staphyloma 
entirely  to  subside  and  leave  a  depression,  instead  of  the  protrusion  which  for- 
merly existed.  The  eye  was  rather  atrophic,  but  retained  some  share  of 
vision. 

Puncturing  the  eye  is  a  practice  whence  much  advantage  is  derived  in  cho- 
roid staphyloma.  (See  page  510).  We  sometimes  meet  with  an  unexpected 
occurrence  in  performing  this  operation.  The  fluid  vitreous  humor,  instead 
of  flowing  out  of  the  eye,  insinuates  itself  between  the  sclerotica  and  conjunc- 
tiva, so  that  the  eye  is  apparently  not  reduced  in  size,  but  looks  rather  larger. 
The  patient  also  feels  more  tension  and  pain  than  he  did  before.  Graduallv 
the  fluid  is  removed  by  absorption,  and  sometimes  the  pressure  appears  to 
have  a  good  effect,  the  eye  never  filling  again,  but  remaining  of  a  small  size. 

When  a  partial  choroid  staphyloma  near  the  front  of  the  eye  is  very  promi- 
nent and  insulated,  it  may  be  removed  like  a  staphyloma  of  the  cornea  and 
iris.  By  passing  a  thread  through  it,  the  fluid  contents  of  the  tumor  drain 
off;  and  the  staphyloma,  now  become  flaccid,  may  be  snipped  off  with  the 
scissors. 

In  cases  of  general  choroid  staphyloma,  involving  the  cornea  and  iris,  the 
anterior  third  of  the  eyeball  is  to  be  extirpated,  so  that  the  eye  may  shrink  to 
a  size  fit  for  the  application  of  an  artificial  eye. 


1  Ammon'sZeitscliriftfiirdieOphtlialmologie;  ''  See  Jones's  Ophthalmic  Medicine  and  Sur- 

Vol.  V.  p.  262;  Heidelberg,  1836.  gery;  p.  195;  London,  1847:  Roser,  Op.  cit.  p. 

■  De  Corneitide  Scrofulosa;  p.  9;  Jenjfi,  1830.  10:    Chelius,   Handbuch  der  Augenheillvunde; 

'  Eutwui-f  einer  anatomisclien    Begriindung  Band  ii.  S.  381,  Stuttgart,  1839. 

der  Augenkraniiheiten;  p.  145;  Prag,  1847.  *  Beer's  Ansicht  der  .staphylomatosen  Meta- 

*  London  Med.  Gaz. ;  VoL  xxi.  p.  847.  morphosen  des  Auges;  Plate  1.  figs.  1,  and  2; 

^  Lectures  on  the  Parts  concerned  in  the  Opera-  Wien,  1805. 

tions  on  the  Eye,  p.  41;  Lond.  1849.  ^  Celsus  de  Re  Medica;  Lib.  vii.  Pars  ii.  Cap. 

'^  Edinburgh  Medical  and  Surgical  Journal;  i.  Sec.  2. 

January  1853;  p.  32.  '"  Lehre  von  den  Augenkrankheiten ;  Vol.  ii. 

p.  216;  Wien,  1817. 


SECTION  XVI. — VARICOSITY  OF  THE  EXTERNAL  AND  INTERNAL  VESSELS 

or  THE  EYE. 

Two  sets  of  bloodvessels  belonging  to  the  eye,  are  apt  to  be  left  in  a  state 
of  varicose  distension,  after  certain  of  the  ophthalmite ;  namely,  the  recto- 
muscular  arteries  or  their  accompanying  veins,  and  the  vasa  vorticosa  of  the 


646  OSSIFICATION   IN   THE   EYE. 

choroid.     The  former  are  left  in  a  varicose  condition,  chiefly  after  arthritic 
iritis  ;  the  latter,  after  choroiditis. 

The  extremely  varicose  twisting  vessels,  occurring  on  the  eye,  are  conjunc- 
tival ;  the  less  varicose  and  straighter,  are  sclerotic.  The  former  are  larger, 
and  of  a  darker  red;  and  their  undulating  course  is  analogous  to  that  of  vari- 
cose veins. 

Blueuess  of  the  attenuated  sclerotica,  in  scrofulous  sclerotitis  and  other 
ophthalmia,  is  in  general  quite  independent  of  any  varicose  dilatation  of  the 
choroidal  vessels. 

Beer  used  to  show  a  preparation,  in  which  were  seen  what  he  considered 
varices  of  the  vasa  vorticosa,  as  large  as  small  peas.  After  his  death  the 
preparation  was  examined,  and  the  protuberances  in  question  were  found  to 
be  melanotic. 

Little  can  be  done,  and  nothing  directly,  to  remove  varicosity  of  the  vessels 
of  the  eye,  which  is  not  only  in  general  beyond  cure,  but  affords  an  unfavor- 
able index  of  the  condition  of  the  humors  and  retini.  Glaucoma  and  amau- 
rosis, in  almost  every  case,  are  either  already  present,  or  are  sooner  or  later 
developed,  when  the  bloodvessels  of  the  eye  are  affected  with  varicose  dis- 
tension. 

I  was  consulted  by  a  lady,  who  complained  of  an  uneasy  feeling  in  one  of 
her  eyes,,  on  the  surface  of  which  ran  a  single  large  varicose  vessel.  The  dys- 
peptic symptoms  of  the  patient  led  me  to  prescribe  the  internal  use  of  a  mix- 
ture of  columbo,  rhubarb,  and  carbonate  of  soda.  The  belladonna  collyriura 
was  employed  as  an  external  application.  By  the  use  of  these  remedies,  the 
syn^ptoms  were  removed. 


SECTION  XVII. — ASTHENOPIA   AND  AMAUROSIS, 

As  I  shall  explain  fully  in  a  subsequent  chapter,  asthenopia,  or  an  incapa- 
bility of  sustaining  the  eye  in  a  state  of  adjustment  to  near  objects,  is  not  an 
uncommon  sequela  of  several  of  the  ophthalmias. 

Complete  or  incomplete  insensibility  to  light  is  a  frequent  consequence  of 
inflammation,  especially  when  it  has  originated  in  the  retina,  or  spread  to  it 
from  the  other  internal  textures  of  the  eye,  as,  the  choroid,  or  the  iris.  When 
the  inflammation  appears  completely  subdued,  but  the  amaurosis  continues, 
recovery  of  sight  may  be  regarded  as  hopeless. 

Syphilitic  amaurosis  is  not  unfrequent.  Along  with  other  secondary  symp- 
toms of  syphilis,  the  patient  has  had  iritis  ;  this  has  been  overcome  by  mercury, 
and  the  eyes  look  tolerably  healthy  ;  the  lenses  are  transparent,  and  the  consist- 
ence of  the  eyes  is  normal ;  but  gradual  loss  of  vision  supervenes,  and  proves 
incurable. 


SECTION  XVni. — OSSIFICATION  IN  DIFFERENT   PARTS  OP   THE   EYE. 

Fig.  Scarpa,  Tav.  II.  Fig.  8.     Wardrop,  PI.  XIV.     Ammon,  Thl.  I.  Taf.  XVIII.     Dalrymple, 

PL  XXVIII.  Figs.  2,  3. 

Ossification,  or  calculous  deposit,  is  an  occasional  sequela  of  long-con- 
tinued ophthalmia ;  and,  indeed,  it  may  be  suspected  that,  in  all  instances, 
and  in  whatever  texture  of  the  body,  abnormal  formation  of  bone  takes  place, 
it  is  preceded  by  a  certain  kind  or  degree  of  inflammatory  action.  The 
crystalline  body  being  dislocated,  or  the  capsule  of  the  lens  being  ruptured 
by  an  injury,  may  become  the  seat  of  osseous  deposits,  with  the  cornea  clear, 


OSSIFICATION   IN   THE   EYE.  64t 

and  the  eyeball  of  normal  size ;  but,  in  general,  those  eyes  in  which  parts  are 
ossified,  are  atrophic,  the  cornea  opaque  and  shrunk,  or  the  iris  and  cornea 
staphylomatous.  Eyes  affected  with  malignant  diseases,  especially  melanosis, 
frequently  furnish  ossifications  on  dissection. 

Almost  every  texture  of  the  eye  has  proved  a  seat  of  chalky  deposit,  or 
of  ossification.  Under  the  conjunctiva  bulbi,  in  the  cornea,  sclerotica,  iris, 
choroid,  ciliary  body,  vitreous  body,  and  crystalline  body,  such  morbid 
changes  have  been  met  with.  It  is  doubtful  whether  the  retina  has  really 
been  found  in  an  ossified  state ;  but  a  cup  of  bone  between  it  and  the  choroid 
is  not  unfrequent. 

Traumatic  inflammation  appears  to  be  the  most  fruitful  source  of  ossifica- 
tion in  the  eye.  Inflammatory  effusion  taking  place  between  the  different 
tissues,  or  into  their  substance,  is  followed  by  chalky  or  ossific  depositions. 
The  choroid  and  the  ciliary  body,  as  Dr.  Meyr  has  pointed  out,*  are  the  chief 
sources  of  those  internal  exudations  which  proceed  to  the  formation  of  bone. 
The  deposits,  in  such  cases,  are  in  general  not  mere  concretions,  but  are 
endowed  with  a  certain  degree  of  vitality.  They  are  composed  of  true  osseous 
tissue,  and  present  traces  of  lacunae  under  the  microscope,  but  no  Haversian 
canals. 

[Dr.  Taylor,^  very  recently  presented  at  a  meeting  of  the  Pathological 
Society  of  London,  a  specimen  of  ossific  deposit  in  the  crystalline  body,  in 
which,  he  stated,  the  Haversian  canals  and  canaliculi  could  readily  be  detected 
by  the  microscope.  It  was  from  the  eye  of  a  man  who  had  died  at  the  age 
of  45.  The  subject  gave  rise  to  some  discussion,  and  the  specimen  was  referred 
to  a  competent  committee  who  reported  that  it  did  possess  the  character 
claimed  for  it,  although,  they  thought  that  there  was  no  evidences  of  its  having 
possessed  vascularity,  or  in  other  words,  that  the  canals  had  never  performed 
the  functions  of  Haversian  canals. — H.] 

§  1.    Ossification  of  the  Cornea. 

YoigteP  mentions,  that  in  the  Walterian  Museum  at  Berlin,  there  was  a 
piece  of  cornea  preserved,  which  had  been  converted  into  bone.  It  was 
three  lines  long,  two  broad,  and  weighed  two  grains. 

Chelius*  states,  that  in  leucomata  of  old  standing  it  is  not  uncommon  to 
find  depositions  of  phosphate  of  lime.  In  the  centre  of  an  albuginous  cornea 
of  a  soldier  who  had  suffered  from  Egyptian  ophthalmia,  D'Arcet  found,  on 
dissection,  a  very  hard  brittle  ossification,  about  the  size  of  a  lentil,  which 
implicated  the  whole  thickness  of  the  part,  and  projected  slightly  towards  the 
crystalline.     The  other  textures  of  the  eye  were  healthy.^ 

In  dissecting  an  eye  of  which  no  history  could  be  obtaii^ed,  Mr.  Wardrop^ 
found  gritty  particles  and  inequalities  on  the  internal  surface  of  the  cornea. 

§  2.    Osseous  Deposit  in  the  Sclerotica. 

Schon''  refers  to  a  case,  related  by  Blasius,  in  his  Observationes  Medicce 
Rariores,  in  which  an  ossified  lamina  was  found  in  the  sclerotica. 

§  3.    Osseous  Dejjosit  in  the  Anterior  Chatnber. 

Mr.  Wardrop  mentions  a  case  which  had  come  under  his  observation,  in 
which  thin  laminaa  of  bone  were  dischai'ged  at  several  times,  from  the  anterior 
chamber,  through  ulcers  formed  in  the  cornea.^ 

§  4.    Ossification  of  the  Iris. 

Schon^  refers  to  two  cases  of  this  sort  which  had  occurred  to  Walter ;  in 
one  of  which  both  eyes  were  affected,  the  iris  in  each  forming  a  cone,  three 


648  OSSIFICATION   IN   THE   EYE. 

lines  long,  connected  by  its  apex  to  the  capsule  of  the  lens.  A  case,  which 
occurred  to  Benedict,  in  a  carcinomatous  eye,  is  referred  to  by  Dr.  Meyr.'" 
Mr.  Wardrop  had  an  opportunity  of  examining  a  case,  under  Mr.  Wishart's 
care,  where,  he  says,  that  portion  of  the  capsule  of  the  aqueous  humor,  which 
is  reflected  over  the  iris,  was  almost  entirely  converted  into  a  bony  shell." 

§  5.    Ossification  of  the  Corpus  Oiliare. 

PraeP'^  found  the  whole  ciliary  body  ossified  in  an  eye,  which  had  been 
disorganized  and  become  atrophic  from  the  pressure  of  an  encephaloid  tumor 
in  the  orbit. 

§  6.    Ossification  of  the  Choroid. 

Yoigtel  has  described  various  preparations  belonging  to  the  Walterian 
Museum,  in  which  the  choroid  was  more  or  less  completely  ossified.  In  one, 
the  posterior  half  was  so  affected  ;  in  others,  the  anterior  part ;  in  some,  the 
whole  choroid.  He  also  quotes  from  Giinz,  an  instance  of  ossification, 
described  as  being  between  the  lamellae  of  the  choroid.^^ 

In  a  preparation  of  coarcted  retina,  now  before  me,  and  which  I  owe  to 
the  kindness  of  Mr.  Norris,  late  of  the  Glasgow  Royal  Infirmary,  the  choroid 
is  partially  ossified.     The  eye  was  atrophic,  and  the  cornea  opaque. 

Two  remarkable  eases  of  sudden  loss  of  vision  are  related,"  the  one  by 
Amraon,  and  the  other  by  linger,  in  which,  the  cornea  remaining  clear,  the 
iris  appears  to  have  shrunk  so  much  as  scarcely  to  be  visible,  while  the  lens, 
become  opaque,  retreated  into  the  vitreous  chamber,  so  as  to  allow  a  white 
opacity  to  be  seen  around  it  and  beyond  it,  which  was  ascribed  to  ossifica- 
tion of  the  choroid,  but  was  probably  owing  to  opacity  and  coarctation  of 
the  retina. 

§  t.    Ossification  between  the  Choroid  and  the  Retina. 

Morgagni,  Morand,  Haller,"  and  others,  have  recorded  instances  of  cup- 
like ossifications  within  the  choroid.  Ossifications  in  this  situation  have 
generally  been  regarded  as  situated  in  the  retina.  The  retina,  however,  is 
rarely,  if  ever,  affected  in  this  way ;  but  is  generally  found  entire  within  the 
ossified  cup,  or  gathered  together  into  the  form  of  a  chord.  The  calcareous 
matter  is  most  probably  deposited  in  a  false  membrane  formed  in  consequence 
of  exudation  from  the  choroid,  conformably  to  Panizza's  opinion,  that  fluids, 
extravasated  between  the  membranes  of  the  eye,  in  consequence  of  inflamma- 
tion, are  capable  of  depositing  calcareous  crusts. 

Morgagni  says,  that  in  the  case  which  fell  under  his  observation,  instead 
of  the  retina,  there  was  a  thin  bony  lamella  under  the  choroid  universally,*^ 

Case  309. — In  Morand's  case,  both  surfaces  of  the  retina  appear  to  have  been  enveloped 
by  the  osseous  substance.  The  patient  had  been  blind  of  the  eye  thus  affected  for  20 
years;  ■\vhen  about  15,  he  had  a  violent  inflammation  of  that  eye,  followed  by  yellow 
cataract,  vrhich  several  oculists  had  offered  to  remove  by  operation,  but  the  patient  would 
never  consent. 

Case  310. — In  Haller's  case,  the  osseous  cup  adhered  to  the  choroid,  while  the  retina, 
gathered  into  a  cord,  passed  forwards,  and  surrounded  the  crystalline,  which  was  also 
ossified. 

Mr.  Wardrop  mentions  that  he  had  met  with  a  few  instances  of  a  thin  cup 
of  bone  between  the  sclerotic  and  the  retina ;  that  the  retina  was  in  imme- 
diate contact  with  the  interior  surface  of  the  bone,  but  that  between  the  scle- 
rotic and  the  ossification  there  was  a  very  thin,  tender,  and  pale-colored 
membranous  expansion,  the  only  vestige  of  the  choroid;  and  that  at  the 
bottom  of  the  cup,  there  was  a  small  round  perforation,  through  which  the 
retina  passed  to  expand  on  the  interior  surface  of  the  osseous  shell. *^ 

Cloquet's  case,  one  of  the  most  accurately  described,  is  as  follows : — 


OSSIFICATION  IN   THE   EYE.  649 

Case  311. — The  eye  was  taken  from  the  dead  body  of  a  man  aged  about  50.  The  cor- 
nea and  iris  were  staphylomatous ;  the  eye  more  voluminous  than  natural,  and  longer  in 
its  transverse  diameter  than  in  any  other.  On  being  pressed  between  the  fingers,  it 
resisted  sufficiently  to  show  that  its  membranes  were  sustained  interiorly  by  some  solid 
body.  The  sclerotica  presented  nothing  particular;  nor  did  the  optic  nerve,  which 
retained  its  natural  size  and  organization.  The  choroid  had  the  ordinary  appearance, 
with  its  vessels  injected.  The  ciliary  ligament  had  almost  entirely  disappeared.  The 
iris,  in  a  deformed  state,  adhered  to  the  posterior  surface  of  the  cornea,  as  did  the  crys- 
talline lens,  which  was  atrophic  and  of  an  irregular  form.  The  aqueous  humor  had  dis- 
appeared ;  the  vitreous  was  very  limpid  and  fluid.  The  internal  surface  of  the  choroid 
adhered  slightly  to  a  very  thin  osseous  shell,  formed  by  the  deposition  of  calcareous  granu- 
lations into  the  substance  of  what  Cloquet  conceives  to  have 
been  a  false  membrane,  existing  between  the  choroid  and  Fig.  83, 

retina.  (Fig.  83.)  The  shell  had  no  adhesion  to  the  retina. 
It  had  a  round  opening  for  giving  passage  to  the  optic  nerve. 
Posteriorly  it  was  pretty  thick,  but  anteriorly  very  thin,  and 
ended  with  an  irregular  fringed  edge.  It  presented  on  dif- 
ferent parts  of  its  extent,  small  irregular  openings,  closed  by  a 
fine  transparent  membrane,  in  the  substance  of  which  were 
observed  many  white  delicate  granulations,  not  yet  united 
into  osseous  laminic.  The  retina  examined  under  water, 
presented  no  visible  alteration  in  its  organization. '^ 

Case  312. — Panizza  examined  the  eye  of  a  man  of  60 
years  of  age,  who  had  lost  the  sight  of  it  in  his  youth,  from 
internal  ophthalmia.  The  cornea  was  completely  opaque, 
and  flattened.  The  sclerotica  was  natural  in  form,  but  some- 
what less  in  size,  and  hard  to  the  touch.  The  sclerotica 
being  divided  circularly,  and  the  choroid  raised,  <a  white, 
hard,  stony  substance,  somewhat  rough,  came  into  view. 
After  the  eye  had  been  left  in  alcohol  for  two  days,  the  dis- 
section was  continued.     On  reversing   the  anterior  segment 

of  the  sclerotica  and  choroid,  the  calcareous  substance  was  found  to  be  present  under 
the  whole  of  the  latter  membrane.  The  iris  adhered  firmly  to  the  internal  surface  of 
the  cornea,  and  to  the  lens,  which  was  shrunk  and  ossified.  The  posterior  segment  of 
the  sclerotica  and  choroid  was  easily  reversed,  thei-e  being  almost  no  connections  between 
tlie  parts,  except  by  means  of  some  vessels  which  passed  into  the  calcareous  substance 
Ij'ing  beneath.  These  attachments  being  separated,  Panizza  noticed  that  the  whole  cal- 
careous mass  hung  from  the  optic  nerve,  which  penetrated  by  an  opening  into  its  interior. 
Desirous  of  ascertaining  the  state  of  the  retina,  he  cautiously  removed  a  portion  of  the 
calcai*eous  substance.  He  found  the  calcareous  shell  very  resisting  on  its  external  sur- 
face, although  brittle,  about  a  line  in  thickness,  and  formed  of  strata,  of  which  the  inner- 
most were  the  least  hard,  and  at  last  almost  membranous.  Having  thus  penetrated  to 
the  cavity  of  the  shell,  he  found  it  filled  with  a  whitish  substance,  albuminous,  of  the 
consistence  of  jelly,  and  arranged  in  strata,  which  became  softer  and  softer  towards  the 
centre  of  the  eye,  and  which  he  compares  to  the  layers  contained  in  an  aneurismal  sac. 
He  removed  a  part  of  this  substance,  and  saw  in  the  middle  of  it  the  retina,  in  the  form 
of  a  membrane  which  had  been  gathered  together.  Passing  from  behind  forwards,  it 
terminated  anteriorly  by  attaching  itself,  in  an  expanded  state,  to  the  posterior  margin 
of  the  corpus  ciliare,  while  its  slender  posterior  extremity  corresponded  to  the  entrance 
of  the  optic  nerve  through  the  sclerotica.  On  making  a  vertical  section  of  the  conical 
portion  of  the  retina,  Panizza  found  within  it  the  hyaloid  membrane,  corrugated,  and 
reduced  to  a  very  small  mass,  along  with  a  little  of  the  vitreous  humor.  Raising  the 
flaps  of  the  divided  retina,  he  found  its  internal  surface  smooth,  and  not  at  all  adherent 
to  the  hyaloid.20 

Reasoniug  from  this  dissection,  Panizza  rejects  the  notions  of  those  who 
have  attributed  such  states  of  the  eye  to  ossification  of  the  hyaloid  or  of  the 
retina,  and  adopts  the  opinion,  already  noticed,  that  such  calcareous  incrusta- 
tions arise  from  the  condensation  of  extravasated  fluids. 

S  8.    Ossification  of  the  Hyaloid  Membrane,  Crystalline  Capsule,  and  Crystal- 
line Lens. 

Many  examples  have  been  recorded  of  ossification  of  the  crystalline  lens 
and  capsule ;  and  in  some  of  these,  the  hyaloid  membrane  has  been  more  or 
less  affected  in  the  same  manner. 


650  OSSIFICATION   IN   THE   EYE. 

Case  313. — Spree,  in  his  thesis,  records  a  case  in  which,  after  the  extraction  of  a  cata- 
ract, the  operation  having  failed  in  restoring  sight,  the  patient  was  affected  with  pain  in 
the  eye  till  the  time  of  liis  death.  On  dissection,  morbid  adhesions  were  found  between 
the  choroid  and  the  neighboring  parts ;  there  was  no  trace  of  the  retina ;  the  optic  nerve 
was  atrophied ;  and  in  place  of  the  vitreous  body,  there  was  a  bony  substance,  convex 
posteriorly  and  concave  anteriorly,  and  half  an  inch  in  thickness. 2' 

"  In  one  case,"  says  Mr.  Wardrop,  "  besides  the  capsule  of  the  lens  being 
ossified,  I  found  several  large,  but  thin  scales  of  bony  matter,  dispersed  in  an 
irregular  manner  throughout  the  vitreous  humor,  which,  in  all  probability, 
were  ossifications  of  the  hyaloid  membrane.  "^'^ 

In  a  case  of  capsular  cataract,  I  found  the  anterior  hemisphere  of  the  cap- 
sule hard  and  gritty  under  the  needle.  The  disease  had  originated  in  iritis, 
followed  by  contracted  pupil  and  lymphatic  exudation.  The  cataractwas  de- 
pressed, and  a  tolerable  share  of  vision  was  restored. 

The  anterior  hemisphere  of  the  capsule  is  more  frequently  ossified  than  the 
posterior.  In  some  cases,  the  whole  capsule  is  converted  into  a  thin  shell  of 
bone,  containing  the  lens  in  an  opaque  state.  In  other  cases,  the  lens  has 
been  previously  absorbed,  in  part  or  completely,  so  that  the  ossified  capsule 
has  a  less  regular  form,  having  become  shrivelled  before  being  converted  into 
bone. 

In  an  eye  sent  to  Mr.  Wardrop  by  Mr.  Allan  Burns,  the  central  portion  of 
the  lens  was  found  converted  into  hard  bone.  This  was  the  only  instance 
which  Mr.  W.  had  met  with,  in  which  ossification  of  the  lens  was  unattended  by 
ossification  of  the  capsule.  The  ossified  centre  of  the  lens  was  of  a  deep 
brown  color,  and  exhibited  a  laminated  structure.-^ 

The  lens,  dislocated  either  into  the  vitreous  humor,  or  into  the  anterior 
chamber,  in  consequence  of  a  blow  on  the  eye,  is  very  apt  to  become  ossified. 
In  those  cases,  where  a  lens,  inclosed  in  a  ruptured  capsule,  comes  into  the 
anterior  chamber  and  is  left  there  till  the  lens  nearly  disappears  by  absorption, 
its  place  seems  always  to  become  partially  occupied,  either  by  amorphous  cal- 
careous deposit,  or  by  a  layer  of  ossific  matter  within  the  capsule. 

When  a  lens,  inclosed  in  its  capsule,  has  been  separated  from  its  suspensory 
ligament,  and  falling  back  into  the  vitreous  humor,  reduced  to  a  state  of  syn- 
chysis,  has  become  ossified,  it  is  apt  to  come  forward  through  the  pupil,  when 
the  patient  happens  to  stoop,  and  if  not  extracted,  gives  rise  to  iritis. 

Cff«e314. — PcUicr^*  relates  a  case,  in  which  the  cornea  of  an  eye  which,  for  20  years, 
had  suffered  more  or  less  from  inflammation,  at  length  gave  way,  and  allowed  an  ossified 
lens  to  be  seen  and  felt.  A  crucial  incision  was  made  through  the  cornea,  and  a  portion 
of  calculous  substance,  of  the  size  of  a  kidney-bean,  was  extracted.  Part  of  the  ossifica- 
tion was  still  left  in  the  eye,  the  patient  having  become  so  restless  that  it  could  not  be 
removed.  Pellier  seems  to  think  that  the  whole  contents  of  the  eye  were  in  an  ossified 
state.     The  piece  extracted  was  rough  and  irregular. 

Case  815. — Though  Mr.  Wardrop  gives  the  following  case,  communicated  to  him  by  INIr. 
Anderson,  surgeon  at  Inverary,  as  one  of  a  piece  of  bone  formed  in,  or  immediately  be- 
hind the  cornea,  I  cannot  help  suspecting  it  to  have  been  merely  a  dislocated  lens  and  cap- 
sule, which  had  become  partially  ossified  in  the  anterior  chamber. 

On  examining  the  right  eye  of  a  woman  of  31  years  of  age,  Mr.  Anderson  observed  a 
substance  of  whitish  appearance,  arising  from  the  inside  of  the  sclerotic  coat,  and  ex- 
tending upwards  behind  the  cornea,  over  a  great  part  of  the  iris  to  very  near  the  pupil. 
It  had  produced  much  irritation  in  the  eye,  with  inflammation,  severe  pain,  an  almost  con- 
stant flow  of  tears,  inability  to  bear  the  light,  and  a  considerable  diminution  of  vision. 
The  eye  was  less  in  size  than  the  other.  The  complaint  was  the  consequence  of  a  fall,  15 
years  before,  at  the  root  of  a  tree,  by  which  the  patient  struck  the  eye,  but  did  not  cut 
any  part  of  it.  From  this  period,  the  substance  seen  through  the  cornea  had  begun  to 
grow,  and  had  gradually  increased  in  size.  The  pain  and  other  symptoms  had  been  suffer- 
able  until  about  nine  months  before  Mr.  Anderson  saw  her,  when  the  complaint  became 
more  violent.  He  made  an  incision  into  the  cornea,  in  the  manner  recommended  for  the 
extraction  of  the  cataract,  raised  the  flap  of  the  cornea  with  a  flat  crooked  probe,  and 
with  the  same  instrument  turned  out  a  small  piece  of  bone.     The  upper  part  of  it  was  as 


OSSIFICATION   IN   THE   EYE.  651 

thin  as  a  piece  of  paper;  at  the  under  part  it  was  thicker,  porous,  and  brittle,  and  of  an 
irregular  semilunar  form.  The  upper  part  was  quite  detached,  the  under  part  slightly 
adhered  to  some  part  of  the  globe  out  of  sight ;  but  it  was  easily  extracted,  without  requir- 
ing the  knife  to  separate  its  adhesions.  From  the  unsteadiness  of  the  patient,  it  was  im- 
possible to  discover  from  what  part  the  ossification  originated. '^s 

On  extracting  a  ruptured  capsule  which  lay  in  the  anterior  chamber,  I  found 
a  quantity  of  amorphous  calcareous  deposit  within  it,  of  a  brownish  color.  I 
have  extracted  several  lenses,  which  had  become  ossified  in  the  vitreous  hu- 
mor, and  had  slipped  forwards  through  the  pupil.  The  surface  of  the  ossi- 
fication was  always  irregular  and  porous,  and  generally  closely  embraced  by 
the  transparent  capsule.  In  one  case,  the  whole  interior  of  the  capsule  was 
coated  by  a  pretty  thick  layer  of  bony  substance,  of  a  nodulated  appearance. 
On  examination,  the  nodules  were  found  to  consist  of  what  appeared  to  be 
cartilage,  inclosing  masses  of  carbonate  and  phosphate  of  lime,  and  surrounded 
by  new  membranous  substance  which  had  formed  within  the  capsule."''  Al- 
though extraction  is  the  best  practice  to  follow  in  such  cases,  the  patient  may 
sometimes  be  temporarily  relieved  by  lying  supine  with  his  head  low,  and 
having  the  pupil  artificially  dilated,  so  as  to  allow  the  ossified  lens  to  gravi- 
tate into  the  vitreous  humor  ;  or  should  this  fail,  by  having  a  curved  needle 
passed  through  the  sclerotica,  with  which  the  lens  may  be  carried  back  through 
the  pupil. 

Cretaceous  degeneration  of  the  lens  or  its  capsule,  even  when  these  textures 
maintain  their  natural  situation,  not  unfrequently  produces  pain  and  irritation, 
both  in  the  diseased  eye,  and,  sympathetically,  in  the  sound  one,  requiring  the 
coruea  of  the  diseased  eye  to  be  opened,  and  the  ossified  parts  to  be  ex- 
tracted ;  or  if  the  cornea  is  opaque  and  adherent  to  the  iris,  part  of  the  cor- 
nea to  be  excised,  and  the  ossified  lens  or  capsule  removed  with  forceps.-' 


'  Beitrage  zur  Augenheilkunde,  p.3J:,- Wien,  '^  De  Sedibus  et  Causis  Morborum;  Epist. 

1850.  lii.  Art.  30. 

'^  [See  Report  of  the  Pathological  Society,  in  ''  Memoires      de    rAcademie      Royale    des 

Assoc.  Med.  Journal,  for  Jan.  5tb,  1855. — H.]  Sciences,  pour  1730;  p.  467;  Amsterdam,  1733. 

'  llandbuch  der   pathologischen  Anatomic;  "  Op.  cit.  "Vol.  ii.  pp.  68  and  272;  London, 

Vol.  ii.  p.  92  ;  Halle,  1804.  1818. 

*  IJeber    die    durchsichtigo    Ilornhaut    des  ""  Pathologic  Chirurgicale,  par  Jules  Cloquet, 
Auges,  p.  56  ;  Karlsruhe,  1818.  p.  130  ;  PI.  x.  figs.  1  and  2  ;  Paris,  1831. 

*  Journal   Hebdomadaire  de   Medecine ;   19  ''°  Panizza,  Ajipendice  sul  Fungo  Midnllare 
Septembre,  1829,  p.  482.  dell'  Occhio;  p.  22  ;  Tav.  i.  fig.  7  ;  Pavia,  1826. 

'^  Morbid  Anatomy  of  the  Human  Eye;  Vol.  ^'  Annales  d'Oculistique  ;    Tome  xiv.  p.  122  ; 

i.  p.  74;  London,  1819.  Bruxelles,  1845. 

"  Zeitschriftfiir  die  Opbthalmologie  ;  Vol.  ir.  ^^  Op.  cit.  Vol.  ii.  pp.  128  and  271  ;  PI.  xiv. 

p.  64;  Leipzig,  1854.  fig.  2;  London,  1818. 

'  Ibid.,  Vol.  ii.  p.  18 ;  London,  1818.  ^^  Ibid.  pp.  96  and  261 ;  PL  xi.  fig.  5. 

'  Op.  cit.  p.  66.  ^'  Recuoil   de  Memoires  et    d'Observations: 

'°  Op.  cit.  p.  26.  Obs.  139  ;  Motitpellier.1783. 

''  Op.  cit.Vol.  ii.  p.  18.  "'  Op.  cit.  Vol.  i.  p.  75. 

'-  Ammon's    Monatsschrift ;  Vol.  i.  p.  482;  "  Sec  case  of  extraction  of  an  ossified  lens; 

Leipzig,  1838.  by  France,  Guy's  Hospital  Reports,  Second  Se- 

'"  Op.  cit.  Vol.  ii.p.  97;  Halle,  1804.  ries  :  Vol.  iii.  p.  197;  London,  1845. 

"  Zeitschrift  fiir  die  Ophthalmologic  ;  Vol.  i.  ^''  See  cases  by  Walton,  Medical  Times  and 

p.  319;  Dresden,  1831.  Gazette,  February  18, 1854,  p.  155. 

"*  Halleri    Opuscula    Pathologica;    p.  136; 
LausannaJ,  1755. 


652  ARTIFICIAL    EYE. 


CHAPTER  XV. 
ADAPTATION  OF  AN  ARTIFICIAL  EYE. 

Syn. — Ocular  prothesis. 

It  would  appear,^  that  iu  former  times,  when  the  eye  and  eyelids  had  been 
destroyed,  or  removed  in  consequence  of  disease,  a  painted  imitation  of  these 
parts  was  sometimes  applied  over  the  front  of  the  orbit,  and  kept  in  its  place 
by  means  of  a  steel-spring  going  round  the  temple  to  the  opposite  side  of  the 
head ;  but,  at  the  present  day,  by  an  artificial  eye  is  generally  meant  a  hollow 
semi-ellipse  or  hemisphere  of  enamel,  colored  to  resemble  the  front  of  the 
natural  eye,  and  introduced  behind  the  eyelids.  Enamelled  plates  of  gold 
were  at  one  time  used  for  this  purpose,  but  artificial  eyes  are  now  made  alto- 
gether of  enamel  and  glass. 

An  artificial  eye  ought  to  be  perfectly  smooth,  and  of  such  a  form  and  size 
as  to  cover  the  remainder  of  the  natural  eye  without  pressing  much  on  it,  or 
irritating  it  in  any  way.  Its  edge  ought  not  to  be  sharp,  but  somewhat  thick 
and  round.  The  internal  surface  of  the  middle  portion,  which  represents  the 
cornea,  ought  to  be  concave,  or  at  least  flat,  and  not,  as  we  sometimes  find 
it,  convex,  which  form  must  necessarily  give  rise  to  pressure  on  the  eye,  unless 
it  be  much  shrunk.  Want  of  attention  to  these  particulars  is  often  the  cause 
of  the  pain  which  patients  feel  from  the  introduction  of  an  ai'tificial  eye,  and 
which  often  leads  them  to  resign  all  thoughts  of  continuing  its  use. 

Artificial  eyes  have  generally  been  made  of  a  semi-elliptical  shape,  or  like 
the  half  of  the  shell  of  an  egg  cut  lengthwise  ;  but  of  late  a  shallower  form, 
approaching  to  the  hemispherical,  has  been  adopted,  as  less  likely  to  pinch 
the  bulb  on  which  the  eye  is  placed,  irritate  the  conjunctiva,  cause  an  appear- 
ance of  strabismus,  or  prevent  the  movements  of  the  artificial  eye. 

Thinness  and  lightness  are  indispensable  requisites  of  an  artificial  eye. 
When  the  eye  to  be  covered  is  large,  unless  the  artificial  eye  is  thin,  the  lids 
are  too  much  pressed  out,  and  are  prevented  from  executing  their  usual 
movements. 

When  the  remains  of  the  eye  are  irregular  in  form,  it  has  been  proposed  to 
make  the  artificial  eye  so  too,  lest  it  should  press  unequally  and  injuriously 
against  any  part.  When  one  or  other  eyelid,  for  example,  is  partially 
adherent  to  the  remains  of  the  eyeball,  unless  the  adhesion  is  removed  by  an 
operation,  the  diameter  of  the  artificial  eye  from  above  downwards  must  be 
shorter  than  common,  or  have  a  notch  in  its  edge  opposite  to  the  point  of 
adhesion. 

The  particular  hue  of  the  white  of  the  eye,  the  appearance  of  the  vessels 
sti'ewed  over  it,  and  the  size  and  color  of  the  iris,  ought  to  be  imitated  from 
the  sound  eye,  although  certainly  these  are  considerations,  much  less  impor- 
tant than  that  the  artificial  eye  should  be  of  a  fitting  size  and  form.  The 
pupil  ought  to  be  represented  at  its  medium  degree  of  expansion,  and  the 
appearance  of  an  anterior  chamber  ought  to  be  given.  The  iris  always  looks 
darker,  when  the  eye  is  introduced  behind  the  eyelids,  than  it  does  when 
examined  in  the  hand. 

The  manufacture  of  artificial  eyes  is  very  simple. '^  The  part  imitating  the 
sclerotica  is  formed  of  white  enamel,  with  a  tinge  of  yellow.     The  poste- 


ARTIFICIAL   EYE.  653 

rior  lamina  of  the  central  piece  is  colored  and  streaked  to  look  like  the  iris  ; 
on  the  middle  of  this  lamina  a  circular  patch  of  black  enamel  is  laid,  to  imitate 
the  pupil ;  the  superficial  lamina  is  transparent  glass.  Threads  of  red  enamel 
are  spread  over  the  surface  in  imitation  of  bloodvessels,  and  are  melted  in 
before  the  blow-pipe. 

If  the  defective  eye,  which  the  patient  is  desirous  of  covering  from  view,  is 
not  larger  than  the  natural  size,  an  artificial  eye  may  be  worn  without  any 
previous  surgical  operation,  but  if  there  is  a  total  staphyloma  of  the  cornea 
and  iris  present,  this  must  first  be  removed.  The  effects  of  any  injury  which 
has  rendered  the  application  of  an  artificial  eye  desirable,  or  of  any  o})eratioa 
which  has  been  performed  on  the  eye,  must  first  be  completely  cured,  and  an 
additional  space  of  some  months  must  have  elapsed,  before  the  artificial  eye 
can  with  propriety  be  tried.  In  some  cases,  indeed,  from  the  great  irritability 
of  the  patient,  causing  a  tenderness  and  epiphora  which  cannot  be  subdued, 
or  from  the  nature  of  the  disease  in  which  the  loss  of  the  eye  took  place,  giving 
ground  to  dread  lest  irritation  might  excite  some  malignant  affection,  we  are 
oljliged  to  resign  thoughts  of  applying  an  artificial  eye. 

The  protrusion  of  a  portion  of  iris,  or  a  staphyloma  racemosura,  sometimes 
renders  the  wearing  of  a  glass  eye  impossible,  from  the  pain  which  is  produced, 
till  the  protrusion  is  removed.  If  there  is  a  prominent  partial  staphyloma  at 
the  upper  or  lower  part  of  the  cornea,  the  ordinary  oval  glass  eye  will  not 
lie  lengthvrise,  as  it  ought  to  do,  but  turn  round,  so  that  its  nasal  end  is  down 
and  its  temporal  end  up.  In  this  case,  a  hemispherical  glass  eye  is  more  likely 
to  answer. 

In  cases  of  eversion  of  the  lower  lid,  the  eversion  may  require  to  be  cured 
by  operation,  before  any  glass  eye  can  be  applied.^  Symblepharon  will 
require  similar  interference.  If  the  eyeball  has  been  extirpated,  the  sinuses 
of  the  conjunctiva  are  so  much  obliterated,  that  there  remains  no  seat  in 
which  an  artificial  eye  may  rest. 

If  there  is  no  inflammation,  no  fungous  excrescence  from  the  eyeball  or 
eyelids,  no  pain  or  irritation  present,  an  artificial  eye  may  be  tried.  The 
mode  of  introducing  it  is  to  lay  hold  of  it  by  its  lower  edge  with  the  thumb 
and  forefinger  of  the  right  hand,  moisten  it,  with  the  left  thumb  raise  the 
upper  eyelid,  under  which  introduce  the  upper  edge  of  the  artificial  eye, 
pressing  it  up  into  the  upper  sinus  of  the  conjunctiva  till  its  most  prominent 
part  is  hid  ;  then  to  allow  the  upper  lid  to  descend.  The  artifical  eye  is  now 
to  be  supported  with  the  right  thumb,  while  with  the  left  forefinger  the  lower 
eyelid  is  to  be  drawn  downwards,  which  allows  the  artificial  eye  to  slide 
behind  it  into  the  lower  sinus  of  the  conjunctiva.  If  the  edge  of  the  artificial 
eye  does  not  reach  the  sinus,  but  rests  on  the  tarsus,  it  is  too  large,  and  a 
smaller  one  must  be  selected. 

For  some  days,  the  eye  is  to  be  worn  only  during  a  few  hours.  It  is  with- 
drawn with  the  aid  of  a  gold  or  silver  probe,  of  the  thickness  of  a  knitting- 
needle,  the  end  of  which  is  rounded  off  and  bent  into  the  form  of  a  hook. 
With  the  forefinger  of  the  left  hand  the  lower  lid  is  to  be  depressed,  so  as  to 
allow  the  hook  to  be  introduced  behind  the  edge  of  the  eye,  which  by  this 
means  is  to  be  raised  till  it  is  no  longer  grasped  by  the  lower  lid  ;  the  eye 
immediately  glides  from  under  the  upper  eyelid,  and  is  to  be  laid  hold  of  by 
the  left  hand.  The  eye  is  to  be  immediately  freed  from  the  mucus  which 
adheres  to  it,  by  rubbing  it  gently  with  a  bit  of  soft  rag,  and  then  laid  aside  till 
next  day.  It  ought  not  to  be  plunged  into  cold  water,  as  this  is  apt  to  make 
it  crack.  If  imperfectly  annealed,  artificial  eyes  are  apt  to  crack,  merely  from 
the  alternations  of  temperature  to  which  they  are  exposed,  when  withdrawn  in 
the  evening,  or  replaced  in  the  morning. 

The  patient  is  soon  able  to  introduce  and  withdraw  the  eye  without  assist- 


654  ARTIFICIAL   EYE. 

ance.  While  withdrawing  it,  he  leans  over  a  bed,  or  over  a  table  with  a  towel 
spread  on  it,  in  order  that,  if  it  should  fall,  it  may  not  be  broken. 

If  the  eyeball  has  shrunk  to  a  small  size,  the  eyelids  lose  that  support  and 
elasticity  necessary  for  the  pei'formance  of  their  motions ;  the  consequence  is, 
that  they  soon  become  entirely  motionless,  and  sink  into  the  orbit,  while  the 
cilia  are  inverted,  and  the  sinuses  of  the  conjunctiva,  which  in  the  natural 
state  of  the  parts  extend  between  the  eyeball  and  the  eyelids,  gradually 
become  contracted,  and  at  last  almost  abolished.  The  superabundant  tears 
and  mucus  cannot  be  properly  excreted,  being  no  longer  pressed  forward  by 
the  convexity  of  the  eyeball,  but  gather  behind  the  lids  and  adhere  to  their 
edges  and  angles,  while  the  nostrils  of  the  same  side  feels  dry.  These  symp- 
toms are  in  general  greatly  lessened  by  the  use  of  an  artificial  eye,  which 
affords  to  the  lids  a  new  support,  restores  to  them  the  elasticity  necessary 
for  their  motions,  and  expands  again  the  folds  of  the  conjunctiva ;  while 
the  renewed  action  of  the  lids  serves  to  convey  the  tears  and  mucus  to  the 
puncta  lachrymalia,  as  in  the  state  of  health.  In  such  cases,  it  is  sometimes 
necessary  to  commence  with  a  small  artificial  eye,  and  employ  larger  ones, 
proportionally  as  the  folds  of  the  conjunctiva  will  admit.  We  need  not  be 
afraid  that  a  small  eye  will,  in  such  circumstances,  fall  out  from  between  the 
lids ;  for  we  may  observe  that  the  lids  are  enabled  to  open  only  in  proportion 
to  the  size  of  the  eye  which  is  placed  behind  them. 

We  may  begin  with  the  use  of  a  small  plain  eye ;  by  which  I  mean  one 
without  any  representation  of  the  iris.  A  series  of  such  eyes  ought  to  be 
kept  by  the  oculist,  and  employed  till  the  patient  becomes  accustomed  to  their 
use.  The  lids  cannot  in  general  be  easily  moved  at  first  over  an  artificial  eye, 
so  that  it  remains  exposed  to  the  foreign  matters  driven  through  the  air,  and 
both  from  this  cause,  and  from  the  first  attempts  of  the  patient  to  remove 
and  replace  it,  is  apt  to  become  scratched,  which  very  soon  destroys  its  ap- 
pearance. Every  two  or  three  days,  a  larger  eye  ought  to  be  introduced,  till 
at  length  the  lids  shall  appear  to  have  reached  nearly  their  natural  degree  of 
expansion. 

The  iris  and  pupil  of  the  eye  which  is  to  be  used  permanently  must  corre- 
spond in  direction  with  those  of  the  sound  eye,  and  must  not  be  placed  nearer 
to  either  canthus  than  they  are  in  it,  else  the  patient  will  appear  to  squint 
with  the  artificial  eye.  Some  artificial  eyes  are  made  for  the  right  or  left  side 
only,  and  have  more  sclerotica  above  than  below  the  iris,  others  are  intended 
to  be  used  on  either  side,  and  have  the  iris  placed  midway  between  the  upper 
and  lower  edges  of  the  eye.  In  all  artificial  eyes  there  is  more  sclerotica  on 
the  temporal  than  on  the  nasal  side  of  the  iris. 

A  properly  adapted  artificial  eye  performs  the  same  motions  as  the  sound 
eye,  especially  if  the  remains  of  the  eyeball  over  which  it  is  placed  are  consider- 
able, and  are  moved  with  facility  by  the  recti.  The  motion  of  the  artificial 
eye,  however,  does  not  depend  upon  this  alone,  but  also  on  the  motion  of  the 
conjunctiva  and  its  folds,  into  which  the  artificial  eye  is  received,  and  which 
possesses  a  simultaneous  movement  with  the  eyeball  and  eyelids.  Hence  it  is 
that,  if  the  artificial  eye  is  of  a  proper  size,  neither  so  small  as  to  escape  the 
grasp  of  the  conjunctiva,  nor  so  large  as  to  prevent  its  influence,  we  find  that 
it  performs  all  the  ordinary  motions  of  the  eye,  even  when  the  stump  which 
is  covered  is  very  small. 

An  artificial  eye  soon  begins  to  suffer  from  the  friction  of  the  eyelids,  and 
the  effect  of  the  tears  and  mucus,  so  that  the  cornea  becomes  dim  from  the 
glass  losing  its  polish.  It  has  been  supposed  that  it  is  the  Meibomian  secre- 
tion which  is  chiefly  detrimental.  The  polish  is  never  completely  preserved 
for  longer  than  three  or  four  months  ;  and  generally  in  six  months  the  whole 
surface  of  the  eye  is  hazy  and  slightly  rough.     The  red  threads,  imitating 


ARTIFICIAL   EYE.  655 

bloodvessels,  sometimes  dissolve  entirely,  leaving  grooves,  before  the  cornea 
or  sclerotica  becomes  altered.  The  rapidity  with  which  this  process  goes  ou 
varies,  depending  on  the  peculiar  qualities  of  the  secretions  of  the  individual. 
Their  speedy  waste,  along  with  their  extravagant  price,  puts  it  out  of  the 
power  of  any  but  those  in  easy  circumstances  to  use  artificial  eyes ;  although 
many  persons  in  indigent  circumstances,  finding  it  difficult  to  obtain  certain 
kinds  of  employment  from  loss  of  an  eye,  are  desirous  of  wearing  an  artificial 
one.  They  must  often  submit,  however,  to  conceal  their  defect  behind  dark- 
colored  glasses,  or  if  the  appearance  of  the  lost  eye  is  very  unsightly,  to  cover 
it  with  a  hollow  shade.  They  ought  never  to  adopt  the  practice  of  covering 
it  up  closely  with  a  patch,  which  heats  the  parts  too  much,  and  renders  them 
inflamed  and  oedematous. 

Enamel  eyes  which  have  lost  their  polish,  prove  hurtful,  their  roughness 
exciting  the  conjunctiva  to  inflammation,  excoriation,  and  the  growth  of  fun- 
gous excrescences.  When  an  artificial  eye,  therefore,  is  observed  to  have 
become  dim,  and  to  be  producing  irritation,  it  must  no  longer  be  used,  any 
irritation  already  present  must  be  calmed,  and  when  the  parts  are  again  per- 
fectly free  from  pain  or  inflammation,  a  new  artificial  eye,  or  the  old  one  re- 
polished,  may  be  applied. 

When  we  wish  an  artificial  eye  made  expressly  for  any  particular  person, 
it  is  necessary  to  send  to  the  enameller  a  drawing  of  the  sound  eye,  repre- 
senting accurately  the  color  and  other  appearances  of  the  iris,  along  with  a 
model  in  wax  or  lead  of  the  size  and  form  of  the  artificial  eye  which  is  to  be 
made,  taking  the  convexity  of  the  model  from  the  sound  eye,  and  marking  on 
it  the  place  and  size  of  the  iris  and  pupil,  and  the  extent  of  sclerotica  exposed 
when  the  eye  is  moderately  open.  The  drawing  and  model  ought  to  be  kept 
by  the  enameller,  so  that  at  any  future  time  the  patient  can  have  an  eye  made 
after  them  and  sent  to  him,  without  further  trouble. 

In  the  use  of  an  artificial  eye,  the  strictest  regard  to  cleanliness  must  be 
observed.  Every  12  hours,  it  must  be  taken  out  and  freed  from  the  mucus 
which  adheres  to  it  and  accumulates  in  its  cavity.  The  eyelids  must  at  the 
same  time  be  bathed  with  tepid  water,  and  should  there  be  any  considerable 
relaxation  of  parts,  or  tendency  to  puro-mucous  inflammation,  a  slightly  as- 
tringent collyrium  is  to  be  employed,  and  the  edges  of  the  lids  smeared  with 
a  little  red  precipitate  salve.  Should  the  conjunctiva  appear  swollen  or  fun- 
gous, it  is  proper  to  touch  it  with  a  lunar  caustic  solution.  Sometimes  it  is 
necessary  to  snip  away  hard  fungous  folds  of  the  conjunctiva.  This  must  be 
done  cautiously,  lest  the  sinuses  be  rendered  too  contracted  to  hold  the  arti- 
ficial eye,  or  adhesions  form  between  the  eyelids  and  the  eyeball. 


'  (Euvres d'Ambroise  Pare ;  Liv.xxiii.  Chap.  1.  Tphere  an  injury  to  the  integuments  of  tho  cheek 

'  On  the  manufacture  of  artificial  eyes,  see  had  produced  ectropiura,  combined  with  loss  of 

Blaneourt's  Art  of  Glass;  Translated  into  Eng-  eyeball;  by  Walton;  Medical  Times  and  Ga- 

lish;  p.  35.3;  London,  1699.  zette;  January  29,  1863;  p.  117. 
'  See  case  of  adaptation  of  an  artificial  eye, 


656 


CONICAL   CORNEA. 


CHAPTER   XVI. 

PARTIAL   AND    GENERAL   ENLARGEMENTS   OF  THE   EYE- 
BALL ;    EFFUSIONS  AND  TUMORS  WITHIN  ITS  COATS. 


Fiff.  84. 


SECTION  I. — CONICAL  CORNEA. 

St/n. — Ochlodes,  Tai/lor.  Staphyloma  pellucidum  coiiicum,  Lyall.  Hyperkeratosis,  Ilunly. 

Fig.  Demours,  PI.  LYII.  Fig.  1.    Ammon,  Thl.  I.  Taf.  III.  Figs.  13—21.     Taf.  X.  Fig.  8.  Thl.  Ill, 
Taf.  VII.  Figs.  8—10.     Dalrymple,  PI.  XXXII.  Fig.  1.     Sichel,  PI.  XXXII.  Figs.  3— C. 

In  this  affection  the  cornea,  instead  of  its  natural  shape,  presents  the  form 
of  a  cone,  more  or  less  acute.     Viewed  in  profile,  the  cornea  in  this  state  looks 

like  a  drop  of  water,  or  like  a  solid  piece  of 
glass,  projecting  from  the  front  of  the  eye. 
(Fig.  84.)  On  placing  the  patient  directly- 
opposite  to  a  window,  and  viewing  the  eye  in 
front,  the  centre  of  the  cone  so  reflects  the  light 
as  to  produce  a  sparkling  effect.  The  cone,  in 
some  cases,  is  small  and  pointed ;  in  others,  al- 
though it  projects  more,  its  apex  is  rounded  off. 
The  apex  of  the  cone  is  generally  in  the  centre, 
but  sometimes  towards  one  side  of  the  cornea. 
In  some  cases,  the  whole  cornea  partakes  of 
the  conical  form ;  in  other  instances,  the  cone 
is  small  in  comparison  to  the  whole  extent  of 
the  cornea,  and  rises  rather  abruptly.  In  certain  positions  of  the  eye,  the 
point  of  the  cone  appears  less  transparent  than  the  rest  of  the  cornea,  and 
not  unfrequently  it  is  actually  nebulous  or  opaque. 

In  slight  cases,  conical  cornea  may  pass  without  being  detected,  till  the 
observer  examines  the  form  of  the  image  of  the  window,  or  of  a  candle,  re- 
flected from  the  surface  of  the  cornea.  The  image  is  so  remarkably  changed 
in  shape,  and  becomes  so  suddenly  small,  when  it  comes  upon  the  apex  of  the 
cone,  as  at  once  to  show  that  the  cornea  has  lost  its  spherical  form. 

In  the  earliest  period  of  the  disease,  short-sightedness  is  the  principal  effect 
which  it  produces  on  vision ;  when  more  advanced,  nothing  is  seen  by  the 
patient  through  the  centre  of  the  cornea ;  all  the  sight  which  he  enjoys  is 
either  over  the  nose,  or  towards  the  temple,  and  in  its  sphere  is  extremely 
limited.  Still,  however,  by  strongly  compressing  the  eye  with  the  half-closed 
lids,  or  with  the  finger,  so  as  to  limit  the  pupil,  and  bringing  the  object  close 
towards  one  or  other  side  of  the  eye,  generally  towards  the  temporal,  the  pa- 
tient is  sometimes  able  even  to  read.  Beyond  two  or  three  inches,  vision 
becomes  very  indistinct,  and  at  a  few  feet  the  patient,  in  general,  distinguishes 
absolutely  nothing ;  he  can  judge  neither  of  the  distance  nor  form  of  objects, 
so  that  he  is  rendered  nearly  as  dependent  as  if  he  were  blind.  It  is  often 
the  case,  that  the  first  symptom  complained  of,  is  dimness  of  sight ;  and  unless 
the  eye  is  carefully  examined,  amaui'osis  may  be  supposed  to  be  present. 

In  its  natural  state,  the  cornea  has  no  surface  large  enough  to  bend  more 
than  a  single  ray  of  light,  and  it  aids  in  concentrating  all  the  single  rays  into 
one  place,  there  to  form  a  vivid  image  of  external  objects  ;  but  in  the  disease 
now  under  our  consideration,  it  presents  inequalities,  each  of  which,  like  a 


CONICAL   CORNEA.  65T 

facette  of  a  multiplying  glass,  bends  a  set  of  rays,  capable  of  forming  a  sepa- 
rate image.  Hence  it  is  generally  the  case,  that  objects  appear  multiplied  to 
an  eye  affected  with  conical  cornea. 

Case  316. — One  of  Mr.  AVanlrop's  patients  observed  that,  when  she  looked  at  a  candle, 
it  was  multiplied  five  or  six  times,  and  that  all  the  images  were  more  or  less  indistinct.  When 
Sir  David  Brewster  examined  her  eye,  he  observed  that,  in  every  aspect  in  which  the  cor- 
nea could  be  viewed,  its  section  appeared  to  be  a  regular  curve,  increasing  in  curvature 
towards  the  vertex.  As  the  disease  was  evidently  seated  in  the  cornea,  which  projected 
to  an  unnatural  degree,  it  did  not  seem  probable  that  there  was  any  defect  in  the  structure 
of  the  crystalline  lens.  He  was,  therefore,  led  to  believe,  that  the  broken  and  indistinct 
images,  which  appeared  to  encircle  luminous  objects,  arose  from  eminences  on  the  cornea, 
which  could  not  be  detected  by  a  lateral  view  of  the  eye,  but  might  be  rendered  visible  by 
the  changes  which  they  would  produce  upon  the  image  of  a  luminous  object  traversing  the 
surface  of  the  cornea.  He,  therefore,  held  a  candle  at  the  distance  of  15  inches  from  the 
cornea,  and,  keeping  his  eye  in  the  direction  of  the  reflected  rays,  observed  the  variations 
in  the  size  and  form  of  the  image  of  the  candle.  The  reiiected  image  regularly  decreased 
in  size  when  it  passed  over  the  most  convex  parts  of  the  cornea ;  but  when  it  came  to  the 
part  nearest  the  nose,  it  alternately  expanded  and  contracted,  and  suffered  such  derange- 
ments as  to  indicate  the  presence  of  a  number  of  spherical  eminences  and  depressions, 
which  sufficiently  accounted  for  the  broken  and  multiplied  images  of  luminous  objects.' 

Sir  David  Brewster  afterwards  examined  various  cases  of  conical  coi'nea  ; 
and,  in  all  of  them,  detected  inequalities  in  the  superficial  conformation  of  the 
cornea. 

It  was  long  a  doubtful  point,  whether  the  cornea  was  merely  protruded 
into  the  conical  form  which  it  assumes,  or  actually  thickened,  and  the  cone 
solid.  The  external  appearance  might  certainly  lead  us  to  think  that  the 
latter  was  the  case  ;  and  accordingly  Sir  William  Adams  described'^  the  dis- 
ease as  a  morbid  thickening  and  growth  of  the  substance  of  the  cornea,  while 
Himly  gave  it  the  name  of  hyj^erkeratosis.  Mr.  Wardrop,  however,  states 
that  the  irregular  portion  at  the  apex  of  the  cone,  which  is  sometimes  clouded 
and  opaque,  is  generally  very  thin  ;  and  that  in  one  case,  a  gentleman  with 
this  disease  receiving  a  blow  in  the  eye,  the  cornea  burst.  This  view  of  the 
matter  has  been  confirmed  by  Dr.  Jiiger,  of  Erlangen,  who,  on  dissecting  the 
eyes  of  a  person  affected  with  conical  cornea,  found  the  apex  of  the  cone 
very  thin,  but  the  circumferential  portion  of  the  cornea  thickened.'  So  thin 
is  the  prominent  part  that,  on  puncturing  the  cornea  in  this  disease,  the  gush 
of  aqueous  humor  allows  the  cone  to  collapse  and  become  wrinkled. 

The  disease  begins  first  in  one  eye,  and  after  a  time  attacks  the  other  also. 
In  general,  the  one  continues  much  more  affected  than  the  other.  It  has 
been  met  with  in  almost  every  stage  of  life;  like  common  myopia,  it  appears 
most  frequently  about  the  time  of  puberty,  or  at  least  advances  rapidly  about 
that  period,  so  that  the  patient  is  perhaps  obliged,  on  account  of  extreme 
shortness  of  sight,  to  give  up  the  trade  he  had  already  learned.  In  one 
instance,  Mr.  Wardrop  met  with  it  in  a  boy  of  8  years  of  age.  Sir  W.  Adams 
had  seen  it  in  patients  from  16  to  tO;  much  more  frequently,  however,  in 
women  than  in  men,  and  in  young  than  in  old  persons.  Dr.  Amraon  states* 
that  conical  cornea  is  sometimes  congenital.  He  once  met  with  it  in  several 
sisters,  who  labored  under  it  from  birth. 

The  progress  of  conical  cornea  is  in  general  unattended  by  inflammation, 
pain,  or  feeling  of  distension.  I  have  known  it,  however,  to  be  preceded  by 
headache  and  pain  in  the  eye,  for  a  considerable  time.  I  have  seen  conical 
cornea  associated  with  scrofulo-catarrhal  ophthalmia,  with  common  specks  of 
the  cornea,  and  with  pterygium.  I  have  also  known  it  to  arise  from  corneitis. 
When  this  is  the  case,  the  cone  embraces  the  whole  of  the  cornea ;  the  form 
is  that  of  a  sugar  loaf,  somewhat  as  in  Demours'  figure,  and  the  apex  is 
rounded,  not  pointed.  When  not  preceded  by  corneitis,  the  cone  is  more 
acute,  does  not  affect  the  whole  extent  of  the  cornea,  and  tends  often  to  one 
42 


658  CONICAL   CORNEA, 

or  otlier  portion  of  its  margin.  In  one  case,  which  I  saw,  conical  cornea 
followed  scarlatina.  In  a  lad  at  the  Glasgow  Eye  Infirmary,  a  blow  on  the 
eye  with  a  snowball  was  supposed  to  have  led  to  it.  Much  weeping  has 
sometimes  been  blamed  for  it. 

It  is  not  likely  that  this  disease  depends  on  any  abnormal  pressure  by  the 
aqueous  humor.  More  probably  it  is  an  effect  merely  of  faulty  nutrition  of 
the  cornea.  It  probably  begins  in  all  cases  with  thinness  of  that  portion  of 
the  cornea,  which  afterwards  becomes  prominent.  I  have  a  suspicion  that 
it  sometimes  arises  from  the  thinning  of  the  cornea  attending  a  transparent 
cicatrice  or  dimple.  In  a  young  lady,  for  whom  I  was  consulted,  it  followed 
haziness  of  the  cornea,  and  one  or  two  small  depressions,  such  as  are  left  after 
the  absorption  of  phlyctenule. 

Treatment. — I  have  never  known  conical  cornea  lessened  by  any  remedy, 
internal  or  external.  The  treatment  should  have  for  object  to  prevent,  if 
possible,  the  progress  of  the  disease,  and  ward  it  off  from  the  other  eye,  if 
only  one  is  affected.  This  will  be  best  accomplished  by  avoiding  every 
employment  which  causes  straining  of  the  sight,  by  exercise  in  the  open  air, 
attention  to  the  bowels,  and  tonics,  such  as  quina. 

It  is  generally  agreed  that  evacuation  of  the  aqueous  humor  is  of  no  use. 

In  a  case,  however,  which  I  saw,  I  was  led  to  believe  that  an  accidental 
giving  way  of  the  cornea  was  followed  by  a  considerable  improvement.  The 
patient  was  a  young  lady  who,  several  years  after  consulting  me,  suddenly, 
on  stooping,  felt  as  if  her  eye  was  giving  wa/,  and  immediately  the  cornea 
was  observed  to  present  a  milky  appearance.  This  was  gradually  removed, 
and  the  form  of  the  cornea  became  nearly  natural. 

Pressure,  astringents,  and  all  other  local  means,  appear  to  have  failed  in 
arresting  the  progress  of  conical  cornea.  M.  Dcsmarres,  however,  has  some 
faith  in  pressure,  which  he  says  should  be  light,  applied  with  exactness,  and 
long  continued.  It  should  be  immediately  preceded  by  puncture  of  the 
cornea.^ 

Mr.  Travers  says  he  has  found  repeated  blisters,  and  the  more  powerful 
tonics,  as  steel  or  arsenic,  decidedly  serviceable."  As  it  is  evident,  however, 
that  he  confounds  conical  cornea  with  aqueous  dropsy,''  it  is  impossible  to 
know  whether  the  benefit  accruing  from  these  remedies,  occurred  in  the  former, 
the  latter,  or  both  of  these  diseases. 

Dr.  Pickford  recommends  emetics  and  purgatives,  which,  he  thinks,  by 
their  influence  on  the  gastric  and  other  nerves,  restore  the  healthy  functions 
of  the  weakened  nutrient  and  absorbent  vessels  of  the  cornea.  The  result, 
he  says,  is  a  slow,  but  progressive  retraction  of  the  cone,  and  a  consequent 
restoration  of  vision.^ 

Sir  David  Brewster  states,  that  the  injurious  effects  of  this  disease  upon 
vision  may,  within  certain  limits,  be  removed  by  glasses,  and  by  preventing  the 
image  from  being  formed  by  rays  passing  through  any  part  of  the  corrugated 
surface  of  the  cornea,  such  as  he  discovered  in  Mr.  Wardrop's  case.  Very 
deep  concave  lenses  produce  a  considerable  effect  in  rendering  objects  dis- 
tinct. 

The  patient  also  sees  better  when  his  eyelids  are  all  but  shut,  and  the  con- 
fusedness  of  vision  is  greatly  lessened  by  his  looking  through  an  opening  of 
the  size  of  the  pupil,  formed  in  a  piece  of  black  wood.  This  affords  more 
aid  in  correcting  vision  than  any  form  of  lens.  The  two  means,  however, 
are  not  incompatible;  namely,  a  deep  concave  lens,  with  a  movable  diaphragm 
behind  it,  attached  by  a  hinge  to  the  spectacle  frame  in  which  the  lens  is 
fixed.  The  diaphragm  may  have  either  a  hole  in  the  middle,  or  a  narrow 
transverse  slit.  This  contrivance  maybe  tried  with  or  without  artificial  dila- 
tation of  the  pupil. 


CONICAL   CORNEA.  659 

Sir  John  Herschel  suggests,  as  worthy  of  consideration,  in  very  bad  eases 
of  irregular  cornea,  whether  at  least  a  temporary  distinct  vision  could  not  be 
procured,  by  applying  in  contact  with  the  surface  of  the  eye,  some  transpa- 
rent animal  jelly  contained  in  a  spherical  capsule  of  glass  ;  or  whether  an 
actual  mould  of  the  cornea  might  not  be  taken  and  impressed  on  some  trans- 
parent medium.  "The  operation,"  says  he,  "would,  of  course,  be  delicate, 
but,"  referring  here  to  extraction  of  the  cataract,  "certainly  less  so  than  that 
of  cutting  open  a  living  eye,  and  taking  out  its  contents. "^  There  would 
be  no  great  difficulty  in  taking  an  impression  of  the  eye,  and  of  forming  a 
concavo-convex  lens,  the  hollow  surface  of  which  should  correspond  to  the 
conical  form  of  the  cornea ;  but  though  such  a  lens  might  be  applied  for  a 
few  seconds,  it  could  not  be  borne  in  contact  with  the  eye  sufficiently  long  to 
serve  any  useful  purpose. 

Dr.  Hull  mentions,"  that  in  as  bad  a  case  as  he  ever  saw,  most  benefit  was 
received  through  an  instrument  formed  of  two  lenses,  with  an  adjustment,  the 
object-glass  large  and  convex,  the  eye-glass  smaller  and  doubly  concave,  an 
arrangement  similar  to  that  of  an  opera-glass. 

Sir  W.  Adams,  from  the  opinion  which  he  had  adopted,  that  the  conical 
form  assumed  in  this  disease  was  the  effect  of  a  morbid  growth  of  the  cornea, 
and  that  the  short  sight  of  the  patient  was  to  be  attributed  to  the  increased 
refractive  power  of  the  part,  which,  together  with  that  of  the  crystalline  lens, 
brought  the  rays  of  light  to  a  point  far  short  of  the  retina,  suggested,  that 
as  it  was  impossible  to  remove  the  morbid  state  of  the  cornea,  without  ren- 
dering it  unfit  for  the  transmission  of  light,  a  useful  degree  of  vision  might  be 
restored  by  removal  of  the  crystalline  lens.  His  opinion  in  favor  of  this  plan 
was  confirmed  by  what  happened  in  the  case  of  a  woman  of  nearly  TO  years 
of  age,  who  placed  herself  under  his  care,  laboring  under  this  disease  accom- 
panied with  cataracts.  These  he  successfully  removed,  and  had  the  gratifica- 
tion to  find  that  the  patient  was  capable  of  seeing  much  more  distinctly  without 
convex  glasses  than  it  is  usual  for  those  to  do  who  have  undergone  the  opera- 
tion for  cataract. 

The  result  of  this  case  determined  him,  at  the  earliest  opportunity,  to  try 
the  effect  of  removing  the  crystalline  lens,  as  a  remedy  for  the  blindness  pro- 
duced by  conical  cornea.  A  favorable  case  presented  itself  the  following 
year  : — 

Case  317. — A  young  woman,  who,  during  six  years  had  found  her  sight  gradually  de- 
creasing, at  the  expiration  of  that  period  became  so  blind,  as  to  be  unable  to  continue  her 
employment  as  a  servant.  The  cornea  of  each  eye  had  assumed  the  conical  form  in  a 
great  degree,  attended  by  a  slight  opacity  in  the  apex  of  each  cone,  but  none  whatever  in 
the  crystalline  lens.  She  could  walk  without  a  guide,  and  could  see  at  the  distance  of 
three  or  four  feet,  so  as  to  avoid  running  against  any  person,  but  had  entirely  lost  the 
jiower  of  reading  or  perceiving  minute  objects,'  however  near  to  the  eyes.  Sir  William 
effected  the  removal  of  the  crj'stalline  lens  of  one  of  her  eyes,  by  the  opei-ation  of  division. 
The  patient,  however,  returned  to  the  country  before  the  eye  had  entirely  recovered  from 
the  operation,  and  Sir  William  did  not  again  see  her  until  nearly  12  months  afterwards, 
when  he  was  gratified  to  find  her  capable  of  discovering  minute  objects,  and  reading  the 
smallest  sized  print,  without  the  assistance  of  a  glass,  while  holding  the  book  at  the  usual 
distance  of  10  or  12  inches  from  the  eye.  The  usual  cataract  spectacles  for  near  objects, 
of  two  inches  and  a  half  focus,  confused  her  sight  nearly  in  the  same  manner  as  it  had  been 
before  the  crystalline  lens  was  removed,  while  with  those  of  9  or  10  inches  focus,  her  capa- 
bility of  seeing  minute  objects  was  somewhat  improved.  Objects  at  a  distance  she  saw 
better  without  than  with  any  glass  which  could  be  found. 

Mr.  Tyrrell  ti'ied  the  effect  of  altering  the  position  of  the  pupil,  removing 
it  from  behind  the  centre  of  the  cornea,  the  part  which  has  its  figure  most 
changed,  to  near  the  margin,  where  the  least  change  occurs.  This  he  did  by 
puncturing  the  cornea  near  its  margin,  introducing  his  small  blunt  hook, 
catching  the  pupillary  edge  of  the  iris,  drawing  it  out,  and  either  leaving  it 


660  DROPSY   or  THE   CORNEA, 

prolapsed,  or  cutting  off  the  portion  of  the  iris  thus  extracted.  No  evil  fol- 
lowed ill  any  case  from  this  operation  ;  and  in  two  cases,  out  of  seven  or 
eight,  very  considerable  relief  was  obtained.'^ 

Mr.  Walker,  of  Manchester,  recommends  that  a  trial  should  first  be  made 
of  the  above  plan  of  displacing  the  pupil ;  and  if  no  sufficient  benefit  were 
found  to  result,  that  the  lens  should  be  extracted,  or  removed  by  absorption. 
He  relates  a  case,  in  which  extraction,  preceded  by  displacement  of  the  pupil, 
was  followed  by  a  satisfactory  result  in  one  eye,  which  lost  its  conical  shape, 
and  served  the  patient  for  reading  small  print  at  the  usual  distance.  The 
other  eye,  having  been  submitted  to  the  same  process,  was  lost  from  ophthal- 
mitis.^^ 

Operative  interference  with  conical  cornea  is  strongly  condemned  by  Mr. 
Lawrence  and  Mr.  Walton.     It  is  not  a  practice  which  I  have  ever  tried.^^ 


*  AVardrop's  Morbid  Anatomy  of  the  Human        '  Article  Light,  in  Encyclopasdia  Metropoli- 
Eye;  Vol.  i.  p.  131;  London,  1S19.  tana,  p.  398:  ^  359.     See  further  on  this  sub- 

^  Journal  of  Science  and  the  Arts ;  Vol.  ii.  p.  joct,  in  a  subsequent  chapter,  under  the  head  of 

403;  London,  1817.  Irregnlat-  licfraction. 

^  Carl  Schmidt's Inaugural-Abhandlung  liber         '"  Cursory  Notes  on  the  Morbid  Eye,  p.  37; 

die  Hyperkeratosis;  p.  17  ;  Erlangen,  1830.  London,  1840. 

*  Zeitschrift  f Ur  die  Ophthalmologic;  Vol.  i,         "  Practical  Work    on    the  Diseases  of  the 
p.  123;  Dresden,  1830.  Eye  ;  Vol.  i.  p.  277  ;  London,  1840. 

'  Traite  des  Maladies  desYeux,  p.  348;  Paris,         ''^  Oculist's   Vade-Mecum,  p.    145;  London, 

1847.  1843. 

"  Synopsis  of  the  Diseases  of  the  Eye  ;  p.  286;         "  On  Conical  Cornea,  consult  Sichel,  Annales 

London,  1820.  d'Oculistique  ;  2e  Vol.  Suppl.  p.  125;  Bru,xelles. 

'  Ibid.  p.  124.  1843:    Lhomnieau,    Ibid.    p.  168:    W.   White 

'  Dublin  Journal  of  Medical  Science;  Vol.  Cooper,  London  Journal  of  Medicine ;  Vol.  ii. 

xsiv.  p.  387  ;  Dublin,  1844.  p.  407  ;  London,  1850. 


SECTION  n. — HYDROPHTHALMIA,    OR    DROPSY   OP  THE  EYE. 

Dropsical  affections  of  the  eyeball  are  sometimes  connected  with  a  cachectic 
state  of  the  system,  as  the  scrofulous,  or  that  which  attends  chlorosis.  They 
do  not  appear  in  any  case  either  to  form  part  of  a  general  dropsy,  or  to  be 
combined,  in  point  of  origin,  with  any  other  local  dropsical  affection.  In 
general,  they  depend  on  some  local  cause,  which  has  operated,  not  so  much  in 
directly  increasing  the  fluid  contents,  as  in  weakening  the  resisting  power  of 
the  tunics  of  the  eyeball,  and  especially  of  the  cornea  and  sclerotica. 

§  1.    Dropsy  of  the  Cornea. 
Syn. — Chronic  vesication  of  the  cornea. 

I  have  had  occasion  (pp.  50Y,  516,  612,)  to  notice  that  the  epithelium  of 
the  cornea  is  sometimes  separated  from  the  anterior  elastic  lamina  by  the  in- 
tervention of  a  watery  fluid.  I  have  seen  this  happen  without  any  previous 
inflammation  of  the  eye,  and  with  the  cornea  perfectly  clear ;  but,  in  general, 
there  is  more  or  less  opacity,  and  the  eye  has  suffered  long  and  severely  from 
one  or  other  of  the  ophthalmiaj.  Falling  into  folds,  on  the  lids  being 
closed,  the  loose  epithelium  causes  the  feeling  as  if  some  foreign  body  were 
in  the  eye. 

Puncturing  the  epithelium,  puncturing  the  cornea,  and  exposing  the  eye  to 
the  vapor  of  hydrocyanic  acid,  are  found  useful  in  this  affection,  along  with 
internal  administration  of  tonics. 


DROPSY   OF   THE  AQUEOUS   CHAMBERS.  661 

§  2.   Drojysy  of  the  Aqueous  CfJiamhers. 

Fig.  Demours,  PI.  LTX.  Fig.  3.  PI.  LXI.  Fig.   3.     Ammon.  Thl.  I.  Taf.  III.  Figs.  22—24. 
Dalrymple,  PI.  XXIV.  Fig.  1. 

Aqueous  dropsy,  the  most  common  variety  of  hydrophtlialmia,  is  a  frequent 
consequence  of  corneitis.  When  it  arises  from  this  cause,  or  from  aquo-cap- 
sulitis,  or  when  it  follows  an  injury  of  the  eye,  or  of  the  surrounding  parts, 
it  rarely  goes  to  a  great  extent ;  but  when  it  occurs  congenitally,  or  has  a 
constitutional  origin,  it  sometimes  proceeds  till  the  anterior  chamber  is  greatly 
dilated. 

Symjjtoms. — 1.  At  first  the  cornea  is  merely  more  prominent  than  natural. 
In  many  cases  (for  instance,  when  it  arises  from  corneitis),  the  disease  never 
goes  beyond  this.  But  in  other  instances,  the  cornea  increases  in  diameter ; 
and  at  the  same  time  becomes  thin.  The  increase  in  breadth  may  go  on  till 
the  cornea  is  twice  its  natural  diameter.  I  had  a  patient  under  my  care,  who 
could  read,  with  a  cornea  still  more  enlarged  than  this.  In  advanced  cases, 
it  always  appears  a  little  cloudy,  and  sometimes  becomes  partially  opaque, 
especially  near  its  edge. 

2.  The  iris  loses  its  power  of  motion,  even  from  the  commencement  of 
the  disease,  and  appears  of  a  dark  color.  The  pupil  is  generally  in  the 
middle  state  between  contraction  and  dilatation  ;  but  sometimes  much  dilated. 
In  some  cases  the  lens  sinks  back  within  the  eye,  followed  by  the  pupil,  so  that 
the  iris  presents  the  form  of  a  funnel.  In  this  case,  the  lens  is  apt  to  become 
opaque.  When  aqueous  dropsy  is  the  consequence  of  a  blow  on  the  eye  or 
on  the  edge  of  the  orbit,  the  iris  is  often  tremulous,  and  the  retina  insensible. 

3.  The  patient  complains  of  pressure  and  distension  in  the  eye ;  rarely  of 
pain,  unless  inflammation  supervenes. 

4.  In  the  commencement,  the  eye  is  short-sighted,  but  this  changes  into  an 
amaurotic  deficiency  of  sight,  seldom  reaching  to  complete  blindness,  except 
in  traumatic  cases.  Muscse  volitantes  are  sometimes  suddenly  complained  of, 
slowly  followed  by  amaurosis.  Objects  sometimes  appear  multiplied  to  the 
hydro phthalmic  eye. 

5.  The  lids  contract  with  difficulty  over  the  ball.  The  motions  of  the  eye 
are  more  and  more  impeded,  in  proportion  as  it  increases  in  size.  At  the  same 
time,  it  becomes  harder  to  the  feeling,  and  the  sclerotica,  necessarily  forced  to 
partake  in  the  extension  of  the  cornea,  becomes  thin,  and  appears  blue,  as  in 
young  children.  The  edge  of  the  pupil  is  apt  to  contract  adhesions  to  the 
opaque  capsule.  The  iris  is  torn  and  absorbed,  in  consequence  of  the  dilata- 
tion of  the  surrounding  parts. 

6.  After  a  time,  the  cornea  and  the  sclerotica  become  flexible  ;  the  eye  is 
partially  atrophied  ;  the  retina  quite  insensible. 

Causes — Except  when  this  disease  results  from  some  evident  injury,  or 
ophthalmia,  its  causes  are  obscure.  The  sudden  suppression  of  cutaneous 
eruptions  has  been  mentioned  as  a  cause. 

Prognosis — Arising  from  corneitis,  or  aquo-capsulitis,  dropsy  of  the  aque- 
ous chambers  generally  remains  unchanged  through  life  ;  but  when  it  is  the 
consequence  of  an  injury,  or  depends  on  some  cachexia,  it  is  apt  to  degene- 
rate into  general  dropsy  of  the  eye. 

When  vision  is  tolerably  good,  only  short,  nothing  should  be  done  to  the 
eye  itself. 

Case  318. — A  seaman  Tvas  sent  to  me  for  advice,  31st  July,  1853,  from  Montrose.  His 
age  was  21;  when  7,  a  fall  on  the  nose,  which  bled  much,  brought  on  corneitis  of  both 
eyes,  but  chiefly  of  the  right.  This  ended  in  aqueous  dropsy,  which,  gradually  increas- 
ing, at  length  rendered  him  unable  to  act  as  a  seaman.  The  diameter  of  the  left  cornea 
measured  ^?  inch;  that  of  the  right  rather  less.  There  had  been  a  speck  on  the  right 
cornea.     Both  were  very  prominent,  but  quite  clear.     The  light,  allowed  to  fall  obliquely 


662  SUB-CHOROID   DROPSY. 

through  the  cornea,  was  concentrated,  and  struck  the  inside  of  the  sclerotica,  so  as  to 
make  it  appear  transparent.  He  read  at  the  distance  of  4J  inches.  He  saw  things 
smaller,  but  not  better,  through  concave  glasses.  He  had  tried  counter-irritation  and 
mercury,  without  benefit.     I  dissuaded  him  from  any  operation. 

Treatment. — 1.  When  the  disease  is  the  result  of  an  injury,  advantage  is 
derived  from  a  succession  of  blisters  to  the  temple,  and  behiud  the  ear ;  and 
from  the  use  of  mercury  combined  with  purgatives. 

2.  If  the  suppression  of  an  eruption,  especially  one  to  which  the  patient 
had  long  been  subject,  and  which  had  been  attended  by  a  discharge,  be  the 
suspected  cause,  an  artificial  eruption,  by  means  of  friction  with  tartar  emetic 
ointment,  is  indicated. 

3.  In  the  incipient  stage,  and  especially  when  the  disease  is  of  local  origin, 
friction  round  the  eye  with  the  mercurial  ointment  has  been  found  useful. 

4.  If  the  disease  is  advanced,  and  vision  much  affected,  but  the  sclerotica 
not  yet  discolored  by  being  involved  in  the  distension  of  the  eye,  para- 
centesis oculi  ought  to  be  employed.^  An  incision  may  be  made  through 
the  cornea,  two  lines  long,  and  at  the  distance  of  half  a  line  from  the 
sclerotica.  Beer  recommends  not  merely  that  the  aqueous  humor  should  be 
evacuated  in  this  way,  but  that  the  wound  should  be  reopened  every  day,  for 
a  number  of  successive  days,  or  even  weeks.  More  than  once  he  had  observed 
general  remedies  to  have  a  good  effect  after  this  operation,  although  they  had 
had  none  before.  If  it  is  not  successful  in  curing  the  disease,  it  proves  at 
least  a  palliative ;  and,  if  too  large  an  opening  is  not  made,  may  be  frequently 
repeated  with  advantage. 

The  above  description  applies  to  dropsy  affecting  either  both  chambers  of 
the  aqueous  humor,  or  the  anterior  chamber  alone.  In  cases  of  closed  pupil, 
a  bulging  of  the  sclerotica  over  the  ciliary  processes  sometimes  occurs,  which, 
is  attributed  to  a  dropsy  of  the  posterior  chamber ;  and  a  similar  state  is  apt  to 
happen  when,  in  consequence  of  perforating  ulcer  of  the  cornea,  the  anterior 
chamber  is  obliterated  by  adhesion  of  the  iris  to  the  corneal  cicatrice.  In 
such  cases  the  tension  may  be  relieved  by  puncturing  the  eye.'' 

§  3.   Sub-Sclerotic  Drojjsy.. 

I  have  already  had  occasion  (page  506)  to  mention  a  watery  effusion  be- 
tween the  sclerotica  and  the  choroid,  or  between  the  choroid  and  the  retina, 
as  an  occasional  result  of  inflammation. 

Although  the  internal  surface  of  the  sclerotica  is  connected  to  the  external 
surface  of  the  choroid  by  numerous  vessels  and  nerves,  a  serous  fluid  some- 
times accumulates  between  these  tunics,  so  as  to  constitute  what  we  may 
term  sub-sclerotic  hydrophthalmia. 

The  symptoms  of  this  disease  will  in  some  respects  resemble  those  arising 
from  a  dropsical  effusion  between  the  choroid  and  the  retina;  and  will,  like 
them,  derive  relief  from  the  operation  of  puncturing  the  eye,  and  allowing  the 
collected  fluid  to  escape. 

§  4.   Suh-CJioroid  Dropsy. 
Fig.  Wardrop,  PI.  XV,  Fig.  2.     Panizza,  Appendice,  Tav.  I.  Figs  .  3—6. 

I  may  here  refer  to  what  I  have  said  on  scrofulous  sclerotitis  and  on 
choroiditis  (550),  which,  in  general,  will  be  found  to  have  preceded  or  to 
accompany  sub-choroid  hydrophthalmia.  This  disease  appears  also  to  origi- 
nate from  injuries,  and  sometimes  from  arthritic  ophthalmia. 

Cases  of  sub-choroid  dropsy,  proceeding  so  far  as  to  cause  absorption  of 
the  vitreous  humor  and  compression  of  the  retina,  have  been  described  by 
many  observers.^     The  progress  of  the  dropsical  effusion  and  the  symptoms 


STJB-CHOROID   DROPSY.  663 

by  which  it  is  accompanied  are  by  no  means  alike  in  all  cases.  When  the 
accumulation  takes  place  slowly,  the  loss  of  vision  is  gradual,  and  the  attend- 
ing pain  and  redness  are  not  severe.  But  if  the  water  is  collected  quickly,  it 
is  accompanied  with  great  pain  both  in  the  eye  and  head.  In  an  early  stage, 
the  patient  retains  a  degree  of  lateral  vision  ;  but  he  soon  becomes  completely 
amaurotic.  The  pupil  appears  of  a  dark  brownish  hue  when  the  eye  is  viewed 
at  a  little  distance.  On  nearer  inspection,  a  whitish  or  yellowish  opacity  is 
seen  behind  the  pupil,  generally  towards  the  nasal  or  temporal  side  of  the 
eye,  and  partially  covered  with  red  vessels.  On  examining  the  eye  catop- 
trically,  the  deep  erect  image  is  observed  to  be  large  and  distinct,  but  the 
inverted  image  is  not  visible  ;  showing  that  the  lens  is  transparent,  but  that 
close  behind  it  there  is  an  opacity,  which,  while  it  acts  as  a  foil  for  the  deep 
erect  image,  prevents  the  inverted  from  being  formed.  As  the  disease 
advances,  the  opaque  substance,  which  is,  in  fact,  the  coarcted  retina,  presents 
a  funnel  shape,  or  the  appearance  of  a  number  of  folds  radiating  from  a  centre, 
and  affected  with  a  floating  or  trembling  motion.  Mr.  Wardrop*  mentions, 
that  in  one  instance  this  appearance  was  mistaken  for  cataract,  and  an  attempt 
made  to  couch  it ;  a  fruitless  operation,  which  gave  great  pain.  Such  a  case 
has  also  been  taken  for  encephaloid  tumor,  and  the  eye  extirpated.  By  and 
by,  the  pupil  is  dilated,  and  sometimes  displaced  ;  the  lens  becomes  opaque, 
and  the  cornea  shrinks.  There  may  be  no  enlargement  of  the  eye  under 
such  circumstances.  But  in  other  cases,  the  choroid  and  sclerotica  become 
attenuated,  while  the  eyeball  undergoes  either  a  general  or  partial  extension. 

Treatment.. — In  suspected  cases  of  sub-choroid  hydropthalmia,  there  can  be 
no  doubt  of  the  propriety  of  following  the  practice  of  Mr.  Ware,  and  punc- 
turing the  eye  at  the  usual  place  of  passing  the  cataract  needle  through  the 
sclerotica  and  choroid.  Mr.  Ware  recommended  a  grooved  needle  for  this 
purpose,  so  that  the  fluid  might  more  certainly  escape  ;  but  a  better  plan  is, 
to  puncture  with  a  broad  cataract  needle,  or  the  point  of  the  extraction  knife, 
and  then  hold  the  edges  of  the  wound  apart  l^y  means  of  a  small  probe.  Care 
should  be  taken  in  making  the  puncture  to  direct  the  point  of  the  instrument, 
so  that  it  may  not  wound  the  posterior  part  of  the  crystalline  capsule.  The 
operation  may  be  repeated  from  time  to  time,  should  the  symptoms  seem  to 
demand  it. 

The  first  case  related  by  Mr.  Ware  affords  a  good  example  both  of  the 
disease,  and  of  the  relief  afforded  by  paracentesis  : — 

Case  319. —  A  lady  of  about  45  years  of  age,  perceived  a  dimness  in  her  left  eye,  the 
cause  of  ivhich  she  Avas  unable  to  assign.  She  supposed  it  to  have  been  the  consequence 
either  of  taking  cold,  or  of  the  cessation  of  a  discharge  from  one  of  her  legs,  to  which  she 
had  been  subject.  The  dimness  was  discovered  accidentally,  on  her  attempting  to  see  an 
object  with  the  left  eye  whilst  the  right  was  shut,  and  in  a  short  time  the  sight  afforded 
by  that  eye  rendered  her  no  assistance ;  objects  placed  straight  before  it  being  invisible, 
and  their  appearance  when  removed  to  the  outer  side  of  the  axis  of  vision,  obscure  and 
indistinct.  The  eye  had  not  altered  its  appearance  in  any  respect,  the  pupil  being  neither 
cloudy  nor  dilated.  In  December,  1804,  about  two  years  after  the  dimness  was  first  per- 
ceived, she  began  to  feel  pain  in  the  eye,  and  it  became  slightly  inflamed.  Although  the 
inflammation  never  appeared  considerable,  the  pain  increased  to  a  most  violent  height, 
aflecting  in  a  few  days,  both  the  eye  and  the  head,  and  proving  particuhirly  severe  during 
the  night.  The  pupil  now,  for  the  first  time,  became  dilated,  and  had  a  misty  appearance; 
but  the  degree  of  opacity  was  very  insufficient  to  account  for  the  total  loss  of  sight. 

Leeches,  blisters,  fomentations  with  poppy  heads,  and  a  free  use  of  opium  internally 
were  repeatedly  tried,  but  did  not  afford  relief.  The  internal  employment  of  muriate  of 
mercur}'  was  equally  ineffectual.  The  progress  of  the  disorder,  and  the  state  of  the 
patient  at  this  period,  closely  resembling  those  of  another  patient,  in  whose  eye,  after 
death,  ^Ir.  Ware  had  found  a  sub-choroid  collection  of  thin  fluid,  with  coarctation  of  the 
retina,  led  him  to  think  that  the  violent  pain  which  this  lady  suffered  might  depend  on  a 
similar  state.  It  also  occurred  to  him  that  if  the  effused  fluid  could  be  discharged,  it 
might  afford  relief.     The  operation  seemed  neither  impracticable  nor  difiBcult,  and  the 


664  SUB-CHOROID   DROPSY. 

patient  readily  acceded  to  submit  to  it,  as  indeed  she  would  have  done  to  any  operation, 
so  extreme  was  the  pain  she  endured. 

Mr.  Ware  introduced  a  spear-pointed  couching  needle  through  the  sclerotica,  a  little 
farther  back  than  where  it  is  usually  introduced  for  depressing  a  cataract.  As  soon  as 
the  instrument  entered  the  eye,  a  yellow  fluid  escaped,  sufficient  in  quantity  to  wet  a 
common  handkerchief  quite  through.  The  needle  was  kept  in  the  eye  about  a  minute,  in 
order  to  aSord  the  fluid  a  more  readj-  exit ;  and  as  soon  as  it  was  withdrawn,  the  discharge 
ceased.  The  tension  of  the  eye  was  considerably  diminished  by  the  operation.  A  com- 
press dipped  in  a  saturnine  lotion  was  bound  upon  it,  and  the  patient  put  to  bed.  She 
continued  in  pain  about  ten  minutes,  but  then  fell  into  a  sound  sleep  which  lasted  upwards 
of  two  hours ;  and  on  awakening,  her  eye  was  quite  easy.  The  compress  was  again 
moistened  with  the  saturnine  lotion,  and  she  took  some  nourishment.  She  passed  the 
next  night  comfortably,  without  laudanum,  although  previously  it  had  been  given  her  in 
large  doses.  The  same  application  was  continued  to  the  eye,  which  afterwards  remained 
perfectly  easy,  with  scarcely  any  appearance  of  inflammation.  The  pupil  continued 
dilated,  but  did  not  become  opaque.  About  three  weeks  after  the  operation,  the  patient 
caught  a  cold,  and  complained  that  the  eye  felt  more  tender  than  usual.  Mr.  AVare  was 
alarmed  lest  a  fluid  might  again  be  eff"used  in  the  old  place,  and  the  pain  return ;  but 
this  was  happily  prevented  by  the  application  of  a  blister  on  the  side  of  the  head.' 

Although  the  following  case  is  related  by  no  less  an  authority  than  Pro- 
fessor Panizza,  as  one  of  medullary  fungus,  I  think  the  reader  will  grant,  that 
the  appearances  on  dissection  vindicate  me  in  placing  it  under  the  head  of 
sub-choroid  dropsy.  The  color,  consistence,  and  relations  of  the  diseased 
mass  are  widely  different  from  what  has  been  observed  in  fungus  hiematodes. 

Case  320. — The  patient  was  a  lively,  healthy  child,  aged  20  months,  affected  with 
•what  was  considered  to  be  malignant  or  medullary  fungus,  originating  in  severe  internal 
ophthalmia,  consequent  to  painful  dentition.  The  .fppearances  attributed  to  fungus  had 
been  observed  for  a  month.  The  diseased  ej'e  was  of  the  same  si2;eas  the  other,  perfectly 
movable,  and  not  inflamed  ;  the  pupil  was  widely  dilated,  and  immovable.  Behind  the 
pupil,  and  apparently  in  the  bottom  of  the  ej^e,  was  a  spot  of  a  pale  yellow  color,  divided  by 
furrows  into  three  tubercular-like  eminences.  In  the  furrows,  a  red  vessel  was  seen  ram- 
ifying. The  spot  was  better  seen,  and  appeared  nearer  to  the  pupil,  by  looking  down  into 
the  eye  than  upwards.  When  it  was  looked  at  in  the  direction  of  the  eye's  axis,  it  seemed 
more  distant,  or  at  the  bottom  of  the  eye.     Vision  was  entirely  lost. 

Donagana  extirpated  the  e^'e,  on  the  10th  December,  1822,  six  weeks  after  the  com- 
mencement of  the  complaint.  In  182G,  when  Panizza  published  the  case,  there  was  no 
reappearance  of  the  disease. 

The  extirpated  eye  was  natural  in  size  and  form,  but  its  consistence  somewhat  firmer 
than  common.  The  optic  nerve  seemed  healthy.  The  canary  colored  spot  was  seen 
through  the  cornea.  On  removing  the  cornea,  the  aqueous  humor  was  discharged.  The 
iris  was  healthy.  By  tearing  it  away  from  the  orbiculus  ciliaris,  the  crystalline  was  ex- 
posed, perfectly  transparent,  and  inclosed  witliin  its  capsule.  Looking  through  the  lens, 
the  spot  to  all  appearance  lay  at  the  bottom  of  the  eye;  but  on  opening  the  capsule,  and 
removing  the  lens,  it  was  seen  to  be  close  to  the  posterior  capsule.  Its  apparent  distance, 
then,  when  viewed  through  the  crystalline,  was  an  optical  illusion.  By  removing  a  line's 
breadth  of  the  choroid,  which,  as  well  as  the  ciliary  processes,  was  natural,  a  yellowish 
soft  fungous  substance  was  exposed,  apparently  containing  a  fluid.  At  its  upper  part, 
there  was  a  triangular  area,  where  the  hyaloid  was  healthy,  and  the  vitreous  humor  lim- 
pid. On  puncturing  the  hyaloid,  and  giving  exit  to  a  small  quantity  of  vitreous  fluid,  one 
of  the  three  yellowish  prominences  suddenly  rose,  as  if  it  had  been  compressed,  and  took 
the  place  which  had  been  occupied  by  the  vitreous  humor  just  discharged.  Panizza  con- 
cluded from  this,  that  the  vitreous  body  had  become  atrophied  by  the  growth  of  the 
tumor. 

The  tumor  was  soft,  elastic,  and  where  it  was  marked  by  the  furrows  already  mentioned, 
its  prominences  could  be  separated  a  little  with  the  probe.  Desirous  of  discovering  more 
completely  the  relations  of  the  tumor,  which  seemed  to  be  the  retina  in  a  fungous  state, 
Panizza  removed  a  portion  of  the  sclerotica  towards  the  back  of  the  eye,  and  was  pro- 
ceeding to  cut  through  the  choroid,  when  there  suddenly  issued  a  fluid  of  a  canary  color, 
and  the  three  tubercular  eminences  immediately  sank  down  a  little.  The  fluid  wliich 
escaped  coagulated  by  coming  in  contact  with  alcohol.  To  prevent  the  remainder  from 
escaping,  the  eye  was  put  into  alcohol.  The  fluid  which  had  escaped  was  glutinous,  and 
of  a  salt  taste;  it  lost  much  of  its  yellowish  color  on  being  suddenly  coagulated  by  the 
alcohol  into  a  homogeneous  consistent  mass.  The  eye  being  left  in  a  cup  filled  with  al- 
cohol till  next  day,  was  found  adhering  to  the  bottom  of  the  cup  by  means  of  some  of  the 
fluid  which  had  coagulated. 


DROPSY   or   THE   VITREOUS   BODY.  665 

Continuing  the  dissection,  Panizza  removed  the  posterior  part  of  the  sclerotica  and 
choroid,  which  were  healthy,  and  exposed  the  interior  of  the  eye,  tilled  with  the  straw 
colored  substance.  This  substance  Avas  granular,  and  when  taken  between  the  fingers,  it 
became  reduced  to  a  fine  powder.  As  there  was  no  appearance  of  the  retina  beneath  the 
choroid,  it  seemed  probable  that  the  tumor  was  the  product  of  a  fungous  degeneration  of 
the  retina,  more  especially  as  the  tumor  was  continuous  with  the  optic  nerve  at  its  entrance 
into  the  eye.  The  nerve,  also,  had  the  same  color  with  the  tumor.  The  tumor  was  some- 
what uneven  on  the  surface,  but  ever^'where  presented,  a  consistent  granular  substance, 
which  on  analysis  was  found  entirely  albuminous. 

Panizza  next  observed  that  the  optic  nerve,  gradually  expanding,  seemed  to  pass  into 
the  tumor.  Cautiously  removing  the  soft  granular  substance,  he  found,  to  his  surprise, 
the  retina  reduced  to  a  conical  form,  shrunk,  and  folded  together  in  the  middle  of  the 
tumor.  It  extended  from  the  entrance  of  the  optic  nerve  to  the  eminences  already  noticed, 
which  were  in  fact  protuberances  of  the  retina,  produced  by  the  push  of  the  yellowish 
fluid  inclosed  behind  it.  Hence  it  appeared  that  the  tumor  did  not  consist  in  a  fungus  of 
the  retina,  but  was  the  eiFect  of  the  yellowish  fluid  graduallj'  accumulating  between  the 
choroid  and  the  retina,  and  causing  the  latter  to  close  towards  the  centre  of  the  eye.  The 
vitreous  humor,  in  proportion  as  the  morbid  deposition  increased,  must  have  necessarily 
disappeared,  and  accordingly  only  a  small  portion  of  vitreous  humor  was  present.  Know- 
ing from  anatomy  with  what  firmness  the  anterior  termination  of  the  retina  adheres  to  the 
great  circumference  of  the  corpus  ciliare,  it  was  easy  to  understand  how  the  fluid,  collected 
between  the  choroid  and  the  retina,  could  not  make  its  way  into  the  posterior  chamber, 
and  hence  into  the  anterior.  It  was  evident,  also,  why  the  retina,  pressed  on  all  sides  by 
the  fluid  accumulating  between  it  and  the  choroid,  was  forced  to  separate  from  the  choroid, 
and,  folding  itself  together  towards  the  centre  of  the  eye,  should  compress  the  hyaloid,  and 
diminish  gradually  the  secretion  of  vitreous  humor.  The  same  fluid  also  forced  the  retina 
to  protrude  anteriorly  in  the  form  of  three  roundish  eminences,  with  furrows  between 
them.  It  was  equally  clear  how  the  morbid  secretion,  had  it  increased  much  more,  would 
have  forced  the  retina  into  contact  with  the  lens,  would  have  pressed  the  lens  against  the 
iris,  and  this  against  the  cornea,  irritating  all  these  parts,  and  rendering  them  dim  and 
atrophic.^ 

§  5.   Dropsy  of  the  Vitreous  Body. 
Fig.  Ammon,  Thl.  I.  Taf.  IV.  Fig.  20.  Taf.  VII.  Figs.  8—11. 

Vitreous  dropsy  is  characterized  by  the  following  symptoms  : — 

1.  An  increase  of  size,  chiefly  behind  the  cornea,  which  is  pushed  forwards 
without  undergoing  any  other  change,  while  the  sclerotica  bulges  out  between 
the  recti,  so  that  the  eye  becomes  somewhat  of  a  square  shape. 

2.  The  aqueous  humor  diminished  in  quantity,  and  the  iris  pressed  forwards, 
or  even  into  contact  with  the  cornea  ;  the  iris  is  not  changed  in  color,  nor  the 
pupil  extremely  dilated. 

3.  The  eye,  touched  with  the  finger,  feels  excessively  hard. 

4.  The  sclerotica,  from  distension,  assumes  a  deep  blue  color. 

5.  Weakness  of  sight,  soon  followed  by  complete  amaurosis,  so  that  not 
even  the  least  sensibility  to  light  remains. 

6.  The  movements  of  the  eye  are  much  sooner  impeded  than  in  aqueous 
dropsy.     At  last  it  becomes  altogether  motionless. 

7.  There  is  pain  in  the  eye  from  the  very  commencement.  It  daily  in- 
creases in  violence,  and  spreads  to  the  half  of  the  head,  to  the  teeth,  and  to 
the  neck.  At  last  the  patient  becomes  almost  mad  with  the  pain,  and  calls 
upon  the  surgeon  to  evacuate  the  contents  of  the  eye.  Beer  saw  a  man  who 
did  this  for  himself  with  his  penknife. 

8.  Even  when  the  pain  is  comparatively  moderate,  the  patient's  sleep  and 
appetite  entirely  fail. 

Causes. — E.xcept  in  cases  of  injury,  these  are  equally  obscure  as  those  of 
dropsy  of  the  aqueous  chamber.  A  scrofulous  or  syphilitic  cachexia  is  blamed, 
or  a  union  of  both  is  sometimes  suspected. 

Treatment. — General  remedies  maybe  directed  against  the  particular  cause 
which  is  supposed  to  give  rise  to  the  disease  ;  but  most  relief  is  derived  from 
diminishing  the  quantity  of  the  vitreous  humor.     In  one  case,  resulting  from 


666  GENERAL  HYDROPHTH ALMIA. 

an  injury,  and  in  which  the  lens  was  opaque  and  displaced,  I  succeeded  in 
curing  the  vitreous  dropsy  by  repeatedly  tapping  through  the  cornea.  But, 
in  general,  this  operation  is  to  be  performed  through  the  sclerotica  and 
choroid,  as  in  cases  of  subchoroid  dropsy.  The  vitreous  humor,  when  the 
puncture  is  made,  is  apt,  as  in  choroid  staphyloma,  to  infiltrate  the  subcon- 
junctival cellular  membrane  to  an  enormous  extent,  sometimes  to  such  a  de- 
gree that  the  cornea  is  hid  by  the  swelling.  In  one  case  in  which  this  event 
happened  in  my  hands,  the  pain  which  ensued  was  very  severe  ;  but  the  dropsy 
was  cured  by  the  continued  pressure,  exercised  for  ten  or  twelve  days,  on  the 
empty  eyeball,  by  the  fluid  lying  under  the  conjunctiva.  Repeated  punctures 
of  the  sclerotica  produce  inflammation  of  the  interior  of  the  eye,  ending  in  a 
destruction  of  the  secreting  power.  Sometimes  the  inflammation  is  more 
severe,  bringing  on  adhesions  of  the  iris,  and  opacity  of  the  cornea.  The 
eye  becomes  atrophic,  soft,  and  free  from  pain. 

Repeated  paracentesis  failing,  the  mode  recommended  by  Beer  will  require 
to  be  adopted;  namely,  a  section  of  the  cornea,  as  in  extraction,  by  which  to 
evacuate  the  lens  with  part  or  the  whole  of  the  vitreous  humor,  after 
which  the  coats  of  the  eye  gradually  shrink. 

§  6.    General  Hydropldlialmia. 

Fig.  Demours,  PI.  LXIL  Fig.  2.     Ammon,  Thl.  III.  Taf.  III.  Figs.  6,  1.  Taf.  V.  Figs.  11,  13. 
Taf.  XV.  Fig.  2.     Dalryinple,  PI.  XXXII.  Fig.  3. 

Both  the  aqueous  and  the  vitreous  humors  may  be  increased  in  quantity  at 
the  same  time,  so  that  the  whole  eye  is  enlarged,  in  which  state  the  name 
hnphtludmos  has  been  bestowed  on  it,  from  its  resembling  the  eye  of  an  ox. 

This  disease  presents  a  union  of  the  symptoms  of  the  second  and  fifth 
varieties  of  hydrophthalmia,  as  far  as  they  can  co-exist.  When  congenital 
it  is  styled  megalophthnlmos,  and  is  often  accompanied  with  opacity  of  the 
cornea.  All  the  tissues  of  the  eye,  in  this  case,  appear  equally  enlarged;  not 
only  is  the  cornea  broader  and  more  prominent,  and  the  aqueous  chambers 
more  capacious,  but  the  iris  is  proportionally  more  developed  than  is  natural. 
In  some  congenital  cases  the  eye  is  so  large  that  the  lids  cannot  be  closed 
without  difliculty.  When  general  hydrophthalmia  occurs  in  after  life,  and  is 
rapid  in  its  progress,  it  is  attended  by  excessive  pain;  the  motion  of  the  eye 
is  lost;  the  patient  is  deprived  of  sleep,  loses  all  appetite  for  food,  and 
becomes  delirious ;  if  the  case  is  neglected,  caries  of  the  orbit  may  even  take 
place,  and  the  patient  die,  worn  out  by  fever. 

Beer  had  met  with  this  disease  only  in  extremely  cachectic,  and  especially 
scrofulous  and  scorbutic  subjects. 

Congenital  cases  sometimes  do  well  without  treatment ;''  the  cornea  gradu- 
ally clearing,  and  the  eye,  if  not  shrinking  to  its  natural  dimensions,  at  least 
remaining  stationary  in  point  of  size."  In  other  cases,  the  disease  continues 
moderate  till  puberty,  when  the  eye  suddenly  enlarges,  the  pupil  widely  dilated, 
contracts  adhesions  to  the  capsule,  which  becomes  opaque;  the  iris  is  lacerated 
by  the  stretching  to  which  it  is  subjected,  the  retina  loses  its  sensibility,  and, 
after  a  time,  the  eye  becomes  soft  and  atrophic. 

Mercury,  squills,  digitalis,  and  counter-irritation  have  been  recommended ; 
but  I  should  place  greater  confidence  in  tonics.  Iodide  of  potassium,  and 
cod-liver  oil  might  be  worthy  of  a  trial.  Other  remedies  failing,  the  evacua- 
tion of  the  contents  of  the  eye  may  be  called  for,  as  in  vitreous  hydroph- 
thalmia. 


'  Xuck,  De  Ductibus  oculorum  aquosis;    p.     in  the  Operations   on   the  Eye;   pp.  77,  140; 
120;  Lugduni  Batavorum,  1723.  London,  1849. 

^  Bowman's  Lectures  on  the  Parts  concerned        ^  Zinn,  Descriptio  Auatomiea  Oculi  llumani. 


SANGUINEOUS   EFFUSION   INTO   THE   EYE.         "  661 

p.  25;  Gottingas,  17S0:   Scarpa,  Trattato  dello  on    tbo  Cataract,  and  Gutta   Serena;    p.  443; 

Malattie  degli   Occhi ;  Vol.  ii.  p.   172;   Pavia,  London,  1812. 

1816:  Ware's  Observations  on   the  Treatment  ^  Sul  Fungo  Midollare  dell' Occhio  Append- 

of  the  Epiphora,  &c.  p.  284;    London,  1818;  ice  di  Bartoloraeo  Panizza,  p.  9 ;  Tav.  i.  fig.  3, 

Wardrop's  Morbid  Anatomy  of  the  Human  Eye:  4,  5,  6  ;  Pavia,  1826. 

Vol.  ii.  pp.  65,  273;  London.  1818.  '  Ware,  Op.  cit.  p.  285. 

'  Op.  cit.  Vol.  ii.  pp.  67,  274.  '  Ammon  gives  figures  representing  the  pro- 

'  Piomarks  on    the  Ophthalmy,  Ac.  p.  233;  gressive  clearing  of  the  cornea  in  such  cases, 

London,  1814.     See  also  Ware's    Observations  in  his  Darstellungen  ;  Theil.  III.  Taf.  VII. 


SECTION  m. — SANGUINEOUS  EFFUSION  INTO  THE  EYE. 
Syn. — HDemophthalmos.     Hypsemia.     Apoplexia  oculi.     Das  Blutauge,  Ger. 

Fig.  Ammon,  Thl.  I.  Taf.  IL  Figs.  16,  17.  Taf.  IX.  Fig.  20.  Taf.  XV.  Fig.  17.  Taf.  IIL  Fig.  5. 
Taf.  XV.  Fig.  21.  Taf.  XVII.  Fig.  4.  Thl.  IL  Taf.  I.  Figs.  1,  11,  16,  17,  20—24. 

To  treat  fully  and  systematically  of  effusion  of  blood  into  tlie  eye,  many 
distinctions  would  require  to  be  observed,  according  as  it  has  a  traumatic 
origin  or  occurs  spontaneously ;  happens  in  a  healthy  eye,  or  in  one  more  or 
less  disorganized  by  previous  disease  ;  according  as  the  constitution  of  the 
patient  is  sound,  or  affected  with  scorbutus,  purpura,  or  any  other  malady; 
and  according  as  the  cornea,  the  aqueous  chambers,  the  vitreous  body,  or  the 
retina  is  the  seat  of  the  hemorrhage. 

Of  effusion  of  blood  from  injuries  of  the  iris,  and  blows  on  the  eye,  I  have 
already  (pp.  310,  411)  spoken.  I  shall  hereafter  have  occasion  to  explain, 
that  a  discharge  of  blood  takes  place  in  all  the  operations  for  the  formation 
of  an  artificial  pupil;  and  that  the  same  accident  is  apt  to  attend,  or  to  follow, 
the  operations  for  cataract.  Under  the  head  of  amaurosis,  I  shall  have  occa- 
sion to  speak  of  apoplexy  of  the  retina.  Small  quantities  of  blood  are  some- 
times seen  to  accompany  hypopium,  especially  that  which  arises  from  the 
bursting  of  an  abscess  of  the  iris.  Blood  is  also  occasionally  effused  into 
the  substance  of  the  cornea,  and  on  the  surface  of  the  iris,  in  consequence 
of  inflammation,  especially  in  syphilitic  and  arthritic  cases.  Beer  describes^ 
extravasation  of  blood  into  the  anterior  chamber  as  occurring  in  the  ophthal- 
mia which  sometimes  occurs  in  scurvy ;  and  Dr.  Graves  has  recorded^  a  case 
of  fatal  purpura  hcemorrhagica,  in  the  course  of  which  an  effusion  of  blood 
took  place  into  both  eyes. 

It  may  be  laid  down  as  a  general  rule,  that  blood  effused  into  any  part  of 
the  eye,  is  absorbed  more  speedily,  as  the  eye  is  healthy.  If  it  is  diseased 
in  other  respects,  the  absorption  is  slow,  and  incomplete ;  and  the  pupil  is 
apt  to  close,  and  the  eye  to  become  atrophic.  Poured  into  the  anterior 
chamber  of  a  healthy  eye,  blood  is  dissolved  in  the  aqueous  humor,  and 
absorbed  in  the  course  of  a  few  days,  unless  it  has  coagulated  so  as  to  form  a 
clot.  When  this  happens,  it  may  take  weeks  or  months  to  disappear.  Even 
fluid  blood  is  long  of  being  absorbed,  if  it  is  effused  into  an  eye,  the  aqueous 
chambers  of  which,  in  consequence  of  previous  disease,  are  occupied,  not  by 
aqueous  humor,  but  by  yellow  serum.  Mr.  Bowman  supposes''  that  the  blood 
corpuscles  swell  in  healthy  aqueous  humor,  and  give  up  their  coloring  matter 
to  it,  and  this  is  the  occasion  of  their  rapid  disappearance  ;  but,  without 
denying  this,  Dr.  Meyr  has  pointed  out*  that  in  wounds  of  the  eye  by  which 
the  aqueous  humor  is  totally  evacuated,  and  its  place  instantly  occupied  by 
blood,  the  blood  will  sometimes  be  absorbed  in  twenty-four  hours,  ])rovided 
proper  means  are  taken  to  prevent  inflammation.  In  respect  to  effusion  of 
blood,  also,  in  other  parts  of  the  eye,  it  is  not  to  be  doul)ted  that  the  means 
most  likely  to  promote  absorption  are  those  which  will  obviate  inflammation. 

The  attention  of  the  reader  should  be  particularly  directed  to  an  internal 


668  SANGUINEOUS   EFFUSION   INTO   THE   EYE, 

liemorrhagy  of  the  eye,  which  appears  neither  to  arise  from  injury,  nor  to 
depend  altogether  on  inflammation,  and  which  sometimes  has  been  called 
apoplexy  of  the  eye.  This  hemorrhagy  may  occur  either  in  an  eye  apparently 
sound,  or  in  one  which  has  suffered  from  previous  disease.  It  arises  from 
active  hyperaemia  in  some  cases ;  from  passive  weakness  of  the  vessels  in 
others. 

An  example  of  sanguineous  effusion,  occurring  in  an  eye  previously  healthy, 
is  related  by  Mr.  John  Bell. 

Case  321. — The  patient,  a  young  gentleman  not  20  years  of  age,  was  six  feet  high,  and 
when  he  was  first  affected  with  the  disease,  was  growing  so  rapidly  that  he  believed  he 
had  gained  five  inches  in  the  year.  Early  in  September,  on  the  day  on  which  he  was  first 
attacked,  he  ate  verj^  heartily  a  hurried  dinner,  when,  a  companion  having  called  while 
he  was  yet  at  table,  and  proposed  a  party  in  a  house  at  some  distance,  he  went  with  him, 
and  being  mere  lads,  and  in  a  playful  humor,  his  friend  ran,  and  he  pursued  at  full  speed, 
for  the  space  of  three  or  four  hundred  yards.  He  instantly  was  sensible  of  his  sight  be- 
coming dim  in  the  left  eye.  He  disregarded  at  first  a  feeling  which  he  imagined  to  be 
temporary,  but,  having  arrived  at  the  house,  and  set  down,  he  was  alarmed  to  find  his 
vision  still  more  obscured,  and  turning  to  those  in  company,  he  asked  M'hether  they  per- 
ceived anything  wrong  in  his  eye.  They  saw  blood  upon  it.  The  bloody  eifusion  took 
place,  the  blood  became  visible,  and  the  vision  of  the  left  eye  was  entirely  obscured  in  the 
space  of  fifteen  minutes.  He  was  then  assailed  with  dreadful  pain.  For  ten  days  he  con- 
tinued entirely  blind  of  that  eye. 

Vision  was  gradually  restored,  by  the  blood,  which  had  filled  the  whole  of  the  anterior 
chamber,  subsiding  below  the  level  of  the  pupil.  Blood  was  still  visible  in  the  lower  part 
of  the  eye,  and  continued  so  for  three  weeks;  it  gradually  vanished,  and  the  ej-e  recovered 
its  wonted  appearance,  except  that,  in  the  very  lowest  part,  below  the  level  of  the  pupil, 
there  remained  a  little  white  clot  of  the  effused  blood.  Such  was  the  first  attack  of  the 
disorder,  from  which  he  continued  free  for  the  space  of  six  months. 

One  evening  in  May,  1804,  while  sitting  at  supper,  not  conscious  of  .any  previous  excite- 
ment, but  probably  affected  by  the  supper,  wine,  light,  and  heat,  and  animated  conversa- 
tion, he  suddenly  perceived  the  obscurity  coming  over  his  vision,  the  blood  again  appeared 
in  the  eye,  which  was  next  morning  afi"ected  with  violent  pain:  yet  this  was,  in  all  respects, 
a  less  severe  paroxysm  than  the  first. 

Little  more  than  a  month  had  elapsed,  when  having,  in  the  warm  month  of  June,  gone 
into  the  river  to  bathe,  as  he  was  in  the  act  of  swimming  and  just  coming  out  of  the 
water,  he  was  struck  with  this  obscurity  of  vision.  The  blood  instantly  came  over  his  eye, 
which,  on  the  ensuing  day,  was  affected  with  most  excruciating  pain,  extending  to  the 
temple;  but  in  three  weeks  or  a  month,  his  sight  was  completely  restored,  and  the  eye 
recovered  its  natural  clearness.  In  the  end  of  September,  or  beginning  of  October,  he 
was  again  attacked,  though  he  was  conscious  of  no  excess,  but  had  been  quiet,  regular, 
and  discreet  in  his  way  of  living;  he  was  seized  while  writing,  and  recollected  no  sensible 
cause  to  which  the  paroxysm  could  be  ascribed,  unless  it  were  the  hanging  of  the  head 
and  straining  of  the  eye.  The  blood  was  absorbed  again  within  the  usual  period,  and  sight 
restored. 

On  the  1st  of  November,  in  walking  across  a  bridge  at  night  betwixt  10  and  11  o'clock, 
he  sustained  the  fourth  attack,  but  without  such  total  loss  of  vision,  or  so  much  effusion 
of  blood  as  heretofore.  The  blood  was  not  so  long  of  being  absorbed,  nor  was  he  so  long 
obliged  to  cover  the  eye  from  the  light:  in  eight  or  ten  days  he  was  able  to  uncover  the 
eye,  the  suffusion  of  blood  was  gone,  but  the  coagulum,  occupying  the  anterior  chamber, 
was  manifestly  accumulating.  On  the  3d  of  February,  180-5,  he  had  a  like  paroxysm, 
arising  from  very  obvious  causes.  Being  the  day  for  electing  a  Member  of  Parliament 
for  Edinburgh,  his  regiment  was  marched  out  of  town  to  the  distance  of  18  miles;  and 
both  in  marching  out  to  the  temporary  quarters  allotted  for  his  regiment,  and  in  returning, 
he  walked  along  with  the  men,  was  greatly  heated  by  the  exercise,  and  very  naturally 
referred  this  attack  to  a  cause  so  expressly  resembling  that  which  first  gave  rise  to  his 
malady. 

From  this  time  the  paroxysms  became  periodical,  and  seemingly  spontaneous ;  they  re- 
turned once  a  month,  the  eye  was  kept  in  a  state  of  constant  irritability  and  frequent  pain, 
so  that  the  patient  was  forced  to  have  it  constantly  covered  from  the  light ;  yet  no  circum- 
spection in  this  respect,  nor  in  his  habits  of  living,  seemed  to  avail  him.  Of  the  few  pa- 
roxysms arising  from  any  obvious  excitement,  one  was  on  the  morning  after  a  review,  in 
the  month  of  August,  when,  after  being  in  the  field,  he  sat  down  to  a  dinner  of  ceremony, 
and  drank  late.  Although  not  conscious  of  having  been  intemperate,  he  went  to  bed,  per- 
haps a  little  heated  with  wine;  he  rose  early  in  the  morning  to  go  upon  guard,  and,  while 


SANGUINEOUS   EFFUSION   INTO   THE   EYE.  669 

stooping  to  Trash  his  face,  he  was  sensible  of  the  effusion  of  blood,  and  return  of  the  blind- 
ness. The  second  memorable  occasion  was  still  more  particular  in  the  circumstances,  and 
the  excitement  more  marked  than  any  of  the  others.  He  had  gone  to  a  supper  party  of 
young  people,  where  a  most  unusual  degree  of  hilarity  prevailed;  he  joined  the  general 
mirth,  and  laughed  so  immoderately,  that  he  saw  the  candles  dim,  and,  in  a  moment,  found 
his  eye  suffused  with  blood. 

The  disease  now  took  a  decided  form;  returning  sometimes  once  a  fortnight,  sometimes 
once  a  month,  two  months  seldom  elapsing  without  a  new  effusion  of  blood.  The  sensi- 
bility of  the  eye  was  such,  that  he  was  obliged  to  keep  it  always  shaded ;  and  each  new 
effusion  was  now  followed  by  a  paroxysm  of  pulsatory  pain  in  the  temple  of  that  side,  in 
some  degree  relieved  by  steady  and  continued  pressure.  The  effusion  now  returned  with- 
out any  express  or  sensible  cause,  the  predisposition  being  so  strong,  that  he  came  to  a 
conviction,  that  laughing,  crying,  singing,  running,  swimming,  stooping,  excess  in  wine, 
or  any  of  those  occasions  which  at  former  times  produced  the  effusion,  would  cause  it  in- 
stantly to  return. 

Mr.  Bell  remarks,  that  it  must  seem  very  surprising,  that  an  organ  so  delicate  as  the 
eye,  should  be  able  thus  to  sustain  rep'eated  effusions  of  blood,  without  having  its  struc- 
ture entirely  ruined.  The  resistance  of  its  coats,  filled  and  tense  with  its  own  humors, 
plainly  had  its  effect  in  limiting  the  effusion.  When  he  drew  up  the  case,  the  coagulum 
which,  in  consequence  of  its  bulk,  was  very  thinly  covered  with  the  blood,  was  almost 
white,  occupied  all  the  lower  part  of  the  anterior  chamber,  and  covered  part  of  the  pupil. 
Vision  was  not  extinct,  but  he  feared  it  was  irremediably  injured.  Strict  regimen,  profuse 
evacuations,  a  seton  in  the  neck,  and  opiates  to  appease  the  sensibility  of  the  eye ;  an 
abstemious,  quiet,  and  regulated  course  of  life,  would,  he  trusted,  prevent  future  effusions ; 
and  when  the  paroxysms  of  local  arterial  action  should  be  abated,  he  hoped  that  much  of 
the  coagulum  would  be  absorbed. ^ 

The  subject  of  the  following  case  recorded^  by  Dr.  C.  Lockhart  Robertson, 
I  had  occasion  to  see  in  consultation  with  Dr.  J.  A.  Robertson,  on  the  27th 
November,  1843.  The  case  affords  a  well  marked  instance  of  effusion  of  blood 
into  the  vitreous  humor,  recurring  at  intervals,  without  direct  injury,  and 
presenting  appearances  so  much  resembling  medullary  carcinoma,  that  the 
nature  of  the  disease  could  be  determined  only  by  the  history  of  the  symp- 
toms. 

Case  322. — Miss ,  aged  29,  when  15  years  of  age  was  affected  with  red  spectra 

before  the  right  eye,  which  in  about  a  week  yielded  to  laxatives.  When  20  years  of  age, 
she  remarked  that  the  left  eye  retained  the  impression  of  an  object  for  some  seconds  after 
the  object  had  been  removed,  and  vision  gradually  became  more  and  more  impaired  in 
that  eye,  till  August,  1839,  when  she  could  not  distinguish  with  it  light  from  darkness. 
Under  the  use  of  leeches  and  blisters,  with  mercury  so  as  to  affect  the  system,  in  Decem- 
ber the  sight  began  to  improve. 

In  June,  1840,  she  had  an  attack  of  blindness  in  both  eyes,  accompanied  by  severe 
pain  in  the  eyes  and  forehead,  which  yielded  to  the  same  remedies.  In  January,  1842, 
she  had  another  attack  in  both  eyes,  of  a  slighter  character.  In  December  of  the  same 
year,  the  disease  suddenly  recurred  in  both  eyes,  and  again  yielded  to  leeches  and  mer- 
curials. AVhile  still  under  treatment,  she  had  in  January,  1843,  a  sixth  attack  in  both 
eyes.  The  same  remedies  were  continued.  Subsequently  electro-magnetism  was  tried, 
with  temporary  improvement.  In  August,  1843,  the  disease  suddenly  recurred,  for  the 
seventh  time,  in  the  right  eye,  owing,  it  was  supposed,  to  a  sudden  fright,  and  again 
yielded  to  leeches  and  mercury.  Sight  continued  improving  till  May,  1845,  when  she 
had  another  slight  attack  in  the  same  eye.  Under  leeches  and  mercury,  vision  ao-ain 
improved. 

The  right  eye,  after  each  attack,  presented  the  following  appearances :  The  conjunctiva 
and  sclerotica  were  healthy,  the  pupil  dilated,  but  perfectly  regular,  the  color  and  texture 
of  the  iris  natural.  On  dilating  the  pupil  by  belladonna,  and  allowing  the  focus  of  a 
double  convex  lens  to  fall  on  the  eye,  it  was  observed  that  an  effusion  of  blood  had  taken 
place  into  the  vitreous  humor  at  its  nasal  side,  and  about  half  way  between  the  iris  and 
the  optic  nerve.  Gradually  the  red  color  disappeared,  leaving  a  mass  of  a  brownish 
yellow  color,  with  a  semi-metallic  lustre.  Under  the  action  of  mercurials,  the  bulk  of 
this  deposit  was  lessened,  and  vision  improved.  When  Dr.  C.  L.  Robertson  drew  up  the 
case,  it  was  about  the  size  of  a  hazel-nut. 

No  effusion  could  be  traced  in  the  left  eye. 

The  pale-colored  mass  in  the  right  eye  presented  appearances  nearly  resembling  those 
observed  in  the  first  stage  of  medullary  carcinoma,  from  which,  Dr.  C.  L.  Robertson  points 
out,  it  was  distinguished  by  the  following  diagnostic  marks: — 


670  SANGUINEOUS   EFFUSION   INTO   THE   EYE. 

1.  By  the  red  color  presented  by  the  tumor,  after  each  effusion,  which  contrasted  with 
the  unvarying  darlc  amber  or  greenish  hue  of  incipient  medullary  carcinoma  ;  while  the 
single  red  vessels,  which,  in  the  latter,  may  be  traced  over  the  tumor,  were  not  present. 

2.  The  pupil,  instead  of  being,  as  it  is  in  medullary  carcinoma,  irregular,  and  having 
the  transverse  diameter  the  larger,  was  equally  and  regularly  dilated  ;  while  the  color  and 
texture  of  the  iris  remained  unaltered,  instead  of  being  thinned,  or  presenting  the  injected 
or  reddish-yellow  hue,  which  it  does  in  incipient  medullary  carcinoma. 

3.  The  tumor  decreased  in  size,  and  sight  gradually  returned,  under  the  use  of  mer- 
curials ;  while  in  the  malignant  affection,  the  size  of  the  tumor  never  decreases,  and  vision 
becomes  more  and  more  impaired,  in  spite  of  all  remedial  means. 

When  I  saw  the  patient  with  Dr.  J.  A.  Robertson,  a  floating  yellow  film  was  visible 
behind  the  lens,  which  was  perfectly  transparent.  I  concluded  from  the  appearances,  that 
the  cells  of  the  vitreous  humor  must  have  been  broken  up.  The  patient  mentioned,  that 
one  of  the  attacks  was  brought  on  from  ascending  Goatfell,  a  high  mountain  in  Arran. 

Ill  the  following  case,  an  injury  of  the  eye,  which  had  produced  opacity  of 
the  lens,  appeared  to  have  left  the  organ  in  *a  state  apt  to  suffer  from  internal 
hemorrhage,  upon  over-exertion  of  the  body. 

Case  323. — A  carter,  whom  I  had  seen,  some  years  before,  with  lenticular  cataract  iu 
the  right  eye,  the  eftect  of  a  blow,  called  on  me  in  March,  1836,  with  the  anterior  chamber 
of  the  eye  half  filled  with  blood.  He  attributed  tliis  to  working  hard  during  three  suc- 
cessive nights.  In  three  days  more,  the  anterior  chamber  was  completely  filled  with  blood 
so  that  the  cornea  appeared  of  a  dark  chocolate  color.  There  was  slight  sclerotitis,  with 
heat  and  pain  of  the  eye,  and  headaclie.  I  advised  rest,  with  cold  applications  to  the  eye, 
and  abstinence  from  spirituous  liquors,  to  which  the  patient  was  rather  addicted. 

The  following  case  aS"ords  an  example  of  effusion  of  blood  occurring  in  an 
eye,  which  had  previously  suffered  disorganizing  inflammation  : — 

Case  324. — Caroline  Pilsen,  aged  nine  years,  of  a  scrofulovis  habit  of  bodj',  came  under 
the  care  of  Dr.  Amnion  in  July,  1829.  Vision  had  been  dim  for  some  months.  On  exa- 
mination, it  was  discovered  that  the  left  ej'e  was  quite  blind,  and  affected  with  strabis- 
mus ;  and  the  right  eye  very  myopic.  The  cornea  of  the  right  eye  had  lost  much  of  its 
convexity,  and  the  iris,  which  was  of  a  yellowish  green  color,  projected  unnaturally  into 
the  anterior  chamber.  The  pupil  was  irregular,  angular,  and  much  contracted.  In  the 
left  eye,  the  outer  portion  of  the  iris  was  much  broader  than  the  inner,  the  pupil  was 
oblong,  and  appeared  angular,  especially  towards  the  inner  side.  The  iris  was  of  a 
brownish  green  color,  and  a  great  many  vessels  were  seen  running  from  its  ciliary  to  its 
pupillary  edge.  The  pupil  of  this  eye  daily  became  larger,  and  the  sensitiveness  of  the 
eye  increased,  so  that  examination  of  it  was  difficult. 

One  day  when  the  eye  was  less  sensitive.  Dr.  Amnion  perceived,  as  he  was  examining  it, 
that  the  pupil  was  nearly  natural,  but  that  on  the  inner  circle  of  the  iris  there  was  a 
deposition  of  a  black  matter,  so  deep  in  its  tint  that  lie  at  first  thought  the  iris  had  been 
removed  by  absorption  at  that  part.  He  also  observed  that  the  lens  was  dislocated  inwards, 
so  that  one  half  of  it  was  concealed  behind  tiie  inner  part  of  the  iris  and  sclerotica,  whilst 
the  other  half  lay  with  its  outer  edge  right  in  the  centre  of  the  pupil.  Through  that  part 
of  the  vitreous  body  which  was  exposed  by  this  displacement  of  the  lens,  a  whitish-gray 
appearance  was  seen  at  the  bottom  of  the  eye. 

Some  days  after  this.  Dr.  A  found  the  girl  lying  on  her  face  asleep.  When  she  awoke, 
he  was  surprised,  on  examining  her  eye,  to  see  a  quantity  of  blood  in  the  anterior  chamber, 
and  the  whole  cornea  quite  red.  Examining  the  eye  next  day,  the  extravasation  of  blood 
was  found  to  have  disappeared.  Dr.  Ammon,  having  made  the  patient  bend  her  head 
forwards,  and  keep  it  so  for  some  minutes,  found  the  anterior  chamber  almost  quite  full 
of  blood,  which  moved  from  one  side  to  the  other  with  the  motions  of  the  head.  Some 
spots  of  the  blood  adhering  to  the  iris,  on  being  examined  with  a  lens  a  few  hours  after, 
were  found  to  have  become  dark  in  color,  next  day  to  have  changed  into  a  brown  color, 
and  in  a  few  days  to  have  become  almost  quite  black.  The  spots,  when  once  formed,  did  not 
disappear,  unless  they  were  on  the  ciliary  edge  of  the  iris,  and  very  small.  This  state 
of  the  eye  continued  for  nearly  two  months,  and  the  slight  degree  of  vision  which  pre- 
viously existed  became  wholly  extinguished.  The  cornea  retained  its  transparency,  but 
grew  flatter  and  flatter,  and  the  black  color  of  the  edge  of  the  pupil  and  of  the  rest  of 
the  iris  increased. 

In  February,  1830,  the  girl  had  a  slight  inflammatory  fever,  and  then  it  was  remarked 
that  the  ecchymosis  in  the  eye  increased  much,  and  that  it  more  quickly  blackened  the 
anterior  surface  of  the  iris.  The  extravasation  of  blood  ceased  at  length  under  the  use 
of  tincture  of  iodine.' 


NON-MALIGNANT   TUMORS   OP   THE   EYEBALL.  Gil 

Cases  are  recorded  which  show  that  hasmophthalmos  may  be  vicarious  with 
the  raeastrual  discharge  f  recurring  either  at  monthly  intervals,  till  the  cata- 
menia  are  established,^  or  supervening  in  consequence  of  their  cessation.*'^ 

The  prognosis  in  spontaneous  hajmophthalmos  must  always  be  dubious,  the 
complaint  being  so  liable  to  return,  and  so  likely  at  last  to  compromise  the 
integrity  of  the  most  important  structures  of  the  eye. 

Attention  to  the  general  health,  an  appropriate  diet,  moderate  and  i*egnlar 
exercise,  and  the  avoidance  of  all  over-exertion,  especially  of  such  as  requires 
stooping,  ought  to  be  urged  on  the  patient,  as  the  most  likely  means  of  pre- 
vention. 

When  the  disease  is  the  result  of  active  hypersemia,  depletion,  general  or 
local,  according  to  the  circumstances  of  the  case,  purgatives,  and  cold  appli- 
cations to  the  eyes  and  head,  will,  in  the  first  instance,  be  proper.  The 
absorption  of  the  effused  blood  will  afterwards  be  aided  by  the  cautious  use 
of  mercury.  In  cachectic  cases,  and  those  in  which  weakness  of  the  vessels 
is  in  fault,  antiscorbutics,  astringents,  and  tonics,  will  be  necessary.  In  all 
instances  the  eyes  should  be  shaded,  and  the  pupils  be  kept  under  the  influence 
of  belladonna.     Some  particular  cases  may  require  paracentesis  corneaB. 


'  Lehre  von  rlen  Augenkrankheiten ;  Vol.  i.  Merkwiirdige  Heilung  eines  Eiteraugcs,  p.  61; 

p.  fi.33  ;  Wien,  1813.  Lamlshut,  iS19. 

^  Dublin  Journal  of  Medical  Science  ;  Vol.  xi.  "  Northern   Journal    of    Medicine;    August 

p.  395;  Dublin,  1S37.  1845. 

'  Lectures  on  the  Parts  concerned  in  Opera-  "  Zeitsehrift  fiir  die  Ophthalmologic  ;  Vol.  i. 

tions  on  the  Eye,  p.  78:  London,  1849.  p.  103  ;  Dresden,  1830. 

*  Beitrage  zur  Augenheilkunde,  p.  17;  Wien,  ^  Walther,  Op.  cit.  p.  50. 

1850.  ^  Tj'rrell's  Practical  Work  on  the  Diseases  of 

'  Bell's  Principles   of  Surgery;   vol.  iii.  p.  the  Eye;  Vol.  i.  p.  40;  Londo.n,  1840. 

270;    London,  1808.      See    eases  by  Walther,  '°  La   Lancette,  quoted  in  London  Medical 

Gazette,  October,  1829;  p.  123. 


SECTION  IV. — NON-MALIGNANT  TUMORS  OF  THE  EYEBxiLL. 

In  the  last  five  sections  of  Chapter  TV.,  I  have  described  certain  ex- 
crescences and  tumors  of  the  conjunctiva,  which,  in  general,  will  easily  be 
distinguished  from  diseases  originating  iu  or  within  the  proper  tunics  of 
the  eye. 

It  is  of  great  importance  to  be  acquainted  with  the  fact,  that  different 
textures  of  the  eye  are  apt  to  be  affected  with  depositions,  tumors,  and 
fungous  degenerations,  which  are  not  malignant,  and  which  sometimes  sub- 
side of  themselves.  There  is  reason  to  think  that  such  growths  have  often 
been  mistaken  for  malignant  diseases,  and  especially  for  fungus  hasmatodes. 

Varieties. — 1.  In  some  cases,  depositions  of  blood  (see  Case  322),  lymph, 
or  pus,  in  different  textures  of  the  eye,  assume  the  appearance  of  fungous 
growths.  Some  of  these  depositions  are  capable  of  becoming  organized,  and 
this  may  add  to  the  resemblance  they  will  bear  to  certain  tumors.  2.  In 
other  cases,  it  seems  probable  that  scrofulous  tubercles,  similar  to  those 
frequently  met  with  imbedded  in  the  cerebrum  of  children  dying  hydro- 
cephalic, form  upon  or  within  the  eye.  3.  Fibrous,  or  fibro-plastic  tumors  (see 
page  271),  are  sometimes  found  attached  to  the  sclerotica,  or  imbedded  in 
its  substance,  or  in  that  of  the  iris,  or  the  choi'oid.  Such  tumors,  lying  deep 
iu  the  eyeball,  will  with  difficulty  be  distinguishable  from  fungus  ha;matodes. 
4.  Cysts,  or  encysted  tumors,  are  met  with  in  the  interior  of  the  eye. 


6'72  NON-MALIGNANT   TUMORS   OF   THE   IRIS. 

§  1.    Non-malignant  Tumors  of  the  Sclerotica  and  Cornea. 

I  have  seen  several  cases  of  what  seemed  scrofulous  tubercles,  but  which, 
perhaps,  were  rather  fibro-plastic  tumors,  originating  from  the  sclerotica, 
sometimes  single,  sometimes  in  clusters,  soft  in  some  cases,  and  firm  in  others, 
but  with  little  or  no  vascularity.  These  tumors  bear  an  external  resemblance 
to  molluscum  contagiosum,  as  we  often  see  it  in  the  eyelids  of  children;  but 
on  microscopical  examination  they  are  found  quite  different,  presenting  an 
obscurely  fibrous  structure.  The  subjects  of  such  aff"ections  were,  in  most 
instances,  cachectic  children,  often  presenting  scrofulous  swellings  in  different 
parts  of  the  body,  and  in  whom  the  affected  eyes  had  suffered  from  internal 
ophthalmia  before  the  appearance  of  the  tumors.  The  conjunctiva  giving 
way,  such  tumors  are  apt  to  undergo  a  process  of  slow  ulceration,  by  which 
they  are'  destroyed,  and  which  often  implicates  the  cornea,  after  which  the 
eye  becomes  atrophic.  Such  tumors  present  themselves  more  frequently  on 
the  temporal  side  of  the  eyeball  than  elsewhere.  They  are  at  first  of  a  whitish 
color;  but  after  they  ulcerate  on  the  surface  they  become  red,  and  sometimes 
send  forth  a  fungus,  connected  by  a  pedicle  to  the  sclerotica,  and  capable  of 
increasing  so  much  as  to  cover  almost  the  whole  eye.  In  one  case  which  I 
saw  with  Dr.  A.  Anderson,  the  tumor  was  destroyed  by  ulceration,  leaving  so 
thin  a  covering  to  the  choroid,  that  the  portion  of  the  eye  where  the  tumor 
had  been  situated,  was  left  of  a  dark,  almost  black  color,  while  the  interior  of 
the  eye  remained  sound.  Several  of  the  patients  whom  I  have  seen  have 
afterwards  died  of  chronic  disease  of  the  lungs. 

I  have  found,  in  the  early  stage,  that  the  application  of  leeches,  and 
counter-irritation  behind  the  ear,  were  useful.  To  improve  the  general 
health,  by  country  air,  mild  nutritious  diet,  and  the  use  of  tonics,  is  of  great 
importance. 

Case  325. — A  girl,  about  7,  had  several  scrofulous  tubercles  on  the  cbeek  and  chin,  and 
a  tumor  on  the  temporal  side  of  one  of  her  eyes,  which  seemed  of  the  same  character. 
The  conjunctiva  covering  it  gave  way,  and  the  tumor  enlarged  to  the  size  of  a  hazel-nut. 
It  was  of  a  white  color  and  soft  consistence,  and  evidently  involved  the  sclerotica.  The 
patient  died  of  tubercular  phthisis. 

Case  32G. — A  young  lady,  about  12,  had  a  scrofulous  tubercle  attached  to  the  upper 
part  of  the  sclerotica ;  the  eye  had  suifered  much  from  scrofulous  internal  inflamma- 
tion ;  the  tubercle  was  of  a  yellow  color,  it  slowly  enlarged  to  the  size  of  an  almond,  and 
seemed  about  to  fall  into  a  state  of  suppuration,  but  did  not  actually  suppurate.  The 
general  health  was  much  impaired,  and  I  learnt  that  the  patient  died  soon  after  the 
occurrence  of  the  symptoms  above  mentioned. 

Case  327. — A  girl  was  brought  to  me  foj."  advice,  who  presented  a  cluster  of  scrofulous 
tubercles  on  the  lower  half  of  the  sclerotica,  close  to  the  cornea.  The  vision  of  the  eye  was 
dim,  the  cornea  hazy,  and  the  pupil  was  dragged  towards  the  side  of  the  eye  on  which  the 
tumors  were  situated.     This  patient  was  benefited  by  the  application  of  leeches. 

Case  328. — A  boy  was  brought  to  me  by  Dr.  Ferrie,  from  the  House  of  Refuge,  with  a 
tumor  occupying  the  temporal  side  of  the  eye.  It  had  ulcerated,  and  presented  a  red 
granular  surface.  The  eye  was  completely  inverted.  The  tumor  felt  as  if  it  iluctuated, 
being  probably  lined  by  the  choroid,  and  filled  with  vitreous  fluid,  similarly  to  a  choroid 
staphyloma.  It  was  excised,  and  the  part  removed  was  microscopically  examined  by  Dr. 
A.  Anderson.   (See  p.  271.) 

§  2.  Non-malignant  Tumors  of  the  Iris. 
Fig.  Dalrymple,  PI.  XXXI.  Figs.  1—3.     Ritterich,  PI.  I.  Fig.  5. 

The  non-malignant  tumors  of  the  iris,  which  I  have  seen,  are  of  two  kinds, 
the  one  encysted  and  the  other  solid. 

1.  In  once  case,  I  saw  a  cyst  form  in  the  iris  in  consequence  of  a  wound. 
It  was  semitransparent,  and  apparently  filled  with  a  thin  fluid;  but  as  it  was 
not  increasing  in  size  and  gave  no  pain,  it  was  not  interfered  with. 


NON-MALIGNANT   TUMORS   OF   THE  IRIS.  673 

Case  329.— A  lady  was  affected  with  considerable  pain  in  one  of  her  eyes,  which  pre- 
sented the  appearance  of  a  small  vesicle  pushing  into 

the  anterior  chamber  from  under  the  ciliary  margin  of  Fig.  85. 

the  iris  behind  the  lower  edge  of  the  cornea.  The 
vesicle  gradually  increased,  separating  the  iris  more 
and  more  from  the  choroid,  and  the  pain  became  severe. 
I  punctured  the  vesicle,  or  encysted  tumor,  with  the  iris 
knife  through  the  cornea.  A  minute  quantity  of  fluid 
was  discharged  from  the  cyst,  which  immediately  con- 
tracted so  much  that  it  was  no  longer  visible.  The  pain 
was  removed.  The  wound  made  in  the  cyst  healed  ;  it 
filled  again  with  fluid,  and  again  appeared  (Fig.  85)  in 
its  former  situation,  but  larger  than  before.  I  punc- 
tured it  a  second  and  a  third  time,  at  intervals  of  six 
and  eight  weeks.     After  the  third  puncture,  it  did  not 

fill  again.  The  iris  returned  to  its  natural  place ;  the  pain  ceased  entirely ;  and  vision 
was  preserved. 

The  notion  which  I  adopted  of  this  case,  at  the  time,  was,  that  the  cyst 
had  formed  in  the  posterioi*  chamber,  and  had  come  into  view  by  pushing 
itself  between  the  edge  of  the  iris  and  that  of  the  choroid;  but  I  now 
regard  Mr.  Bowman's  view  as  the  correct  one,  that  the  disease  is  a  morbid 
formation  of  fluid  between  the  iris  and  its  posterior  epithelium,  commonly 
called  the  uvea. 

"This  disease,"  says  Mr.  B.,  "is  not  accompanied  by  any  other,  is  of 
slow  growth,  and  appears  first  as  a  bulge  of  a  portion  of  the  iris  towards  the 
cornea.  I  imagine  that  the  first  formation  of  the  fluid  is  attended  with  a 
swelling  of  the  uvea  backwards  towards  the  suspensory  ligament  and  lens; 
but,  as  the  contact  of  these  resisting  parts  must  very  speedily  arrest  any 
further  advance  in  that  direction,  the  accumulating  fluid  next  begins  to  push 
forward  the  proper  tissue  of  the  iris,  which  separates  it  from  the  anterior 
chamber.  There  it  meets  with  less  resistance.  The  highly  extensile  fibres 
of  the  iris  slowly  yield,  until  in  the  course  of  months  they  bulge  to  a  large 
extent  before  the  fluid,  and  come  into  contact  with  the  cornea,  and  that  some- 
times so  widely  as  to  throw  the  pupil  towards  the  opposite  side,  and  even 

to  put  it  out  of  sight,  by  becoming  rolled  in  front  of  it If  the 

cyst  be  punctured  in  front,  the  transparent  contents  are  ejaculated  with  force 
by  the  undiminished  contractility  of  the  distended  iris;  and  in  the  course  of 
a  few  minutes,  thei'e  remains  no  trace  of  the  pre-existing  disease,  the  iris 
having  in  all  respects  resumed  its  natural  aspect.  The  cavity,  however,  is 
apt  to  refill  more  than  once."^ 

The  practice  to  be  adopted  in  cysts  of  the  iris,  is  to  puncture  them  through 
the  coriiea.2  Should  this  plan  fail,  after  being  repeatedly  tried,  the  cornea 
will  require  to  be  opened  to  a  considerable  extent,  the  front  of  the  tumor  laid 
hold  of  with  Schlagintweit's  hook  or  the  canular  forceps,  drawn  forth  through 
the  wound  of  the  cornea,  and  snipped  off.  No  attempt  should  be  made  to 
extract  the  whole  cyst. 

Akin  to  the  cases  just  spoken  of  appears  the  following,  recorded^  by  Mr 
Turner,  of  Keith. 

Case  330. — A  woman,  aged  02,  presented  herself  with  an  encysted  tumor,  projecting 
through  the  pupil,  and  causing  severe  inflammation.  It  formed  a  semitransparent  mem- 
branous-like bag,  and  occupied  the  greater  part  of  the  anterior  chamber.  Mr.  T.  punc- 
tured it  through  the  cornea ;  the  contents  escaped  into  the  aqueous  humor,  and  the  cyst 
collapsed. 

2.  The  solid  tumor  of  the  iris  is  distinctly  described  by  Delarue,'*  under 
the  head  Des  Excroissances  charnues  de  VIris,  and  numerous  cases  of  it  are 
recorded.  It  appears  to  be,  in  general,  a  scrofulous  tubercle.  The  ii'is 
generally  becomes,  first  of  all,  whitish  at  some  particular  part  of  its  extent, 
and  then  rises  into  a  tumor,  which  assumes  a  yellowish  color,  with  red  ves- 
43 


6t4  NON-MALIGNANT   TUMORS   OF   THE   CHOROID, 

sels  ramifying  over  it.     Sometimes  such  a  tumor  suppurates,  and  bursts 
tlirough  the  sclerotica,  after  which  the  eye  becomes  atrophic. 

Case  331. — A  pale,  weakly,  female  child,  seven  or  eight  years  of  age,  laboring  under 
caries  of  the  left  foot,  was  brought  to  Dr.  Rittei'ich,  on  account  of  a  complaint  in  her  right 
eye.  Along  with  slight  intolerance  of  light,  and  moderate  redness  of  the  conjunctiva,  he 
found  a  white  elevation  at  the  pupillary  edge  of  the  iris,  but  not  entirely  embracing  it. 
The  iris,  everywhere  else  contracted,  was  at  this  place  dilated,  and  the  pupil  immovable. 
The  patient  did  not  see  with  this  eye,  and  complained  now  and  then  of  pain  in  it.  After  a 
time,  the  swelling  extended  to  the  ciliary  edge  of  the  iris,  and  also  approached  closer  to 
the  cornea.  Dr.  Ritterich  at  first  considered  the  disease  an  abscess;  but  he  found,  on 
attempting  to  evacuate  it  through  the  cornea,  that  it  was  a  fungous  excrescence  of  the 
iris.  For  a  long  time  after  this,  he  did  not  see  the  patient;  and  when  he  did  see  her, 
he  found  the  tumor  much  increased;  so  that,  fearing  it  might  implicate  the  whole  organ, 
he  proposed  to  remove  the  front  of  the  eyeball.  But  the  patient  was  not  brought  back 
to  him  for  a  year,  when  he  found  the  eyeball  atrophic,  and  instead  of  the  cornea,  a  thick 
cicatrice.  The  health  of  the  girl  was  improved,  and  her  foot  so  well  that  she  could  walk; 
several  pieces  of  bone  had  come  out  of  it.  The  mother  said  that  the  cure  took  place 
spontaneously.* 

Case  832. — On  the  inferior  part  of  the  iris,  in  a  boy  about  three  years  old,  a  small 
patch  of  lymph  was  deposited.  The  pupil  was  not  influenced  by  it,  but  moved  as  usual. 
There  was  no  ophthalmia,  nor  any  irritability  to  light.  In  a  fortnight,  the  mass  of  lymph 
was  so  much  increased  that  it  occupied  the  inferior  half  of  the  anterior  chamber.  A  process 
of  organization  now  commenced  in  the  lymph,  and  an  action  analogous  to  inflammation 
was  set  up  in  the  cornea.  It  became  turbid  and  vascular ;  the  iris  and  cornea  united ; 
a  blue  mass  arose  in  the  situation  of  the  ciliary  ligament,  which,  together  with  the 
whole  of  the  cornea,  ulcerated  or  suppurated,  and  an  ill-conditioned  and  very  luxuriant 
fungus  shot  forth.     By  degrees  the  fungus  diminished,  and  finally  the  eyeball  healed.^ 

Case  333. — In  a  boy,  about  eight  or  nine  years  of  age,  Mr.  Lawrence  saw  an  apparently 
simple  vascular  growth,  of  a  light  brown  color,  equal  in  size  to  a  small  pea,  proceeding 
from  the  iris,  without  much  redness  or  pain,  and  without  opacity  of  the  pupil.  It  caused 
ulceration  of  the  cornea,  and  thus  appeared  externally.  As  the  patient  was  removed 
to  his  residence  in  the  country,  INIr.  Lawrence  did  not  witness  the  termination  of  the  case; 
but  he  was  informed  that  the  tumor  subsided  after  a  time,  and  that  the  eye  shrunk.' 

Case  334. — Sarah  ISIacniven,  aged  19,  was  admitted  at  the  Glasgow  Eye  Infirmary,  17th 
February,  1835.  About  five  weeks  before  her  admission,  her  left  eye  had  been  consider- 
ably inflamed,  with  pain  in  the  eye  and  circumorbital  region.  The  conjunctiva  and 
sclerotica  were  injected  with  blood,  the  cornea  slightly  nebulous,  the  iris  somewhat 
changed  in  color,  vision  very  imperfect,  and  the  motions  of  the  pupil  sluggish.  At  the 
bottom  of  the  anterior  chamber,  there  was  a  yellowish  mass,  having  much  the  appearance 
of  pus,  with  reddish  streaks,  as  if  from  bloodvessels,  passing  over  its  surface.  This 
yellowish  substance  gradually  increased  in  size,  and  assumed  the  appearance  of  a  scrofu- 
lous tubercle.  It  caused  an  elongation  of  the  cornea  downwards,  so  that  the  cornea 
had  an  oval  shape.  The  tumor  diminished  considerably,  and  the  inflammatory  symptoms 
subsided,  under  the  internal  use  of  mercury,  quina,  and  belladonna.  The  patient  was  now 
seized  with  insomnia,  spectral  illusions,  delirium,  and  loss  of  motion  of  the  right  arm.  She 
died  on  the  11th  April.  Permission  could  not  be  obtained  to  inspect  the  body;  but  it 
is  not  improbable  that  other  scrofulous  tubercles  existed  within  the  cranium,  similar  to 
the  one  attached  to  the  iris. 

Case  335. — Maitre-Jan  relates  the  case  of  a  soldier,  whose  eye  was  completely  covered 
by  a  fleshy  excrescence,  which  he  compares  to  a  mushroom,  and  which  projected  even 
from  between  the  eyelids.  He  destroyed  it  by  the  repeated  application  of  one  part  of 
corrosive  sublimate  with  four  of  dry  crust  of  bread,  after  which  he  discovered  that  its 
root  was  narrow,  forcing  its  way  through  an  ulcer  of  the  cornea,  and  arising  from  the 
ii-is.  Under  the  continued  use  of  escharotics,  the  front  of  the  eye  sloughed,  and  the  lens 
and  vitreous  humor  were  evacuated,  after  which  the  pain  ceased,  and  the  ulcer  cica- 
trized.* 

§  3.  Non-malignant  Tumors  of  the  Choroid  and  Corpus  Ciliare. 

The  posterior  part  of  the  choroid  is  sometimes  the  seat  of  a  tumor,  which 
is  probably  of  the  nature  of  scrofulous  tubercle,  or  of  tibro-plastic  tumor. 
It  separates  the  membrane  into  two  laminae,  between  which  it  is  deposited. 
Much  more  frequently  have  non-malignant  growths  been  observed  in  the 
anterior  part  of  the  choroid. 

Case  336. — A  child,  about  six  years  old.  came  under  Mr.  Lawrence's  care  at  the  London 


NON-MALIGNANT   TUMORS   DEEP   IN   THE   EYE.  6^75 

Ophthalmic  Infirmary,  with  external  inflammation  of  one  eye,  attended  with  so  much  swell- 
ing of  the  palpebrfe,  that  the  exact  state  of  the  globe  could  not  be  ascertained.  Heat  of 
skin,  quickness  of  pulse,  furred  tongue,  great  pain  in  the  head  and  eye,  restlessness,  and 
want  of  sleep,  showed  the  local  inflammation  to  be  serious.  At  the  end  of  three  or  four 
days,  after  the  use  of  leeches  and  suitable  internal  means,  Mr.  Lawrence  succeeded  in  ob- 
taining a  view  of  the  eye,  in  which  there  was  vivid  external  redness,  with  a  dull  state  of 
the  cornea ;  the  iris  was  pushed  forward,  and  tlie  pupil  partially  opaque.  In  spite  of 
antiphlogistic  means,  the  child  continued  to  sufl'er.  A  tumor  gradually  arose  behind  the 
edge  of  the  cornea ;  it  was  of  a  yellowish  color,  and  acquired  the  size  of  a  horsebean. 
Subsequently,  two  or  three  other  projections  took  place,  of  smaller  size,  arranged  with 
the  first,  in  aregular  series,  at  a  short  distance  from  the  margin  of  the  cornea.  The  inflam- 
mation still  continued  severe,  although  leeches  and  aperients  were  frequently  used.  At 
length  the  inflammation  abated,  the  pain  became  less,  the  protuberances  diminished  in  size, 
the  cornea  shrunk  completely,  the  eye  became  atrophic,  and  the  child  recovered  without  any 
farther  ill  consequences.^ 

Case  337. — A  girl,  about  ten  years  old,  was  brought  to  Mr.  Saunders,  for  the  purpose 
of  obtaining  an  opinion  whether  she  was  blind.  Of  that  there  was  no  question,  as  the 
affected  ej'e  gave  no  sign  of  vision. 

The  sclerotica  was  unusually  vascular,  but  not  inflamed.  The  vessels  were  large  and 
serpentine.  The  iris  seemed  to  be  twice  as  far  from  the  cornea  as  is  natural.  The  pupil 
was  dilated,  and  iris  contained  many  distinct  red  vessels.  The  cornea,  with  the  aqueous, 
crystalline,  and  vitreous  humors,  was  at  this  time  transparent.  In  the  course  of  a  few 
weeks,  the  crystalline  became  opaque,  and  the  iris,  covered  with  lymph,  and  as  red  as  if 
injected,  advanced  towards  and  touched  the  cornea.  Shortly  after,  a  blue  excrescence  was 
thrown  out  at  the  superior  part  of  the  eye,  at  that  part  of  the  sclerotica  which  unites 
with  the  ciliary  ligament.  •  It  increased  rapidly,  and  became  as  large  as  the  anterior  por- 
tion of  the  globe.  It  ulcerated,  and  for  a  long  time  a  thin  watery  fluid  was  discharged, 
then  pus,  and  ropy  lymph.  After  some  months,  the  aperture  closed  ;  the  eyeball,  much 
reduced  in  bulk,  became  tranquil,  and  even  retained  some  vestiges  of  the  coi'nea,  the  blue 
excrescence  being  totally  extinct.  During  this  process,  there  was  nothing  like  acute  in- 
flammation, and  the  pain  was  very  trivial. '° 

Case  338. — A  scrofulous  child  had  scrofulous  ophthalmia  for  a  year,  with  an  ulcer  at 
the  lower  edge  of  the  cornea,  which  gave  way.  Through  the  opening,  a  hard,  irregular, 
reddish  white  swelling  gradually  protruded.  Atrophy  of  the  bulb  and  tabes  mesenterica 
supervened  about  the  same  time,  and  soon  after  subacute  hydrocephalus. 

The  eye  was  examined  by  Jager,  who  ascertained  that  the  disease  arose  from  the  corpus 
ciliare,  and  that  the  other  textures,  although  atrophied,  were  not  connected  with  the 
tumor,  which  had  spread  outward,  between  the  iris  and  cornea." 

Case  339. — A  woman,  aged  40,  of  arthritic  diathesis,  applied  to  Professor  Rosas,  on 
account  of  a  fungus  in  the  anterior  chamber,  which  appeared  to  arise  from  the  ciliary  pro- 
cesses, and  involved  a  third  of  the  iris.  The  rest  of  the  iris,  with  its  pupilary  edge,  was 
healthy,  as  well  as  the  other  textures  of  the  eye.  AVith  the  extraction  knife  a  flap  was 
formed  in  the  external  inferior  part  of  the  sclerotica,  about  half  a  line  from  the  edge  of 
the  cornea,  and  the  fungus  cut  out,  along  with  which  came  the  lens  and  a  portion  of  the 
vitreous  humor.  In  some  weeks  the  wound  was  healed,  the  cornea  remained  flattened, 
and  at  its  inferior  external  part,  nebulous;  looking  downwards  into  the  eye,  the  pupil  was 
observed  dilated,  vision  was  confined  to  a  mere  perception  of  light,  and  no  trace  of  the 
growth  remained.'^ 

§  4.  Non-malignant  Depositions  or  Tumors  occiqjying  the  place  of  the 
Vitreous  Hilrnor. 

Fig.  Dalrymple,  PI.  XXII.  Fig.  6. 

It  may  now  be  regarded  as  a  generally  received  opinion,  that  frequent  in- 
stances occur  of  changes  of  structure  deep  in  the  eyeball,  producing  many,  if 
not  all  of  the  visible  appearances  of  fungus  ha?matodes  of  the  eye  ;  but  which 
do  not  turn  out  to  be  malignant.  Such  cases  are  not  uncommon  after  injuries. 
They  constitute  a  diseased  state  of  the  eye,  which  Beer  included,  along  with 
other  conditions  of  the  deep-seated  parts  of  the  organ,  of  a  nature  totally  dif- 
ferent, under  the  name  of  Amaurotic  caVs  eye.  Traumatic  cat's  eye  is  the 
appellation  given  to  such  cases,  when  they  are  evidently  the  result  of  an  injury. 
To  distinguish  them,  not  only  from  malignant  tumors,  but  from  posterior 


G1Q  NON-MALIGNANT   TUMORS   DEEP  IN   THE   EYE. 

h£emopbthalmus  and  subchoroid  dropsy,  will  require  very  great  attention. 
(See  pp.  662,  668.) 

The  injuries  which  are  apt  to  be  followed  by  the  appearances  referred  to, 
rarely  penetrate  through  the  tunics.  I  have  known  a  blow  on  the  eye,  or  a 
cut  of  the  conjunctiva,  to  produce  this  affection.  After  pretty  severe  inflam- 
mation of  the  conjunctiva  and  sclerotica,  the  sight  grows  dim,  while  behind 
the  pupil,  sometimes  on  the  opposite  side  of  the  eye  from  that  which  was  in- 
jured, sometimes  in  the  fundus  of  the  eye,  a  whitish  or  yellowish  red  deposit 
makes  its  appearance,  the  result  of  lymphatic  effusion  between  the  choroid  and 
retina,  or  between  the  retina  and  hyaloid.  After  a  time,  cataract  follows,  and 
subsequently  the  eye  shrinks. 

If  we  extirpate  such  eyes,  under  the  notion  that  they  are  affected  with  fun- 
gus haematodes,  the  patient  will  continue  well,  and  we  shall  fall  into  the  ei'ror 
of  supposing  that  our  operation  has  been  an  exception  to  the  general  failure 
which  attends  the  removal  of  the  eye  in  that  disease.  This  error  has  probably 
been  committed  by  Mr.  Wishart^-'andby  Mr.  Porter,"  in  two  cases  which  have 
been  given  to  the  public.  In  Mr.  Wishart's  case,  the  disease  in  the  eye  arose 
from  a  blow  ;  in  Mr.  Porter's  case,  the  fungus  was  partially  contained  in  two 
cysts  ;  in  both  cases,  the  optic  nerve  was  sound ;  all  of  which  circumstances 
lead  me  to  suspect  that  they  were  not  cases  of  fungus  ha?matodes.  In  the 
second  edition  of  this  work,  printed  in  1834,  I  stated  that,  in  the  case  of  an 
adult,  whose  eye  I  had  extirpated  four  years  before,  there  had  been  no  return 
of  fungus  hiematodes.  The  patient  referred  to  continued  well  during  the  rest 
of  her  life,  which  extended  to  twenty  years  beyond  the  date  of  the  operation  ; 
but  a  re-examination  of  the  extirpated  eye,  and  a  comparison  of  the  symptoms 
with  those  of  some  non-malignant  cases  which  [  have  since  seen,  or  of  which 
I  have  read,  have  led  me  to  regard  the  case  as  certainly  not  one  of  fungus 
haimatodes.  The  facts  that  one  of  the  fungous  masses  had  been  developed  in  the 
substance  of  the  choroid,  and  that  the  other,  which  occupied  the  place  of  the 
vitreous  humor,  and  was  attached  to  the  termination  of  the  optic  nerve,  was 
contained  within  a  distinct  firm  cyst,  have  led  me  to  this  change  of  opinion. 

Mr.  Lawrence  states  that  he  had  seen  children  with  the  appearances  of 
fungus  hiematodes  in  the  first  stage ;  namely,  the  altered  color  of  the  pupil, 
the  metal-like  reflection  in  the  bottom  of  the  eye,  and  so  on.  The  uniformly 
unfavorable  result  of  extirpation  deterred  him  from  proposing  the  operation. 
Yet,  in  some  instances,  very  contrary  to  his  expectation,  the  case  has  remained 
for  some  time  in  the  state  just  now  mentioned,  and  afterwards  the  eye  has 
shrunk  and  become  atrophic.'* 

Mr.  Travers,  .ilso,  has  published  some  important  observations  on  the  difficul- 
ties attending  the  diagnosis  of  fungus  ha^matodes.  He  is  of  opinion  that  the 
tapctum-like  appearance  at  the  bottom  of  the  eye,  in  the  early  stage,  cannot  be 
relied  on  as  diagnostic.  He  mentions  that  he  had  seen  several  cases,  in  which 
this  appearance  was  stationary  for  a  time,  after  which  the  eyeball  dwindled,  so 
that  they  might  fairly  be  presumed  not  to  have  been  instances  of  malignant 
disease.  It  so  happened,  however,  that  long  continued  alterative  courses 
of  mercury,  or  protracted  salivations,  had  been  used  in  these  cases,  so  that  the 
fact  of  their  disappearance  was  consequently  open  to  another  explanation ; 
namely,  that  they  were  examples  of  malignant  disease  which  had  been  arrested 
by  this  treatment.  That  the  appearance  in  these  cases  was  very  analogous  to 
that  of  medullary  tumor,  we  may  readily  admit  from  the  fact,  that  in  one  of 
them,  Mr.  Travers  being  about  to  extirpate  the  eye,  the  operation  was  over- 
ruled, only  by  one  dissentient  voice,  at  a  consultation  including  some  eminent 
members  of  the  profession.  Several  years  before  Mr.  Travers  published  this 
statement  of  her  case,  the  patient  had  recovered  with  the  loss  of  sight,  and 
still  continued  in  perfect  health. 


NON-MALIGNANT   TUMORS   DEEP   IN   THE   EYE.  6T7 

It  accords  exactly  with  my  own  experience,  that  inflammation  of  the 
internal  structnres  of  the  eye,  arising  in  consequence  of  an  injury,  not  unfre- 
quently  terminates  in  a  deposit,  apparently  of  lymph,  which  in  all  probability 
undergoes  vascular  organization,  and  which  certainly  presents  an  appearance, 
deep  in  the  eye,  closely  resembling  incipient  medullary  tumor.  The  first  case 
of  this  kind  which  fell  under  my  observation,  occurred  in  1815,  the  inflamma- 
tion being  the  consequence  of  a  blow,  on  the  eye  of  a  child,  with  a  snow))all. 
In  some  of  the  cases  in  question,  I  have  observed  that  the  ciliary  edge  of  the 
iris  appears  wrinkled,  the  larger  circle  is  drawn  somewhat  backwards,  while 
the  smaller  circle  projects  forwards,  and  is  broader  than  usual ;  the  pupil  is 
in  a  middle  state  of  dilatation,  and  its  edge  is  fringed  with  uvea ;  the  surface 
of  the  deposition  or  tumor  at  the  bottom  of  the  eye  is  sometimes  of  a  pale 
tint,  sometimes  yellowish  or  reddish,  and  not  so  defined  as  in  the  malignant 
cases.  The  deep  erect  image  of  the  candle  is  greatly  magnified  by  such 
deposits,  which  evidently  act  on  it  as  a  foil.  In  some  cases,  points  of  sup- 
puration form  through  the  sclerotica  and  conjunctiva,  most  frequently  below 
the  lower  edge  of  the  cornea.  After  bursting,  a  fleshy  fungus  projects,  then 
shrinks  ;  and  the  eyeball  becomes  atrophic. 

Mr.  Travers  states  that  in  a  young  lady's  eye,  the  fawn  colored  resplendent 
surface,  with  red  vessels  branching  over  it,  was  so  strongly  marked,  that  he 
should  certainly  have  considered  it  to  be  the  nascent  malignant  disease,  but 
for  the  circumstance  of  its  having  followed  a  wound  with  a  pair  of  fine  scis- 
sors, a  fortnight  before.  The  instrument  had  passed  obliquely  between  the 
margin  of  the  iris  and  the  ciliary  body.  Deep-seated  inflammation  ensued, 
and  blindness,  after  three  days,  became  complete.  The  lens  remained  trans- 
parent for  months,  so  as  to  permit  the  appearances  described  to  be  observed. 
At  length,  a  cataract,  with  constricted  pupil,  ensued  upon  the  chronic  inflam- 
mation of  the  iris  ;  and  the  eyeball,  which  had  never  enlarged,  gradually 
shrunk. 

From  what  I  have  observed  of  non-malignant  growths  within  the  eye,  I  am 
disposed  to  conclude  that  appearances  resembling  those  of  medullary  fungus, 
may  always  be  regarded  as  doubtful  when  they  arise  from  an  evident  wound 
or  injury,  or  when  they  follow  or  are  combined  with  scrofulous  affections  of 
other  organs. 

Mr.  Travers  remarks  that  either  hydrophthalmic  enlargement,  or,  on  the 
contrary,  shrinking  by  interstitial  absorption  of  the  contents  of  the  eyeball, 
is  a  sure  indication  that  the  disease  is  not  malignant.^^ 

Case  340. — Agnes  Campbell,  aged  12,  was  admitted  at  the  Glasgow  Eye  Infirmary,  on 
the  2()th  December,  1833.  Sis  days  before  that  date,  a  mixture  of  sulphuric  acid  and 
water,  with  particles  of  broken  glass  in  it,  had  been  projected  against  the  left  eye.  There 
was  an  irregular  cicatrice  towards  the  inner  angle  of  the  eye,  about  two  lines  and  a  half 
from  the  margin  of  the  cornea,  which  looked  as  if  it  had  been  produced  by  a  fragment  of 
the  glass.  No  roughness  could  be  felt  on  examination  with  the  probe,  nor  any  breach  of 
continuity  of  the  sclerotica.  She  was  unable  to  discern  any  object  with  the  injured  eye, 
which  retained  merely  a  faint  perception  of  light.  The  pupil  was  in  a  middle  state  of 
dilatation;  but  contracted  momentarily  on  sudden  exposure  of  the  sound  eye  to  light,  and 
then  speedily  returned  to  its  former  state.  The  conjunctiva  was  red.  The  iris  was 
wrinkled  towards  its  ciliary  edge,  and  had  assumed  a  reddish  tinge.  The  pain  was  very 
trifling.     Leeches  wei-e  applied,  and  calomel  with  opium  was  ordered. 

For  some  time  the  inflammation  increased,  and  then  diminished.  By  and  by,  the  bottom 
of  the  eye  presented  a  glaucomatous  appearance.  On  the  13th  January,  1834,  the  eye- 
ball was  found  to  be  shrunk,  and  charged  in  form  by  the  action  of  the  recti ;  the  pupil 
presented  a  greenish  j'ellow  hue  ;  and  there  was  an  appearance  as  if  the  retina  was  pushed 
forward,  from  the  side  on  which  the  eye  had  been  wounded.  At  last,  a  bright  reflection 
from  the  bottom  of  the  eye,  of  a  whitish-red  color,  was  evident,  very  similar  to  what 
occurs  in  incipient  medullary  fungus,  while  a  grayish-white  matter  was  seen  to  be  deposited 
a  little  behind  the  iris,  towai-ds  the  nasal  side  of  the  eye.  The  eye  continued  to  shrink ; 
notwithstanding  which,  the  patient  still  retained  the  power  of  perceiving  light  and  shadow 
with  it.     In  the  course  of  some  months,  the  lens  became  opaque. 


678  NON-MALIGNANT   TUMORS   DEEP  IN   THE   EYE. 

Case  341. — Charles  Kelly,  aged  11,  was  admitted  at  the  Glasgow  Eye  Infirmary,  on  the 
27th  September,  1832.  The  right  conjunctiva  and  sclerotica  were  injected,  the  cornea 
somewhat  hazy,  the  pupil  dilated  and  fixed  ;  the  color  of  the  iris  had  changed  from  bluish- 
gray  to  yellowish-brown;  several  spots  near  the  external  circumference  of  the  iris  were 
of  a  blood  red  color;  the  anterior  chamber  was  enlarged,  and  the  iris  turned  back;  vision 
appeared  to  be  extinct.  On  examining  the  bottom  of  the  eye,  a  tawny  appearance 
presented  itself,  exactly  similar  to  tliat  which  attends  the  incipient  stage  of  medullary 
fungus. 

Eight  months  before  applying  at  the  Eye  Infirmary,  he  had  had  a  fever,  after  which  his 
mother  observed  that  he  could  not  read  long  at  a  time,  and  she  thought  he  had  a  weakness 
and  giddiness  in  his  head.  He  had  also  been  troubled  with  frequent  vomiting.  The  dis- 
eased appearances  in  his  eye,  however,  hail  been  noticed  only  10  days  before  coming  to 
the  infirmary,  four  days  previously  to  which  he  had  been  much  terrified  by  being  exposed 
to  a  storm  of  thunder  and  lightning,  and  was  immediately  afterwards  attacked  with  pain 
in  the  right  side  of  his  head. 

Neither  Dr.  Rainy,  Mr.  Nimmo,  nor  myself  felt  any  hesitation  in  pronouncing  this  to 
be  a  case  of  medullary  fungus.  AVe  recommended  extirpation  of  the  eye,  but  to  this  the 
mother  would  not  consent.     Calomel  with  opium  was  administered. 

On  the  29th  September,  the  eye  appeared  less  irritable,  and  he  had  rested  better;  but 
the  tawny  reflection  from  the  bottom  of  the  eye  was  more  distinct. 

On  the  10th  of  November,  the  vascularity  of  the  conjunctiva  appeared  to  have  increased, 
the  eyeball  was  enlarged,  and  presented  a  considerable  prominence  towards  the  inner 
canthus ;  the  anterior  chamber  was  diminished  in  size  by  the  iris  bulging  forward,  while 
the  lens  was  seen  projecting  through  the  pupil,  so  as  to  touch  the  cornea. 

On  the  21st,  the  ball  of  the  eye  was  so  much  increased  in  size,  that  the  lids  could  not 
be  brought  together.  The  prominence  above  mentioned  was  now  more  pointed,  and  the 
cornea  seemed  falling  into  a  state  of  ulceration. 

By  the  31st  December,  the  prominent  point  on  the  nasal  side  of  the  eye  had  given  way, 
and  discharged  a  quantity  of  thick  purulent  matter.  The  cornea  had  become  opaque, 
and  was  much  reduced  in  size.  Before  this  time,  a  scrofulous  enlargement  of  the  left 
ring-finger  was  observed. 

By  the  1st  June,  1833,  the  eye  had  shrunk  so  much,  as  to  allow  the  lids  to  close  over 
it.  The  pus  discharged  had  been  considerable,  but  was  now  diminishing.  The  remaining 
part  of  the  globe  presented  a  granular  appearance,  of  a  reddish-brown  color. 

By  the  7th  April,  1834,  the  lids  were  very  much  collapsed,  from  the  extremely  atrophic 
state  of  the  eyeball.  The  finger  had  burst,  and  discharged  curdy  pus.  On  introducing 
a  probe,  caries  was  detected. 

Case  342. — A  boy,  about  10,  came  under  Mr.  Lawrence's  care  at  St.  Bartholomew's 
Hospital,  in  consequence  of  a  wound  in  the  eye,  three  or  four  days  previously.  The  point 
of  a  table-fork,  which  had  been  thrown  at  him  by  his  sister,  had  passed  through  the  upper 
eyelid  and  the  cornea.  The  eye  was  inflamed  and  painful,  and  the  pupil  was  occupied 
by  a  thin  grayish  film,  which  Mr.  Lawrence  supposed,  on  the  first  cursory  inspection,  to 
be  opacity  of  the  lens,  caused  by  the  accident.  The  use  of  leeches  and  other  antiphlo- 
gistic measures  lessened  the  inflammation,  and  removed  the  opacity  from  the  pupil.  The 
inflammation,  however,  recurred,  and  soon  after  a  bright  yellow  appearance  was  seen, 
which  gradually  extended  over  the  whole  fundus  of  the  globe.  The  iris  was  changed  in 
color;  the  pupil  was  fixed  in  the  middle  state,  and  clear;  vision  extinct.  In  a  short 
time,  the  globe  felt  soft,  and  began  to  shrink;  atrophy  was  considerably  advanced,  when 
the  lens  became  opaque,  and  completely  concealed  the  change  in  the  back  of  the  eye; 
the  globe  became  completely  atrophic. '^ 

Patlwhcjical  Anatomy. — It  is  to  be  hoped  that,  attention  being  roused  to 
the  fact  that  there  are  various  disordered  states  of  the  interior  of  the  eye, 
wliich  simulate  the  disease  called  fungus  hasmatodes,  an  accurate  examination 
will  be  instituted  into  their  nature,  by  those  who  may  have  opportunities  of 
dissecting  eyes  so  affected,  either  after  extirpation,  or  after  the  death  of  the 
patient. 

It  is  probable  that,  in  some  cases,  an  effusion  of  blood,  lymph,  or  pus, 
into  the  vitreous  cells,  on  the  surface  of  the  retina,  or  between  the  retina  and 
the  choroid,  will  be  found  to  be  the  whole  cause  of  the  appearances,  especially 
when  these  have  quickly  succeeded  to  injuries  of  the  eye;  while,  in  other 
instances,  scrofulous  or  other  tubercles  will  be  found  growing  from  the  optic 
nerve,  imbedded  in  the  choroid,  or  adherent  to  some  of  the  other  textures. 
In  such  cases,  the  optic  nerve,  beyond  the  eye,  will  probably  be  found  healthy, 


NON-MALIGNANT   TUMORS   DEEP   IN   THE   EYE.  619 

or  shrunk;  whereas,  in  fungus  hsematodes,  it  is  generally  thickened  and 
diseased. 

Mr.  Travers  extirpated  the  eye  of  an  infant,  eight  months  old,  the  disease 
being  supposed  to  be  malignant  fungus  in  its  nascent  state.  Upon  making  a 
section  of  the  eye,  the  cells  of  the  vitreous  humor  were  found  to  be  filled  with 
an  opaque  lardaceous  substance.  The  child  grew  up  to  be  a  healthy  boy, 
and  the  other  eye  remained  sound.  It  is  evident  that  an  opaque  lardaceous 
substance,  or  one  resembling  curd,  or  ground  rice  boiled,  all  of  which  com- 
parisons are  made  use  of  by  Mr.  Travers*^  in  speaking  of  the  contents  of  the 
vitreous  cells,  denotes  a  morbid  state  altogether  different  from  that  which 
exists  in  fungus  haematodes. 

The  following  case  was  published'^  as  one  of  fungus  haematodes ;  but  the 
dissection  discloses  morbid  appearances  quite  distinct  from  those  which  exist 
in  genuine  examples  of  that  disease.  They  approach  evidently  to  what  Mr. 
Travers  had  met  with,  in  the  case  just  now  referred  to. 

Case  343. — A  boy,  under  the  care  of  Mr.  Wardrop,  two  years  and  eight  months  old, 
became  dropsical,  and  died  after  having  been  twice  tapped. 

It  had  been  remarked,  some  weeks  previous  to  his  decease,  that  there  was  a  peculiar 
appearance  in  the  left  eye ;  the  bottom  of  the  vitreous  chamber  having  a  metallic  lustre, 
produced  by  a  yellowish  opaque  body. 

On  dissection,  a  sac  was  found,  adhering  to  the  peritoneum,  and  containing  a  large 
quantity  of  puriform  fluid,  mixed  with  serum.  The  sac  was  formed  by  the  separation  and 
thickening  of  the  two  laminte  of  the  great  omentum.  There  was  another  C3'st  between 
the  two  lamince  of  the  lesser  omentum,  containing  about  a  pint  of  similar  fluid. 

The  optic  nerve  of  the  affected  eye  was  perfectly  similar  to  that  of  the  opposite  side, 
from  the  thalamus  till  it  entered  the  globe.  The  consistence  or  density  of  the  sclerotica 
was  not  perceptiby  altered.  The  choroid  coat  appeared  rather  paler  than  natural ;  and 
being  lacerated  at  one  point,  during  the  dissection,  a  quantity  of  a  creamy  fluid  escaped. 
On  turning  back  the  choroid,  the  vitreous  chamber  appeared  filled  with  an  opaque  white 
mass,  on  the  anterior  part  of  which  lay  the  crystalline  lens.  By  immersion  in  spirits, 
the  retina  was  rendered  more  opaque  than  the  new  production,  and  was  found  of  its 
natural  appearance,  and  enveloping  the  diseased  growth.  The  hyaloid  membrane  also 
surrounded  the  tumor,  and  had  become  opaque  in  a  few  points  where  the  diseased  pro- 
duction was  found  firmly  adherent  to  it.  This  presented  a  mass  consisting  of  granules, 
or  lobules,  united  by  fine  reticulated  membrane.  It  seemed  to  have  commenced  at  the 
point  where  the  optic  nerve  pierces  the  sclerotic ;  at  least,  it  was  connected  to  that 
point  by  a  small  pedicle,  which  was  continuous  with  the  larger  mass  attached  to  the 
hyaloid  membrane,  the  structure  of  the  whole  being  perfectly  identical,  viz :  small  gra- 
nules, about  the  size  of  a  millet-seed,  connected  together  by  reticulated  membrane. 

The  disease  which,  in  the  following  case,  destroyed  the  retina  and  the  vitre- 
ous body,  and  simulated  fungus  ha3matodes,  appears  to  have  been  posterior 
hffimophthalmos. 

Case  344. — In  the  left  eye  of  a  child,  five  months  old,  iMr.  Critchett  found  the  con- 
junctiva and  sclerotica  congested,  the  surface  of  the  iris  dull,  and  the  anterior  chamber 
rather  diminished  in  size  by  the  bulging  forward  of  the  iris.  He  treated  the  case  as  one 
of  scrofulous  iritis,  for  about  a  month,  without  any  improvement.  A  complete  change, 
however,  soon  afterwards  appeared ;  the  sclerotica  became  thin  and  dark-colored,  while 
a  yellow  shining  mass,  gradually  advancing  from  the  posterior  part  of  the  globe,  ex- 
panded the  pupil,  and  pressed  the  lens  against  the  cornea.  The  case  was  presumed  to 
be  one  of  medullary  tumor,  and  the  eye  was  extirpated.  No  untoward  symptom  followed ; 
and,  three  months  afterwards,  the  child  was  steadily  improving  in  general  health. 

On  laying  open  the  diseased  organ,  which  was  not  enlarged,  the  following  state  of  parts 
was  found  to  exist :  Immediately  behind  the  cornea  lay  the  iris,  and  immediately  behind 
this  the  lens,  both  so  close  to  the  posterior  surface  of  the  cornea  as  almost  to  obliterate  the 
aqueous  chambers.  The  anterior  half  of  the  lens  was  transpai-ent,  the  posterior  half 
slightly  opaque,  Avhile  its  posterior  surface  presented,  near  its  centre,  a  small  nodular 
swelling,  applied  against  a  fibro-vascular  membrane,  yellowish,  opaque,  smooth,  and 
glistening,  insep.arably  connected  to  a  gelatinous  mass  behind  it,  which  consisted  of  the 
textur.al  elements  of  the  retina  broken  up,  and  variously  modified.  The  ciliary  processes 
were  thrown  backwards.  The  remaining  cavity  of  the  globe  was  occupied  by  a  grumous 
albuminous  fluid,  which  lay  in  contact  with  the  choroid,  no  hyaloid,  nor  expanded  portion  of 
retina,  being  visible.     The  fluid  had  suspended  in  it,  blood-corpuscles,  fat  granules,  disin- 


680 


MALIGNANT  AFFECTIONS  OF  THE  EYEBALL. 


tegrated  cells,  exudation  corpuscles,  pigment  cells,  and  a  few  delicate  ciliated  epithelial 
cells.  The  optic  nerve,  where  it  passed  through  the  sclerotic,  and  for  some  way  behind 
that  point,  was  atrophied.  Hemorrhage  from  the  choroid  must  in  this  case  have  forced 
the  retina  away  from  the  optic  nerve,  and  pushed  it  towards  the  lens.  The  debris  of  the 
choroid  must  have  furnished  some  of  the  elements  found  in  the  fluid  which  occupied  the 
place  of  the  vitreous  humor.^° 

Non-malignant  tumors  may  not  only  assume  a  formidable  appearance  and 
destroy  the  organ,  but  from  their  size  and  dangerous  effects  render  necessary 
the  extirpation  of  the  eye.  In  general,  however,  the  affected  eye  becomes 
atrophied,  and  gives  no  further  trouble. 


'  Lectures  on  the  Parts  concerned  in  Opera- 
tions on  the  Eye;  p.  75;  London,  1849. 

"  See  Case  by  Dalrymple,  cured  by  thrice 
puncturint;;  Lancet,  August  31,  1844;  p.  713: 
Case  by  AVharton  Jones,  in  which  the  cyst 
suppurated  after  being  twice  punctured;  lb. 
June  12,  1852,  p.  568. 

^  Monthly  Journal  of  Medical  Science;  Vol. 
i.  p.  270;  Edinburgh,  1841. 

■*  Cours  complet  des  Maladies  des  Yeux;  p. 
206;  Paris,  1820. 

'  Ritterich  Jahrliche  Beitrage  zur  Vervoll- 
kommnung  der  Augenheilkunst;  Vol.  i.  p.  37; 
Leipzig,  1827. 

'  Treatise  on  some  Practical  Points  relating 
to  the  Diseases  of  the  Eye,  by  J.  C.  Saunders, 
p.  119;  London,  1811. 

''  Treatise  on  Diseases  of  the  Eye,  by  AV. 
Lawrence,  p.  593;  London,  1833. 

'  Traite  des  Maladies  de  I'CEil,  p.  456;  Troyes, 
1711. 

'  Op.  cit.  p.  591. 

"  Op.  cit.  p.  iir. 


"  Canstatt  iiber  Markschwamm  des  Auges 
und  araaurotisches  Katzenauge;  p.  78;  Wiirz- 
burg,  1831. 

'*  Handbuch  der  theoretischen  und  prac- 
tischen  Augenheilkunde,  von  Anton  Rosas; 
Vol.  ii.p.  617;  Wien,  1830. 

'^  Edinburgh  Medical  and  Surgical  Journal; 
Vol.  xix.  p.  51  ;  Edinburgh,  1823. 

'*  Dublin  Journal  of  Medical  Science;  Vol. 
ix.  p.  263;  Dublin,  1836. 

"  Lectures  in  the  Lancet;  Vol.  x.  p.  518; 
London,  1826. 

'^  Observations  on  the  Local  Diseases  termed 
Malignant,  by  Benjamin  Travers;  Medico-Chi- 
rurgical  Transactions;  Vol.  xv.  p.  235;  Lon- 
don, 1829. 

'■  Op.  cit.  p.  617. 

"  Op.  cit.  pp.  202,  400  ;  PI.  iii.  fig.  7. 

"  Lancet,  Vol.  xi.  p.  87  ;  London,  1827. 

^°  Lancet,  March  4,  1854,  p.  242.  For  some 
additional  particulars  of  this  case,  I  am  in- 
debted to  Mr.  James  Dixon. 


CHAPTER  XVII 


MALIGNANT  AFFECTIONS  OF  THE  EYEBALL. 

The  eyeball  is  subject  to  at  least  three  malignant  affections ;  namely,  sctrrhus, 
encephaloid  tumor,  and  melanosis.  We  draw  our  descriptions  from  insulated 
cases  of  these  affections;  but  it  is  important  to  know,  that  they  may  be  con- 
joined. 

Leaving  out  of  view,  for  the  present,  the  last  enumerated,  I  am  led,  from 
what  I  have  seen  of  the  other  two  malignant  diseases  of  the  eye,  to  say,  that 
the  iirst  is  slow  in  its  progress ;  never  ends  in  a  tumor  of  a  large  size ;  and 
upon  extirpation,  so  far  from  presenting  anything  like  a  fungus,  or  like  medul- 
lary substance,  is  found  so  extremely  firm,  and  of  such  a  fibrous  or  striated 
texture,  as  to  merit  the  name  of  scirrhus.  This  degeneration  of  the  eye  I 
have  never  met  with,  except  in  persons  advanced  in  life,  and  more  frequently 
in  women  than  in  men. 

In  the  second  of  the  three  diseases  above  named,  the  tumor,  after  bursting 
through  the  fore-part  of  the  eye,  advances  with  great  rapidity,  and  often 
reaches  an  enormous  size ;  it  presents  a  spongoid  or  fungous  texture,  becomes 
attended  at  last  by  frightful  hsemorrhagy,  and  is  found,  on  dissection,  to  con- 
sist of  a  brownish-white  substance,  almost  entirely  destitute  of  fibres,  and 
which  may  be  compared  in  point  of  consistency  and  general  appearance,  to 


SCIRRHUS   OF   THE   EYEBALL.  681 

brain.     This  kind  of  tumor  I  have  met  with  both  in  children  and  in  adults, 
but  much  more  frequently  in  the  former. 

Extirpation  of  the  eye  is  sometimes  attended  with  complete  success  in  the 
first  set  of  cases ;  although  even  in  these  there  is  a  danger  of  scirrhus  after- 
wards attacking  the  eyelids,  the  cellular  substance  of  the  orbit,  or  the  muscles 
of  the  eyeball.  In  the  numerous  cases  of  the  second  kind  in  children,  which 
have  come  under  my  observation,  the  operation  of  extirpation  has  never  been 
attended  by  permanent  success ;  a  fatal  reproduction  of  fungous  excrescence 
from  the  optic  nerve,  has  invariably  followed  in  such  subjects,  and  generally 
within  the  period  of  a  few  months. 


SECTION  I. — SCIRRHUS   OP  THE   EYEBALL. 
Fig.  Dalrymple,  PL  XXXV. 

Scirrhus  of  the  eyeball  is  always  preceded  by  long-continued  inflammation 
in  the  eye  originating  in  many  cases  from  cold,  supervening  in  females  about 
the  time  of  life  when  menstruation  ceases,  attended  by  racking  pain  in  the  eye 
and  head,  and  soon  followed  by  dimness  of  sight,  and  at  length  by  total  blind- 
ness in  the  eye  affected.  To  these  symptoms  we  find  that  there  has  succeeded 
a  deformed  and  indurated  state  of  the  eye;  the  cornea  having  become  opaque, 
misshapen  and  shrunk;  the  sclerotica  of  a  dingy-yellow  color,  and  irregularly 
prominent;  the  external  bloodvessels  varicose;  and  the  conjunctiva  some- 
times thickened  or  even  tuberculated.  The  eye  is  affected  with  sensations  of 
.itchiness,  burning  heat,  and  lancinating  pain  overflows  with  tears  on  the  least 
exposure,  and  is  unable  to  bear  the  slightest  touch.  Severe  hemicrania,  ag- 
gravated during  the  night,  totally  prevents  sleep,  deprives  the  patient  of  all 
desire  for  food,  and  renders  him  unfit  for  any  continued  employment  of  body 
or  mind.  One  of  the  most  remarkable  characteristics  of  the  disease  is  the 
length  of  time  during  which  it  may  continue  without  affecting  the  neighboring 
parts,  or  advancing  to  ulceration.  At  last,  however,  the  eyelids  and  areolar 
tissue  of  the  orbit  are  involved  in  the  carcinomatous  inflammation ;  the  lids 
become  swollen,  red,  and  indurated;  the  eyeball  is  no  longer  capable  of  mo- 
tion; and  the  lymphatic  glands  of  the  face  and  neck  become  enlarged  and 
painful ;  the  conjunctiva  begins  to  ulcerate,  discharging  a  thin  acrid  matter  ; 
the  ulcer  spreads  and  grows  deep  ;  and  one  part  after  another  being  destroyed, 
as  in  cancer  of  the  eyelids,  the  patient  is  gradually  worn  out  by  fever,  pain,  and 
anxiety. 

If  the  eye  is  extirpated  before  the  disease  is  allowed  to  proceed  to  such  a 
length,  the  sclerotica,  especially  near  the  optic  nerve,  is  found  greatly  thick- 
ened, hard  almost  cartilaginous,  and  on  being  divided  with  the  knife,  presents 
the  whitish  bands,  which  are  deemed  diagnostic  of  scirrhus ;  the  muscles  of 
the  eye  are  similarly  affected ;  the  eyeball  itself  is  misshapen,  in  some  cases 
shrunk,  in  others  enlarged ;  its  natural  contents  are  absorbed,  or  if  any  of 
them  remain,  they  are  with  difficulty  recognized ;  while  a  whitish  or  yellowish 
substance,  of  less  firm  consistence  than  the  diseased  sclerotica,  but,  like  it, 
divided  by  membranous  septa,  occupies  the  place  of  the  vitreous  humor.* 

Prognosis  and  Treatment. — Neither  any  internal  medicine,  nor  external  ap- 
plication, appears  to  have  the  slightest  power  to  arrest  the  progress  of  the 
disease.  Its  nature  is  intractable ;  but  from  the  slowness  of  its  course,  years 
may  elapse  before  it  proves  fatal. 

In  the  early  stage,  that  is  to  say,  so  long  as  the  disease  appears  to  be  con- 
fined to  the  globe  of  the  eye,  and  this  remains  movable  in  the  orbit,  extirpa- 
tion ought  to  be  had  recourse  to  and  may  be  urged  as  a  means  likely  to  be 


682  FUNGUS   H^JVIATODES   OF   THE   EYEBALL. 

successful.  If  the  conjunctiva,  eyelids,  or  orbital  tissues  be  in  any  degree 
affected,  removal  of  the  parts  cannot  be  so  confidently  recommended,  on  ac- 
count of  the  liability  of  the  disease  to  return.  Still  the  operation  ought  to 
be  adopted,  unless  we  have  reason,  from  the  completely  fixed  state  of  the  eye- 
ball, strongly  to  suspect  that  its  muscles,  the  ocular  capsule,  the  whole  areolar 
tissue  of  the  orbit,  and  perhaps  even  the  periosteum,  are  involved  in  the  scir- 
rhous degeneration. 

Should  the  patient  refuse  to  submit  to  extirpation  of  the  eye,  or  should  it 
appear  to  the  surgeon,  either  from  the  state  of  the  general  health,  or  the  ad- 
vanced stage  of  the  local  affection,  that  it  would  be  improper  to  propose  an 
operation,,  palliatives  must  be  used  to  mitigate  the  pain,  and  lessen  the  con- 
stitutional disturbance.  Much  may  be  done  in  this  way  by  careful  attention 
to  the  state  of  the  bowels,  the  observance  of  a  mild  and  nourishing  diet,  and 
the  avoidance  of  whatever  fatigues  the  body  or  irritates  the  mind.  Narcotics 
are  to  be  had  recourse  to,  first  of  all  externally,  as  in  fomentation  and  the 
like  ;  and  should  such  applications  fail,  opium  maybe  administered  in  clyster, 
or  by  the  mouth.  In  advanced  cases  of  ulcerated  cancer  of  the  eye,  large 
doses  of  the  preparations  of  opium  are  necessary,  to  relieve  the  sufferings  of 
the  patient. 


1  On  the  microscopic  characters  of  scirrhus,  see  Paget's  Lectures  on  Surgical  Patho- 
logy ;  Vol.  ii.  p.  297,  London,  1853. 


SECTION  II. — FUNGUS  H^MATODES,  OR  ENCEPHALOID  TUMOR  OF  THE  EYEBALL. 
F!rj.  Ammon,  Thl.  I.  Taf.  XXL  XXII.    Dairy mple,  PI.  XXXIIL  XXXIV.  XXXVL  Fig.  1. 

The  disease  described  by  Professor  Burns,'  under  the  appellation  of  spongoid 
inflammation,  afterwards  by  Mr.  Hey,^  under  that  of  fungus  hcBmatodes,  and 
which  has  been  known  also  by  the  names  of  soft  cancer,  medullary  sarcoma,^ 
and  encephaloid  tumor,  not  unfrequently  attacks  the  eyeball.  A  case  of  this 
kind  was  dissected*  by  Paw,  in  1597.  The  tumor  of  the  eye  was  as  large  as 
two  fists,  and  was  attended  by  another  tumor  on  the  side  of  the  head.  The 
substance  of  the  tumors.  Paw  compares  to  brain.  A  case  of  this  disease,  in 
which  the  eye  was  extirpated  by  Mr.  Hunter,  was  published  in  1761.^  Mr. 
Ware,  in  1800,  viewing  the  disease  as  carcinomatous,  published"  a  case,  in 
which  both  eyes  of  a  child  were  affected.  Mr.  Hey  expressed  an  opinion,  that 
fungus  ha^matodes  not  unfrequently  affected  the  globe  of  the  eye,  causing  an 
enlargement  of  it,  with  destruction  of  its  internal  structure  ;  and  that  if  the 
eye  were  not  extirpated,  the  sclerotica  burst,  a  bloody  sanious  matter  was  dis- 
charged and  the  patient  sunk  under  the  complaint.^  Mr.  Wardrop  proved^ 
by  numerous  cases  and  dissections,  that  in  this  opinion  Mr.  Hey  was  perfectly 
correct. 

Symptoms. — Fungus  hoematodes,  or  encephaloid  tumor,  arising  within  the 
eyeball,  presents  three  stages.  In  the  first,  or  incipient  stage,  the  exterior 
form  of  the  eye  is  unchanged,  and  the  disease  is  perceived  through  the 
cornea  and  pupil.  In  the  second  stage,  the  form  of  the  eye  is  altered,  the 
organ  enlarged,  and  its  tunics  ready  to  give  way.  In  the  third,  or  fungous 
stage,  the  eye  has  burst,  and  the  tumor  protrudes. 

1st.  Stage. — The  iris  has  lost  its  natural  color,  the  pupil  is  somewhat  irreg- 
ular, slightly  dilated,  and  immovable  ;  and  behind  it,  deeply  seated  in  that 
part  of  the  eye  naturally  occupied  by  the  vitreous  humor,  a  whitish  or  reddish- 
yellow  appearance  is  observed,  particularly  when  the  eye  is  looked  at  from 
one  side  and  at  some  distance,  and  when  the  patient  turns  it  in  certain  direc- 


FUNGUS   HiEMATODES   OF   THE   EYEBALL.  683 

tions.  The  light,  especially  when  not  strong,  is  peculiarly  reflected  from  the 
bottom,  or  from  one  side  of  the  eye,  where  the  retina  is,  or  ought  to  be,  so 
that  there  is  some  resemblance  between  the  eye  in  this  state,  and  that  of  a 
cat  or  a  sheep,  in  which  the  light  is  reflected  from  the  shining  tapetum  of  the 
choroid.  The  appearance  in  question  is  sometimes  best  seen  in  candle  light, 
and  is  always  rendered  more  evident  by  artificially  dilating  the  pupil.  By  and 
by,  it  is  evident,  that  this  appearance,  now  become  bright,  like  the  reflection 
from  the  surface  of  a  brass  plate,  and  so  remarkable  as  to  attract  the  notice 
of  the  most  casual  observer,  arises  from  the  presence  of  a  new  substance  at 
the  bottom  of  the  eye.  Slowly  in  the  course  of 
months  or  of  years,  this  body  is  observed  to  be  ad-  Fig.  86. 

vancing  towards  the  pupil  (Fig.  86.),  which,  in 
general, *is  now  widely  and  irregularly  expanded. 
At  this  point  of  its  progress  it  has  sometimes 
been  mistaken  for  cataract,  and  attempts  have  been 
made  to  couch  it.^  The  surface  of  the  tumor, 
sometimes  of  a  pretty  deep  orange  hue,  in  other  ■;. 
cases  of  a  white  pearl  color,  is  seen  to  be  more  or  ^•^ 
less  irregular,  sometimes  divided  into  two  or  three 
distinct  masses,  and  partially  covered  with  the 
ramifications  of  the  central  artery  of  the  retina. 
As  it  advances,  the  tumor  presses  the  vitreous  hu- 
mor and  crystalline  lens  before  it ;  the  former  is 
absorbed,  the  latter  presses  in  its  turn  the   iris  (From  Ammon.) 

convexly  forward  ;  by  and  by,  the  lens  becomes 

opaque,  and  is  generally  absorbed.  Still  more  readily  is  the  disease,  at  this 
period,  apt  to  be  mistaken  for  cataract,  by  one  not  much  acquainted  with  eye 
diseases.  The  fixed  pupil  and  the  iris  bulging  towards  the  cornea,  -might 
warn  agiiinst  this  mistake.  The  tumor  now  touches  the  iris,  and  still  ad- 
vancing presses  it  into  contact  with  the  cornea.  The  iris  loses  more  of  its 
natural  color,  and  becomes  of  a  grayish  or  yellowish  brown.  It  separates 
here  and  there  from  the  choroid,  or  is  partially  absorbed,  allowing  the  tumor 
to  be  seen  through  the  new  openings. 

When  it  once  begins  to  shoot  forward  from  the  bottom  of  the  eye,  the  tu- 
mor generally  proceeds  with  rapidity.  I  have  known  it  lie  as  if  dormant,  for 
nearly  three  years  ;  but  in  a  few  weeks  after  commencing  to  advance,  it  not 
only  occupied  the  whole  cavity  of  the  eye,  but  dilated  it  to  twice  its  natural 
size,  the  first  stage  hurrying  thus  into  the  second. 

The  first  stage  is,  in  general,  unattended  by  pain  or  external  inflammation  ; 
but,  in  some  cases,  inflammation  of  the  eye,  with  epiphora,  intolerance  of  light, 
and  headache,  is  the  earliest  symptom  observable.  In  other  instances,  stra- 
bismus first  attracts  notice.  The  eye  is  blind  from  the  first.  I  have  known 
the  disease  treated  for  months  as  an  ophthalmia,  without  its  nature  being 
once  suspected. 

2d  Stage. — By  the  end  of  the  first  stage,  the  sclerotica  around  the  cornea, 
has  probably  assumed  a  leaden  color ;  and  the  eye,  fixed  in  the  orbit,  appears 
larger  than  natural,  and  feels  harder  to  the  touch.  These  symptoms  soon 
become  more  decided,  and  are  attended,  from  time  to  time,  by  smart  attacks 
of  pain,  epiphora,  and  external  inflammation.  The  cornea  rapidly  expands 
to  perhaps  double  its  natural  diameter,  and  the  iris  almost  disappears.  The 
form  of  the  eye  is  changed.  It  grows  knobbed  at  one,  or  sevei*al  places,  the 
sclerotica  becoming  attenuated,  and  the  tumor  pressing  outwards.  Covered 
by  the  conjunctiva  only,  the  tumor  feels  soft,  appears  white,  and  looks  like 
a  collection  of  pus,  so  that  by  the  inexperienced,  it  may  be  taken  for  an 
abscess,  and  opened  with  the  lancet.     Sometimes,  however,  a  suppuration 


684  FUNGUS   H^MATODES   OF   THE   EYEBALL. 

does  actually  form  in  the  interior  of  the  eye  ;  and  bursting  through  the  sclero- 
tica and  conjunctiva,  gives  relief  to  the  pain  which  attends  this  stage.  If  the 
disease  is  not  interfered  with,  and  no  suppuration  forms,  the  conjunctiva 
becomes  oedematous,  and  the  eyelids  swell.  In  some  cases,  the  cornea  can 
scarcely  be  brought  into  view,  on  account  of  the  tumor  pressing  against  the 
sclerotica,  either  at  the  temporal  or  nasal  edge  of  the  eye,  and  turning  the 
cornea  in  the  opposite  direction.  In  other  cases,  the  tumor  advances  into 
contact  with  the  cornea,  behind  and  in  the  substance  of  which  matter  is 
deposited.  Becoming  prominent,  opaque,  and  vascular,  the  cornea  ulcerates, 
and  is  ready  to  burst.  As  the  eye  enlarges,  and  undergoes  the  other  changes 
now  mentioned,  the  patient  is  subjected  to  severe  fits  of  pain,  chiefly  in  the 
forehead  and  in  the  neck.  They  are  worse  during  the  night  than  during  the 
day,  penetrate  deep  into  the  head,  and  cause  delirium  and  fever.      ^ 

Sd  Stage. — When  the  cornea  gives  way,  a  fetid,  bloody,  yellowish  fluid 
is  discharged,  and  the  patient  feels  somewhat  relieved.  The  lens  also  is  dis- 
charged, unless  indeed-  it  has  been  absorbed.  All  appearance  of  an  eye  is 
speedily  lost.  The  tumor,  protruding  through  the  ruptured  cornea  or  sclero- 
tica (in  the  latter  case  still  covered  for  a  while  by  the  inflamed  conjunctiva, 
which  it  pushes  before  it),  grows  with  great  rapidity,  so  that  it  is  no  longer 
capable  of  being  covered  by  the  eyelids,  or  contained  within  the  orbit.  The 
eyelids  are  everted,  and  stretched  round  the  base  of  the  tumor,  which  rests 
upon  the  cheek.  Supplied  by  a  great  many  bloodvessels,  the  coats  of  which 
are  thin  and  easily  ruptured,  it  assumes  the  appearance  of  a  dark  yellow  or 
dark-red  fungus,  irregular  on  its  surface,  soft  and  spongy  to  the  touch,  readily 
torn,  and  bleeding  yn'ofusely  on  the  sliglitest  irritation.  Clots  of  extravasated 
blood  form  in  the  interior  of  the  encephaloid  mass.  Extravasations,  indeed,  of 
this  kind  are  apt  to  supplant  almost  the  whole  of  the  diseased  structure,  so 
that  the  wame  fungus  Itcematodes  now  becomes  more  appropriate.  The  tumor 
ulcerates  by  times,  and  discharges  a  fetid  sanies,  which  irritates  and  excoriates 
the  surrounding  integuments.  Portions  of  the  tumor  die,  blacken,  and  slough 
off"  from  time  to  time  ;  but  the  general  bulk  of  the  fungus  is  not  at  all  reduced. 
On  the  contrary,  it  increases  so  as  to  distend  the  eyelids  to  an  enormous 
degree,  and  even  to  dilate  or  destroy  the  orbit,  making  its  way  into  the 
nostrils  and  antrum,  and  pressing  directly  on  the  brain,  while  the  portion 
which  projects  upon  the  face,  sometimes  much  exceeds  the  size  of  a  man's  fist. 

The  veins  of  the  eyelids  and  forehead  become  varicose,  and  bursting,  bleed 
profusely.  The  lymphatic  glands  of  the  cheek  and  neck  enlarge,  sometimes 
to  a  very  great  extent.  In  some  instances,  the  opposite  eye  is  protruded 
fi'om  its  socket,  by  the  pressure  of  the  original  tumor,  while  other  tumors  of 
the  same  character  form  under  the  scalp,  and  in  the  bones  of  the  skull. 

The  patient  cannot  sufi'er  the  lightest  covering  on  the  tumor.  He  becomes 
affected  with  great  constitutional  irritation,  restlessness,  thirst,  frequent  vom- 
iting, want  of  sleep,  and  disturbance  of  all  the  functions  of  the  body;  and  at 
length  expires,  comatose  or  convulsed,  exhausted  by  loss  of  blood,  and  worn 
out  by  hectic  fever. 

The  duration  of  the  disease  is  variable,  the  history  of  some  cases  extending 
to  a  few  weeks  only,  while  in  others  it  embraces  several  years.  The  whole 
progress  is  slower  in  adults  than  in  children.  The  second  and  third  stages 
are  much  more  rapid,  in  genei'al,  than  the  first.  The  first  is  often  overlooked, 
till  it  suddenly  passes  into  the  second. 

Pathological  Anatomg. — I  have  now  before  me  an  eye,  extirpated  by  the 
late  Dr.  Monteath,  during  the  first  stage  of  this  disease.  Immediately  after 
the  operation,  I  divided  the  cornea  and  sclerotica  by  a  crucial  incision,  and 
laid  back  the  four  flaps.  The  iris  and  choroid  were  entire.  I  divided  them  in 
like  manner,  laid  them  back,  and  along  with  the  choroid  I  found  that  I 


FUNGUS   IliEMATODES   OP   THE   EYEBALL.  685 

reflected  also  the  retina,  which,  thongli  broken,  and  here  and  there  deficient, 
is  still  sufficiently  entire^to  give  a  white  coating  to  the  internal  surface  of  the 
choroid,  and  has  evidently  nothing  to  do  in  this  instance  with  the  tumor, 
which  occupies  the  whole  space  of  the  vitreous  humor  and  crystalline  lens, 
and  springs  from  the  optic  nerve  by  a  pedicle.  The  tumor,  enveloped  in  a 
delicate  membrane  similar  to  the  hyaloid,  was  of  the  consistence  of  brain,  and 
of  a  yellowish-white  color.  The  optic  nerve  exterior  to  the  sclerotica,  did  not 
appear  diseased. 

The  subject  from  whom  this  eye  was  removed,  was  a  child  of  about  three 
years  of  age.  In  a  few  months  after  the  operation,  the  orbit  was  filled  with 
a  new  tumor,  and  the  child  soon  after  died.  I  carefully  examined  the  parts, 
and  have  them  now  before  me.  The  orbit  was  occupied  by  a  diseased  mass, 
sprouting  from  the  stump  of  the  optic  nerve,  and  similar  in  texture  to  that 
which  had  formerly  existed  within  the  eye.  I  opened  the  cranium,  and  found 
the  optic  nerves,  from  their  origin  in  the  brain  to  their  union,  apparently 
healthy ;  but  from  their  union  to  the  optic  foramen,  the  nerve  of  the  diseased 
side  was  as  thick  as  the  middle  finger.  By  passing  through  the  optic  fora- 
men, it  was  constricted  as  if  it  had  been  surrounded  by  a  ligature ;  but 
instantly  on  entering  the  orbit,  it  again  expanded  so  as  to  fill  the  space 
between  the  recti.  The  tumor,  covered  by  these  muscles,  filled  the  orbit  so 
completely,  that  it  still  retains  the  pyramidal  form  of  that  cavity. 

The  appearances  on  dissection,  in  cases  of  fungus  hoematodes  of  the  eye, 
are  far  from  being  uniform.  They  may  all,  however,  be  referred  to  the  effects 
of  a  cancerous  growth  of  the  species  denominated  encephaloid,  springing 
most  frequently  from  the  optic  nerve.  The  bloodvessels  which  are  seen  on 
the  surface  of  the  tumor,  in  the  first  stage,  are  the  branches  of  the  central 
artery  of  the  retina.  From  the  first,  the  disease  is  a  growth  from  the  optic 
nerve,  or  from  some  other  part,  and  not  a  deposit  of  fibrin,  as  Mr.  Dalrymple 
thinks,^"  becoming  organized. 

Although  the  retina  was  tolerably  entire  in  the  case  which  I  have  just 
related,  in  general  it  is  so  completely  changed  that  no  part  of  it  can  be 
detected.  In  the  case  before  me,  the  tumor  had  pressed  forward  from  the 
end  of  the  optic  nerve,  within  the  retina,  in  such  a  manner  as  to  produce  the 
complete  displacement  and  absorption  of  the  vitreous  humor  and  crystalline 
lens ;  but  in  some  cases,  the  tumor  has  been  known  to  push  itself  between 
the  sclerotica  and  choroid;  while,  in  other  instances,  the  fungus  has  arisen 
from  the  optic  nerve,  before  its  entrance  into  the  eye,  and  proved  destructive 
to  this  organ,  by  pressure  exercised  on  it  from  without."  It  may  even  happen 
that  there  shall  be  several  fungous  growths,  arising  in  succession,  but  latterly 
going  on  together,  one  perhaps  behind  the  sclerotica,  another  between  the 
sclerotica  and  choroid,  and  a  third  within  the  sphere  of  the  retina.^^ 

The  sclerotica  appears  to  suffer  less,  in  general,  from  this  disease  than  any 
other  part  of  the  eye. 

The  choroid  is  sometimes  pushed  to  one  side  by  the  tumor,  and  on  dissec- 
tion appears  like  an  irregularly  shaped  bag,  containing  vitreous  humor.  In 
some  cases,  shreds  merely  of  the  choroid  can  be  discovered,  dispersed  through 
the  morbid  growth.  In  other  cases,  portions  of  the  choroid  are  increased 
to  five  or  six  times  the  natural  thickness,  and  contain  medullary  fungous 
matter.     Occasionally,  no  ti-ace  of  this  membrane  appears. 

Mr.  Travers  tells  us  that  medullary  fungus  may  arise  in  any  of  the  textures 
of  the  eye,  with  the  exception  of  the  crystalline  lens  and  cornea.  He  had 
found  it  between  the  layers  of  the  sclerotica.  Although  this  is  a  much  more 
frequent  seat  of  melanosis  than  of  encephaloid,  I  have  seen  the  latter  sprout 
from  the  junction  of  the  cornea  and  sclerotica,  the  cornea  and  the  interior 
of  the  eye  being  sound. 


686  FUNGUS   H^MATODES   OF   THE   EYEBALL. 

The  humors  ai-e  absorbed  in  proportion  to  the  pressure  of  the  tumor ;  and 
in  cases  where  it  has  burst  through  the  sclerotica  or  cornea,  they  are  gene- 
rally altogether  destroyed. 

I  believe  that,  on  minute  examination,  it  will  rarely  be  found  that  the 
optic  nerve,  exterior  to  the  eye,  presents  a  healthy  structure.  It  will,  in 
general,  be  found  thicker  than  natural,  softer,  of  a  yellowish  color,  and  pre- 
senting, instead  of  bundles  of  nervous  filaments  interlaced  together,  as  it 
ought  to  do,  a  uniform  pulpy  substance.  In  some  cases,  the  nerve  is  found 
to  be  split  into  several  pieces,  the  growth  filling  up  the  intervening  spaces, 
surrounding  the  several  portions  of  the  nerve,  and  forming  one  connected 
mass  with  the  morbid  contents  of  the  eyeball. 

The  diseased  state  of  the  nerve  will  in  general  be  found  to  extend  to  that 
portion  of  it  which  is  contained  within  the  cranium ;  and  in  many  cases  the 
brain  itself  is  affected,  being  changed  into  a  soft  pulpy  mass,  and  presenting 
cavities,  either  in  the  substance  of  the  part  which  has  suffered  the  spongoid 
degeneration,  or  around  it,  filled  with  blood."  The  disease  in  the  brain 
seems  secondary  to  that  in  the  eye ;  but  the  affection  of  the  brain  may  kill, 
before  the  eye  is  at  all  enlarged. 

Greatly  shrunk  after  death,  and  its  dark  red  color  changed  to  a  pale  hue, 
the  tumor  varies  in  appearance  in  different  cases ;  but  has  always  more  or  less 
reseml)lance  to  the  medullary  substance  of  the  brain,  being  in  general  opaque, 
whitish,  homogeneous,  and  pulpy.  It  consists  of  cellular  membrane,  brain- 
like matter,  consisting  of  microscopic  cells  and  nuclei,  and  bloodvessels." 
Like  brain,  it  becomes  soft  when  exposed  to  the  air,  mixes  readily  with  cold 
water,  and  dissolves  in  it;  while  in  alcohol  or  acids,  it  becomes  firm,  or  even 
hard.  When  the  softer  parts  are  washed  away  in  water,  or  when  the  mass  is 
forcibly  compressed,  the  more  solid  parts  remain,  and  are  found  to  consist  of 
a  filamentous  substance,  resembling  cellular  membrane.  The  consistence  of 
the  tumor  varies,  to  a  certain  extent,  in  different  cases,  and  in  different  parts 
of  the  same  mass,  being  in  some  as  fluid  as  cream,  in  others  firmer  than  the 
most  solid  parts  of  a  fresh  brain.  In  some  rare  instances,  gritty  particles, 
probably  bony,  have  been  found  interspersed  through  the  morbid  growth. 
The  color  of  the  tumor,  although  commonly  that  of  the  medullary  substance 
of  the  brain,  or  a  very  little  darker,  is  sometimes  redder,  or  even  of  a  dark- 
brown  color,  while,  in  the  advanced  stage,  it  often  presents  portions  which 
nearly  reseml)le  clots  of  blood. 

When  the  absorbent  gland  lying  over  the  parotid,  or  any  of  the  absorbent 
glands  of  the  neck,  are  enlarged  in  this  disease,  they  are  found  to  be  con- 
verted into  a  substance  resembling  in  every  respect  that  which  composes  the 
tumor  of  the  eyeball  and  brain.  In  come  cases,  the  glands  ulcerate  before 
death,  forming  very  unhealthy,  sloughy  sores;  but  most  frequently  the  patient 
dies  before  the  skin  covering  the  glandular  swellings  is  destroyed.  Mr.  Ward- 
rop  mentions,  that  after  the  skin  covering  such  contaminated  glands  had 
given  way,  he  never  observed  any  fungus  to  arise  from  them. 

In  a  case  related  by  Mr.  Saunders,  this  disease  occurred  first  in  one  eye, 
and  six  months  after,  in  the  other  also.  I  saw  it,  nearly  equally  advanced, 
in  both  eyes  of  a  child.     A  similar  instance  is  noticed  by  Mr.  Stevenson.*^ 

On  examining  the  bodies  of  those  who  die  of  spongoid  tumor  of  the  eye, 
the  same  disease  is  sometimes  discovered  in  the  viscera  of  the  abdomen  or 
thorax ;  especially  in  the  liver,  kidneys,  uterus,  or  lungs.  The  brain  and  the 
testicle  are  parts  very  subject  to  be  attacked  by  it,  and  I  have  found  it  de- 
veloped even  in  the  walls  of  the  heart.  The  eye  is  certainly  the  part  of  the 
body  most  liable  to  this  disease. 

Subjects. — Encephaloid  tumor  is  much  more  frequent  in  children  than  in 
adults.     Out  of  24  cases  which  had  come  to  Mr.  Wardrop's  knowledge,  20 


FUNGUS   H.EMATODES   OF   THE   EYEBALL.  687 

of  them  occurred  in  subjects  under  12  years  of  age.  The  greatest  number 
of  cases  has  been  observed  in  children  from  two  to  four  years  old.  Some- 
times the  disease  has  been  met  with  within  a  few  mouths  after  birth.  In  one 
case,  I  saw  it  in  an  infant  nine  weeks  old.  The  mother  had  observed  it  six 
weeks  before ;  so  that  it  probably  was  congenital.  Instances  have  happened, 
on  the  other  hand,  in  which  it  has  attacked  adults,  or  even  persons  far  ad- 
vanced in  life. 

The  children  who  fall  victims  to  this  disease  are  generally  of  a  well  marked 
scrofulous  constitution,  or  belong  to  scrofulous  families.  Mr.  Dalrymple 
remarks,'^  that  in  the  first  stage  of  the  disease  they  generally  appear  very 
healthy.  He  thinks,  that  the  health  falling  off,  the  disease  consequently 
makes  progress ;  but  the  opposite  hypothesis  seems  more  likely  to  be  true — 
that  as  the  local  affection  slowly  and  insidiously  grows  in  the  eye  and  within 
the  cranium,  the  general  health  fails. 

Exciting  Causes. — In  many  of  the  cases  on  record,  a  blow  on  the  eye  is 
mentioned  as  having  preceded,  and  apparently  excited,  this  disease.  It  may 
be  doubted,  however,  whether  the  blindness  of  the  affected  eye  does  not 
render  the  children  more  liable  to  meet  with  blows  on  that  side,  after  which 
the  eye,  being  examined,  may  be  found  to  present  symptoms  which  had  pre- 
viously existed,  but  without  attracting  attention. 

Diagnosis. — I  have  already  (page  675)  had  occasion  to  speak  of  the  diffi- 
culties attending  the  diagnosis,  in  the  early  stage  of  medullary  tumor.  In 
the  fungous  stage,  it  is  apt  to  be  confounded  with  exophthalmia  arising  from 
the  pressure  of  enlarged  lachrymal  gland,  or  of  encysted  or  other  tumors  in 
the  orbit,  from  severe  inflammation  of  the  orbital  cellular  membrane,  or  even 
from  ophthalmitis.^''  A  deep  transverse  section  from  the  outer  to  the  inner 
canthus  of  the  enlarged  eye,  so  as  completely  to  evacuate  its  contents,  is  an 
efficient  remedy  in  simple  exophthalmia,  that  is,  protrusion  and  disorganiza- 
tion of  the  eyeball  originating  from  an  inflamed  state  of  its  natural  textures. 
Even  a  mere  puncture  of  the  eye  is  often  sufficient  to  produce  collapse 
under  such  circumstances.  In  the  medullary  tumor  these  proceedings  are  of 
no  avail ;  but,  as  Mr.  Travers  advises,  if  any  doubt  of  the  nature  of  the  case 
exist,  a  section  of  the  eye  should  be  practised.  In  the  malignant  disease 
the  globe  remains  firm,  the  section  being  followed  only  by  a  small  discharge 
of  blood ;  but  if  a  considerable  discharge  of  discolored  fluid  or  matter  takes 
place,  and  the  globe  collapses,  the  disease  is  not  malignant,  and  the  cure  is 
complete. 

Treatment. — Encephaloid  tumor,  like  scirrhus,  has  hitherto  resisted  the 
power  of  all  external  and  internal  medicines. ^^  It  is  proper  to  try  the  effect 
of  an  improved  diet,  change  of  air,  and  other  influences  likely  to  maintain 
the  general  health.  That  they  retard  the  advance  of  the  disease,  is  well 
shown  by  the  cases  recorded  by  Mr.  Tyrrel.^'' 

Extirpation  of  the  eye  has  frequently  been  performed  on  account  of  this 
disease ;  but  there  seems  to  be  no  sufficient  evidence  that  it  has  ever  effected 
a  radical  cure.'^"  In  most  cases,  the  disease  has  certainly  been  known  to 
return  after  extirpation  of  the  eye  ;  the  optic  nerve  having  probably  been 
diseased  previously  to  the  operation,  or,  at  all  events,  giving  rise  afterwards 
to  a  new  growth,  sufficient  to  fill  the  orbit  in  the  course  of  a  few  months,  or 
even  weeks ;  so  that  although  the  removal  of  the  eye  may  have  saved  the 
patient  from  the  suffering  whicli  always  attends  the  rupture  and  destruction 
of  that  organ,  yet  it  probably  hastens  rather  than  retards  the  fatal  termina- 
tion of  the  disease.  In  children,  the  extirpation  of  the  eye  has  always  failed 
when  the  disease  was  so  far  advanced  that  the  vitreous  chamber  was  filled  by 
the  fungous  mass ;  whether  it  might  be  more  successful  were  it  performed 
when  the  disease  first  appears  at  the  bottom  of  the  eye,  it  is  impossible  to 


688 


FUNGUS   H^MATODES   OF   THE   EYEBALL. 


say.  At  that  early  period  the  relatives  of  the  patient  could  scarcely  be 
expected  to  bring  themselves  to  consent  to  extirpation  of  the  eye ;  nor,  after 
the  statements  of  Mr.  Lawrence  and  Mr.  Travers,  regarding  the  uncertainty 
of  the  diagnosis,  could  the  surgeon  fairly  insist  on  this  measure,  as  being 
absolutely  indicated. 

After  the  eye  has  burst,  and  a  large,  heavy,  pendulous  mass  protrudes,  this 
may  be  cut  off  as  a  palliative  measure. 

During  the  inflammatory  attacks  which  attend  the  progress  of  encephaloid 
tumor  within  the  eye,  or  in  the  orbit  after  the  eye  has  been  extirpated,  advant- 
age will  be  derived  from  the  application  of  leeches  to  the  temple,  a  mild  diet, 
laxatives,  and  evaporating  lotions.  If  bleeding  occurs,  as  the  parts  will  not 
bear  pressure,  we  must  trust  to  the  application  of  cold  water,  alum  solution, 
and  the  like.  In  the  advanced  stages  of  the  disease,  opiates  will  be  required 
internally ;  and  their  external  application  also  gives  relief. 


1  Dissertations  on  Inflammation ;  Vol.  ii.  p. 
302  :  Glasgow,  1800. 

^  Practical  Observations  in  Surgery  ;  p.  23.3  ; 
London,  1803. 

'  Abernethy's  Surgical  Observations,  contain- 
ing a  Classification  of  Tumors,  itc;  p.  51;  Lon- 
don, 1804. 

'  "  Puerulo  trienni  aperui  caput.  Ilic  ali- 
quot mensibus  ingenti  laborabat  tuuioro  ex 
oculo  sinistro,  adeo  quidem  ut  integer  bulbus 
ocularis  cum  musculis  omnibus  foras  protuber- 
aret,  in  tantamque  accrevisset  molem  ut  duos 
pugnos  protuberantia  aHjuarct.  Huic  duabus 
ante  mortem  septimanis  alius  tumor  ortus 
fuerat  prope  musculum  temporalem  sinistrum, 
quem,  ablata  cute,  vidimus  peculiar!  (eaque 
crassa  satis)  membrana  obductum  intra  cutem, 
craniumiiuo  hicrere.  Cranium  exiguum  babe- 
bat  foramiuulum,  per  quod  materiam  ejecerat 
natura.  Ablato  cranio,  vidimus  ocularis  tn- 
moris  materiam  intra  cranium  et  duram  matrem 
collcctam  universam  integro  plane  et  illaiso 
cerebro.  Aperto  utroquo  tumore,  vidimus  eos 
substantia  cerebro  planfe  simili  repletos,  pcr- 
mixto  sanguine  concreto,  baud  aliter  ac  si  molse 
substantiara  vidisses."  Petri  Pawii  Observa- 
tiones  Anatomica; ;  p.  38;   Ilafnire,  1656. 

iSicolaus  Larcbeus,  in  a  letter  to  Marcus 
Aurelius  Severinus,  has  described  and  figured 
a  fatal  case  of  what  appears  to  have  been  fun- 
gus hwmatodes,  in  a  child  of  live  years  of  age. 
He  describes  the  tumor  as  originating  under 
the  eye.  See  Severinus  de  recoudita  Absces- 
suum  Xatura,  p.  150,  Fraucofurti  ad  Moenum, 
1643. 

'  Case  of  Diseased  Eye,  by  Mr.  Hayes ;  read 
August  26tb,  1765:  Medical  Observations  and 
Inquiries;  Vol.  iii.  p.  120;  London,  1767; 
>  Descriptive  Catalogue  of  the  Pathological  Spe- 
cimens in  the  Museum  of  the  Royal  College  of 
Surgeons  of  England;  Vol.  iv.  p.  167;  London, 
1849. 

^  Chirurgical  Observations  relative  to  the 
Epiphora,  &c.;  p.  49;  London,  1800. 

'■  Op.  cit.  p.  283. 

'  Observations  on  Fungus  Hcematodes;  p.  6; 
Edinburgh,  1809. 


'  Carron  du  Villards  has  the  candor  to  con- 
fess his  having  fallen  into  this  error;  Journal 
Complementaire  des  Sciences  Medicales;  Tomo 
xliv.  page  6  ;   Paris,  1832. 

'"  Medico-Chirurgical  Transactions  ;  Vol. 
xxiii.  p.  209  ;  London,  1840. 

' '  See  Case  of  Extirpation  of  the  Eyeball, 
by  J.  H.  Wishart;  Edinburgh  Medical  and 
Surgical  Journal ;  Vol.  xl.  p  274  ;  Edinburgh, 
1833:  Panizza  (Sul  Fongo  Midollare  del  Oechio, 
p.  16.  pi.  iii.  Fig.  1  ;  Pavia,  1821)  found,  on 
dissection,  in  a  girl  of  six  years  of  age,  a  small 
tumor  surrounding  the  left  optic  nerve,  within 
the  orbit,  the  nerve  itself  being  sound,  the  right 
nerve  fungous,  and  a  largo  cerebriform  mass  in 
the  basis  of  the  brain. 

'^  See  case  by  Bowman,  with  dissection  of 
eye;  Medical  Times  and  Gazette,  January  29, 
1853,  p.  116:  Descriptive  Catalogue  of  the 
Pathological  Specimens  in  the  Museum,  &c., 
loc.  cit. 

"  See  Case  of  Fungus  Haematodes  of  the 
Eye  and  Brain,  with  Dissection  of  the  Brain, 
by  Lightfoot ;  Medical  Times  and  Gazette,  Sep- 
tember 4,  1852,  p.  247. 

'*  On  the  microscopic  characters  of  encepha- 
loid tumor,  see  Paget's  Lectures  on  Surgical 
I^athology;  Vol.  ii.  p.  367;  London,  1853. 

'^  On  the  Nature,  Ac,  of  Amaurosis;  ji.  37; 
London,  1821. 

"  Op.  cit. 

"  See  Case  by  Dr.  R.  Hibbert  Taylor:  Lon- 
don Medical  Gazette,  July  4,  1845,  p.  425. 

"  Professor  Rosas  writes  me,  that  be  has 
found  mercury  useful  in  arresting  the  progress 
of  medullarj'  tumor  of  the  ej'e. 

"  Practical  Work  on  the  Diseases  of  the  Eye; 
Vol.  ii.  p.  165;  London,  1840. 

-°  On  the  propriety  of  extirpation,  see  Syme, 
Edinburgh  Medical  and  surgical  Journal;  Vol. 
xliv.  p.  6;  Edinburgh,  1835.  He  is  against 
operating.  "  In  no  case  of  genuine  medullary 
fungus  of  the  eye,"  saj's  Dalrymple,  "  would 
I  either  perform,  or  sanction  by  my  advice, 
the  extirpntion  of  the  eyeball."  Pathology 
of  the  Human  Eye,  explanation  of  Plate  xxxiii. 
London,  1852. 


MELANOSIS   OF   THE   EYEBALL.  689 


SECTION  in. — MELANOSIS   OF   THE   EYEBALL. 

Fi'om  fx.i\ai,  black. 

Fl'j.  Travers,  PI.  IV.  Figs.  3,  6.   Ammon,  Thl.  I.  Taf.  XXIII.   Dalrymple,  PI.  XXXIY.  Figs.  4,  5. 

To  this  morbid  growth  Laennec  gave  the  name  of  melanosis,  on  account  of 
its  black  color.^  Equivocal  traces  of  an  acquaintance  with  it  are  to  be  found 
in  the  works  of  Bonetus,  Haller,  Morgagni,  and  others;  but  the  Continental 
pathologists  of  our  own  times  have  been  the  first  to  treat  of  melanosis  as  a 
distinct  and  peculiar  affection.  In  the  beginning  of  the  present  century,  Bayle 
and  Laennec  first  published  upon  the  subject ;  but  it  would  appear  from  a  con- 
troversy which  arose  on  that  occasion,  that  M.  Dupuytren  had  been  acquainted 
with  the  disease  several  years  before,  and  had  annually  mentioned  it  in  his 
lectures."  Since  this  period,  melanosis  has  attracted  the  attention  of  numerous 
pathologists,  both  on  the  Continent  and  in  this  country;  of  whom  we  may 
mention  particularly  M.  Breschet,  who  has  inserted  a  paper  on  the  subject  in 
the  first  volume  of  Magendie's  Journal ;  and  Mr.  Fawdington,  who  has  given 
to  the  public  an  interesting  case,  with  observations  on  the  pathology  of  the 
disease,  and  eight  lithographic  plates,  illustrative  of  its  appearances  in  various 
organs  of  the  body. 

The  most  striking  physical  character  of  melanosis,  in  whatever  region  of 
the  body  or  under  whatever  form  it  occurs,  is  its  dark  color,  varying  from  the 
hue  of  Indian  ink  to  a  light  bistre,  and  depending  on  the  presence  of  pigment 
granules  or  nuclei,  similar  to  those  of  the  pigmentum  nigrum.  In  consistence, 
the  product  of  melanosis  often  bears  a  considerable  resemblance  to  that  which 
the  contents  of  a  decaying  lycoperdon,  or  common  puif-ball,  would  present  if 
rendered  cohesive  by  the  addition  of  a  small  quantity  of  liquid.  Melanosis 
displaces  or  destroys  the  different  textures  of  the  body  in  a  variety  of  ways. 
It  is  most  frequently  met  with  in  tubercles,  or  even  in  considerable  masses  ; 
is  sometimes  encysted  and  connected  to  the  neighboring  parts  by  pedicles ; 
sometimes  diffused  through  the  parenchyma  of  the  viscera ;  in  other  cases, 
deposited  upon  their  surface,  or  under  their  investing  membrane.  It  appears 
that  no  tissue  is  free  from  the  invasion  of  this  disease,  although  it  attacks  some 
parts  more  readily  than  others.  Like  fungus  h^ematodes,  it  attacks  several 
organs  of  the  body  together,  or  in  succession ;  the  eye,  for  example,  and  the 
liver.  In  its  progress  it  involves  indiscriminately  the  adjacent  textures,  sup- 
planting and  destroying  all  that  oppose  a  barrier  to  its  ravages.  Even  the 
bones  are  not  exempt  from  its  influence. 

M.  Breschet  was  at  some  pains  to  Ascertain  whether  the  substance  of 
melanosis  was  truly  organized.  With  this  view,  he  threw  into  the  arteries 
and  veins  of  the  contiguous  parts  some  of  the  finest  and  most  diffusible  injec- 
tions, without  discovering  any  continaity  of  vessels  between  the  cyst  and  the 
substance  it  contained.  The  cells,  of  course,  wdiich  compose  this  substance, 
must  have  their  periods  of  growth,  maturity,  and  decline. 

Dr.  Rainy,  on  examining  some  melanotic  substance  taken  from  an  eye 
which  he  had  extirpated,  along  with  the  eyelids,  observed  that  a  granular 
matter  escaped  when  the  melanotic  substance  was  torn  under  the  microscope, 
while  the  solid  part  presented  the  appearance  of  contorted  hollow  fibres,  not 
unlike  some  kinds  of  moss,  or  the  villi  of  the  chorion.  These  fibres  were 
quite  difi"erent  in  their  aspect  from  bloodvessels,  and  seemed  filled  Avith 
granules,  not  globules.  Next  day,  Dr.  Rainy  examined  a  portion  of  another 
eye,  which  had  been  extirpated  18  months  before,  and  found  the  same  sort 
of  fibres.^ 

The  composition  of  the  tumors  in  melanosis  has  been  ascertained,  by 
chemical  analysis,  to  approach  very  nearly  to  that  of  the  fcoagulum  of  the 
44 


690  MELANOSIS   OF   THE   EYEBALL. 

blood.  Thenard  and  Barruel  recognized  a  large  quantity  of  carbon  in 
melanosis,  and  to  this  some  have  attributed  the  black  color ;  but  erroneously-, 
for  the  blackness  of  melanosis  is  discharged  by  the  action  of  chlorine. 

Melanosis  is  undoubtedly  of  a  fungous  nature,  and  being  not  unfrequently 
found  in  conjunction  with  other  kinds  of  fungous  disease,  especially  the 
medullary,  it  has  been  regarded  by  Mr.  Wardrop*  and  others,  merely  as  a 
variety  of  fungus  hasraatodes.  This  view  is,  no  doubt,  countenanced  by  the 
fact  that  tumors  have  been  met  with,  possessing  almost  every  possible  degree 
of  intermediate  feature,  so  as  to  render  it  difficult  to  determine  whether  the 
character  of  melanosis  or  that  of  medullary  fungus  prevailed.  If,  however, 
we  take  the  extreme  states  of  each  disease,  we  discover,  as  Mr.  Favvdington 
observes,  differences  of  a  very  marked  and  striking  character.  In  the  ana- 
tomical structure  of  melanosis,  the  paucity  of  vessels  constitutes  a  distin- 
guishing peculiarity;  while  medullary  tumor,  which  invades  the  system  as 
extensively,  appears  under  similar  forms,  attacks  the  same  textures,  and 
eventually  produces  a  like  influence  on  the  general  economy,  is  remarkable 
for  a  luxuriant  vascularity.  Laennec  remarked  that  fungus  hsmatodes  is 
in  general  supplied  by  a  great  many  bloodvessels,  the  trunks  of  which  ramify 
on  the  exterior  of  the  tumors,  or  between  their  lobes  only,  Avhile  the  minuter 
branches  penetrate  into  the  substance  of  the  morbid  growth  ;  and  that 
the  coats  of  these  vessels  being  very  fine,  they  are  readily  ruptured,  thus 
giving  rise  to  clots  of  extravasated  blood  in  the  interior  of  the  tumors,  some- 
times of  considerable  size.  Nothing  of  this  kind  is  observable  in  melanosis  ; 
no  extraordinary  development  of  arterial  branches  leading  to  the  tumors, 
none  visibly  ramifying  on  the  cysts  which  surround  them,  none  in  the  morbid 
substance. 

Mr.  Fawdington  has  carefully  compared  the  local  phenomena  presented 
during  life  by  these  two  diseases.  In  fungus  hai'matodes,  if  the  tumor  l)e  at 
all  advanced,  there  is  pain,  constant  or  occasional,  sharp  and  lancinating,  and 
often  accompanied  by  signs  of  low  vascular  excitement.  As  the  disease  pro- 
ceeds, the  suffering  is  increased ;  an  ulcerated  breach  having  been  produced 
in  the  integuments,  the  fungus  grows  and  sloughs  by  turns  ;  it  discharges  an 
offensive  sanies,  and  considerable  bleeding  takes  place,  which  for  a  time  re- 
lieves both  the  vascular  and  nervous  irritation  attendant  on  the  progress  of 
the  disease.  Lastly,  the  absorbent  glands  in  the  vicinity  participate  in  the 
mischief,  and  the  general  powers  become  exhausted,  from  the  combined  in- 
fluence of  pain,  irritation,  and  discharge.  In  melanosis,  unless  the  growth  of 
the  tumor  be  circumscribed  by  textures  which  yield  with  difficulty,  such  as 
the  tunics  of  the  eyeball,  or  the  cavity  of  the  orbit,  there  is  neither  pain,  as  a 
necessary  concomitant,  nor  an  excited  state  of  the  vessels  in  the  circumjacent 
structures.  As  to  the  phenomena  of  melanosis  in  the  ulcerated  stage,  there 
seems  to  be  a  blank  still  left  to  future  observers  to  fill  up  ;  but  reasoning  from 
its  low  state  of  organization,  it  may  be  concluded  that  many  of  the  patholo- 
gical changes  which  attend  the  career  of  f  angus  hoematodes  will  not  be  found 
to  exist  in  melanosis.  The  process  upon  which  the  softening  of  this  tumor 
depends,  is  as  inexplicable  as  the  laws  of  its  production  and  increase  ;  but 
that  it  arises  from  a  power  inherent  in  the  morbid  structure,  and  distinct  from 
the  common  conditions  of  suppurative  inflammation  in  other  structures,  is  to 
be  inferred  from  the  absence  of  those  agents  which  support  the  latter,  in  the 
situation  where  the  softening  is  first  observed. 

Symptoms  of  melanosis  of  the  eyeball. — When  the  disease  is  seated  within 
the  eyeball,  the  patient,  in  the  early  stage,  complains  of  imperfect  or  destroyed 
vision,  with  a  sense  of  fulness  and  pain  in  and  around  the  eye,  followed  by  a 
peculiar  opaque  appearance  of  the  pupil  and  attenuation  of  the  sclerotica,  so 
that  a  mass  of  brown  or  black  substance  appears  shining  through  it.    The  swell- 


[ 


MELANOSIS   OP   THE   EYEBALL.  691 

mg  and  pain  come  and  go  for  a  time.  Sometimes  the  pain,  in  the  early  stage,  is, 
along  with  loss  of  sight,  the  most  prominent  symptom.  In  a  case  of  this 
sort,  the  pain  was  so  insufferable,  that  M.  Gensoul  extirpated  the  eye  on  this 
account  alone ;  and  found  within  it  a  melanotic  tumor,  Avhich  had  not  ex- 
tended beyond  the  retina.^  The  eyeball  is  rarely  much  enlarged.  The  cornea 
or  sclerotica  gives  way,  and  black  fungus  protrudes,  which  increases  slowly, 
and  in  general  does  not  bleed  much.  In  one  case  only  have  I  seen  much  he- 
morrhage from  an  eye  affected  with  melanosis.  The  patient,  a  middle  aged 
female,  came  to  the  Glasgow  Eye  Infirmary  with  a  dark  fungus  protruding 
thi'ongh  the  ruptured  cornea :  it  had  bled  so  profusely  that  she  was  completely 
blanched.  I  immediately  extirpated  the  eye,  and  found  the  melanotic  tumor 
to  spring  from  the  end  of  the  optic  nerve,  exactly  as  eucephaloid  tumor  does 
in  the  majority  of  cases. 

Melanosis  attacks  eyes  which  are  already  disorganized  by  other  diseases  ; 
eyes  which  are  shrunk,  or  staphylomatous ;  which  is  not  the  case  with  fungus 
htiematodes.  Sometimes  melanosis  looks  like  a  staphyloma,  and  has  been  ope- 
rated on  as  such.  On  making  his  incision,  the  surgeon  finds  the  eye  solid, 
being  filled  with  melanotic  deposit. 

If  the  tumor  wiiich  protrudes  from  the  eye  be  cut  off,  the  part  heals,  and 
by  and  by  the  melanosis  protrudes  afresh.  This  I  have  witnessed  in  several 
instances. 

In  one  of  the  cases  in  which  Dr.  Rainy  extirpated  the  eyeball,  at  the  Glas- 
gow Eye  Infirmary,  the  optic  nerve  was  affected  with  the  melanotic  degeneration, 
but  not  all  the  way  back  to  the  optic  foramen. 

Between  the  choroid  and  the  retina  is  the  most  frequent  seat  of  melanosis  ; 
but,  like  fungus  hcematodes,  it  occasionally  occurs  exterior  to  the  eyeball,  in 
the  eyelids,  under  the  conjunctiva,  on  the  surface  of  the  cornea  (p.  2 VI),  at 
the  junction  of  the  cornea  and  sclerotica,  and  in  the  cellular  membrane  of  the 
orbit  (p.  343).  In  the  last-mentioned  situation,  the  tumor  pushes  the  eye  be- 
fore it,  and  at  last  the  eye  is  destroyed  by  inflammation. 

Cases. — In  Mr.  Wardrop's  work  on  Fungus  Hsematodes,  and  again  in  Mr. 
Allan  Burns'  Observations  on  the  Surgical  Anatomy  of  the  Head  and  Neck, 
the  following  well-marked  case  of  melanosis  of  the  eye  is  related,  merely  as  a 
variety  of  medullary  tumor: — 

Case  345. — Mrs.  Scott,  about  41  years  of  age,  had  always  been  of  a  delicate  habit  of 
body,  and  sallow  complexion.  The  disease  of  the  eye  occupied  a  period  of  two  years  and 
a  half.  It  first  manifested  itself,  by  the  patient  being  unable  to  see  distinctly  with  her  left 
eye  ;  and  on  looking  at  the  organ,  a  milkiness  was  seen  behind  the  pupil.  This  opacity, 
which  Mr.  Burns  speaks  of  as  seated  in  the  lens,  gradually  increased  during  four  months, 
when  the  patient  became  completely  blind  of  that  eye.  About  four  months  after  losing 
the  sight  of  the  eye,  it  became  much  inflamed,  without  any  obvious  cause.  By  bleeding 
with  leeches,  &c.,  the  inflammation  abated,  but  the  redness  and  pain  never  entirely  left 
the  eye.  From  what  Mr.  B.  had  been  able  to  learn,  the  opacity  of  the  lens  could  not  be 
so  decidedly  ascertained  after  this  attack,  owing  to  the  turbid  state  of  the  contents  of  the 
anterior  chamber. 

The  further  progress  of  the  case  was  not  traced  till  within  six  months  of  the  time  when 
Mr.  B.  thought  it  necessary  to  remove  the  contents  of  the  orbit  by  operation.  At  the  be- 
ginning of  that  period,  a  tumor  began  to  protrude  from  the  lower  side  of  the  sclerotic 
coat,  just  behind  the  edge  of  the  cornea.  Two  months  after  this,  Mr.  B.  found  the  cornea 
rather  more  prominent  than  usual,  but  he  could  distinguish  with  accuracy  neither  the  iris 
nor  the  crystalline.  The  appearance  impressed  him  with  the  idea,  that  a  fungus  was 
lodged  behind  the  cornea,  ready  to  protrude  as  soon  as  the  latter  should  give  way.  The 
tumor  at  the  lower  part  of  tlie  sclerotica  was  now  about  the  size  of  a  musket-ball,  and 
seemed  to  contain  a  dark-colored  fluid,  the  cyst  being  formed  by  that  part  of  the  conjunc- 
tiva which  covers  the  sclerotica,  while  over  the  surface  of  the  sac  a  number  of  red  vessels 
ran  in  every  direction.     The  pain  was  intense  and  lancinating. 

After  four  months  more,  matters  were  in  ii  much  worse  state,  and  the  patient's  health 
completely  broken ;  she  had  confirmed  hectic  fever,  was  much  reduced,  and  had  not  been 
out  of  bed  for  two  months.     The  cyst,  which  formerly  had  not  been  larger  than  a  musket- 


692  MELANOSIS   OF   THE   EYEBALL. 

ball,  had  now  attained  the  size  of  a  pigeon's  egg,  and  formed  a  solid  fungous  mass,  -which 
could  with  difficulty  be  raised,  so  as  to  uncover  the  lower  eyelid.  The  cornea  was  flat, 
and  was  hid  beneath  the  upper  eyelid.  From  the  body  of  the  large  fungus,  two  small 
fungi  protruded,  and  towards  the  temporal  extremity  of  the  lower  eyelid,  there  was  a  hard 
tumor,  situated  under  the  integuments  and  adhering  firmly  to  the  cheek-bone. 

The  patient  was  anxious  to  have  the  parts  removed  by  operation,  which  was  accordingly 
done  by  Mr.  Burns,  assisted  by  j\lr.  Wardrop.  As  the  tumor  exterior  to  the  eyelids  was 
of  considerable  size,  Mr.  B.  separated  them  by  an  incision  at  their  temporal  angle.  He 
then  grasped  the  tumor,  and  dissected  back  the  eyelids  from  it.  As  he  wished  to  take 
out  all  the  diseased  parts  in  connection,  he  endeavored  to  detach  them  from  the  lower  mar- 
gin of  the  orbit;  but  to  his  surprise  and  regret,  he  found  that  the  bone  on  which  they 
rested  was  softened  and  black  in  color.  He,  therefore,  gave  up  the  attempt,  and  proceeded 
with  the  scalpel  to  detach  the  eyeball  from  its  connections.  By  the  pressure  employed  in 
pulling  forward  the  parts,  they  burst,  and  a  quantity  of  inky  fluid  was  poured  from  the 
opening.  Mr.  B.  traced  the  optic  nerve  to  its  exit  from  the  skull,  and  there  divided  it. 
Its  medullary  substance  was  as  black  as  ink.  He  next  chiselled  away  as  much  as  he 
could  of  the  diseased  edge  of  the  orbit.  The  bleeding  from  the  divided  vessels  was  easily 
restrained. 

As  soon  as  possible  after  the  operation,  a  section  was  made  of  the  parts  which  had  been 
removed.  AVhen  dividing  the  eyeball  and  optic  nerve,  a  great  quantity  of  a  thick,  viscid, 
dark-brown  matter,  colored  the  knife.  The  eyeball  and  tumor  seemed  entirely  composed  of 
a  similar  dark-colored  matter,  of  the  consistence  of  thick  oil-paint,  though  not  so  clammy 
and  oleaginous.  It  soiled  the  fingers  of  a  dark  brown  or  amber  color.  It  readily  dissolved 
in  water,  and  both  Mr.  Burns  and  Mr.  Wardrop  were  struck  with  its  resemblance  to  the 
pigmentum  nigrum.  The  cornea  appeared  sound.  The  crystalline  lens  was  of  an  amber 
color.  The  sclerotica,  at  that  part  which  corresponded  to  the  malar  portion  of  the  orbit, 
was  ruptured  by  the  tumor,  and  the  torn  edges  were  separated  about  a  quarter  of  an  inch 
from  one  another.  The  sclerotica  Avas  at  the  same  place  split  into  two  layers,  a  small 
quantity  of  the  dark-colored  substance  being  interposed  between  them.  No  distinct  re- 
mains could  be  traced  of  the  iris  ;  but  the  choroid  appeared  much  more  vascular  than  natu- 
ral, and  at  one  part  was  five  or  six  times  its  usual  thickness.  At  the  place  where  the 
sclerotica  was  ruptured,  the  choroid  insensibly  terminated  in  a  white  pulpy  substance,  com- 
posing part  of  the  diseased  mass.  The  contents  of  the  eyeball  were  composed  chiefly  of 
a  medullary  substance,  tinged  in  different  places  by  the  dark-brown  coloring  matter.  The 
tumor  projecting  beyond  the  sclerotic  coat,  appeared  to  be  composed  of  a  similar  structure 
and  upon  maceration,  numerous  white  stritc,  and  in  some  places  spots,  appeared  through- 
out the  substance  of  the  diseased  mass.  Exterior  to  the  eyeball,  the  tumor  was  covered 
with  a  thick  mucous  membrane,  except  at  the  two  small  prominent  parts  where  it  had 
ulcerated,  this  covering  being  probably  derived  from  the  conjunctiva,  which  the  tumor  in 
its  progress  had  pushed  before  it. 

The  optic  nerve  was  of  its  natural  size ;  but  on  examining  its  section,  it  was  found  that 
the  medullary  part  of  it  had  a  black  appearance,  exactly  resembling  the  tumor  in  the  eye- 
ball, while  its  neurilemma  was  apparently  healthy.  No  remains  of  the  retina  could  be 
detected.  One  of  the  lymphatic  glands  lying  by  the  side  of  the  optic  nerve,  was  changed 
into  a  dark-colored  substance. 

Although  much  reduced  by  hectic,  and  emaciated  to  a  great  degree,  the  patient  soon 
gained  flesh  and  strength,  her  appetite  was  restored,  she  slept  well,  and  was  able  to  walk 
about.  The  orbit  discharged  good  pus  in  moderate  quantity,  and  was  at  last  filled  up 
with  a  soft  substance,  which,  although  dark  in  color,  skinned  over. 

When  recovery  seemed  certain,  the  weather  became  cold  and  damp;  the  patient  lost  her 
appetite,  and  became  unable  to  walk  from  pains  in  the  loins.  She  could  obtain  no  sleep, 
except  from  opium.  The  lower  eyelid  was  protruded  by  an  elastic  fungus,  which  also 
began  to  project  from  between  the  lids.  The  disease  in  the  orbit  gave  her  no  uneasiness, 
her  whole  complaint  being  seated  in  the  back  and  loins.  The  pain  there  was  excruciating. 
She  could  neither  turn  in  bed  nor  permit  herself  to  be  turned.  In  this  condition,  she  lin- 
gered for  two  or  three  months ;  the  tumor  below  the  orbit  all  the  while  increasing  in  size, 
and  the  pain  in  the  loins  in  no  degree  remitting.  AVhen  Mr.  B.  saw  her  three  weeks  be- 
fore her  death,  she  was  emaciated  to  the  last  degree.  The  tumor  below  the  orbit  was  as 
large  as  a  pullet's  egg;  its  surface  unequal,  the  most  prominent  parts  of  it  covered  with 
livid  integuments,  and  the  swelling  conveying  to  the  fingers  the  impression  as  if  it  con- 
tained a  fluid.  From  between  the  eyelids,  a  very  small  fungus  protruded,  covered  with 
bloody-looking  matter.  She  had  little  or  no  pain  in  either  the  orbit  or  the  head,  and  the 
vision  of  the  other  eye  remained  unimpaired.  From  this  time  to  her  death,  she  sunk 
gradually,  the  tumor  going  on  to  enlarge,  and  becoming  more  discolored  on  its  surface, 
and  more  irregular,  but  the  fungus  between  the  lids  undergoing  no  change.  About  twenty- 
four  hours  previous  to  her  death,  she  became  suddenly  comatose. 


MELANOSIS  OF  THE  EYEBALL.  693 

On  dissection,  the  liver  was  found  to  contain  tumors  of  a  similar  texture  and  appear- 
ance with  the  contents  of  the  eyeball,  as  ascertained  after  its  extirpation.  There  was 
also  a  cyst  in  the  substance  of  the  liver,  filled  with  a  great  quantity  of  grumous-looking 
purulent  matter.  Above  the  kidneys  there  were  similar  tumors  of  pretty  considerable 
size,  and  the  uterus  was  cartilaginous.  The  urinary  bladder  was  enormously  distended 
with  a  turbid  bloodj'-looking  fluid ;  but  otherwise  in  so  far  as  this  viscus  was  examined,  its 
structure  appeared  healthy. 

By  making  a  vertical  section  of  the  orbit  and  fungus  it  contained,  the  tumor  was  found 
to  arise  entirely  from  the  antrum,  which  had  burst  both  above  and  in  front.  The  fungus 
projected  also  beyond  the  lower  spongy  bone  and  investing  membrane  of  the  nose,  into 
the  nostril.  The  tumor  proceeding  from  the  antrum,  studded  over  on  its  outer  surface 
with  small  knobs  of  a  dark  lived  color,  was  internally  made  up  of  a  soft  substance  of  an 
ink  color,  intersected  by  membranous  slips,  and  intermixed  with  a  grayish  substance,  and 
with  ragged  fragiiieuts  of  bone.  The  anterior  wall  of  the  antrum  was  destroyed  at  its 
upper  part,  and  the  floor  of  the  orbit  was  elevated,  so  as  to  have  merely  the  periosteum 
and  a  thin  layer  of  fat  between  it  and  the  orbitary  plate  of  the  frontal  bone.  The  fungus 
was  exterior  to  the  orbit,  although  from  the  destruction  of  the  periosteum  attached  to  the 
malar  portion  of  the  orbit,  it  had  been  allowed  to  protrude  from  between  the  eyelids. 
This  portion  of  the  periosteum  was  destroyed  partly  by  disease,  and  partly  in  consequence 
of  the  removal  of  a  carious  portion  of  the  bone,  when  the  eye  was  extirpated. 

With  regard  to  the  optic  nerve,  it  was  expected  that  its  extremity  would  have  been  con- 
nected with  the  fungus.  Between  them,  however,  the  periosteum  of  the  floor  of  the  orbit 
was  interposed.  The  nerve  itself  was  of  its  natural  size,  but  of  a  black  color  where  it 
entered  the  foramen  opticum.  From  this  point  to  near  where  it  had  been  divided 
in  the  extirpation  of  the  eyeball,  it  was  in  a  similar  state ;  the  neurilemma  had  only  a 
slight  connection  with  the  diseased  substance  of  the  nerve.  At  the  bottom  of  the  orbit 
there  was  considerable  matting  and  induration  of  the  origin  of  the  muscles.  At  its  ter- 
mination, the  nerve  formed  a  sharp  point,  its  coats  adhered  to  the  thickened  periosteum 
of  the  floor  of  the  orbit,  which  was  pressed  into  contact  with  it  by  the  fungus  frofii  the 
antrum.  The  optic  nerve  within  the  cranium  was  as  thick  as  the  little  finger,  and  as  dark 
in  color  as  the  part  contained  in  the  orbit.  The  junction  of  the  nerves  was  so  much  en- 
larged, that  it  formed  a  tumor  extending  into  the  third  ventricle.  The  dark  color  was 
found  to  extend  much  beyond  the  point  where  the  nerves  join ;  but  this  change  of  color 
was  confined  to  the  left  side,  or  to  the  nerve  of  the  afifected  eye.  On  the  right  side,  the 
nerve  was  of  its  natural  size  and  color,  and  was  attached  to  the  black  diseased  parts  merely 
by  cellular  shreds. 

Case  346. — In  January,  1824,  Thomas  Peckett,  aged  30,  a  robust  healthy-looking  man, 
consulted  Mr.  Wilson  of  Manchester,  respecting  a  violent  and  incessant  pain  in  his  left 
eye.  Six  months  previously  he  had  received  a  blow  upon  the  organ,  from  a  small  piece 
of  iron;  but  the  injury  appeared  trifling,  as  he  experienced  but  little  pain,  and  the  eye 
did  not  exhibit  any  external  appearance  to  attract  notice.  About  a  fortnight  after  the 
accident,  he  experienced  a  sensation  of  fulness  in  the  globe,  and  upon  shutting  his  right 
eye,  discovered  that  his  sight  in  the  left  was  very  imperfect.  The  pain  and  dimness 
gradually  increased,  the  former  to  a  most  distressing  degree,  afl"ecting  chiefly  the  ball  of 
the  eye  and  margin  of  the  orbit. 

The  conjunctival  vessels  were  now  enlarged  and  tortuous,  and  the  sclerotica  generally 
inflamed  and  undergoing  absorption,  the  dark  choroid  being  visible  towards  the  internal 
canthus.  The  iris  was  immovable,  and  a  slate-colored  opacity  occupied  the  centre  of  the 
dilated  pupil.  No  symptoms  of  cerebral  aff"ection  were  manifested.  The  treatment  had 
been  limited  to  the  occasional  application  of  leeches  to  the  temple. 

By  drawing  blood  freely  and  repeatedly  from  the  temple  and  nape  of  the  neck,  together 
with  blistering,  active  cathartics,  and  an  abstemious  diet,  th^  pain  was  removed;  but  no 
amendment  in  vision  ensued.  After  remaining  in  Manchester  nearly  a  month,  he  was 
permitted  to  return  into  Staff"ordshire. 

Towards  the  end  of  ]\Iarch,  he  applied  on  account  of  a  return  of  pain.  A  few  days 
after  he  returned  home,  he  had  experienced  his  former  sensations,  and  the  pain  was  now 
so  violent  and  incessant,  as  to  prevent  him  from  sleeping.  The  sclerotica,  at  its  upper 
part,  and  towards  the  inner  canthus,  was  extremely  attenuated;  the  choroid  covering  the 
protruding  substance.  The  opaque  appearance  in  the  pupil  had  assumed  a  dirty-red 
color,  resembling  newly  organized  lymph,  and  this  seemed  to  be  the  apex  of  a  conical- 
shaped  body,  situated  deep  in  the  ej'e. 

The  former  treatment,  with  moderate  ptyalism,  was  ineffectually  adopted,  and  on  the 
19th  of  April,  Mr.  Wilson  removed  the  contents  of  the  orbit. 

A  section  of  the  eyeball  discovered,  in  the  situation  of  the  vitreous  humor,  a  black 
pultaceous  tumor,  occupying  more  than  one-half  of  the  interior  of  the  globe.    There  were 


694  MELANOSIS   OF   THE   EYEBALL. 

two  cavities  or  cells  filled  with  a  brownish-red  fluid,  one  situated  at  the  side  of  the  tumor, 
the  other  anterior  to  it,  and  behind  the  lens.  No  trace  of  the  vitreous  body  could  be 
discovered.  The  choroid  was  entire,  and  could  easily  be  separated  from  the  sclerotica, 
except  at  one  point  towards  its  superior  and  internal  part,  where  it  ceased  to  be  dis- 
tinguishable from  the  general  mass  of  the  tumor.  The  sclerotica  was  here  reduced  to  an 
extreme  degree  of  tenuity,  and  had  a  split  appearance.  The  retina  was  quite  detached 
from  the  choroid  by  the  interposition  of  the  disease,  and  lay  folded  across  the  globe, 
forming  a  kind  of  septum  between  the  black  mass  and  the  larger  of  the  two  cavities, 
containing  the  brownish-red  fluid.  The  lens  was  opaque,  and  the  capsule  thickened,  but 
partially  transparent;  a  fold  of  retina  covered  the  posterior  capsule.  The  ciliary  liga- 
ment was  distinct,  and  some  ragged  portions  of  membrane  at  the  margin  of  the  lens,  and 
posterior  to  the  iris,  which  was  perfect,  showed  a  remnant  of  the  ciliary  processes.  The 
optic  nerve,  where  it  had  been  divided  at  the  time  of  the  operation,  appeared  to  be 
sound. 

He  recovered  from  the  operation,  and  returned  home  at  the  end  of  a  month,  apparently 
well. 

In  August,  he  again  applied,  on  account  of  three  or  four  tumors  on  the  face,  about  the 
size  of  leaden  shot,  perfectly  black,  but  unattended  by  uneasiness.  He  complained  of 
difficulty  of  breathing,  and  stitches  in  his  side,  with  a  short  cough.  He  had  evidently 
wasted  in  flesh,  and  his  pulse  was  quick  and  remarkably  sharp.  A  tumor,  similar  to 
those  on  the  face,  was  discovered  on  the  skin  of  the  back,  between  tlie  scapulte.  In  a 
few  days,  one  or  more  were  found  on  the  scalp. 

His  strength  rapidly  declining,  he  came  under  the  care  of  Mr.  Fawdington,  on  the  2d 
October.  His  general  aspect  indicated  a  deficient  supply  of  nutriment,  or  an  imperfect 
appropriation  of  it  to  the  purposes  of  the  system.  The  surface  of  his  body  Avas  pale 
and  exsanguineous,  and  there  was  a  considerable  degree  of  muscular  emaciation,  with 
oedema  of  the  legs.  But  the  most  striking  feature  of  the  case  was  an  exceedingly  pro- 
tuberant abdomen,  apparent!}'  from  enlargement  of  one  of  its  viscera,  and  this  probably 
the  liver.  The  face  and  scalp  displayed  several  perfectly  developed  melanotic  tubercles, 
and  one  on  the  lower  lid  of  the  extirpated  eye  appeared  on  the  verge  of  ulceration.  The 
bottom  of  the  orbit  was  free  from  any  visible  melanotic  deposition.  In  every  other 
situation,  excepting  two  or  three  points  on  the  trunk,  the  cutis  had  escaped  the  direct 
invasion  of  the  disease;  but  the  subcutaneous  tissue,  over  the  whole  chest  and  abdomen, 
was  evidently  loaded  with  melanosis,  giving  rise,  where  the  cysts  encroached  on  the  skin, 
to  faint-blue  elevations,  more  or  less  distinct,  and  of  various  sizes ;  none,  however, 
exceeded  the  fourth  of  an  inch  in  diameter.  The  patient  die^  on  the  3d  November.  On 
dissection,  the  subcutaneous  cellular  texture  on  the  front  of  the  trunk  was  found  granu- 
lated with  melanotic  tubercles.  The  liver,  enlarged  to  four  times  its  natural  size,  was 
disorganized  by  the  same  disease ;  with  which  also  the  peritoneum,  pancreas,  spleen, 
kidney's,  pleuriE,  lungs,  and  heart,  were  more  or  less  aifected.  The  brain  was  not 
examined.^ 

Case  347. — John  Taylor,  aged  41,  of  a  dark  unhealthy  complexion,  was  admitted  at 
the  Glasgow  Ej'e  Infirmary,  on  the  13th  May,  1834.  About  nine  years  before,  while  in 
America,  the  vision  of  his  left  eye  became  dim,  and  was  soon  entirely  lost.  The  bulb  of 
the  eye,  on  his  admission,  was  shrunk  and  knobbed.  There  were  still  some  traces  of 
cornea,  behind  which  was  a  white  substance,  apparently  the  lens.  Adhering  to  the  bulb 
of  the  eye,  at  its  nasal  margin,  there  was  a  prominent  tumor  larger  than  a  pea,  smooth 
on  the  surface,  covered  by  the  conjunctiva,  and  firmly  attached  to  the  bulb.  Pressure  on 
the  tumor  occasioned  pain.  The  patient  also  complained  of  uneasy  feelings  in  the  fore- 
head, especially  above  the  left  e^'ebrow.  The  left  lower  eyelid  was  inverted,  and  the 
consequent  friction  of  the  eyelashes  seemed  to  excite  irritation  in  the  tumor.  The  right 
eye  was  sound. 

On  the  19th,  the  inversion  of  the  e^'elid  having  been  already  cured  by  operation,  a  por- 
tion of  the  tumor  was  removed  with  the  scissors.  Its  contents  were  dark-colored,  and 
of  considerable  consistence,  so  that  the  tumor  did  not  collapse. 

On  the  23d,  a  grayish  fungus  protruded  in  the  situation  of  the  tumor.  The  patient  was 
advised  to  have  the  eye  extirpated ;  but  unwilling  to  submit  to  the  operation,  he  discon- 
tinued his  attendance. 

He  returned  on  the  5th  August,  and  signified  his  wish  to  have  the  eye  removed. 

The  dark-colored  soft  tumor,  occupying  the  nasal  half  of  the  left  eye,  had  now  attained 
the  size  of  a  large  filbert,  and  was  rapidly  increasing.  Its  anterior  surface  was  marked 
■with  a  stellated  scar,  the  result  of  the  former  operation.  (Fig.  87.)  The  patient  com- 
plained of  considerable  pain  of  the  left  side  of  his  head,  down  to  his  neck,  preventing 
sleep.     His  stomach  was  very  irritable. 

On  the  7th,  I  extirpated  the  eye,  after  which  the  lids  were  covered  with  a  piece  of 
simple  dressing  and  a  roller. 


MELANOSIS  OF  THE  EYEBALL. 


695 


Fio;.  87. 


On  examination,  the  whole  eye  was  found  atrophic.  The  cornea,  as  could  be  seen  before 
the  operation,  was  not  more  than  two  lines  in  diameter; 
it  was  transparent,  so  that  the  opaque  lens  could  be 
seen  through  it.  The  optic  nerve  was  much  reduced  in 
thiclvness,  indeed  nothing  but  the  neurilemma  of  the 
fibrils  seemed  to  be  left,  all  the  medullary  matter  being 
absorbed.  The  tumor,  which  was  about  five  or  six  lines 
in  diameter,  protruded  through  an  opening  in  the  scle- 
rotica, on  the  nasal  side  of  the  dwarfish  cornea.  It  was 
covered  externally  by  a  production  of  the  conjunctiva. 

On  making  a  section  of  the  tumor,  it  was  found  to 
consist  of  a  light  bistre-colored  tissue,  nearly  of  the 
consistence  of  muscle,  which,  when  torn,  indicated  a 
fibrous  structure.  The  section  through  the  tumor  hav- 
ing been  continued  through  the  eyeball,  the  latter  was 
found  to  have  undergone  extensive  disorganization. 
There  were  some  remains  of  the  choroid  and  annulus 
albidus ;  but  a  bony  lamina  occupied  the  place  of  the 
retina;  and  the  neurilemma,  Avhich  was  all  that  remained 
of  the  optic  nerve,  at  the  place  where  this  joins  with  the 
retina,  had  several  earthy  deposits  in  it.  The  lens  was 
entirely  converted  into  an  earthy  matter,  Avhich  afiTected 
a  laminar  arrangement.     The  capsule  was  very  tough. 

There  was  no  trace  of  iris  nor  posterior  chamber.  The  anterior  chamber  was  very  small. 
All  the  rest  of  the  interior  of  the  eye  was  filled  by  a  melanotic  mass,  of  a  pappy  con- 
sistence, from  which  the  tumor  appeared  to  rise.  There  was,  moreover,  towards  the 
inner  side  and  back  part  of  the  eye,  a  small  mass  of  a  reddish-white  matter  like  brain, 
and,  close  by  this,  a  small  quantity'  of  a  soft  dark-red  matter.  In  the  interior  of  the  tumor, 
some  dark-red  matter  was  also  observed  surrounding  and  isolating  a  nodule  of  the  bistre- 
colored  substance  from  the  rest  of  the  mass. 

The  pappy  melanotic  matter  contained  in  the  interior  of  the  eye,  being  examined  with 
the  microscope,  was  observed  to  be  composed  of  black  particles  of  no  definite  form, 
interspersed  among  which  were  some  minute  crj'stals  of  a  rhomboidal  sliape.  The 
tissue  composing  the  tumor,  which,  as  has  been  said,  was  somewhat  fibrous,  on  exami- 
nation with  the  microscope,  was  seen  to  consist  of  flattened  globules,  considerably  larger 
than  those  of  the  blood,  united  together  in  fibres  by  a  delicate  cellular  tissue.  The  most 
of  the  globules  were  light-colored  :  but  there  were  interspersed  among  them  a  number  of 
dark-colored  bodies,  which  appeared  to  be  globules,  containing  in  their  substance  black 
particles.  The  brain-like  and  dark-red  matters  were  also  composed  of  globules,  but  very 
few  black  bodies  were  observed  among  them. 

The  patient  experienced  no  uneasiness  after  the  operation,  and  felt  quite  relieved  of 
the  pain  which  he  complained  of  before  the  removal  of  the  eye. 

Case  348. — In  July,  1835,  Mr.  Espie,  a  surgeon  at  Falkirk,  was  called  to  visit  James 
Campbell,  aged  40,  a  laborer  in  the  parish  of  Larbert.  When  10  years  of  age,  the  patient 
lost  the  use  of  the  left  eye  from  traumatic  cataract.  Fourteen  years  before  Mr.  Espie's 
visit,  a  swelling  formed  at  the  left  angle  of  the  lower  jaw,  suppurated,  and  burst  in- 
ternally. This  suppuration  left  a  pain  in  and  around  the  right  orbit,  with  dimness  of 
sight  in  the  right  eye.  These  symptoms  increased,  and  after  two  years  the  patient  con- 
sulted the  late  Dr.  Monteath,  of  Glasgow,  who  considered  the  vision  of  the  right  eye  all 
but  gone,  and  advised  no  remedy  for  it,  but  recommended  the  removal  of  the  left  lens. 
The  patient  went  to  Edinburgh,  and  repeatedly  submitted  to  the  operation  of  couching, 
the  lens  having  several  times  reascended.  At  length,  extraction  was  practised ;  but  the 
eye  inflamed  violently,  the  cornea  became  opaque,  and  all  hope  of  restoring  the  sight  was 
lost.  The  friends  of  the  patient,  about  this  lime,  observed  the  right  sclerotica  becoming 
black,  and  the  eyeball  enlarged. 

Mr.  Espie  found  the  right  eyeball  much  enlarged,  burst,  and  sending  forth  a  black  fun- 
gus, which,  in  several  places,  had  given  way,  and  was  discharging  considerable  quantities 
of  melanotic  matter.  There  appeared  to  be  much  determination  of  blood  to  the  right 
orbit.  The  general  health  was  impaired,  and  the  bowels  irregular.  Mr.  Espie  ordered 
repeated  leeching  around  the  orbit,  and  a  blister  behind  the  ear.  The  patient  found  great 
relief  from  the  local  bleeding,  and  his  general  health  improved  under  the  use  of  a  nourish- 
ing diet,  and  occasional  doses  of  laxative  medicine. 

Mr.  Espie  saw  nothing  more  of  the  patient  till  September,  183G,  when,  being  again 
called  to  visit  him,  he  found  the  eyeball  still  larger  than  before,  with  blood  oozing  from  it, 
and  melanotic  matter  continuing  to  be  occasionally  discharged  from  it.  The  patient  com- 
plained of  pain  in  the  right  side  of  his  head,  and  darting  from  the  orbit  to  the  hind-head. 


696  MELANOSIS   OF   THE   EYEBALL. 

His  general  health  was  again  somewhat  impaired.     The  same  advice  was  given  as  before, 
and  was  followed  by  a  similar  improvement. 

The  fungus  continuing  to  enlarge,  and  the  discharges  from  it  to  increase,  particularly 
the  bleeding,  in  January,  1837,  Mr.  Espie  sent  the  patient  to  me  for  advice. 

At  this  period,  the  tumor,  which  hung  from  the  eye  through  the  destroyed  cornea,  was 
of  the  size  and  shape  of  a  large  French  plumb  flattened  ;  it  was  no  longer  within  the  cover 
of  the  eyelids,  but  lay  upon  the  cheek,  and  wagged  about  as  the  patient  moved  his  eye. 
It  was  slightly  lobulated,  and  quite  black.  Its  investing  membrane  appeared  as  if  abraded, 
and  occasionally  gave  way  and  bled.  It  had  a  most  offensive  smell.  The  patient  still 
complained  of  pain,  and  of  a  feeling  of  traction  in  the  course  of  the  optic  nerve.  I  had 
no  hesitation  in  recommending  extirpation  of  the  eye,  with  as  much  as  possible  of  the 
optic  nerve. 

The  patient  having  been  seized  with  influenza,  the  operation  was  postponed  till  the  20th 
Februar3%  when  it  was  performed  by  Mr.  Espie. 

On  examining  the  parts  which  were  removed,  the  sclerotica  appeared  entire,  but  greatly 
atrophied,  the  natural  contents  of  the  eyeball  completely  destroyed,  a  pretty  thick  cup- 
like deposit  of  bone  witliin  the  sclerotica  at  the  back  part  of  the  eye,  the  rest  of  the  cavity 
filled  with  the  melanotic  tumor.  At  one  period  the  optic  nerve,  on  its  way  to  the  retina, 
had  passed  through  a  small  hole,  which  was  found  in  the  ossific  deposit.  On  making  a 
section  of  the  tumor,  it  appeared  divided  by  septa.  The  melanotic  matter  had  an  olea- 
ginous appearance,  and,  with  some  shades  of  dark  brown,  was  of  a  deep  black  color.  The 
optic  nerve  was  reduced  to  about  one-half  of  its  ordinary  thickness  ;  it  was  somewhat 
softened,  but  not  black. 

In  10  days,  the  patient  had  perfectly  recovered  from  the  operation,  and  acknowledged 
that  he  had  not  enjoyed  such  good  health  for  12  years. 

He  continued  to  enjoy  excellent  health,  locally  and  generally,  up  to  March,  1850;  when, 
stooping  rashly,  the  right  orbit  sustained  a  severe  blow  from  a  cow's  horn.  Smart  anti- 
phlogistic treatment  was  necessary  to  prevent  the  extension  of  the  orbital  inSammation  into 
the  brain ;  but  after  about  four  weeks,  the  pain  had  gone,  and  the  swelling  nearly  so. 

Mr.  Espie  heard  nothing  more  of  tiie  case  until  March,  1852;  when  he  learned  that, 
while  forciblj'  pulling  at  a  rope  attached  to  a  cow,  the  patient  felt  something  give  way  sud- 
denly in  the  right  orbit,  so  that  he  called  aloud — "  My  eye  is  out  I"  When  Mr.  E.  saw 
him  next  day,  the  right  orbit  was  greatly  swelled,  somewhat  discolored,  very  painful,  and 
felt  like  to  burst.  There  was  obscure  fluctuation.  Mr.  E.  found  it  necessary,  at  tlie  end 
of  two  days,  to  relieve  the  extreme  tension,  by  an  incision  inider  the  upper  eyelid,  which 
gave  exit  to  a  large  tablespoonful  of  melanotic  matter.  Poultices  and  anodynes  were  had 
recourse  to  ;  and,  in  four  daj's,  the  swelling  having  increased,  burst  through  the  upper  and 
inner  part  of  the  upper  eyelid.  Through  the  opening  tlius  formed,  melanotic  matter 
was  freely  discharged  for  four  or  five  weeks,  when  it  subsided,  along  with  the  general 
orbital  swelling. 

The  condition  of  the  orbit  had  never  been  quite  satisfactory  since  the  injury  received 
in  1850  ;  the  swelling  never  having  completelj'  subsided. 

In  March,  1854,  the  patient  was  in  good  health  ;    suffering  only  from  sciatica. 

Causes  and  treatment. — As  to  the  remote  and  exciting  causes  of  melanosis, 
we  are  quite  in  the  dark ;  nor  can  we  say  anything  with  certainty  on  the 
method  of  cure. 

Does  extirpation  afford  any  greater  hope  of  permanent  benefit,  than  in  cases 
of  fungus  h?ematodes  ?  Mr.  Lawrence^  thinks  it  does.  "In  the  early  stage 
of  melanosis,"  says  he,  "when  you  can  be  confident  that  it  has  not  extended 
beyond  the  original  seat  in  the  eye,  there  seems  to  be  a  chance  of  permanent 
cure  by  removing  the  disease."  He  refers  to  the  case  of  an  Irishman,  about 
30,  from  whom  he  removed  an  eye  affected  with  melanosis.  Between  one  and 
two  years  after  the  operation,  he  was  perfectly  well.  In  another  case,  where 
the  disease  had  existed  longer,  the  patient  died  ten  or  twelve  days  after  the 
operation,  and  on  dissection,  the  liver  was  found  enormously  enlarged,  and 
filled  throughout  with  melanotic  depositions.^  The  experience  of  the  profes- 
sion generally,  within  the  last  twenty  years,  shows  that  melanosis,  although 
slower  in  its  progress,  is  scarcely  less  liable  than  encephaloid  tumor,  to  affect 
the  brain  and  other  internal  organs,  and  thus  to  prove  fatal. 

[Mr.  Holmes  Coote  states  as  the  result  of  an  experience  which  has  evidently 
been  by  no  means  limited,  that  an  operation  is  utterly  inefficient  for  the  rad- 
ical cure  of  this  disease,  and  even  doubts  whether  it  can  prolong  the  life  of 


EXTIRPATION   OP   THE   EYEBALL.  697 

the  patient.  "Patients,"  he  says,  "may  fairly  be  recoramendecl  to  submit  to 
the  removal  of  superficial  tumors,  which,  by  their  position  or  size,  produce 
inconvenience  ;  but  the  more  serious  operation  of  extirpation  of  the  eye  ought 
never  to  be  undertaken,  except  at  the  patient's  express  desire,  and  after  he 
has  been  fairly  made  acquainted  with  the  circumstances  of  the  case."^  He 
gives  an  interesting  table  of  fifteen  cases  in  which  the  operation  was  per- 
formed, and  the  result  carefully  observed  for  a  period  of  over  three  years. 
The  result  of  these  observations  is  that  the  average  duration  of  life  after  the 
operation,  has  been  about  13  months.  The  late  Dr.  Geo.  McClcllan,^"  of 
Philadelphia,  was  of  opinion,  that  melanosis  recurred  more  frequently  after 
extirpation  than  even  an  encephaloid  tumor. — H.] 


'  Some  of  the  lower  animals,  and  especially  Transactions  of  the  Medico-Chirurgieal  Society 

the  horse,  are  subject  to  black  tumors,  which  of  Edinburgh,  Vol.  i.  pp.  272,  274  ;  Edinburgh, 

are  said  not  to  partake  of  a  cancerous  ormalig-  1824:   Grafo  und  AValther's  Journal  der  Chirur- 

nant  character.  gie  und  Autjenheilkunde,  Vol.  xii.  p.  602;  Ber- 

^  Journal  de  Medecine  de  Corvisart ;   Tomes  lin,  1828:  Liston,  Medical  Gazette,  Vol.  vi.  p. 

ix.  et  X.  224:  London,  1830:  Pruschade  Melanosi  Bulbi 

^  On  the  microscopical  characters  of  melano-  Oculi,  pp.  33,37  ;  Vienna?, 1831 :  Byron,  Dublia 

sis,  see  Paget's  Lectureson  Surgical  Pathology;  Medical  Press,  April  20,  1842,  p.  247  :  Robert- 

Vol.  ii.  p.  484;  London,  1853.  son,  Northern  .Journal  of  Medicine,  November, 

*  Observations  on   Diseased  Structures,  pre-  1844:  Windsor,  Provincial  Medical  and  Surgical 

fixed  to  the  second  volume  of  Baillie's  Works,  Journal,  May  1,  1850:  Lawrence,  Lancet,  Au- 

p.  liii.;  London,  1825.  gust,  1,  1846,  p.  122:  Critchett,  lb.  October  25, 

'  Annales    d'Oculistique;  Tome   vii.   p.  31;  1851,  p.  386 :  Hancock,  lb.  December  25,  1852, 

Bruxelles,  1842.  p.  687  :  Bowman,  Medical  Times  and  Gazette, 

^  Case  of  Melanosis,  by  Thomas  Fawdington;  May  21,  1853,  p.  525. 

London,  1826.  '  '[Lancet  for  August  8, 1846.— H.] 

'  Lectures  on  Surgery,  London  Medical  Ga-  '"  [McClellan's   Principles   and  Practice   of 

zette,  Vol.  vi.  p.  39;  London,  1830.  Surgery,  p.  420.— H.] 

"  For   cases   of   melanosis   of  the   eye,    see 


CHAPTER   XVIII. 

EXTIRPATION  OP  THE  EYEBALL. 

L  When  we  are  about  to  extirpate  the  eyeball,  it  is  better  to  lay  the  pa- 
tient on  his  back,  with  his  head  raised  on  a  pillow,  than  to  keep  him  in  a 
sitting  position.  He  ought  then  to  be  brought  fully  under  the  influence  of 
chloroform. 

2.  When  the  eyeball  is  not  enlarged,  the  fissure  of  the  lids  wide,  and  the 
eye  the  only  part  to  be  removed,  the  extirpation  may  be  accomplished  without 
disuniting  the  lids  at  their  temporal  angle.  But  if,  on  the  contrary,  there  is 
considerable  enlargement  of  the  eyeball,  or  if  the  muscles  of  the  eye,  or  the 
whole  contents  of  the  orbit,  are  to  be  dissected  out,  it  is  necessary  first  to  dis- 
unite the  lids,  by  means  of  an  incision  carried  outwards  from  their  external 
angle,  towards  the  temple,  else  the  lids  will  probably  be  cut  and  disfigured  in 
accomplishing  the  extirpation.  Even  when  the  eye  is  small,  such  disunion 
of  the  lids  enables  us  to  accomplish  the  operation  with  much  greater  facility. 
Nor  ought  it  to  leave  any  additional  deformity ;  for  the  edges  of  the  incision, 
being  brought  together  when  the  operation  is  finished,  generally  adhere  by  the 
first  intention.  Care  must  be  taken  in  making  this  separation  of  the  lids,  not 
to  limit  the  incision  to  the  skin,  but  to  go  through  the  fibrous  layer  and  the 
conjunctiva,  so  that  the  eyeball  may  be  fully  exposed. 

3.  The  operator  now  passes  a  large  curved  needle,  armed  with  a  thick 


698  EXTIRPATION   OF   THE   EYEBALL. 

waxed  thread,  through  the  eyeball,  from  its  temporal  to  its  nasal  side,  avoid- 
ing any  part  which  appears  to  be  so  disorganized  that  it  would  give  way 
under  traction  by  the  ligature.  The  needle  is  then  cut  away,  and  the  ends 
of  the  double  thread  knotted  together.  By  means  of  the  thread,  the  eye  can 
be  carried  in  any  particular  direction  during  the  remaining  steps  of  the  opera- 
tion. Some  prefer  a  large  sharp  hook  for  the  same  purpose  ;  others,  a  double 
volsella. 

4.  When  the  disease  is  entirely  confined  within  the  eyeball,  and  this  not 
much  enlarged,  and  freely  movable,  the  eye  may  be  extirpated,  as  was  pointed 
out  by  O'Ferrall'  and  Bonnet,^  and  has  been  practised  by  Stober,^  Critchett,* 
and  others,  simply  by  laying  open  the  ocular  capsule  in  front.  The  lids 
being  held  apart,  the  surgeon  takes  hold  of  the  conjunctiva  at  the  inner 
canthus  with  forceps,  and  cuts  it  through  with  scissors,  as  if  he  were  about  to 
operate  for  strabismus.  He  divides  the  internal  rectus  near  its  insertion, 
and  sliding  the  point  of  the  scissors  under  the  other  recti,  he  divides  them  in 
succession  along  with  the  conjunctiva,  all  round  the  cornea.  Next,  he  divides 
the  two  obliqui,  and  lastly,  the  optic  nerve,  close  to  the  sclerotica.  In  this 
method  of  operating,  the  hemorrhage  is  very  slight,  as  the  larger  branches  of 
the  ophthalmic  artery  are  not  divided ;  the  principal  nerves  of  the  orbit,  with 
the  exception  of  the  optic,  are  also  spared;  and  a  better  cushion  is  left, 
whereon  to  place  an  artificial  eye. 

5.  When  the  eyeball  is  enlarged,  it  will  generally  be  found  that  the  ocular 
capsule  is  adherent  to  the  sclerotica,  so  that  the  method  of  operating  now 
described  is  not  available.  The  muscles,  the  orbital  tissues,  and  the  lachrymal 
gland,  are  also  so  much  implicated  in  many  cases,  that  they  require  to  be 
removed.  In  this  case,  the  lids  being  held  asunder  by  the  assistant,  and  the 
eye  carried  upwards  and  outwards  by  means  of  a  ligature,  the  operator  plunges 
a  double-edged  scalpel  directly  backwards  into  the  orbit,  between  the  eyeball 
and  the  internal  canthus,  and  then  carrying  the  instrument  round,  he  separates 
the  eyeball  from  the  lower  eyelid,  by  a  division  of  the  conjunctiva.  Next, 
moving  the  eye  inwards  and  downwards,  the  connection  of  the  upper  part  of 
the  conjunctiva  is  disunited,  the  scalpel  passing  round  the  eyeball  to  the 
inner  canthus.  In  this  part  of  the  operation,  care  should  be  taken  to  leave 
as  much  of  healthy  conjunctiva  as  possible,  especially  if  it  is  contemplated 
that  the  patient  should  wear  an  artificial  eye.  The  cellular  connections 
between  the  muscles  of  the  eye  and  the  walls  of  the  orbit  are  next  to  be 
divided,  and  the  inferior  oblique  muscle  cut  across  near  its  origin,  the  direc- 
tions of  the  sides  of  the  orbit,  and  the  thinness  of  its  roof,  being  carefully 
borne  in  mind.  The  optic  nerve,  surrounded  by  the  origins  of  the  recti,  at 
last  forms  the  only  remaining  connection  which  prevents  the  complete  extrac- 
tion of  the  eye.  Dragging  the  eye  forward  by  means  of  the  ligature,  the 
nerve,  thus  put  on  the  stretch,  along  with  the  origin  of  the  recti  and  superior 
oblique,  is  to  be  divided  with  the  scalpel,  or  strong  curved  scissors  recom- 
mended for  this  purpose  by  Louis,  and  commonly  called  Louis's  scissors.  The 
nerve  ought  to  be  cut  as  close  to  the  optic  foramen  as  possible. 

6.  As  soon  as  the  bleeding  from  the  branches  of  the  ophthalmic  artery 
has  ceased,  the  operator  examines  the  orbit  with  his  index-finger,  in  order  to 
discover  whether  any  of  the  diseased  substance  be  left  behind.  If  there  is 
any  such,  it  must  be  dissected  out.  The  lachrymal  gland  also  if  diseased,  is 
to  be  laid  hold  of  with  a  pair  of  forceps,  and  removed  with  the  scissors. 
Indeed,  it  is  often  deemed  a  safe  precaution,  in  cases  of  scirrhus,  fungus 
hsematodes,  or  melanosis,  that  the  whole  soft  parts  should  be  removed,  leaving 
only  the  periorbita.  The  muscles  are  very  liable  to  be  affected  in  cases  of 
scirrhus  ;  if  they  be  so  affected,  any  portion  of  them  left  in  the  orbit,  gives 
rise  to  a  fatal  renewal  of  the  disease.     In  some  cases,  the  bones  are  implicated, 


EXTIRPATION   OF   THE   EYEBALL.  699 

and  it  may  be  proper  to  attempt  the  removal  of  the  portion  of  them  which  is 
diseased.  This  is  particularly  apt  to  happen  in  cases  of  scirrhus,  originating 
in  injuries.  A  pair  of  cutting  pliers  and  other  instruments  should,  therefore, 
be  provided  for  this  purpose. 

*r.  It  was  formerly  the  practice,  after  the  extirpation  was  finished,  to  stuff 
the  orbit  with  lint,  rolled  up  into  a  ball,  and  surrounded  by  a  thread,  which 
was  left  hanging  from  between  the  eyelids.  This  is  now  generally  laid  aside, 
being  likely  to  excite  inflammation,  which  might  extend  to  the  membranes  of 
the  brain.  The  lids  are  merely  brought  together,  and  covered  with  a  piece 
of  spread  lint,  a  light  compress,  and  a  roller.  It  cannot  be  denied,  however, 
that  such  a  procedure  favors  union  between  the  lids  and  the  areolar  tissue  left 
in  the  orbit,  and  may  thereby  impede  or  entirely  prevent  the  application  of  an 
artificial  eye  after  recovery  from  the  operation.  If  the  lids  have  been  disunited 
by  an  incision  carried  from  their  outer  angle  towards  the  temple,  the  edges  of 
the  wounds  are  to  be  brought  into  contact,  and  kept  so  by  a  stich  or  two  ; 
and  if  any  accidental  cuts  have  been  made  in  the  lids,  they  are  to  be  neatly 
brought  together  in  the  same  way. 

8.  As  for  the  hemorrhagy  which  occurs  during  or  after  extirpation  of  the 
eye,  the  free  exposure  of  the  bleeding  vessels  to  the  air  for  a  few  seconds,  or 
the  injection  of  cold  water  into  the  orbit,  is  in  general  sufficient  to  produce 
their  contraction.  We  are  of  course  provided,  however,  with  the  tenaculum, 
and  ought  to  tie  any  considerable  vessel  within  reach,  which  may  continue  to 
bleed.  If  bleeding  goes  on  to  any  great  extent  from  the  deep  part  of  the 
orbit,  pressure  must  be  had  recourse  to.  Sometimes  the  pressure  of  the 
finger  for  a  few  minutes  is  sufficient,  but  in  other  cases  it  is  necessary  to 
introduce  to  the  bottom  of  the  orbit  a  conical  roll  of  lint,  pressing  it  against 
the  bleeding  orifice  of  the  ophthalmic  artery  for  some  minutes,  and  then 
removing  it.  Should  the  hemorrhage  still  continue,  the  orbit  must  be  stuffed 
with  lint,  against  which  the  lids  being  supported  by  a  double-headed  roller 
going  around  the  head,  the  bleeding  is  completely  checked.  The  lint  may  be 
left  in  the  orbit  for  two  or  three  days. 

9.  It  occasionally  happens  that  a  disease  of  the  eyelids  has  extended  to 
the  eyeball,  or  that  a  disease  of  the  eyeball,  has  propagated  itself  to  the  eye,- 
lids,  and  that  the  eyelids  are  either  adherent  to  the  eyeball,  present  a  number 
of  irregular  prominences  and  fungosities,  or  have  become  affected  with  ulcera- 
tion. In  such  circumstances,  it  may  be  judged  necessary  to  remove  the  eye- 
lids as  well  as  the  eyeball.  In  this  case,  the  best  plan  is  to  divide  the  lids 
round  their  base,  including  all  the  diseased  parts,  then,  by  the  incision  thus 
formed,  pass  a  ligature  through  the  eyeball,  and  proceed  to  extirpate  the 
eyelids  and  eyeball  together.  It  is  amazing  how  rapidly  the  edges  of  the 
extensive  wound  left  after  this  operation,  close  in  upon  the  orbit,  and  ulti- 
mately cover  it  completely. 

10.  The  patient  must  be  kept  quiet,  fed  on  spoon-diet,  and  his  bowels 
carefully  attended  to.  In  general,  little  or  no  fever,  and  no  bad  effects  of 
any  kind,  follow  the  operation.  The  clotted  blood  which  fills  the  orbit 
dissolves,  granulation  follows,  and  the  cavity  is  partly  filled  by  newly  formed 
areolai'  tissue.  It  sometimes  happens,  however,  especially  if  lint  has  been 
left  within  the  orbit,  that  violent  imflammation  ensues,  followed  by  suppura- 
tion, within  that  cavity,  in  the  eyelids,  under  the  integuments  of  the  forehead, 
or  even  within  the  cranium.  Mr.  Travers  mentions  that  he  lost  a  patient,  a 
middle-aged  countryman,  otherwise  in  health,  within  a  fortnight  after  the 
operation,  owing  to  a  suppuration  of  the  dura  mater,  on  the  same  side  of 
the  head.  The  attack  of  inflammation  was  sudden  and  rapid,  commencing 
about  a  week  after  the  operation,  and  ushered  in  by  a  severe  rigor,  after 
imprudent  exposure  to  cold.^ 


TOO  ARCUS    SENILIS. 

11.  An  artificial  eye  can  rarely  be  used  with  good  effect  after  extirpation 
of  the  eyeball ;  never,  indeed,  if  the  eye  bad  naturally  been  large  and  promi- 
nent. If  it  had  been  small  and  sunk,  the  lids  narrow,  and  only  the  ball 
removed,  the  application  of  an  artificial  eye  may  in  some  degree  succeed. 
Dieffenbach  attempted  to  fill  the  orbit  by  a  flap  taken  from  the  temple,  and 
thus  form  a  cushion  for  an  artificial  eye.^ 


«  O'Ferrall,  Dublin  Journal  of  Medical  Sci-  "  Lancet,  October  21,  1851,  p.  386. 

ence  ;  Vol.  xix.  p.  355  ;  Dublin,  1841.  »  Synopsis  of  the  Diseases  of  the  Eye,  p.  309; 

^  Annales    d'Oculistique;    Tome  vii.  p.  30;  London,  1820. 

Bruxelles,  1842.  °  Journal  Complementaire  des  Sciences  Medi- 

'  lb.  p.  31.  cales;  Vol.  xl.  p.  391;  Paris,  1831. 


CHAPTER  XIX. 

ARCUS  SENILIS. 

Si/n. — Gerontoxon  externum  et  internum.     Marasmus  senilis  corueae  et  lentis.     Macula 
arcuata.     Arcus  senilis  adiposus,  Canton. 

Fig.  Ammon,  Thl.  L  Taf.  IX.  Fig.  22.  Taf.  VIL  Fig,  11.  Taf.  IX.  Figs.  1,  2.  Taf.  XIX.  Fig.  13. 

In  old  people,  the  cornea,  at  a  small,  but  variable  distance,  within  its 
circumference,  not  unfrequently  presents  an  opaque  ring  of  a  whitish  color, 
more  or  less  broad,  and  more  or  less  complete.  The  opacity  is  often  semi- 
lunar, and  is  situated  at  the  upper  or  lower  edge  of  the  cornea.  This  arcus 
senilis,  as  it  is  termed,  occurs  without  any  previous  inflammation,  and  has 
generally  been  ascribed  to  a  diminished  nutrition  or  marasmus  of  the  part. 
Mr.  Canton*  has  demonstrated,  what  appears  to  have  been  surmised,^  that  it 
is  a, fatty  degeneration,  innumerable  oil-globules  being  found  between  the 
layers  of  the  cornea  at  the  part  afi'ected,  on  submitting  a  thin  section  of  it  to 
the  microscope.  The  anterior  and  posterior  elastic  lamina?  are  entirely  free. 
A  somewhat  similar  opacity  is  occasionally  seen  in  young  people,'  but  this 
seems  to  depend  merely  on  an  unusual  overlapping  of  the  sclerotica,  or  on  a 
loss  of  transparency  from  atrophy  of  the  cornea.  Such  a  state  is  sometimes 
the  result  of  injury  and  inflammation,  and  in  the  course  of  years  may  become 
very  broad.  Instead  of  an  arched  form,  it  sometimes  presents  that  of  a  seg- 
ment of  a  circle,  or  of  two  segments  uniting  at  an  angle. 

An  arcus  senilis,  closely  examined,  is  seen  to  consist  of  two  arches  or  rings, 
the  outer  of  a  grayish-white  color,  and  which  seems  to  be  an  encroachment 
of  the  sclerotica  on  the  cornea;  the  other  of  a  milky  color,  which  is  the  result 
of  fatty  degeneration.  These  two  arches  are  separated  by  a  portion  of  cor- 
nea which  is  clear,  and  which,  while  it  seems  depressed,  is  probably  weaker 
than  natural,  for  I  have  known  it  burst  by  an  accidental  blow  with  the  person's 
own  thumb,  allowing  a  large  protrusion  of  iris.  The  inner  arch  sometimes 
encroaches  towards  the  centre  of  the  cornea,  so  as  to  leave  only  so  much  of 
it  uncovered,  as  corresponds  to  a  moderately  sized  pupil. 

Mr.  Canton  has  in  no  instance  found  arcus  senilis,  when  well  developed, 
unaccompanied  by  fatty  degeneration  of  the  muscles  of  the  eye,  and  of  the 
heart.  Arcus  senilis,  therefore,  in  cases  of  embarrassment  of  the  circulation 
and  respiration,  not  referable  to  any  other  lesion,  may  be  regarded  as  afford- 
ing some  ground  for  suspecting  the  muscular  fibres  of  the  heart  to  be  changed 


CATARACT.  101 

into  fat.  I  believe,  however,  that  many  cases  of  fatty  degeneration  of  the 
heart  occur,  without  any  accompanying  arcus  senilis. 

We  owe  to  Dr.  Ammon*  the  observation,  that  in  those  eyes  where  there  is 
an  arcus  senilis  of  the  cornea,  a  similar  opaque  ring  is  apt  to  exist  round  the 
margin  of  the  crystalline  body.  The  first  time  he  noticed  this,  was  in  the 
left  eye  of  a  woman  of  62  years  of  age.  The  lower  half  of  the  edge  of  the  cor- 
nea presented  an  arcus  senilis.  The  upper  half,  as  well  as  the  right  cornea, 
was  perfectly  transparent.  On  dissecting  the  left  eye,  Dr.  Ammon  was 
greatly  surprised  to  find  a  crescentic  opacity  of  the  lower  edge  of  the  lens, 
exactly  corresponding  to  the  arcus  senilis  of  the  cornea.  The  capsule  was 
perfectly  natural. 

Subsequent  investigations  by  Dr.  Schon^  have  shown  that  arcus  senilis  of 
the  crystalline  body  affects  the  posterior  capsule  more  frequently  than  the 
lens;  but  that,  in  some  instances,  both  the  posterior  capsule  and  the  lens 
are  partially  opaque,  the  opacity  corresponding  pretty  nearly,  in  form  and 
extent,  to  that  of  the  cornea.  The  opacity  at  the  edge  of  the  lens  is  partly 
formed  by  streaks  radiating  inwards.  _  No  arcus  senilis  appears  to  have  been 
detected  in  the  anterior  capsule.  In  several  cases  of  external  and  internal 
arcus  senilis,  Dr.  Schon  found  the  ophthalmic  artery  ossified. 

Such  opacities  of  the  crystalline  body  as  are  described  by  Ammon  and 
Schon,  Mr.  Canton  has  never  met  with  in  any  of  his  numerous  dissections. 
He  is,  therefore,  led  to  believe  their  occurrence  to  be  accidental. 

Arcus  senilis  has  not  been  regarded  as  of  much  importance  in  a  practical 
point  of  view,  except  with  regard  to  the  section  of  the  cornea,  in  extraction 
of  the  cataract.  A  broad  arcus  senilis  has  been  stated  as  an  objection  to 
extraction,  on  account  of  the  difficulty  with  which  the  incision  unites,  if  it 
be  carried  through  the  opaque  portion  of  the  cornea.  This  alleged  difficulty 
of  union,  however,  does  not  always  occur;  for  I  have  seen  the  section  of  the 
cornea  through  an  arcus  senilis  heal  with  perfect  facility. 


'  Lancet,  May  11,  1850,  p.  560;  January  11  of  the  orbieulus  ciliaris,  in  his  Darstellungen; 

and  18,  1S51,  pp.  35,  66.  Theil  i,  Taf.  i.  figs.  11,  12.     Dalrymple  gives 

^  Schon,   Amnion's  Zeitschrift  fiir  die  Oph-  a  figure  of   a  congenital  case  of   annular  en- 

thalmologie;   Vol.   i.  p.   162;   Dresden,  1831:  croachment  of  the    sclerotica;    PI.    XXXIV. 

Middlemore's  Treatise  on   the  Diseases  of  the  fig.  2. 

Eye;  Vol.  i.  p.  456;  London,  1835.  *  Griife  und  Walther's  Journal  der  Chirurgie 

^  Wardrop's  Morbid  Anatomy  of  the  Human  und  Augenheilkunde ;  Vol.  xiii.  p.  114;  Ber- 

Eye  ;  Vol.  i.  p.  88,  144,  PI.  L,  fig.  1.    PI.  VIL,  lin,  1829. 

fig.  3;    London,  1819.      Ammon  represents  a  '  Op.  cit.  pp.  119,  151. 
similar   opacity  as  the  result  of  inflammation 


CHAPTER   XX. 

CATARACT. 

Syn. — rxa^Kw/z-a,  Hippocrates.  "fTxLyyfxa.  n  lTTi)(ys-i<;  vypou,  Galen.  Suifusio,  Celsus.  Gutta 
opaca.  Aqu.'i ;  aqua  descenJens  in  oculo  ;  aquaj  descensus,  vel  cataracta,  Latino-bar- 
harous  translators  of  the  works  of  Albucasis  and  other  Arabians.  Caligo  lentis,  Cullen. 
Der  graue  Staar,  Germ. 

SECTION   I. — DEFINITION  AND  DIAGNOSIS  OF  CATARACT;  METHOD  OF  EXAMINING 

CASES  OP  THE  DISEASE;    CAUSES  AND  PROGNOSIS. 

By  the  terra  cataract^  is  understood  an  opacity  situated  between  the  vitre- 
ous humor  and  the  pupil. 


702  CATARACT. 

Enumerating  the  parts  so  situated,  we  hsixe,  ^first,  the  posterior  hemisphere 
of  the  crystalline  capsule;  secondly,  the  crystalline  lens;  and,  thirdly,  the  an- 
terior hemisphere  of  the  crystalline  capsule.  Any  of  these  parts  may  lose 
its  natural  transparency,  and  there  will  then  be  formed  a  capsular  or  a 
lenticidar  cataract,  according  as  the  opacity  is  seated  in  the  capsule  or  the 
lens.  Between  the  internal  surface  of  the  capsule  and  external  surface  of 
the  lens,  there  exists,  in  the  natural  state,  a  considerable  degree  of  adhesion, 
through  the  medium  of  the  intracapsular  cells  of  Werneck;  but  in  conse- 
quence of  disease,  the  natural  cohesion  of  the  lens  to  the  capsule  is  sometimes 
destroyed,  and  an  opaque  fluid  is  deposited  between  them,  forming  what  is 
termed  a  Morgagnian  cataract.  Any  opacity  situated  in  or  within  the 
crystalline  capsule,  is  termed  a  true  cataract,  and  it  is  evident  that  all  those 
above  enumerated  fall  under  this  denomination. 

Between  the  anterior  crystalline  capsule  and  the  pupil  lies  the  aqueous 
humor  of  the  posterior  chamber.  This  cannot  become  opaque,  without  the 
whole  of  the  aqueous  humor  being  similarly  affected ;  but  it  may  be  displaced 
by  an  opaque  substance;  such  as  coagulated  lymph,  pus,  blood,  or  pigment 
from  the  uvea.  Such  a  cataract  is  termed  spurious,  and  has  its  seat  loithout 
the  capsule. 

Practitioners  in  former  ages  were  of  opinion  that  cataract  was  owing  to 
the  effusion  of  a  humor  {vnox^rii.^  iypov)  between  the  uvea  and  the  crystalline, 
which,  becoming  gradually  consolidated,  covered  the  anterior  surface  of  the 
crystalline  in  the  msjnner  of  a  veil ;  and  that  sight  was  restored  by  depressing 
the  concreted  humor  with  the  needle.  The  erroneousness  of  this  opinion  was 
demonstrated,  in  the  course  of  the  seventeenth  century,  by  Lasnier,  Rolfiiik, 
Borel,  and  others,  dissection  showing  that,  while  a  membranous  or  spurious 
cataract  sometimes  forms  within  the  pupil,  true  cataract  is  an  opacity  of  the 
crystalline  body  itself. 

Whether  cataract  be  true  or  false,  the  opacity  of  a  part  naturally  trans- 
parent, necessarily  stops,  in  a  greater  or  less  degree,  the  light  which  should 
be  transmitted  through  the  interior  of  the  eye ;  the  impression  on  the  retina 
is  consequently  rendered  imperfect;  and  partial  blindness  ensues.  Cataract 
never  produces  total  blindness. 

When  the  terra  cataract  is  used  without  any  appellative,  lenticular  opacity 
is  generally  meant.  For  instance,  when  we  say  that  cataract  is  a  slow  disease, 
occupying  months  or  years  in  its  progress,  it  is  of  lenticular  cataract  that  we 
speak  ;  for  all  the  others,  and  especially  the  spurious  kinds,  may  be  the  pro- 
duct of  a  few  days  or  hours.  It  would  appear,  however,  that  even  lenticular 
cataract  is  sometimes  fully  developed  in  a  very  short  space  of  time.  Richter 
relates  a  case  in  which  cataract  was  formed  in  the  course  of  one  night.  A 
patient,  laboring  under  gout,  accidentally  exposed  his  feet  to  a  great  degree  of 
cold  during  the  night,  in  consequence  of  which  the  gout  reti'oceded,  and  he 
was  deprived  of  sight.^  Richter  saw  him  next  morning,  and  found  a  complete 
pearl- colored  cataract.^  Mr.  Wathan  was  of  opinion  that  blacksmiths,  and 
all  mechanics  who  work  near  large  fires,  were  more  subject  to  cataracts  than 
other  persons,  and  he  mentions  that  he  had  had  two  patients  who  were 
instantly  seized  with  cataract,  at  the  very  time  they  were  thus  employed.^  Dr. 
Mavtin,  of  Portlaw,  at  a  meeting  of  the  Surgical  Society  of  Ireland,  related 
two  cases  of  the  sudden  formation  of  lenticular  cataract.  The  one  occurred 
in  a  cachectic  woman,  who,  after  sitting  up  for  several  nights  with  her  invalid 
mother,  and  crying  a  great  deal,  awoke  one  morning  with  her  lenses  serai- 
opaque,  and  presenting  the  appearance  of  being  stellated  from  the  centre,  as 
if  breaking  up  during  maceration.  The  other  was  in  a  man,  who  having 
been  married  to  a  farmer's  daughter,  retired  to  bed,  after  the  usual  fun  of  an 
Irish  wedding,  his  eyes  being  perfect,  and  awoke  early  in  the  morning,  with 


DIAGNOSIS   OF   CATARACT.  703 

his  sight  greatly  impaired  from  cataracts.*  I  have  not  witnessed  any  such 
sudden  formation  of  cataract  in  eyes  previously  sound.  A  patient,  however, 
was  attending  at  the  Glasgow  Eye'  Infirmary,  with  glaucoma  and  amaurosis 
of  one  eye,  but  without  any  appearance  of  cataract,  and  was  present  as  usual, 
on  a  Monday  or  Wednesday,  the  eye  exhibiting  exactly  the  appearances  which 
it  had  done  for  some  months  before.  On  the  Friday,  I  was  surprised  to  find 
the  surface  of  the  lens  completely  opaque,  and  stellated  by  lines  radiating 
from  its  centre. 

Diagnosis. — It  is  of  much  importance  that  we  should  distinguish  incipient 
cataract  from  incipient  amaurosis.  In  the  fully  developed  state,  these  tM^o 
diseases  can  scarcely  be  confounded  by  any  one  in  the  least  acquainted  with 
the  diseases  of  the  eye  ;  but  in  the  early  stages,  such  a  mistake  may  readily  be 
committed,  and  may  be  productive  of  serious  bad  consequences.  For  example, 
if  a  patient  with  incipient  amaurosis  presents  himself  to  a  practitioner  who 
mistakes  the  case,  and  supposes  it  to  be  one  of  incipient  cataract,  the  advice 
which  he  will  give,  will  be  to  wait  with  patience  till  the  disease  be  fully 
developed,  and  then  to  submit  to  an  operation.  Should  the  patient  return  after 
some  months  with  a  fully  developed  amaurosis  instead  of  a  cataract,  the  practi- 
tioner would  necessarily  feel  that,  by  his  ignorance  or  inattention,  he  had  lost 
the  only  season  for  treating  an  amaurotic  affection  with  success.  The  opposite 
mistake  would  probably  lead  him  to  the  employment  of  depletion,  mercury, 
and  counter-irritation,  by  which  his  patient's  health  might  be  seriously  com- 
promised, but  which  could  have  no  effect  in  removing  an  incipient  opacity 
of  the  lens. 

The  symptoms  of  cataract  and  amaurosis,  as  indeed  of  all  diseases  whatever, 
are  subjective  or  objective ;  that  is  to  say,  they  consist  either  in  certain  feelings 
Avhich  the  patient  experiences,  as  impaired  vision,  headache,  giddiness,  &c.,  or 
in  certain  changes  which  the  observer  perceives  in  the  form,  col'or,  texture, 
consistency,  vascularity,  and  mobility  of  the  different  parts  of  the  organ  of 
vision.  Both  sets  of  symptoms  will  require  to  be  very  closely  examined  in 
suspected  cases. 

Subjective  or  physiological  signs. — 1.  As  to  the  impaired  state  of  vision 
which  attends  these  diseases  in  the  incipient  stage,  the  patient  affected  with 
either,  finds  a  difficulty  in  discerning  objects  with  distinctness.  In  cataract, 
this  difficulty  generally  increases  slowly  for  a  time,  and  is  compared  to  what 
might  be  produced  by  a  diffused  mist,  thin  cloud,  or  gauze,  intervening 
between  objects  and  the  eye,  and  gradually  becoming  thicker,  till  at  length 
it  becomes  so  thick  that  everything  seems  concealed  by  it;  whereas,  in 
amaurosis,  the  attack  is  often  sudden,  and  being  partial,  is  described  as  a 
dark  spot  or  spots,  occupying  certain  parts  only  of  the  field  of  view,  but 
rendering  vision  altogether  so  confused,  that  small  objects  cannot  be  distin- 
guished. With  common  muscce  volitantes,  or  floating  muscce,  as  they  are 
often  called,  neither  cataract  nor  amaurosis  has  any  connection.  The  dark 
spots  seen  in  amaurosis  are  what  are  called  j^'xer/  muscce,  and  when  the  eyes  are 
closed  and  shaded  from  the  light,  are  generally  replaced  by  shining  spectra.  It 
is  a  fact,  however,  which  strikingly  illustrates  the  uncertainty  which  attends 
the  diagnosis  of  cataract  and  amaurosis,  that  the  latter  not  unfrequently 
declares  itself  in  the  early  stage  by  the  sensation  of  a  gauze  or  mist  which, 
slowly  increasing  in  density,  at  length  totally  deprives  the  patient  of  sight. 
So  complete  a  degree  of  blindness  never  occurs  in  cataract.  That,  however, 
is  of  little  consequence,  so  far  as  the  diagnosis  in  the  incipient,  not  in  the 
advanced  stage  is  concerned. 

2.  We  generally  find  that  the  sensation  of  a  mist  or  cloud  is  perceived  most 
when  the  cataractous  patient  looks  straight  forward,  and  that  he  sees  con- 
siderably better  when  he  looks  sideways.     This  circumstance  might  appear 


^Oi  DIAGNOSIS   OF   CATARACT. 

likely  to  afford  ground  for  distinguishing  incipient  cataract  from  amaurosis, 
were  it  not  well  ascertained  that  also  those  who  begin  to  be  affected  with 
diminished  sensibility  of  the  retina,  are  in  many  instances  able  to  see  things 
placed  to  one  side,  much  better  than  what  stands  directly  before  them;  and 
that  some  in  whom  amaurosis  is  even  far  advanced,  continue  to  see  only  when 
they  look  inwards  or  outwards,  while  in  every  other  direction  they  see  very 
obscurely,  or  not  at  all.^ 

3.  The  different  degrees  of  light  in  which  those  affected  with  incipient 
cataract  or  amaurosis  see  best,  are  worthy  of  attention.  In  those  cases  in 
which  vision  begins  to  fail  from  diminished  sensibility  of  the  optic  nerve, 
there  is  in  general  a  desire  for  increase  of  light ;  when  the  patient  reads  with 
candle-light,  he  brings  the  book  close  to  the  candle  ;  and  his  period  of  most 
distinct  vision  is  noon-day,  when  objects  are  most  brilliantly  illuminated  by 
the  sun.  This  is  the  very  time  when  the  cataractous  patient  sees  worst.  So 
much  light  causes  the  pupil  to  contract,  fewer  rays  of  light  enter  the  eye, 
and  hence  vision  is  obscure  ;  but  in  the  twilight,  when  the  pupil  is  dilated, 
more  light  is  admitted,  and  the  patient  finds  his  vision  improved.  To  witness 
the  effects  of  moderating  the  intensity  of  the  light,  and  thus  allowing  a  greater 
quantity  of  it  to  penetrate  to  the  retina,  we  require  only  to  make  the  patient 
look  to  and  from  the  window.  In  the  former  position,  he  sees  perhaps  very 
little  ;  but  turn  his  back  to  the  light,  and  he  instantly  discerns,  more  or  less 
distinctly,  every  object  around  him.  Yet  even  this  must  not  be  absolutely 
depended  on.  We  meet  with  amaurotic  patients  to  whom  strong  light  is 
distressing,  and  who  see  best  with  a  moderate  degree  of  illumination. 

4.  To  the  patient  affected  with  incipient  amaurosis  the  flame  of  a  candle 
generally  appears  broken  and  confused,  iridescent,  and  spreading  out  into 
rays.  To  him  who  has  an  incipient  cataract,  a  candle  or  a  street  lamp  seems 
expanded  into  a  large  globe  of  weaker  light ;  it  looks,  to  use  the  phrase  of  a 
countryman  at  the  Glasgow  Eye  Infirmary,  as  if  "  every  lamp  was  as  big  as  a 
corn-sieve." 

5.  In  incipient  cataract,  the  patient  sometimes  sees,  with  one  eye,  objects 
multiplied.  Looking  at  the  moon,  for  instance,  he  sees  three  or  four  moons. 
This  does  not  occur,  I  think,  in  incipient  amaurosis,  although  diplopia,  with 
both  eyes  open,  is  common. 

G.  It  is  rarely  the  case  that  incipient  amaurosis  is  not  attended  by  a  variety 
of  other  subjective  symptoms  besides  failure  of  sight;  especially  by  headache, 
vertigo,  and  derangement  of  the  digestive  organs.  Incipient  lenticular  cata- 
ract most  frequently  occurs  without  any  such  combination  of  complaints. 

Ohjective  or  anatomical  signs. — 1.  The  gait  and  aspect  of  the  amaurotic 
patient  are  different  from  those  of  the  cataractous.  The  latter  approaches 
with  his  eyes  shaded  with  his  hand,  and  his  head  turned  downwards  and  to 
one  side,  so  as  to  dilate  his  pupils,  and  see  past  the  obstruction.  The  former 
stalks  on  with  a  vacant  expression,  looking  forwards  and  upwards.  There 
are  few  cases  of  amaurosis,  even  in  the  incipient  stage,  in  which  the  natural 
movements  of  the  eye  are  perfectly  retained.  No  impediment  of  this  kind  is 
present  in  cataract ;  the  patient  opens  the  eyes,  and  converges  them  towards 
objects  without  the  least  difficulty,  and  in  a  manner  perfectly  natural.  But 
in  almost  all  cases  of  amaurosis,  we  may  observe  a  want  of  direction  in  the 
eyes,  or  even  an  approach  to  strabismus. 

2.  The  mobility  of  the  iris  affords  a  valuable  ground  for  diagnosis  ;  for  in 
incipient  cataract,  the  pupil  contracts  and  expands  as  extensively  and  as 
vividly  as  in  the  healthy  state  of  the  eye  ;  whereas  in  incipient  amaurosis,  if 
the  pupil  is  not  already  dilated  and  fixed,  its  motions  generally  are  limited 
and  slow.  If  we  apply  belladonna  for  the  purpose  of  dilating  the  pupil,  in 
half  an  hour  this  is  fully  accomplished,  if  the  case  be  one  of  cataract;  but 


DIAGNOSIS   OP   CATARACT.  705 

after  several  hours,  there  is  often  but  little  dilatation  produced,  if  amaurosis 
be  present. 

3.  It  is  rarely  the  case  in  amaurosis,  even  in  its  incipient  stage,  that  the 
pupil,  except  in  young  subjects,  presents  the  jet-black  color  of  health.  The 
appearance,  however,  is  not  so  much  an  actual  opacity,  as  a  paleness,  or 
greenishness.  This  symptom  is  what  is  termed  glaucoma,  which  has  by  mis- 
take been  attributed  to  opacity  of  the  vitreous  humor.  Dissections  of  the 
eye  in  the  state  of  glaucoma  have  convinced  me  that  yellowness  of  the  central 
part  of  the  lens,  without  opacity,  is  the  cause  of  the  greenish  reflection  ;  that 
the  lens  has  in  fact  become  dichromatic,  reflecting  the  mean  rays  of  the  pris- 
matic spectrum,  and  hence  appearing  green  while  seated  in  the  eye  ;  but  on 
being  viewed  by  transmitted  light  out  of  the  eye,  showing  the  color  of  amber. 
I  am  speaking  of  incipient  glaucoma  ;  for  in  the  advanced  stage,  the  kernel 
of  the  lens  is  dry,  of  a  reddish-brown  color,  and  has  lost  in  part  its  transpa- 
rency. 

To  distinguish  glaucoma  from  cataract,  especially  in  the  incipient  stage, 
proves  to  beginners  one  of  the  most  difficult  pieces  of  diagnosis,  and  some- 
times not  to  beginners  only,  but  to  those  who  for  a  length  of  time  have 
attended  to  the  diseases  of  the  eye.  A  gentleman  was  sent  to  me  by  his 
brother,  a  medical  practitioner  in  the  country,  desirous  to  know  if  I  thought 
the  cataracts,  which  he  said  I  would  see  in  his  eyes,  Avere  ready  for  operation. 
The  disease  was  glaucoma,  with  a  great  degree  of  shortness  of  sight,  but 
without  any  cataract.  With  much  difficulty  could  I  convince  the  practitioner 
of  the  real  nature  of  the  case,  so  wedded  was  he  to  the  opinion  that  the 
appearance  which  he  saw  through  the  pupil,  was  cataract. 

Attention  to  the  following  circumstances,  will  in  general  enable  the  observer 
to  discriminate  between  glaucoma  and  cataract : — 

a.  The  cloudiness  in  glaucoma  is  always  of  a  gi'cenisli  liue :  ■whereas,  in  incipient  cat- 
aract, the  opacity  is  whitish,  or  of  the  bluish  tint  of  milk  and  water. 

^.  The  opacity  in  glaucoma  is  best  seen  when  we  look  directly  into  the  pupil;  and  dis- 
appears in  a  great  measure,  or  altogether,  when  we  look  sideways  into  the  eye.  In  cata- 
ract, the  opacity  is  seen  whether  we  look  sideways  or  directly. 

y.  In  glaucoma,  the  disease  appears  to  be  seated  at  a  considerable  distance  behind  the 
pupil,  or  even  deep  in  the  vitreous  humor ;  the  superficial  laminte  of  the  lens  are  evidently 
not  involved,  and  the  opacity  seems  surrounded  by  a  broad  transparent  ring.  In  lenticu- 
lar cataract,  the  opacity  evidently  affects  the  surface  of  the  lens,  is  close  behind  the  pupil, 
and  appears  bounded  by  the  edge  of  that  aperture.  In  posterior  capsular  cataract,  the 
opacity  is  deep  in  the  eye,  but  is  always  streaked;  whereas  the  glaucomatous  reflection 
is  always  uniform  ;  never  spotted,  nor  radiated. 

J.  When  we  examine  narrowly  the  surface  of  a  cataractous  opacity,  especially  while 
concentrating  the  light  upon  it  by  means  of  a  double-convex  lens,  it  generally  appears 
slightly  rough,  and  somewhat  dull;  in  these  respects  forming  a  striking  contrast  to  the 
smoothness  and  lustre  of  the  glaucomatous  opacity. 

e.  The  eyeball,  in  cases  of  amaurosis  combined  with  glaucoma,  always  feels  firmer  than 
natural ;  while  in  cataract,  it  presents  its  usual  degree  of  resistance  to  the  pressure  of 
the  finger. 

f.  Having  dilated  the  pupil  of  the  suspected  eye  by  means  of  the  extract  of  belladonna, 
or  the  solution  of  atropine,  the  crystalline  should  be  examined  catoptrically,  according 
to  the  method  of  Purkinje.  The  observer  and  the  patient  should  be  placed  in  a  room 
from  which  the  daylight  is  entirely  excluded ;  the  patient  should  be  seated  so  that  the 
observer  may  look  rather  down  into  the  eye  than  up  ;  a  candle  used  which  burns  steadily 
and  does  not  blaze  much ;  and  the  candle  shaded  by  the  hand  of  the  observer,  so  that  its 
light  does  not  fall  into  his  eyes. 

When  a  lighted  candle  is  held  before  a  healthy  eye,  at  the  distance  of  a  few  inches, 
three  reflected  images  of  it  are  seen,  situated  one  behind  the  other.  Of  these,  the  anterior 
and  posterior  are  erect,  the  middle  one  inverted.  The  anterior  is  the  brightest  and  most 
distinct;  the  posterior,  the  least  so.  The  middle  one  is  the  smallest.  The  anterior  is 
formed  by  the  cornea;  the  middle,  by  the  posterior  surface  of  the  crystalline  ;  tlie  poste- 
rior, by  its  anterior  surface.  In  the  formation  of  these  images,  the  cornea  and  the  ante- 
rior surface  of  the  crystalline  act  as  convex  mirrors ;  the  posterior  surface  of  the 
45 


706  DIAGNOSIS  OP   CATARACT. 

crystalline,  as  a  concaTe  mirror.  Tlie  focus  of  tbe  inverted  image  is  positive,  and  is 
situated  within  the  crystalline.  The  deep  erect  image  has  a  virtual  focus,  situated  in  the 
vitreous  humor.  The  superficial  erect  has  also  a  virtual  focus,  in  the  aqueous  humor. 
When  we  move  the  candle,  the  erect  images  move  in  the  same  direction ;  the  inverted  one, 
in  the  opposite  direction. 

In  cataract  and  glaucoma,  the  superficial  erect  image  which  is  formed  by  the  cornea, 
suffers  no  change.  Cataract,  even  at  an  early  stage,  obliterates  the  inverted  image,  and 
renders  the  deep  erect  one  very  indistinct.  Glaucoma,  only  when  much  advanced,  oblit- 
erates the  inverted  image ;  Avhile,  in  all  its  stages,  it  renders  the  deep  erect  one  more 
evident  than  it  is  in  the  healthy  eye. 

In  estimating  the  changes  which  occur  in  the  appearances  of  the  images  reflected  from 
the  eye  in  its  several  diseased  states,  it  is  necessary,  as  Dr.  Staberoh  has  remarked,^  to 
take  into  account  two  sources  of  these  changes ;  viz :  the  state  of  the  surfaces  which  form 
the  images,  and  that  of  the  media  through  which  we  see  them. 

The  following  particulars  are  worthy  of  careful  attention: — 

(1.)  In  incipient  glaucoma,  or  what  we  may  call  the  first  stage  of  the  disease,  both  the 
deep  erect  image  and  the  inverted  one  are  distinct.  The  deep  erect  image  is  rather 
larger  and  brighter  than  in  the  healthy  eye.  It  is  also  somewhat  of  a  yellow  hue. 
With  the  advance  of  glaucoma,  the  inverted  image  also  becomes  larger,  and  of  a  yellowish 
color.     Its  outline  becomes  sooner  diffused  than  that  of  the  deep  erect  image. 

(2.)  In  mean  cases,  or  what  we  may  call  the  second  stage  of  glaucoma,  the  inverted 
image  is  pretty  distinct,  when  formed  near  the  edge  of  the  crystalline.  If  it  is  the  right 
eye  which  is  the  subject  of  examination,  and  if  the  observer  moves  the  candle  towards 
the  right  side  of  the  patient,  the  inverted  image  will  be  seen  behind  the  nasal  edge  of 
the  pupil ;  but  if  the  candle  be  brought  slowly  in  fi'ont  of  the  eye,  the  inverted  image,  as 
it  moves  across  the  pupil,  is  seen  to  become  less  and  less  distinct,  and  in  some  cases  is 
altogether  extinguished;  till,  on  the  candle  approaching  the  patient's  left  side,  the  inverted 
image  reappears  behind  the  temporal  edge  of  the  pupil,  being  again  formed  by  the  cir- 
cumferential portion  of  the  posterior  capsule.  No  such  appearance  as  this  is  seen  in 
lenticular  cataract,  a  disease  which  speedily  affects  the  superficial  laminas  of  the  lens  in 
such  a  way  as  to  prevent  the  formation  of  the  inverted  image  by  any  part  of  the  posterior 
surface  of  the  crystalline  body.  The  extinction  of  the  inverted  image,  when  the  candle 
is  placed  directly  before  the  pupil  of  an  eye  affected  with  glaucoma  of  the  second  degree, 
is  owing  to  a  loss  of  transparency  in  the  kernel  of  the  lens,  which  suffers,  as  I  have 
already  mentioned,  a  peculiar  degeneration,  characterized  by  dryness  of  substance,  and 
a  reddish-brown  color. 

(3.)  In  complete  lenticular  glaucoma,  or  glaucoma  in  the  third  stage,  the  inverted 
image  is  no  longer  visible,  even  at  the  edge  of  the  lens. 

(4.)  The  deep  erect  image  is  better  seen  in  the  second  and  third  stages  of  glaucoma 
than  in  the  healthy  eye.  It  is  large  and  evident ;  but  its  outline  is  not  so  shai-p,  so  that 
it  often  appears  like  a  diffused  blaze.  The  fact  that  it  is  more  distinct  than  in  the  healthy 
eye  is  to  be  attributed  to  the  reddish-brown  kernel  of  the  lens  acting  as  a  foil  to  the  image. 

(5.)  In  incipient  lenticular  cataract,  the  inverted  image,  though  changed  neither  in  color 
nor  in  size,  is  indistinct,  and  its  outline  as  if  washed  off.  It  is  extinguished  before  any 
opacity  is  visible,  and  consequently  long  before  the  cataract  is  fully  developed  ;  a  fact  of 
the  greatest  importance  in  the  diagnosis  which  we  are  now  considering.  In  capsulo-len- 
ticular  cataract,  the  inverted  image  fsides  sooner  than  in  mere  lenticular  cataract ;  and 
even  when  the  capsule,  or  the  superficial  substance  of  the  lens,  seems  to  be  alone  opaque, 
the  inverted  image  disappears  much  sooner  than  might  be  expected  from  the  apparently 
moderate  degree  of  opacity. 

(6.)  In  lenticular  cataract  there  is  merely  a  general  reflection,  but  no  distinct  image, 
from  the  anterior  surface  of  the  crystalline  body. 

(7.)  If  the  lens  is  not  in  its  place,  but  has  been  absorbed  in  consequence  of  an  injury, 
been  removed  by  an  operation,  or  fallen  down  into  a  dissolved  vitreous  humor,  neither 
inverted  nor  deep  erect  image  is  formed. 

(8.)  In  the  diagnosis  of  incipient  cataract  and  incipient  amaurosis,  the  catoptrical  testis, 
in  ordinary  cases,  decisive  ;  for  in  amaurosis  uncombined  with  glaucoma,  the  three  images 
are  distinct,  while  even  in  the  early  stage  of  cataract  the  inverted  image  is  obscure  or 
extinct.  The  diagnosis  of  incipient  cataract  and  incipient  glaucoma  requires  the  catop- 
trical test  to  be  familiar  to  the  observer,  else  he  may  not  distinguish  that,  when  the  candle 
is  held  in  the  axis  of  the  eye,  the  inverted  image  is  indistinct  in  both  diseases  ;  but  when- 
ever it  is  moved  to  one  side,  it  becomes  distinct  in  glaucoma;  whereas  in  cataract,  it 
either  remains  as  obscure  as  before,  or  from  the  circumferential  part  of  the  lens  being 
more  affected  than  the  central,  it  is  obliterated. 

(9.)  It  must  not  be  omitted  to  be  stated,  that  there  are  cases  of  combined  cataract 


SYMPTOMS   OF   CATARACT.  707 

and  amaurosis,  which,  along  with  a  sluggish  pupil  and  very  deficient  vision,  present,  even 
in  an  early  stage,  no  inverted  image. 

( 10. )  Even  a  slight  degree  of  spurious  cataract  causes  obliteration  of  the  inverted  image. 
In  cases  of  this  sort,  I  have  known  the  inverted  image  totally  invisible,  till  after  the  free 
action  of  aloes  and  blue  pill  on  the  bowels,  and  smart  counter-irritation  behind  the  ears 
by  tartar  emetic  plasters  ;  by  which  means  absorption  was  probably  excited  of  some  thin 
stratum  of  deposit  in  the  pupil,  so  that  the  inverted  image  again  became  distinct,  along 
with  a  considerable  improvement  of  sight.  This  shows  the  propriety  of  having  recourse 
to  frequent  catoptrical  examination  of  the  eye  in  the  course  of  treating  such  cases. 

n.  Glaucoma  proceeds  in  general  very  slowly  in  its  course.  Years  pass  over  without 
much  more  appeai'ance  of  opacity  than  what  was  at  first  observed,  and  with  little  or  no 
further  loss  of  sight ;  while  in  cataract,  vision  generally  declines  rapidly,  keeping  pace 
with  the  growing  opacity. 

Circumstances  to  be  attended  to  in  cases  of  cataract. — To  ascertain  with 
accuracy  the  existence  of  cataract,  and  the  nature  of  any  cataract  which  may 
present  itself,  it  is  necessary  to  attend  minutely  to  the  following  circum- 
stances : — 

1.  The  opacity  ;  its  color,  extent,  form,  and  seat.  Whiteness  denotes  either 
a  dissolved  lens,  or  a  capsular  cataract ;  grayness,  a  lenticular  cataract ; 
amber,  or  dark  grayness,  that  the  lens  is  hard ;  light  grayness,  that  it  is  soft. 
If  the  whole  extent  of  the  pupil  is  uniformly  opaque,  the  cataract  is  lenticu- 
lar ;  if  the  opacity  is  streaked  or  speckled,  it  is  more  likely  to  be  capsular. 
If  opaque  streaks  radiate  from  a  centre,  it  is  probable  that  the  exterior  lamellae 
are  chiefly  affected,  or  that  the  posterior  hemisphere  of  the  capsule  is  the 
seat  of  the  disease ;  if  the  form  of  the  streaked  opacity  is  convex,  that  the 
anterior  hemisphere  of  the  capsule  is  the  part  affected ;  if  concave,  the  pos- 
terior hemisphere.  With  the  light  concentrated  on  the  pupil  by  means  of  a 
double-convex  glass,  all  these  particulars  are  carefully  to  be  ascertained. 

2.  The  iris  is  to  be  examined;  its  color,  mobility,  form,  situation,  and  the 
shadow  it  throws  upon  the  cataract.  Is  it  green,  or  otherwise  discolored,  de- 
noting previous  inflammation,  which  may  have  left  the  eye  in  a  state  unfavor- 
able for  any  operation  ?  Covering  the  eye  which  we  are  not  examining,  that 
all  sympathetic  motion  of  the  iris  may  be  avoided,  we  examine  whether  the 
pupil  moves  briskly,  and  extensively,  as  in  health  ;  or  slowly,  and  to  a  very 
limited  degree,  so  as  to  lead  to  the  suspicion  of  the  retina  being  imperfectly 
sensible.  Is  the  pupil  fixed  and  irregular,  as  if  adherent  to  the  capsule,  in 
consequence  of  eflused  lymph  ;  or  does  the  iris  tremble  on  every  motion  of 
the  eye,  an  appearance  denoting  a  paralytic  state  of  its  fibres,  attended  by  a 
dissolution  of  the  vitreous  humor  and  generally  by  amaurosis  ?  Is  the  iris 
convex,  and  nearer  to  the  cornea  than  natural,  an  unfavorable  circumstance 
for  the  operation  of  extraction  ?  Is  the  shadow  thrown  by  the  iris  on  the 
opaque  body  distinct,  or  is  there  no  shadow  ?  This  depends  on  the  distance 
of  the  opaque  body  from  the  iris,  or,  in  other  words,  the  depth  of  the  posterior 
chamber.  If  there  is  no  shadow,  the  posterior  chamber  is  probably  obliterated 
by  the  pressure  of  a  large  and  soft  lenticular  cataract.  If  the  shadow  is 
distinct,  the  lens  is  probably  small  and  hard;  and  at  any  rate  does  not  exceed 
its  normal  bulk.  Does  the  iris  preseut  a  funnel  shape,  the  pupil  being  drawn 
back  ?     This  appearance  denotes  that  the  lenticular  body  is  reduced  in  size. 

3.  The  eyeball  in  general  deserves  attention  ;  its  color,  degree  of  firmness, 
size,  and  place  in  the  orbit.  A  dingy  color  of  the  sclerotica  marks  ill  health, 
which,  of  course,  is  unfavorable  for  attempting  an  operation.  A  flexible  cornea 
or  sclerotica  marks  deficiency  of  vitreous  humor,  attended  by  amaurosis.  A 
stony  hardness  of  the  eye  denotes  glaucoma,  with  a  superabundance  of  dissolved 
vitreous  humor.  An  eye  considerably  below  the  medium  size  never  recovers 
more  than  a  very  imperfect  degree  of  sight.  A  very  prominent,  or  a  very  sunk 
eye,  is  unfavorable  for  extraction.  In  the  former  case,  if  the  section  of  the 
cornea  be  made  downwards,  the  lower  lid  tends  to  intrude  between  the  lips 


708  CAUSES   OF   CATARACT. 

of  the  wound,  and  keep  it  from  healing.     In  the  latter  case,  the  section  of 
the  cornea  necessary  for  extraction,  can  scarcely  be  performed. 

4.  The  degree  of  vision  must  be  carefully  examined,  both  as  denoting  the 
sentient  state  of  the  retina,  and  serving  to  determine  the  propriety  of  an 
immediate  operation.  If  the  patient  can  distinguish  the  objects  around  him, 
while  regarding  them  with  his  back  turned  to  the  light,  the  operation  ought 
to  be  deferred  till  the  sight  is  more  obscured.  If,  when  turned  to  the  light, 
he  distinguishes  the  shade  cast  by  the  hand  when  it  is  moved  before  him,  the 
retina  is  sensible,  and  the  operation  may  be  performed  with  some  prospect 
of  success.  If  he  sees  the  shadow  of  a  single  finger  cast  on  his  eye  at  the 
distance  of  12  inches,  the  retina  is  quite  healthy. 

5.  The  mobility  of  the  eye  is  a  point  of  considerable  importance.  A  squint- 
ing eye,  or  one  which  moves  readily  only  in  one  direction,  or  with  which  the 
patient  perceives  the  light  only  when  the  eye  is  turned  very  much  in  one 
direction,  is  not  likely  to  be  much  benefited  by  the  removal  of  a  cataract. 
The  operation  of  extraction  may  be  greatly  impeded  by  the  eye  being  in- 
capable of  moving  in  every  direction,  as  the  operator  may  desire. 

6.  The  age  of  the  person  affects  materially  the  consistence  of  the  lens, 
whether  in  health  or  disease.  Soft  in  childhood  and  in  youth,  firm  at  middle 
age,  hard  in  old  age,  the  lens  affected  with  opacity  may  readily  be  divided  in 
the  first  two  periods  by  the  needle,  and  will  dissolve  in  the  aqueous  humor, 
while  in  the  last  two,  these  processes  may  be  difficult  or  impracticable. 

7.  The  young  practitioner  ought  never  to  pronounce  absolutely,  even  on 
the  existence  of  cataract,  without  dilating  the  pupil  by  belladonna,  and 
examining  the  eye  catoptrically ;  and  the  most  experienced  may  derive  ad- 
vantage from  exposing  in  this  way  the  whole  field  of  the  disease  to  his  view, 
and  testing  the  state  of  the  crystalline.  Marginal  cataract  would  often  escape 
detection,  were  the  pupil  not  fully  dilated.  It  is  important  also  to  observe 
the  degree  of  celerity  with  which  the  pupil  yields  to  the  influence  of  bella- 
donna.  (See  p.  704.) 

Proximate  causes. — 1.  The  most  frequent  kind  of  cataract  is  that  which 
occurs  independently  of  inflammation  or  injury,  and  which  we  meet  with  so 
often  in  persons  far  advanced  in  life.  AVe  ascribe  this  variety  of  cataract  to 
a  defective  nutrition,  gradual  decay,  or  marasmus  of  the  lens.''  But  in  fact 
we  are  unacquainted  with  the  proximate  cause  of  this  sort  of  cataract.  Old 
age  is  certainly  not  its  sole  exciting  cause,  for  we  meet  with  it  in  young  per- 
sons and  even  in  infants.  The  process  has  been  supposed  to  begin  in  the 
central  part  of  the  lens,  at  the  greatest  distance  from  its  source  of  nourish- 
ment, and  to  spread  slowly  to  the  ambient  strata;  l)ut  this  is  certainly  incor- 
rect. If  we  examine  a  cataractous  lens  immediately  after  it  has  been 
extracted,  we  find  the  whitish  opacity  which  constitutes  cataract  and  has 
impeded  vision,  to  affect  principally  its  superficial  laminte ;  the  interior 
lamella?  being  generally  pretty  transparent,  although  often  presenting  the 
amber  or  the  reddish-brown  hue  of  glaucoma.  The  superficial  laminae  of  a 
cataractous  lens,  not  only  present  a  state  of  opacity,  but  appear  to  have 
undergone  a  peculiar  change,  which,  by  some,  has  been  compared  to  a  coagu- 
lation, and  by  others  to  a  necrosis,  and  which  is  entirely  wanting  in  the 
purely  glaucomatous  state  of  the  lens.^  In  cataract,  the  lens  also  loses  its 
natural  adhesion  to  the  internal  surface  of  the  capsule  ;  in  some  cases  a  fluid, 
arising  from  the  disintegration  of  the  superficial  lamina?,  is  deposited  within 
the  capsule  ;  while  in  others,  the  whole  lens  is  softened,  or  reduced  to  the 
condition  of  a  fluid. 

2.  Next  in  point  of  frequency  is  cataract  from  injuries.  These,  rupturing 
the  capsule,  will  admit  the  aqueous  humor  into  contact  with  the  lens.  Even 
the  smallest  puncture  of  the  capsule  will  bring  on  lenticular  cataract.     If 


CAUSES   OF   CATARACT.  ^09 

the  rupture  of  the  capsule  is  considerable,  in  four-and-twenty  hours  we  see 
a  considerable  portion  of  the  lens  opaque;  an  effect  attributed  to  the  coagu- 
lating influence  of  the  aqueous  humor. 

Should  the  rupture  of  the  capsule  remain  open,  the  whole  lens,  in  a  young 
subject,  may  dissolve  in  the  aqueous  humor,  be  absorbed,  and  thus  the  pupil 
clear.  In  this  case,  opaque  portions  of  the  capsule  often  remain  visible, 
although  by  the  dissolution  of  the  lens  a  considerable  share  of  vision  is 
restored.  If  the  wound  of  the  capsule  closes,  the  dissolution  of  the  lens 
ceases,  the  cicatrice  of  the  capsule  assumes  a  chalk-white  appearance,  and 
thus  a  particular  variety  of  capsulo-lenticular  cataract  is  formed. 

It  has  been  conjectured  that  the  capsule  is  occasionally  ruptured  in  that 
tetanic  state  of  the  eyes  which  attends  the  convulsions  of  young  children,  so 
that  the  aqueous  humor  being  admitted  within  the  capsule,  the  lens  becomes 
opaque.  In  some  cases,  a  blow  on  the  eye,  without  any  penetration  of  its 
tunics,  ruptures  the  capsule ;  while  in  others  cataract,  generally  attended  by 
amaurosis,  follows  a  blow  on  the  eye,  or  a  blow  or  fall  on  the  edge  of  the 
orbit,  without  any  apparent  rupture  or  dislocation.  This  effect  may  not 
show  itself  for  several  years  after  the  injury.    (See  Chapter  XII.  Section  iv.) 

3.  Inflammation  is  in  some  cases  the  proximate  cause,  not  merely  of  spu- 
rious, but  even  of  true  cataract.  Indeed,  anterior  and  posterior  capsular 
cataracts  may  be  compared  to  specks  of  the  cornea ;  while  in  some  instances, 
the  lens  also,  from  long-continued  inflammation,  becomes  opaque,  dissolves 
into  a  milk-like  fluid,  or  even  suppurates.  (See  Chapter  XIII.  Section  xxx.) 
Ossification  of  the  capsule  and  lens  is  another  termination  of  inflammation 
in  these  parts,  and  has  already  been  spoken  of,  at  page  649.  The  different 
varieties  of  iritis  are  sometimes  followed,  not  only  by  opacity  of  the  capsule, 
but  also  of  the  lens.  Such  cataracts  are  generally  attended  by  adhesion  of 
the  iris  to  the  capsule. 

4.  In  congenital  cataract,  it  is  supposed  that  the  lens  is  opaque  at  a  certain 
period  of  the  foetal  life,  and  that  an  arrest  of  development  leaves  it  so.  Beer's 
notion^  that  what  is  called  congenital  cataract  is  not  really  so,  but  arises  from 
exposing  the  eyes  to  too  much  light  after  birth,  is  disproved  by  the  fact  that 
we  find  the  disease  in  several  successive  children  in  the  same  family,  and  that 
it  is  observed  immediately  after  birth. 

Remote  and  predisposinfj  causes. — Many  of  the  remote  and  predisposing 
causes  of  cataract  must  have  escaped  detection  ;  but  the  following  are  more 
or  less  frequent  in  their  operation  : — 

1.  Old  age.  Of  500  cataract  patients  treated  by  Fabini,"  268  were  males 
and  232  females.     Their  ages  were  as  follows  : — 

From  1  to  10  years     .....         14 

16 

18 

18 

51 

102 

172 

109 

500 

The  disposition,  then,  to  cataract  is  small  before  the  age  of  40,  but  is  much 
increased  as  life  advances  beyond  that  period. 

2.  Hereditary  tendency.  Instances  are  not  uncommon  of  this  disease 
attacking  individuals,  one  of  whose  parents  or  near  ancestors  had  been  affected 
with  it,  about  the  same  period  of  life ;  while  in  other  instances,  several 
brothers  and  sisters  are  either  born  with  cataract,  or  possessing  a  congenital 


11 

"  20  " 

21 

"  30  " 

31 

"  40  " 

41 

"  50  " 

51 

"  60  " 

61 

"  70  " 

71 

upwards 

710  PROGNOSIS   OF   CATARACT. 

predisposition  to  the  disease,  become  cataractous  in  after-life,  and   about 
one  age. 

3.  Those  who  are  much  exposed  to  strong  fires,  as  glass-blowers,  forgeraen, 
cooks,  laundresses,  &c.,  are  supposed  to  be  more  frequently  than  others,  the 
subjects  of  this  disease. 

4.  In  the  early  years  of  my  practice,  I  met  with  a  greater  number  of  stock- 
ing-weavers, affected  with  cataract,  than  of  any  other  single  trade.  The 
disease  was  often  attended  in  those  persons  with  amaurosis.  Their  sedentary 
life,  and  the  intense  looking  at  an  object  in  motion,  which  their  occupation 
requires,  probably  caused  their  eyes  to  become  thus  diseased. 

5.  The  use  of  wine  and  spirituous  liquors,  but  especially  the  former,  appears 
to  favor  the  production  of  cataract,  which  is  a  common  disease  in  all  countries 
where  wine  is  so  cheap  as  to  be  the  habitual  beverage  of  the  low^er  order." 

6.  Cataract  is  said  to  be  frequent  among  the  Turks,  and  is  attributed  to 
the  constant  use  of  opium. ^^ 

7.  The  inhabitants  of  volcanic  countries,  as  Xaples  and  Sicily,  are  said  to 
be  very  subject  to  cataract. 

8.  The  sudden  application  of  cold  to  the  extremities  of  the  body,  so  as  to 
check  any  natural  or  morbid  effort  or  evacuation,  such  as  menstruation,  or  a 
paroxysm  of  gout,  is  apt  to  produce  cataract. 

9.  As  a  general  rule,  the  subjects  of  cataract  enjoy  good  general  health. 
They  complain  more  frequently  of  rheumatic  affections,  than  of  any  other ; 
dyspepsia,  pains  in  the  head,  and  giddiness,  not  unfrequently  precede  cataract, 
especially  in  women  ;  but  the  majority  of  cataractous  patients  have  not  been 
troubled  with  any  disease  of  importance. 

10.  I  have  in  three  instances  seen  lenticular  cataract  attack  women  of  from 
18  to  25,  laboring  under  diabetes  mellitus.  I  have  also  met  with  the  same 
complication  in  males,  at  a  later  period  of  life. 

General  prognosis. — The  prognosis  in  cases  of  cataract  must  vary  con- 
siderably according  to  the  particular  species  which  is  present,  the  local 
complications  of  the  disease,  and  the  age  and  general  health  of  the  patient. 

In  the  incipient  stage,  we  seldom  hesitate  to  prognosticate,  especially  if 
the  lens  itself  be  the  part  affected,  an  uninterrupted  increase  of  opacity  and 
decrease  of  vision,  till  a  perception  of  light  aud  shade  be  all  that  is  retained. 
Should  the  anterior  hemisphere  of  the  capsule  be  the  seat  of  partial  opacity, 
the  disease  may  remain  stationary  for  a  number  of  years,  or  through  the 
whole  of  life,  without  affecting  the  transparency  of  the  lens  ;  but  posterior 
capsular  cataract  rarely  continues  long  without  bringing  on  lenticular  opacity. 

With  regard  to  the  prognosis  inclusive  of  the  probabilities  of  eure,  practi- 
tioners are  too  much  in  the  way  of  raising  sanguine  hopes  in  the  minds  of 
patients  affected  with  cataract,  that  by  surgical  operations  on  the  eyes,  their 
sight  may  be  almost  perfectly  restored,  not  weighing  with  sufficient  consider- 
ation the  frequency  with  which  other  morbid  changes  in  the  organ  of  vision 
are  associated  with  this  disease,  especially  in  advanced  life,  such  as  dissolution 
of  the  vitreous  humor,  and  imperfect  insensibility  of  the  retina. 

The  dangers,  too,  attending  the  operations  for  cataract,  are  much  too  lightly 
estimated,  in  pronouncing  an  ultimate  prognosis.  The  risk  of  a  badly 
performed  operation,  and  that  of  disorganization  from  inflammation  and 
other  causes  after  even  the  best-performed  one,  are  too  much  kept  out  of 
view.  Much  depends  on  the  style  in  which  the  operation,  whatever  it  be,  is 
executed,  and  much  on  the  conduct  of  the  after-treatment.  Many  operators 
on  the  eye  seem  to  think  that  they  have  done  enough,  when  by  the  publication 
of  a  few  successful  cases,  they  have  persuaded  the  profession  and  the  public  of 
their  expertness ;  but  unless  the  circumstances  of  each  case  are  minutely 
detailed,  and  a  history  given,  not  of  select  cases,  but  of  every  case  occurring 


PROGNOSIS   OF   CATARACT,  Til 

during  a  year,  or  longer  period,  and  each  history  brought  down,  not  merely 
to  a  few  days  or  weeks  after  operation,  but  to  a  year  or  more,  no  conclusion 
can  be  drawn  regarding  either  the  abilities  of  the  operator,  the  merits  of  his 
particular  mode  of  operating,  or  the  general  success  of  operations  for  the  cure 
of  cataract.  Such  facts  only  as  the  following  are  capable  of  serving  as  data 
for  an  ultimate  prognosis  in  cataract : — 

1.  The  Royal  Academy  of  Surgery,  solicitous  to  know  the  truth  with  respect 
to  Daviel's  success,  applied  to  M.  Caque,  one  of  their  correspondents,  who 
resided  at  Rheims.  This  gentleman  by  a  letter  dated  15th  January,  1*753, 
informed  them,  that  Daviel  had  there  operated  on  34  cases  ;  17  of  which  were 
perfectly  restored  to  sight,  8  saw  indifferently,  and  9  received  no  benefit." 

2.  In  June  1153,  La  Faye,  Poyet,  and  Morand,  operated  the  same  day 
upon  19  cataracts ;  the  two  former  by  extraction,  although  each  according  to 
his  own  method  ;  Morand,  by  depression.  Of  those  operated  on  by  La  Faye, 
two  saw  well,  two  indifferently,  and  two  received  no  benefit.  Two  of  Poyet's 
cases  saw  well,  two  less,  one  could  discover  only  daylight,  and  two  nothing. 
Three  of  Morand's  patients  could  see  tolerably  well,  and  three  remained  as 
dark  as  before." 

3.  Mr.  Sharp,  in  a  paper  read  before  the  Royal  Society,  22d  November, 
1753,  gives  an  account  of  his  having  performed  the  operation  of  extraction 
on  19  eyes,  with  about  half  of  which  he  had  what  he  thought  tolerable  success  ; 
though  he  grants  that  not  a  single  one  escaped  a  considerable  degree  of 
inflammation.'^ 

4.  Dr.  Tartra*^  has  published  the  results  of  the  operations  for  cataract, 
performed  in  the  Hotel  Dieu  at  Paris,  from  the  commencement  of  1806  to 
1810  inclusively.  The  total  number  of  cases  was  113,  70  of  which  were 
extracted,  and  43  displaced;  19  of  the  70  extractions,  and  24  of  the  43  dis- 
placements were  successful ;  6  extractions  aud  4  displacements,  were  followed 
by  partial  success  ;  8  extractions  and  5  displacements,  were  total  failures ; 
and  the  results  of  the  rest  were  either  unknown,  or  more  or  less  unfavorable. 
Dr.  Tartra  observes,  that  by  adding  to  the  43  successful  cases,  the  other  10, 
where  the  operation  was  attended  by  partial  success,  it  appears  that  nearly 
half  the  patients  operated  on  obtained  a  greater  or  less  degree  of  sight.  He 
adds  that  it  is  generally  thought  that  two  out  of  five  patients  operated  on  for 
cataract  recover  their  sight. 

5.  During  the  year  1830,  the  autumn  of  1832,  and  the  spring  of  1833, 
Professor  Roux  operated  by  extraction,  on  115  patients,  and  179  eyes,  at  the 
Gharite  in  Paris,  with  the  following  results  : — • 


40  men, 
3  women. 
2  men, 
5  women. 


73  patients  recovered  sight,  yiz.  .      \  oo 

97  operations  succeeded,  in  •      \  at 

r-n  L-        c  •^    T    •  f  32  men, 

/  2  operations  failed,  in      .  •      ■{  tn 

^  '  1. 40  wome 

10  partially  succeeded,  in  .  -      \  a         ' 
^           J                  '  (^  4  women 


Professor  Roux  was  successful  then,  in  somewhat  more  than  five  out  of 
every  eight  patients  on  whom  he  operated,  and  in  somewhat  less  than  five  out 
of  every  nine  eyes.*^ 

Such  is  a  specimen  of  the  data  on  which  to  found  a  prognosis  of  the  cure 
of  cataract  by  operation,  furnished  from  the  practice  of  general  surgeons, 
some  of  whom  were  probably  not  very  minutely  acquainted  with  the  diseases 
of  the  eye,  nor  particularly  skilful  in  the  operations  for  cataract,  or  the  after- 
treatment.  In  the  practice  of  one  thoroughly  acquainted  with  eye-diseases, 
able  to  discriminate  the  cases  fitted  for  extraction,  and  those  fitted  for  division, 


712 


GENERA  AND   SPECIES   OF   CATARACT, 


able  to  perform  those  operations  well,  and  careful  and  skilful  in  the  after- 
treatment,  I  should  think  three-fourths  of  those  operated  on  would'  recover 
useful  vision,  and  two-thirds  excellent  vision.'* 

The  constitution  of  the  patient,  as  well  as  the  state  of  his  eyes,  bears 
strongly  on  the  probabilities  of  an  operation.  In  a  scrofulous  or  an  arthritic 
subject  for  example,  or  in  one  whose  nervous  and  circulating  systems  are 
impaired  by  the  use  of  wine  or  spirits,  opium  or  tobacco,  an  operation  for 
cataract,  on  account  of  the  danger  of  inflammation,  is  not  nearly  so  likely  to 
be  successful  as  in  a  healthy  person.  An  eye,  which  at  any  previous  period, 
has  suffered  from  serious  disease,  as  smallpox,  scrofulous  ophthalmia,  iritis, 
and  the  like,  is  not  likely  to  be  benefited  by  an  operation  for  cataract. 


'  The  word  x*T*pp'a'KT«c  was  never  used  by  the 
Greeks  to  signify  a  disease.  The  application  of 
the  Lntin  word  catdt-acta  to  a  disease  of  the  eye 
arose  in  the  following  way; — Galen's  nnme  for 
the  disease  in  question  was  vTr'-.yjj^*.  or  Cto^v- 
aic  uypov,  that  is  to  saj',  "  a  sutfiijion  or  flowing 
down  of  a  humor;"  the  Araliians  translated 
this  by  words  which  their  Latino-barbarous 
translators  rendered  literally  by  "aqua;  de- 
scensus," from  which,  as  a  synonym,  arose 
"cataracta."  In  one  of  the  Latin  editions  of 
Albucnsis,  a  chapter  is  entitled,  "  De  Cura  AquiB 
quaB  descendit  in  oculo,  vel  Cataracta."  Bit 
Cange  refers  us  to  the  "Acta  Sanctorum"  for 
the  use  of  the  word  cataracta  as  signifying  a 
disease  of  the  eye. 

*  Treatise  on  the  Extraction  of  the  Cataract; 
translated  from  the  German;  p.  3;  London, 
1797. 

^  Dissertation  on  the  Theory  and  Cure  of  the 
Cataract,  p.  12  ;  London,  1785. 

*  Dublin  Medical  Press,  May  4,  1842;  p.  274. 
'  See  Hey,  Medical  observations  and  Inquir- 
ies; Vol.  V.  p.  27;   London,  1 770. 

'  Medical  Gazette;  Vol.  xxi.  p.  107;  Lon- 
don, 1838. 

'  I  have  noticed,  on  dissection,  that  the  len- 
ticular cataract  of  old  persons  is  occasionally 
attended  by  ossification  of  the  arteries  of  tlie 
brain.  Is  it  frequently  so  accompanied  ?  If 
frequently,  are  these  two  morbid  changes  con- 
nected? 

'The  aid  of  the  microscope,  and  of  chemistry, 
has  been  invoked  to  explain  the  proximate  cause 
of  lenticular  opacity. 

Rather  than  opacity  of  the  fibres  themselves, 
Dr.  Rainy  found  white  opaque  grains  deposited 
between  them.  Mr.  Jones,  in  an  old  subject, 
found  the  fibres  shrivelled  and  irregular.  In 
hard  cataract,  Lebert  (Lancet,  December  27, 
1851,  p.  604)  observed  an  opaque  granular  sub- 
stance between  the  lamella;,  which  were  horny 
and  atrophied.  In  soft  cataract,  he  found  an 
effusion  into  the  intracapsular  cells,  of  a  milky 
fluid,  in  which  crystals  of  choleaterin  were  dis- 


tinguished ;  the  lamellae  being  softened  and 
hypertrophied.  Davaine  found  (Gazette  Me- 
dieale  de  Paris,  December  4,  1852,  p.  777)  the 
fibres  eroded,  their  calibre  diminished,  their  sur- 
face no  longer  polished,  but  uneven,  like  that 
of  a  file,  their  transparency  much  changed,  and 
their  texture  falling  into  pieces  much  more 
readily  than  usual.  Vogel  (London  Medical  Ga- 
zette, Vol.  i.  for  1845,  p.  6)  found  the  fibres  tur- 
bid and  opaque,  especially  towards  the  centre  of 
the  lens,  lie  never  detected  any  foreign  opaque 
substance  deposited  between  the  fibres. 

Wurzer  and  Lassaigne  (Simon's  Animal 
Chemistrj',  translated  by  Day,  Vol.  ii.  p.  420, 
London,  1846)  say,  that  the  lens,  in  cataract, 
contains  an  excess  of  phosphate  of  lime.  Si- 
mon remarks  that  this  may  be  the  cause  of  the 
opacity ;  or  that  the  opacity  may  be  due  to  the 
coagulation  of  the  protein  compounds  con- 
tained in  the  lens  by  the  presence  of  a  free 
acid. 

'  Das  Auge,  p.  68;  Wien.  1S13. 

'"  (jriife  und  Walther's  Journal  derChirurgie 
und  Augenheilkunde ;  Vol.  xiv.  p.  545;  Berlin, 
1820, 

* '  "  Saure  Weine  veranlassen  Staarblind- 
heit." — Soemmern'nt). 

'*  Reveillee-Parise,  Hygibne  Oeulaire,  p.  25  ; 
Paris,  1823. 

'"  Mcmoires  de  I'Acadcmie  Royale  de  Chi- 
rurgie  ;  Tome  v.  p.  397;  Paris,  1787. 

"  Ibid.  Tome  vi.  p.  332. 

"  Philosophical  Transactions  for  1723;  Vol. 
xlviii.  Part  i.  p.  322;  London,  1754. 

"  De  rOperation  de  la  Cataracte,  p.  83; 
Paris.  1812. 

' ''  Essai  sur  quelques  Points  de  I'llistoire  de 
la  Cataracte;  parTheodoreMaunoir;  pp.  78,84; 
Paris,  1833. 

"  On  the  Statistics  of  Operations  for  Cat- 
aract, see  Jager,  Monthly  Journal  of  Medical 
Science,  September,  1847,  p.  198:  Dalrymple's 
Pathology  of  the  Human  Eye,  Explanation  of 
PI.  xxvii. :  Dinge,  Archives  d'Ophthalmologie  ; 
Tome  ii.  p.  5;  Paris,  1854. 


SECTION  II. — GENERA  AND  SPECIES  OF  CATARACT. 

The  most  important  classification  of  cataracts  is  that  which  arranges  them 
into  true  and  spurious ;  the  true  having  their  seat  i>i  or  wiihin  the  crystalline 
capsule,  and  the  spurious  without.     The  distinction  of  the  genera  and  species, 


GENERA   AND    SPECIES   OF   CATARACT.  113 

admitted  under  each  of  these  classes,  is  founded  either  upon  the  particular 
part  affected,  or  particular  substance  forming  the  impediment  to  vision. 

True  cataract  frequently  exists  without  any  complication  ;  spurious  cataract 
is  always  combined  with  other  morbid  changes  in  the  eye. 


CLASS  I.— TRUE  CATARACTS. 

GENUS  I. — LENTICULAR  CATARACT. 

Fiq.  Wardrop,  PI.  XI.  Fij;.  3.  PL  XII.  Fi?.  3.  Beer,  Band  II.  Taf.  III.  Y\%.  1.  Ammon, 
Thl.  I.  Tiif.  IX.  Fia;?.  12-15.  Tnf.  X.  Figs.  5,  6.  Taf.  XI.  Fij^s.  11-U,  16-:^7,  40-46.  Dal- 
ryinple,  PI.  XXV.  PI.  XXVI.  PI.  XXVII.  Figs.  1,  2,  3.  Sichel,  PI.  XIV.  PI.  XV.  Figs.  5, 
6.  PI.  XVII.  1,  2,  5.  Pi.  XVIII.  Fig.  4. 

Opacity  affecting  only  the  lens  is  the  most  frequent  kind  of  cataract.  Its 
color  and  consistence  vary  according  to  the  period  of  life  at  which  it  occurs. 
In  old  persons,  in  whom  it  is  most  common,  the  opacity  is  generally  of  a 
pretty  dark  ash  color,  tending  sometimes  to  yellowish  or  amber  ;  in  younger 
subjects,  it  is  often  of  the  hue  of  half-boiled  white  of  egg  ;  in  children,  still 
lighter,  and  approaching  more  to  the  color  of  milk  diluted  with  water. 

In  young  persons,  in  whom  the  lens  is  soft,  its  whole  substance  often 
appears  cataractous;  in  the  old,  in  whom  the  lens  is  hard,  generally  only  the 
surface,  and  chiefly  the  anterior  surface,  is  affected  with  cataract,  the  rest 
being  of  a  turbid  amber  color.  In  middle-aged  subjects,  the  external  half 
of  the  cataractous  lens  is  not  unfrequently  whitish,  and  so  soft  that  it  mixes 
with  the  aqueous  humor,  when  acted  on  by  the  needle,  while  the  central  half 
is  hard  and  amber  coloi'ed. 

The  opacity,  viewed  in  the  eye,  generally  appears  uniform  in  color,  and 
presents  itself  equally  behind  the  whole  field  of  the  pupil.  Sometimes  it  has 
a  pearly  shining  appearance;  occasionally  it  is  marked  by  radii,  stretching 
from  its  centre  towards  its  circumference,  the  lens  already  tending  to  break 
into  such  divisions  as  we  see  it  fall  into  when  left  to  putrefy  or  to  undergo 
desiccation.  Such  a  lens,  even  in  an  old  person,  is  apt  to  break  into  frag- 
ments, under  the  needle.  It  is  not  an  uncommon  appearance  to  see  opaque 
stria3,  stretching  from  the  circumferenee  of  the  lens  a  short  way  into  its 
substance.  Mr.  Dixon*  considers  the  ordinary  formation  of  cataract  in  elderly 
persons  to  be  in  strice,  proceeding  from  the  circumference  of  the  lens  towards 
the  poles.  If  such  striaj  run  upon  the  back  of  the  lens,  they  seem  to  be 
situated  in  the  vitreous  humor;  Ijut  this  is  an  optical  illusion.  One  variety 
may  be  called  cortical,  the  edge  of  the  lens  being  fringed  with  dense  opaque 
spots,  whence  strife  proceed  over  the  anterior  and  posterior  surfaces,  while  the 
nucleus  is  more  or  less  transparent.  The  anterior  surface  of  the  opaque  lens 
appears  plain,  or  slightly  convex,  and  at  a  sufficient  distance  behind  the  pupil, 
to  permit  a  shadow  to  be  cast  on  it  by  the  iris. 

A  lenticular  cataract,  after  it  is  extracted  from  the  eye,  always  appears 
less  white  and  more  of  an  amber  color,  than  it  did  while  in  the  eye.  Some 
are  of  a  mahogany  color,  and  extremely  hard.  I  have  seen  a  few  cases  of 
lenticular  cataract,  in  which  the  opacity  was  so  very  dark  that,  without  close 
examination,  the  disease  might  have  passed  without  detection.  On  concen- 
trating the  light  on  the  pupil,  the  opacity  appeared  striated.  Such  cases 
have  been  called  black  cataracts."^  I  have  not  seen  the  lens  after  it  was  ex- 
tracted, in  any  of  those  cases. 

Lenticular  cataract  has  rarely  any  influence  on  the  motions  of  the  pupil, 
being  scarcely  ever  so  large  as  to  obliterate  the  posterior  chamber  and  press 
against  the  iris.     I  have  met  with  cases  of  cataract,  in  which  the  pupil  was 


tl4  GENERA   AND    SPECIES   OF   CATARACT. 

fixed,  althongli  the  retina  was  sound.  The  pupil  dilated,  however,  under 
belladonna.  The  eyeball  is  in  general  healthy,  except  in  old  people,  in  whom 
opacity  of  the  lens  is  often  accompanied  by  a  fluid  state  of  the  vitreous  humor. 
The  patient  is  never  totally  deprived  of  sight  by  lenticular  cataract.  In  by 
far  the  greater  number  of  cases,  he  continues  to  distinguish,  not  only  light 
and  shade,  but  even  bright  colors;  and  in  the  twilight,  when  the  pupil  ex- 
pands, he  often  discovers  the  forms  of  large  objects.  On  entering  a  bright 
light,  he  sees  none ;  and  in  some  rare  cases,  the  opacity  is  so  dense  to  the 
very  circumference  of  the  lens,  that  even  light  and  shade  are  distinguished 
with  difficulty 

Lenticular  cataract  is  the  most  favorable  for  operation,  and  a  pure  case  of 
it  with  a  lively  pupil,  and  an  ordinarily  prominent  eye,  ought  always  to  be 
selected  by  the  young  operator,  for  his  first  extraction. 

GENUS  II. — CAPSULAR  CATARACT. 
Syn. — Cataracta  membranacea. 

Species  1.     Anterior  Capsular  Cataract. 

Fig.  Wardrop,  PI.  XL  Fig.  4.  PI.  XII.  Fig.  1.     Beer,  Band  II.  Taf.  III.  Fig.  2.     Ammon,  Thl. 
I.  Taf.  IX.  Figs.  6-10.  Taf,  XI.  Figs.  4,  7,  8.     Sichel,  PI.  XXIII.  Fig.  6. 

The  anterior  hemisphere  of  the  capsule  is  much  thicker,  and  more  con- 
sistent than  the  posterior ;  it  exactly  resembles  the  lining  membrane  of  the 
cornea,  and  like  it  possesses  an  elasticity  of  texture,  by  which,  when  lacerated 
or  freed  from  its  natural  connections,  it  rolls  itself  together,  like  a  piece  of 
parchment  or  goldbeater's  leaf.  It  is  much  more  subject  to  opacity  than  the 
posterior  hemisphere,  and  is  often  partially  opaque  when  the  posterior  is 
transparent.^ 

The  opacity  in  anterior  capsular  cataract  is  never  uniformly  diffused  like 
lenticular  opacity,  but  always  streaked  or  spotted;  and  is  generally  of  a 
chalky  or  pearl-white  color.  Sometimes  there  is  only  one  spot;  in  other 
cases,  there  are  many.  They  are  very  irregular  in  form  and  disposition ; 
some  of  them  stretching  from  the  edge  of  the  capsule,  others  occupying  its 
centre.  In  some  cases,  we  observe  a  single  pyramidal  speck  projecting  from 
the  centre  of  the  capsule.  On  operating,  I  have  sometimes  found  those 
specks  to  separate  readily  from  the  capsule,  on  being  touched  with  the  needle, 
and  to  fall  forward  through  the  dilated  pupil  into  the  anterior  chamber.  In 
most  cases,  however,  the  deposition  appears  to  be  in  the  membrane,  not  on 
it  merely ;  its  texture  is  thickened  and  opaque  throughout. 

The  loss  of  sight  may  be  greater  or  less  than  in  lenticular  cataract,  de- 
pending partly  on  the  place  and  extent  of  the  specks,  partly  on  coincident 
changes  in  the  eye.  Not  unfrequently  so  much  vision  is  preserved,  that  it 
would  be  unwarrantable  to  operate. 

As  we  have  reason  to  believe  that  anterior  capsular  cataract  is  in  almost 
all  instances  the  result  of  inflammation,  we  might  expect  to  find  it  frequently, 
or  always,  conjoined  with  marks  of  iritis.  Yet  this  is  rarely  the  case.  The 
nutrition  of  the  anterior  hemisphere  of  the  capsule  is  derived  chiefly  from  the 
ciliary  processes,  and  not  from  the  iris.  Anterior  capsular  cataract  often 
continues  for  many  years,  or  for  life,  without  leading  to  lenticular  opacity. 

Species  2.     Posterior  Capsular  Cataract. 

Fig.  Ammon,  Thl.  I.  Taf.  XI.  Figs.  3,  5. 

Opacity  of  the  posterior  hemisphere  of  the  crystalline  capsule  is  much 
rarer  than  that  of  the  anterior.     An  opaque  state  of  the  posterior  capsule  is 


GENERA   AND    SPECIES    OF   CATARACT.  ^15 

much  more  apt  than  a  similar  condition  of  the  anterior,  to  superinduce  opacity 
of  the  lens.  When  it  does  so,  the  ultimate  changes  of  the  posterior  hemi- 
sphere of  the  capsule,  are  of  course  hid  from  our  view.  In  an  instance  which 
came  under  my  observation,  posterior  capsular  cataract  occurred  suddenly  in 
both  eyes,  in  consequence  of  stoppage  of  the  menses  from  cold,  and  was 
speedily  followed  by  lenticular  opacity. 

The  opacity,  in  posterior  capsular  cataract,  is  never  uniformly  diffused,  but 
always  exhibits  the  form  of  radiating  lines,  proceeding  from  the  centre  of  the 
affected  membrane.  The  ground  upon  which  these  opaque  lines  are  placed, 
is  evidently  concave,  while  the  lines  themselves,  being  seen  through  the  crys- 
talline, have  a  watery  dull  aspect,  which  forms  a  striking  contrast  to  the  sharp 
chalky  whiteness  of  the  specks  in  anterior  capsular  cataract.  Occasionally 
both  hemispheres  of  the  capsule  are  the  seat  of  partial  opacity,  the  lens  re- 
maining transparent.  I  have  known  this  state  continue  in  both  eyes  for  more 
than  eight  years,  without  producing  lenticular  opacity.  Both  hemispheres 
were  streaked  with  opaque  lines.  When  the  pupils  were  in  their  natural  state, 
the  patient  saw  very  little,  but  during  all  the  period  above  mentioned  she  was 
in  the  use  of  a  vinous  solution  of  belladonna,  which  she  generally  dropped 
every  morning  upon  the  eyes.  This  remedy  never  appeared  to  lose  its  effect 
and  the  patient  fully  appreciated  its  value. 

Posterior  capsular  cataract  has  no  influence  on  the  pupil;  but  I  have  once 
or  twice  observed  it,  combined  with  amaurosis,  and  in  these  cases  the  iris 
was  inactive.  I  have  repeatedly  met  with  it  without  any  complication  what- 
ever. 

Vision  is  impaired  by  this  cataract  in  very  various  degrees,  the  patient  being 
able,  in  some  cases,  to  read  with  the  aid  of  a  magnifying  glass;  while  in  other 
instances,  he  is  almost  deprived  of  sight. 

GENUS  III. — MORGAGNIAN  CATARACT. 

Syn. — Cataracta  lactea.     Cataracta  puriformis.     Cataracta  fluido-dura. 

Fig.  Beer,  Band  11.  Taf.  III.  Fig.  3.     Sichel,  PI.  XVII.  Figs.  3,  4,  6. 

The  deposition  of  an  opaque  fluid  between  the  lens  and  its  capsule,  arising 
from  a  disintegration  of  the  intra-capsular  cells,  or  of  the  superficial  laminae 
of  the  lens,  constitutes  the  incipient  stage  of  Morgagnian  cataract.  In  the 
advanced  stage,  a  considerable  portion  of  the  exterior  laminte  of  the  lens  is 
reduced  to  a  fluid  state,  and  not  unfrequently  capsular  opacity  is  added,  so 
that  the  disease  becomes  capsulo-lenticular. 

So  long  as  it  consists  in  a  mere  layer  of  deposition  between  the  capsule 
and  lens,  the  cataract  presents  a  cloudy  appearance,  as  if  formed  of  milk  and 
water  imperfectly  mixed.  It  is  stated,  that  if  the  eyeball  in  this  state  is  re- 
peatedly rubbed  with  the  finger,  through  the  medium  of  the  eyelid,  the  clouds 
of  opacity  change  their  outline  and  position;  and  sometimes  they  do  so, 
merely  on  quick  motion  of  the  eye  from  side  to  side. 

The  capsule  is  sometimes  distended  in  cases  of  Morgagnian  cataract,  and, 
pressing  against  the  iris,  obliterates  the  posterior  chamber,  and  impedes  the 
motions  of  the  pupil. 

When  the  disease  is  incipient,  vision  is  sometimes  but  slightly  impaired, 
only  small  objects  escaping  the  observation  of  the  patient,  and  this  especially 
after  the  eye  has  been  rubbed  or  moved;  but  in  the  advanced  stage,  when  a 
great  portion  of  the  lens  is  dissolved,  the  sight  is  limited  to  the  perception  of 
light  and  shade. 

Beer  observes,  that  this  disease  is  sudden  in  its  accession.  The  only  cause 
he  had  known  to  operate  apparently  in  its  production,  was  exposure  of  the 


716  GENERA  AND    SPECIES   OF   CATARACT. 

eyes  to  the  evaporation  of  mineral  acids,  during  tlie  oxidation  of  metals.  The 
only  instance  of  the  disease,  in  the  incipient  stage,  which  I  have  seen,  was  in 
a  lady,  who  embarked  at  Liverpool  with  her  sight  perfect,  was  very  sick  during 
her  passage  to  Greenock,  and  next  day  landed  there  with  a  cataract  in  one  of 
her  eyes,  such  as  1  have  not  observed  in  any  other  case,  and  which  corresponded 
to  the  description  of  commencing  Morgagnian  cataract,  except  that  I  could 
see  no  change  in  the  form  of  the  opacity  upon  rubbing  the  eye. 

Incipient  Morgagnian  cataract  is  not  to  be  touched  in  the  way  of  operation ; 
and  may  perhaps  be  curable  by  antiphlogistic  means,  if  attended  to  sufficiently 
early. 

Morgagnian  cataract,  in  the  advanced  stage  is  known  by  the  name  of  cata- 
racta  Jiuido-dura,  and  from  the  appearance  of  the  fluid  which  escapes  from  it 
when  the  capsule  is  penetrated  by  the  needle,  is  also  called  milky  or  2)unfoi-m 
cataract.  Its  most  remarkable  character  is  the  difference  of  color  which  it 
presents,  according  as  the  patient  is  in  the  erect  or  in  the  horizontal  posture. 
In  the  former,  the  cataract  presents  a  pretty  dark  brownish  color,  owing  to  the 
kernel  of  the  lens  gravitating  forwards  towards  the  pupil ;  but  the  instant  the 
patient  lies  down,  the  cataract  assumes  a  white  color,  the  kernel  falling  back 
towards  the  vitreous  humor.  The  disintegration  of  the  lens  may  proceed  to 
such  an  extent,  tluit  only  a  small  nucleus  of  it  remains,  commonly  of  a  dark 
amber  hue.  On  puncturing  the  capsule  in  the  operation  of  division  or  in  that 
of  displacement,  the  fluid  part  of  the  cataract  escapes,  and  mixes  immediately 
with  the  aqueous  humor. 

Severe  vomiting  and  inflammation  are  apt  to  follow  any  operation  performed 
on  such  a  cataract.* 

GENUS  IV. — CAPSULO-LENTICULAR  CATARACT. 

This  is  a  union  of  the  first  two  genera,  or  even  of  the  three  kinds  of  cata- 
ract, already  described.  Not  only  is  the  opacity  of  the  capsule  various  in 
degree  and  extent,  but  even  in  more  essential  circumstances  are  the  different 
cases  of  capsulo-lenticular  cataract  so  unlike,  that  it  is  necessary  to  distin- 
guish several  species  of  this  genus.  The  circumstances  in  question  influence 
the  choice  and  manner  of  operation.  The  opacity  of  the  capsule  is  frequently 
on  the  external  surface  of  the  membrane,  so  that  it  separates  from  it,  in  the 
form  of  a  thin  scale,  when  touched  with  the  needle. 

Species  1.      Central  Oapsulo-lenticular  Cataract. 

Fig.  Wardrop,  PI.  XII.  Figs.  4,  6.     Amnion,  Thl.  I.  Taf.  IX.  Figs.  1-5.  Taf.  XI.  Fig.  10.  Thl. 
III.  Taf.  XIV.  Fig.  18.     Dalryraple,  PI.  XXVI.  Fig.  3. 

This  species  presents  in  general  a  very  limited  white  point  in  the  centre  of 
the  lens  and  anterior  capsule,  which  is  apt  to  remain  unchanged  through  life. 
We  meet  with  it  not  unfreciuently  in  children,  whom  it  appears  to  render 
myopic,  and  so  deficient  in  sight  that  they  cannot  learn  to  read.  In  some 
instances  the  lenticular  opacity  is  considerably  broader  than  the  capsular,  and 
not  so  opaque. 

This  disease  is  perhaps  in  some  instances  congenital.  It  frequently  follows 
ophthalmia  neonatorum.  (See  p.  464.)  In  one  case  which  fell  under  my 
observation,  it  was  not  observed  till  after  scarlet  fever,  and  was  supposed  to 
have  originated  in  that  complaint. 

When  very  small,  so  that,  when  belladonna  is  used,  the  patient  sees  perhaps 
to  read,  it  is  not  to  be  interfered  with.^ 


GENERA   AND    SPECIES   OF   CATARACT.  TIT 

Species  2.      Common  Capsido-lenticular  Cataract. 

Fig.  Saunders,  PI.  IV.  Figs.  5,  3,  4,  6.  PI.  VII.  Fig.  1.  Ammon,  Thl.  I.  Taf.  IX.  Figs.  16-19, 
23,  24.  Taf.  X.  Figs.  1,  3,  7,  9.  Dalryinple,  PI.  XXVI.  Figs.  4,  5.  PI.  XXVII.  Fig.  5.  Pi. 
XXVIII.  Fig.  4.     Sichel,  PL  XVIII.  Figs.  2.  5.  PI.  XXIV. 

Common  capsulo-lenticular  cataract  may  originate  in  the  capsule,  in  the 
lens,  or  in  a  Morgagnian  effusion.  Injury  of  the  capsule  and  lens  gives  rise 
to  this  kind  of  cataract.  A  frequent  cause  is  probably  an  insidious  inflamma- 
tion of  the  capsule.  The  opacity  often  affects  the  lens  for  a  considerable 
time,  before  the  capsule  is  involved. 

Part  only,  or  the  whole,  of  one  or  other,  or  of  both  hemispheres  of  the 
capsule,  may  be  opaque.  The  lens  also  may  be  partially  or  wholly  opaque. 
The  opacity  is  partly  pearly,  as  in  anterior  capsular  cataract ;  partly  milky 
or  cloudy,  as  in  the  Morgagnian.  The  lens  is  sometimes  as  dark  as  mahog- 
any. The  specks  of  the  capsule  have  innumerable  forms,  and  on  these  were 
founded  the  old  distinctions  of  cataracta  marmoracea,  fenestrata,  stellata, 
punctata,  dimidiata ,  S^c. 

In  some  cases,  the  opacity  of  the  lens  and  capsule  is  so  partial,  that  on 
dilating  the  pupil  by  belladonna,  the  patient's  vision  is  considerably  improved. 
We  should  consider  well  what  the  eye  is  to  lose,  in  such  a  case,  by  an  opera- 
tion, as  well  as  what  it  may  gain,  before  touching  it.  The  operation  will 
probably  clear  away  the  opaque  substance  which  occupies  the  centre  of  the 
pupil,  and  thus  do  good ;  but  it  will  destroy  the  transparent  portion  of  the 
crystalline,  and  thus  the  patient  may,  unless  aided  by  a  glass,  see  worse  than 
he  did  before  the  operation. 

The  lens  presents  various  degrees  of  consistence  in  capsulo-lenticular  cat- 
aract ;  being  sometimes  hard,  in  other  cases  partially  or  completely  converted 
into  an  opaque  fluitl.  In  the  latter  state,  the  capsule  is  sometimes  so  much 
distended,  that  the  posterior  chamber  is  obliterated,  and  the  iris  prevented 
from  moving  with  facility.  Belladonna  slowly  dilates  the  pupil,  which  still 
more  slowly  returns  to  its  former  size.  It  is  sometimes  the  case,  that  even 
the  anterior  chamber  is  diminished  by  the  pressure  of  the  distended  capsule, 
and  the  consequent  advancement  of  the  iris. 

Sensibility  to  light  is  occasionally  very  feeble  in  capsulo-lenticular  cataract, 
owing,  in  some  cases,  to  the  density  of  the  opacity,  but  more  frequently  to 
the  presence  of  amaurosis.  Cataract  supervening  to  amaurosis,  and  especially 
to  traumatic  amaurosis,  is  often  capsulo-lenticular.  The  cataract  is  slow  in 
its  progress,  under  such  circumstances :  at  length  the  vitreous  humor  dissolves, 
and  the  iris  and  the  cataract  become  tremulous.  Often,  indeed,  in  capsulo- 
lenticular  cataract,  the  retina  is  unsound,  and  the  vitreous  humor  fluid,  although 
the  disease  has  not  been  preceded  by  amaurosis.  In  most  cases,  then,  of 
this  kind  of  cataract,  the  prognosis  is  unfavorable ;  the  result  of  operating 
will  generally  disappoint  both  patient  and  surgeon. 

In  some  cases  of  advanced  capsulo-lenticular  cataract,  the  lens  having  dis- 
solved, it  is  observed,  when  the  pupil  is  dilated  by  belladonna,  that  if  the 
patient  remains  perfectly  at  rest,  and  in  the  sitting  position,  for  a  quarter  of 
an  hour,  the  whiter  and  thicker  part  of  the  dissolved  lens  falls  to  the  bottom 
of  the  cavity  of  the  capsule,  and  the  anterior  hemisphere  of  the  capsule  not 
being  altogether  opaque,  but  merely  speckled,  vision  becomes  clearer,  from 
the  light  being  better  transmitted  through  the  upper  half  of  the  cataract ; 
but  on  motion  of  the  eye,  the  contents  of  the  capsule  are  again  mingled 
together,  and  the  vision  becomes  as  obscure  as  before. 

A  still  more  remarkable  improvement  in  vision  occasionally  takes  place,  in 
such  cases,  after  simply  puncturing  the  capsule  with  the  cataract-needle,  so 
as  to  allow  the  opaque  fluid  contained  within  it  to  escape.     The  fluid  is 


•718  GENERA   AND    SPECIES   OP   CATARACT. 

speedily  absorbed,  and  the  ligbt,  transmitted  through  the  transparent  portions 
of  the  cataracta  fenestrata  which  remains,  is  sometimes  sufficient  for  a  con- 
siderable share  of  vision. 

Congenital  cataract  {?,  oii&UQ'&i  mQi  \f\t\\  m  the  capsulo-lenticular  state.  I 
believe  it  to  be  generally  lenticular  at  birth,  and  only  after  some  months  to 
become  capsulo-lenticular. 

In  congenital  cases,  the  eyes  are  apt  to  be  affected  with  perpetual  oscilla- 
tion; and  the  cornea  and  iris  are  not  unfrequently  smaller  than  natural,  show- 
ing an  impeded  development  in  other  textures  besides  the  lens. 

Species  3.     Siliculose  Capsido-lenticvlar  Cataract. 

Fid.  Beer,  Band  II.  Taf.  III.  Fig.  4.     Saunders,  PI.  IV.  Fig.  1.     Aramon,  Thl.  I.  Taf.  XII.  Figs. 
^  3-11. 

Siliculose  capsulo-lenticular  cataract  is  met  with  in  adults,  but  oftener  in 
children,  constituting  in  the  latter,  one  of  the  varieties  of  the  congenital  dis- 
ease. In  both,  the  chief  characteristics  are  interrupted  nutrition,  and  even 
diminution  or  entire  absorption  of  the  lens,  with  a  shrivelled  capsule.  In 
the  adult,  a  mere  scale  of  lens  remains,  which  is  hence  compared  to  a  shrunk 
seed  surrounded  by  a  large  withered  pouch.  In  the  young  subject,  the  lens 
is  not  unfrequently  completely  absorbed,  so  that,  by  the  age  of  18  or  20  years, 
the  two  hemispheres  of  the  capsule  are  in  contact,  so  as  to  form  an  opaque, 
elastic,  double  membrane. 

In  adults,  siliculose  cataract  is  an  occasional  result  of  penetrating  wounds 
of  the  capsule,  through  which  the  aqueous  humor  having  been  admitted,  the 
exterior  softer  parts  "of  the  lens  are  dissolved,  and  the  nucleus  left. 

Schmidt  had  observed  this  kind  of  cataract  only  in  young  persons,  who,  in 
childhood,  had  been  affected  with  convulsions,  during  which  he  supposed 
rupture  of  the  capsule  to  take  place,  and  thus  the  aqueous  humor  to  be  ad- 
mitted to  the  lens.  Beer,  however,  met  with  it  in  children  scarcely  two  months 
old,  who  had  never  suffered  from  convulsions. 

I  am  inclined  to  believe  that  any  soft  lenticular  cataract,  left  to  itself,  is 
apt  to  degenerate,  first  of  all  into  capsulo-lenticular,  the  centre  of  the  anterior 
hemisphere  of  the  capsule  becoming  opaque  and  thickened,  or  numerous 
opaque  spots  forming  in  the  capsule,  and  that  then  absorption  of  the  lens 
may  take  place,  so  that  merely  a  thin  scale  of  it  shall  remain.  This  was  the 
state  in  one  eye  of  a  lady,  whose  cataracts  I  had  watched  for  18  years.  lu 
her  other  eye,  the  lens  was  also  reduced  in  thickness,  but  there  was  no  cap- 
sular opacity.  The  disease  had  lasted  for  25  years,  before  she  submitted  to 
an  operation. 

The  opacity  of  a  siliculose  cataract  in  children,  is  generally  of  a  light  ash 
color,  rarely  very  white.  The  capsule  is  evidently  corrugated,  the  cataract  of 
small  volume,  and  at  a  considerable  distance  behind  the  iris.  Sometimes  the 
pupil  is  evidently  retracted.  In  adults,  again,  this  cataract  is  often  very  white, 
especially  at  any  spot  where  the  capsule  has  suffered  from  injury ;  elsewhere, 
it  is  dusky,  or  yellowish.  It  does  not  advance  in  a  convex  form,  but  ap- 
pears flat. 

Neither  in  children,  nor  in  adults,  is  the  iris  affected  in  its  motions,  unless 
it  is  adherent  to  the  capsule  from  inflammation. 

In  some  congenital  cases,  the  lens  and  capsule,  not  having  grown  in  pro- 
portion to  the  rest  of  the  body,  but  remaining  nearly  of  the  size  they  were  at 
birth,  on  dilating  the  pupil,  a  black  zone,  formed  exteriorly  by  the  ciliary 
process,  and  interiorly  by  the  space  between  them  and  the  circumference  of 
the  capsule,  is  brought  into  view,  surrounding  the  cataract.  This  state  con- 
stitutes what  has  been  called  cataracta  cum  zonula.     The  zone,  if  examined 


GENERA  AND   SPECIES   OF   CATARACT.  T19 

while  light  is  thrown  upon  it  by  means  of  a  lens,  is  seen  to  be  striated. 
The  patient  whose  eyes  are  in  the  state  of  cataracta  cum  zonula,  is  often  able 
to  count  the  fingers,  to  distinguish  colors,  and  sometimes  even  to  read.  A 
medical  gentleman  in  this  state,  by  whom  I  was  consulted,  reads,  writes,  and 
continues  to  practise  as  a  surgeon.  He  is  myopic,  but  does  not  use  concave 
glasses,  and  sees  worse  with  convex  ones. 

In  siliculose  cataract,  vision  is  sometimes  completely  lost,  from  the  effects 
of  the  original  cause  on  the  retina ;  in  other  cases,  distinct  sensibility  to  light 
is  retained,  so  that  an  operation  may  be  had  recourse  to  with  a  reasonable 
hope  of  success. 

Species  4.      Cystic  Ccqjsulo-lenticular  Cataract. 

Fig.  Ammon,  Thl.  I.  Taf.  X.  Fig.  4. 

Cystic  cataract  is  generally  the  result  of  a  blow  on  the  eye  or  edge  of  the 
orbit,  sufficiently  violent  to  separate,  by  its  concussion,  the  lens  inclosed  in 
its  capsule,  from  its  organic  connections.  In  consequence  of  such  an  accident, 
the  vitreous  humor  is  destroyed,  the  capsule  and  lens  become  opaque,  and 
sometimes  the  lens  dissolves. 

The  opacity  is  white,  and  nearly  uniform;  the  opaque  body  is  almost 
spherical,  and  presses  against  the  circumference  of  the  pupil.  After  a  time, 
the  cataract,  dropping  down,  lies  behind  the  lower  edge  of  the  pupil,  and  is 
seen  bobbing  about  on  every  motion  of  the  head.  In  this  state,  the  disease 
is  called  cataracta  cystica  tremulans  vel  natatilis.  The  iris  also  becomes 
tremulous.  Like  a  lens  bursting  through  the  capsule  from  a  blow,  and  pass- 
ing into  the  anterior  chamber,  the  cystic  cataract  sometimes  rolls  forward 
through  the  pupil,  and,  resting  between  the  cornea  and  iris,  excites  inflam- 
mation. 

Cystic  cataract  is  always  attended  by  amaurosis,  so  that  if  extraction  is 
had  recourse  to,  it  is  with  no  hope  of  restoring  vision,  but  merely  to  free  the 
patient  from  the  pain  which  is  certain  of  being  excited,  if  the  cataract  comes 
forward  into  the  anterior  chamber,  and  from  the  danger  of  sympathetic 
Inflammation  attacking  the  other  eye.  On  extraction,  the  opaque  capsule  is 
sometimes  found  greatly  thickened. 

Species  5.     Bursal  Capsulo-lenticular  Cataract. 

One  of  the  rarest  kinds  of  cataract,  consisting  in  capsulo-lenticular  opa- 
city, combined  with  the  presence,  within  the  capsule,  of  a  small  cyst  filled 
with  purulent  matter,  is  styled  cataracta  cum  bursa  ichorem  continente.  The 
cyst  has  generally  been  found  behind  the  lens,  but  occasionally  in  front  of  it. 

The  opacity  is  orange  ;  the  iris  sluggish;  the  posterior  chamber  obliterated 
by  the  pressure  of  the  over-distended  capsule  ;  the  perception  of  light  indis- 
tinct; the  whole  habit  of  the  patient  weak  and  cachectic. 

Inflammation  is  the  origin  of  bursal  cataract,  and  probably  traumatic 
inflammation  in  most  cases. 


CLASS  II.— SPURIOUS  CATARACTS. 

GENUS  I. — FIBRINOUS  CATARACT. 

Si/n. — Cataracta  lymphatica. 

An  efi'usion  of  coagulable  lymph,  in  consequence  of  inflammation  of  the 
iris  and  capsule,  constitutes  by  far  the  most  frequent  kind  of  spurious  cata- 
ract.   It  is  in  almost  all  cases  attended  by  partial,  sometimes  by  total,  opacity 


•720  GENERA   AND    SPECIES   OF   CATARACT. 

of  the  anterior  hemisphere  of  the  capsule  (see  p.  631),  and  occasionally  by 
capsulo-lenticular  cataract.  The  effused  lymph  is  met  with  in  different  states, 
and  hence  the  distinctions  which  follow. 

Species  1.     Flocculent  Fihrinoiis  Cataract. 
Ficj.  Beer,  Band  II.  Taf.  III.  Fig.  6. 

The  opacity  visible  behind  or  within  the  pupil,  is  in  the  form  of  a  fine  net- 
work, surrounded  by  a  misshapen,  contracted,  and  partially  or  completely 
adherent  ])upil. 

Vision  is  much  impaired,  although  not  always  in  proportion  to  the  quantity 
of  effused  lymph  ;  for  sometimes  when  the  pupil  is  small,  and  the  spurious 
cataract  considerable,  a  tolerable  degree  of  sight  is  retained ;  while  in  other 
cases,  although  the  pupil  is  large,  and  the  network  of  lymph  thin,  the  patient 
is  almost  totally  blind,  the  inflammation  in  which  these  morbid  changes  had 
originated  having  probably  extended  to  the  retina. 

Species  2.      Clotted  Fibrinous  Cataract. 
F!'j.  Wanlrop,  PI.  VIII.  Fig.  3. 

A  clot  of  lymph,  apparently  unorganized,  occupies  the  pupil,  and  sometimes 
even  projects  through  it,  so  as  to  form  a  cataracta  pyramidata  spuria.  The 
opacity  "is  white;  the  pupil  angular  and  motionless;  sensibility  to  light 
indistinct,  or  wanting.  In  most  cases,  the  lymph  is  adherent  to  the  capsule, 
which  is  also  opaque  and  thickened ;  but  occasionally  the  lymph  is  unadherent, 
and  the  capsule  transparent,  except  within  the  area  of  the  pupil. 

Species  3.      Trabecular  Fibrinous  Cataract. 

In  this  variety  of  spurious  cataract,  the  cataracta  barree  of  the  French,  the 
pupil  is  angular  and  narrowed,  and  behind  it  lies  a  capsulo-lenticular  cataract, 
in  front  of  "which  there  is  a  stripe,  or  bar  of  lymph,  running  sometimes  in  one 
direction,  sometimes  in  another.  This  substance  is  connected  at  each  side 
with  the  edge  of  the  pupil,  but  it  does  not  cease  there.  Passing  behind  the 
iris,  it  attaches  itself  to  that  membrane,  or  to  the  ciliary  processes.  The  bar 
varies  in  consistence,  being  sometimes  as  firm  as  cartilage,  or  is  even  osseous. 

The  iris  is  motionless  ;  the  perception  of  light  extremely  indistinct,  or 
wanting  ;  and  the  eyeball  not  uufrequently  atrophic. 

GENUS  II. — PURULENT  CATARACT. 

A  spurious  cataract,  consisting  in  purulent  matter,  is  much  less  frequent 
than  one  arising  from  a  lymphatic  effusion.  In  cases  of  neglected  hypopium, 
the  pus  is  after  a  time  absorbed,  and  the  pupil  again  brought  into  view.  It 
sometimes  happens,  however,  that  the  pupil  is  occupied  by  a  spurious  cataract, 
of  a  yellowish  color,  which  is  nothing  more  than  purulent  matter,  involved  in 
the  interstices  of  a  web  of  fibrin.  Vision,  under  such  circumstances,  is  in 
general  irretrievably  lost. 

GENUS  III. — SANGUINEOUS  CATARACT. 

Like  the  last  mentioned,  this  kind  of  spurious  cataract  has  its  basis  in  a 
fibrinous  effusion,  in  the  interstices  of  which,  minute  clots  of  red  blood  are 
observed  to  lodge,  the  bloodvessels  of  the  iris  or  choroid  having  been  rup- 
tured by  some  previous  injury,  or  during  severe  inflammation.  Reasoning 
from  what  was  observed  in  Case  324,  we  might  expect  sanguineous  cataract 


DISTINCTIONS   OF   CATARACT.  721 

sometimes  to  present  a  black  color.     I  have  seen  it  retain  a  red  color  for 
years. 

The  pupil  is  not  so  much  contracted  in  this  as  in  some  of  the  other  kinds 
of  spurious  cataract,  unless  hypopium  also  has  been  present. 

GENUS  IV. — PIGMENTOrS  CATARACT, 
Fhj.  Ammon,  Thl.  I.  Taf.  X.  Fig.  2.  Taf.  XI.  Fig.  31.  Taf.  XII.  Fig.  12. 

Portions  of  the  pigraentum  nigrum  from  the  posterior  surface  of  the  iris, 
adhering  to  the  capsule,  constitute  what  is  called  pigmeutous  cataract.  In 
some  cases,  this  spurious  cataract  is  the  result  of  iritis,  during  the  course  of 
which  belladonna  having  been  applied,  while  other  remedies  were  probably 
neglected,  the  proper  substance  of  the  iris  was  forced  to  contract,  leaving  the 
uvea  bound  to  the  capsule  by  effused  lymph.  In  other  cases,  a  blow  on  the 
eye  has  the  effect  of  detaching  a  portion  of  the  pigment  from  the  iris.  Fall- 
ing upon  the  capsule,  it  adheres  to  it,  and  the  capsule  afterwards  becoming 
opaque,  probably  from  the  same  cause  which  detached  the  pigmentum  nigrum, 
this  substance  forms  a  striking  contrast  with  the  white  ground  upon  which  it 
is  placed.  In  either  of  these  sets  of  cases,  the  flakes  of  black  pigment  present 
somewhat  of  a  leafy  appearance,  and  hence  the  name  cataracta  arhorescens, 
which  Richter  bestowed  on  this  sort  of  spurious  cataract. 

The  degree  of  vision  is  generally  very  limited,  whether  injury  or  iritis  has 
been  the  cause. 


1  Lancet,  Vol.  ii.  for  1852.  pp.  260,  455.  capsular  being  regarded  as   depositions  on  the 

-  Janin,  Memoires  sur  rQ-Iil.  pp    259,  261  ;  outer  or  inner  surface  of  the  membrane.     See 

Lyon,  1772  :  Warnatz.  Amnion's  Zeitschrift  fiir  Gros.  Gazette  Medicale  de  Paris,  24  Avril,  1851 ; 

die  Opbthalmologie  ;  Vol.  iii.  p.  295:  Dresden,  p.  271. 

1S32  :  Scott  on  Cataract,  p.  2;  London,  1843:  *  On  Morgagnian  Cataract,    consult   Wilde, 

Beauclair,  Annales  d'Oculistique ;  Tome  xxiii.  Medical  Times  and  Gazette,  October  2,  1852,  p. 

p.  130;  Bruxelles,  1850:  Blot,  Gazette  Medicale  327;  Dixon,  Lancet,  February  26, 1853,  p.  198. 

de  P.-xris,  26  Juin,  1852,  p.  412.  *  ConsultBechde  Cataracta  Centrali  j  Lipsise, 

^  The    capability  of  the   capsule  to   become  1830. 

opaque  has  been  doubted;  the  opacities  reputed 


SECTION  m. — VARIOUS   ADDITIONAL   CLASSIFICATIONS   AND   DISTINCTIONS 

OF  CATARACT. 

Cataracts  are  often  classified,  or  at  least  distinguished,  according  to  their 
consistence,  size,  color,  duration,  and  curability.  Those  who  have  carefully 
studied  the  classification  of  cataracts  founded  on  the  part  or  parts  affected  in 
each  genus,  can  be  at  little  loss  in  regard  to  these  additional  circumstances, 
which  may  therefore  be  dismissed  in  a  few  words. 

§  1.    Consistence. 

1.  Hard. — Only  a  lenticular  cataract  can  be  hard,  but  all  lenticular  cataracts 
are  not  possessed  of  this  property,  not  even  when  they  occur  in  persons  far 
advanced  in  life.  "Very  rarely  do  we  meet  with  hard  cataract  in  those  under 
forty-five  years  of  age.  In  an  old  person,  the  darker  the  color,  and  the 
smaller  a  lenticular  cataract  is,  the  harder  it  will  be  found.  A  hard  lens  is 
never  white  ;  its  centre  is  darker  than  its  circumfei'ence,  its  anterior  surface 
appears  flat,  and  it  is  never  so  large  as  to  impede  the  free  motion  of  the  pupil, 
or  prevent  a  shadow  from  being  thrown  on  it  by  the  iris.  [The  cause  of 
cataract  presenting  these  features  in  old  persons,  can  readily  be  perceived  by 
reference  to  the  changes  effected  by  age  on  the  healthy  lens.  In  earlv  life 
46 


722  DISTINCTIONS   OF   CATARACT, 

the  lens  is  soft,  more  oi'  less  spheroidal  and  perfectly  colorless,  but  as  age 
advances  it  becomes,  gradually,  firmer,  flatter,  and  more  or  less  tinted;  hence 
the  impairment  of  vision,  and  light  color  of  pupil  observable  in  old  persons, 
who  have,  however,  no  cataract.  "  Hard  lenticular  cataract,"  as  Mr.  Haynes 
Walton  says,  "is  merely  grayness  or  opacity  appearing  in  an  already  dis- 
colored and  somewhat  dense  lens,  and  the  greater  the  discoloration  of  the 
lens,  the  less  will  be  the  amount  of  grayness  reciuired  to  obstruct  vision. 
Mere  opacity  does  not  create  hardness,  and  the  cataract  of  an  old  person  is 
not  harder  than  the  lens  would  be  in  the  same  indivdual,  though  the  property 
of  transmitting  light  had  not  been  lost ;  hence,  hard  cataract  can  not  occur 
before  that  time  of  life  at  which  the  lens  begins  to  increase  in  density." — H.] 

2.  Tough. — The  capsule,  or  some  substance  effused  into  the  posterior 
chamber,  may  possess  the  property  of  toughness.  Cystic,  siliculose  and 
trabecular  cataracts  are  of  this  description.     They  are  all  more  or  less  white. 

3.  Soft. — Softness  is  a  property  which  resides  in  the  lens.  In  subjects 
about  twenty-five,  we  find  lenticular  cataract  soft  and  cohesive,  so  that 
although  the  needle  passes  freely  through  its  substance,  the  fragments  do  not 
readily  separate,  at  least  on  a  first  operation.  After  the  aqueous  humor  is 
admitted  into  contact  with  such  a  cataract,  it  becomes  more  friable,  A  soft 
cataract  is  of  a  pearl,  light  ash,  or  whitish  color.  Not  unfrequently,  the  soft 
lenticular  cataract  is  stellated,  from  the  division  of  the  lens  into  triangular 
portions.     During  extraction,  such  a  cataract  is  liable  to  fall  into  pieces. 

4,  Fluid. — The  capsule  is  generally  opaque,  when  it  contains  a  fluid,  or 
dissolved  lens.  In  some  cases,  the  opacity  and  fluidity  of  the  lens  precede 
the  opacity  of  the  capsule  ;  while  in  other  cases,  the  diseased  state  of  the 
capsule  appears  to  lead  to  the  disorganization  and  dissolution  of  the  lens. 
The  latter  is  probably  the  fact  in  ordinary  cases  of  capsulo-lenticular  cataract ; 
while  in  congenital  cases,  the  opacity  of  the  capsule  is  certainly  preceded 
by  that  of  the  lens.     Fluid  cataract  is  always  white, 

5,  Mixed. — The  Morgagnian  is  an  example  of  a  mixed  cataract;  the 
capsule  being  tough,  the  nucleus  of  the  lens  hard  or  soft,  according  to  the 
age  of  the  patient,  and  the  intervening  disintegrated  portion  of  the  lens  fluid. 
The  bursal  cataract,  and  capsulo-lenticular  cataracts  in  general,  are  also 
mixed. 

These  distinctions,  founded  on  the  consistence  of  cataract,  are  important 
chiefly  in  reference  to  the  choice  of  an  operation  for  the  cure  of  this  disease,* 

§  2,   Size. 

The  hard  lenticular  cataract  is  small,  as  is  also  the  siliculose  cataract;  the 
soft,  fluid,  and  mixed  cataracts  are  generally  large.  The  size  is  estimated 
by  the  presence  or  absence  of  aqueous  humor  in  the  posterior  chamber,  as 
indicated  by  the  breadth  of  shadow  thrown  on  the  cataract  by  the  iris,  or  the 
absence  of  such  shadow, 

§  3,   Color. 

The  opacity  of  the  lens,  affected  with  cataract,  is  of  a  bluish-white,  light 
ash,  amber,  or  brown  color,  according  to  the  age  of  the  patient,  and  the 
nature  of  the  disease.  Green  cataract  is  a  complication  of  lenticular  cataract 
with  glaucoma.  In  the  cataracte  lenticulaire  verte  operable  of  M,  Sichel,  the 
lens  is  hard  and  dichromatic,  as  in  glaucoma,  with  a  slowly  increasing  turbid- 
ness  throughout  its  whole  substance,  and  a  slight  coagulation  of  its  superficial 
lamellae  but  without  any  complication  of  amaurosis.  The  bursal  cataract  is 
orange.  Capsular  cataract  is  always  of  a  pearly  or  chalky  white.  Cholesterin 
cataract  presents  not  merely  a  white  color,  but  a  shining  metallic  lustre  (see 


I 


COMPLICATIONS   OF   CATARACT.  'l23 

p.  633),  and,  when  broken  down,  either  spontaneously  or  by  the  needle,  its 
particles  glance  so  much,  that  they  have  been  taken  for  globules  of  mercury 
in  the  aqueous  humor.^ 

§  4.   Duration  and  Development. 

In  former  times,  the  distinction  of  ripe  and  unripe  cataracts  was  considered 
of  great  importance.  It  was  supposed  that  cataract  depended  on  the  coagu- 
lation of  a  fluid  ;  and  till  this  process  was  judged  to  be  sufficiently  advanced  to 
permit  of  the  cataract  being  displaced  by  the  needle,  the  disease  was  deemed 
unripe.^  If  we  are  still  to  retain  the  terras  ripe  and  unripe,  we  must  employ 
them  with  a  very  different  meaning.  However  small  or  soft  a  cataract  may 
be,  we  may  call  it  ripe  when  it  is  completely  developed,  susceptible  of  no 
farther  progress,  or  when  it  deprives  the  patient  of  the  power  of  distinguishing 
objects ;  whereas,  we  may  call  it  un^ripe,  when  it  is  not  yet  fully  formed,  when 
there  is  a  suspicion  that  the  opacity  may  make  considerably  farther  progress, 
as  in  posterior  capsular,  and  central  cataract,  or  when  the  patient  still  retains 
so  much  vision  as  to  see  the  eyes  of  a  person  sitting  before  him,  or  distinguish 
the  different  articles  of  furniture  in  a  room.  Cases  such  as  these  may  continue 
for  years  unripe  for  operation. 

The  distinctions  of  sudden  and  slow  cataracts,  and  of  those  which  exist 
from  birth,  or  supervene  at  various  periods  of  life,  are  not  undeserving  of 
attention.  It  must  be  observed,  however,  that  congenital  cataract  is  not 
always  of  the  same  sort,  but  may  be  capsular,  lenticular,  or  capsulo-lenticular  ; 
and  hence  the  impropriety  of  using  the  phrase  congenital  cataract,  as  if  it 
were  significant  of  anything  more  than  the  date  of  the  disease. 

§  5.    Curability. 

Pellier*  introduced  a  practical  or  empirical  distinction  of  true,  or  curable 
cataracts  ;  mixed,  or  doubtful ;  and  false,  or  incurable.  The  true,  or  curable, 
was  to  be  known  by  the  pupil  retaining  its  power  of  contracting  and  dilating 
in  perfection,  while  the  patient  was  at  the  same  time  able  to  distinguisb'the 
light  of  a  candle,  or  of  any  other  luminous  body,  and  even  certain  bright 
colors,  such  as  red,  green,  &c.  The  mixed,  or  doubtful,  was  characterized  by 
feeble  contraction  and  dilatation  of  the  pupil,  and  the  patient  could  scarcely 
distinguish  light  from  darkness.  Along  with  an  opaque  state  of  the  lens, 
this  variety  was  supposed  to  be  attended  with  disease  of  the  retina,  or  of 
some  other  part  of  the  eye.  In  the  false,  or  incurable  cases,  along  with  an 
opaque  state  of  the  lens,  there  was,  whatever  might  be  the  degree  of  light  to 
which  the  eyes  were  exposed,  either  an  immovably  dilated  or  contracted  pupil, 
and  the  patient  unable  to  distinguish  between  the  most  brilliant  light  and 
perfect  darkness. 


'  Much  more  importance  is  ascribed  to  the  ^  "  Expectandum  igitur  est  donee  jam  non 

hardness  or  softness  of  the  lens  in  cataract,  by  fluere, sed  duritie  quadam  concrevisso  videatur." 

some  authors,  than  what  I  have  given  it  in  the  — Celsus  de  re  Medico, ;  Lib.  vii.  Pars  ii.  Cap.  1. 

text.    See  llasner's  Entwurf  eineranatomisehen  Sect.  2. 

Begriindung  der  Augenkrankheiten,  p.    189 j  *  Cours    d'Operations   sur  la  Chirurgie   des 

Prague,  1S47.  Yeaux;  Tome  i.p.  172;  Paris,  1789. 

-  Beer's  E,epertorium,  vol.  ii.  p.  97 ;  Wien, 
1799. 


SECTION  IV. — COMPLICATIONS  OF  CATARACT. 

Cataract  frequently  presents  itself  along  with  other  diseases  of  the  eye, 
which  are  either  purely  local,  or  of  constitutional  origin  ;  while  in  other  cases, 


124:  COMPLICATIONS   OF   CATARACT. 

it  is  complicated  with  constitutional  diseases,  which  may  or  may  not  have 
been  instrumental  in  producing  the  cataract  itself,  but  are  very  likely  to  aifect 
the  success  of  any  attempted  cure  by  operation.  A  perfectly  uncomplicated 
case  is  rarely  met  with.  The  following  questions  must  evidently  be  of  the 
highest  importance,  in  every  instance  :  Is  the  organ  of  vision  in  a  condition 
to  resume  its  office  to  any  useful  extent,  were  the  cataract  removed  ?  Is 
there  nothing  in  the  general  health  likely  to  frustrate  the  success  of  an 
operation,  no  local  disease  in  any  other  organ  likely  by  sympathy  to  affect 
the  eye  and  bring  on  inflammation  ? 

1.  As  for  purely  local  complications,  I  may  mention  those  arising  from 
inflammation  of  the  cornea  and  iris,  such  as  specks  of  the  cornea,  adhesion 
between  the  iris  and  cornea,  or  between  the  iris  and  the  capsule.  Such  com- 
plications will  readily  be  recognized,  and  will  influence  us  in  the  choice  of  an 
operation,  and  in  the  mode  of  executing  the  particular  operation  we  select. 
Ophthalmia  tarsi,  or  chronic  catarrhal  ophthalmia,  debars  an  operation,  and 
especially  extraction.  Trichiasis  or  distichiasis,  and  inversion  or  eversion  of 
the  lids,  must  also  be  remedied,  before  any  operation  be  attempted  for  the 
cure  of  cataract.  Local  complications  often  point  to  a  state  of  constitution 
unfavorable  for  any  operation,  especially  for  extraction.  A  speck  on  the 
cornea,  for  example,  the  result  of  scrofulous  ophthalmia,  existing  either  in 
the  eye  which  is  to  be  operated  on,  or  in  the  opposite  eye,  reduces  the  pro- 
bability of  success. 

2.  Some  other  local  complications  cannot  easily,  if  at  all,  be  discovered, 
except  at  the  moment  of  oj)eration ;  such  as  preternatural  adhesion  between 
the  capsule  and  the  lens,  sufficient  to  prevent  extraction  from  being  accom- 
plished, unless  with  much  difficulty,  or  a  dissolved  state  of  the  vitreous 
humor,  a  complication  scarcely  less  perplexing.  The  latter  is  a  frequent 
attendant  on  glaucoma,  and  if  the  patient  is  known  to  have  been  glaucoma- 
tous before  becoming  the  subject  of  cataract,  we  must  be  on  our  guard 
against  a  fluid  vitreous  humor  ;  but  in  many  instances  nothing  is  known  re- 
garding the  previous  state  of  the  eye,  and  there  is  no  very  manifest  sign  to 
lead  us  to  a  knowledge  of  the  fact.  Abnormal  hardness  of  the  eye,  however, 
or  a  greenish  tinge  in  the  cataract,  should  lead  us  to  suspect  a  dissolved 
vitreous  humor. 

3.  Such  complications  as  the  following  are  very  unfavorable,  yet  not  suffi- 
ciently so  as  absolutely  to  forbid  an  operation  ;  myosis,  tremulous  iris,  vari- 
cosity of  the  external  vessels,  slight  attenuation  of  the  sclerotica,  slight 
bogginess,  preternatural  firmness  of  the  eyeball.  In  all  of  these  cases,  we 
may  suspect,  along  with  other  morbid  changes  in  the  interior  of  the  eye,  an 
imperfect  sensibility  of  the  retina,  and  that  although  the  patient  may  recover 
a  certain  share  of  vision  by  the  removal  of  the  cataract,  the  improvement 
will  be  small  and  temporary. 

4.  When  myopia  forms  the  complication,  the  opaque  lens  appears  as  if 
seated  further  behind  the  pupil,  and  the  posterior  chamber  to  be  more  capa- 
cious than  common.  The  patient  retains  a  share  of  useful  vision  longer,  and 
the  cataract  is  slower  of  coming  to  such  a  pitch  as  to  demand  operative  in- 
terference. I  have  known  a  patient  remain  in  this  stationary  position  for 
many  months,  still  able  to  distinguish  one  person  from  another,  and  to  write 
his  name,  and  if  the  characters  were  black  and  broad,  to  read  it. 

5.  If  the  pupil  is  dilated  and  fixed,  and  the  patient  unable  to  distinguish 
day  from  night,  there  can  be  no  doubt  that  such  a  degree  of  amaurosis  is 
present,  as  renders  it  needless  to  think  of  an  operation.  But  we  would  not 
willingly  operate,  even  in  cases  where  a  much  less  degree  of  amaurosis  was 
present,  were  we  aware  of  the  fact.  The  mere  perception  of  the  hand  pass- 
ing between  the  light  and  the  eye,  is  by  no  means  a  sufficient  index  that  the 


I 


COMPLICATIONS   OP   CATARACT.  725 

retina  is  free  from  disease.  The  amaurosis,  indeed,  must  be  incomplete  if  so 
much'  sensibility  is  retained ;  but  if  from  the  history  of  the  case,  and  the 
appearances  of  the  eye,  there  is  reason  to  dread  that  the  retina  retains  merely 
the  power  of  distinguishing  light  and  shade,  as  it  often  does  in  incomplete 
amaurosis,  it  would  be  much  better  to  let  the  patient  alone,  than  to  be  raising 
in  his  mind  false  hopes  of  restoration  to  sight,  subjecting  him  to  the  anxieties 
attendant  on  an  operation,  and  exposing  him  to  the  troubles  which  are  liable 
to  follow,  and  which  are  sometimes  severe  and  long-continued.  For  instance, 
if  a  patient,  far  advanced  in  life,  discerns  merely  light  and  shade,  and  does 
not  possess  the  natural  degree  of  control  over  the  muscles  of  the  eyes,  so 
that  on  being  desired  to  look  in  any  particular  direction,  he  gazes  in  that 
direction  with  a  movement  of  the  whole  head,  but  without  any  movement  of 
the  eyes,  it  is  almost  useless  to  operate. 

6.  I  have  sometimes  operated  for  cataract  on  an  eye  affected  with  strabis- 
mus, but  even  when  I  have  done  this  in  children,  in  expectation  that  the 
accession  of  vision  consequent  to  the  removal  of  the  cataract  would  assist  in 
curing  the  squint,  I  have  been  disappointed.  (See  pp.  357,  371,  385.) 
When  cataract  is  combined  with  strabismus,  the  latter,  I  think,  should  be 
cured  by  operation,  before  the  former  is  interfered  with.  The  opposite  plan, 
however,  w^as  followed  successfully  by  Dr.  Franz,  in  a  congenital  case.* 

7.  Glaucoma,  in  any  stage,  may  become  complicated  with  cataract,  an 
opacity  more  or  less  of  a  whitish  color  being  superinduced  on  the  surface  of 
the  lens  previously  amber-colored,  but  appearing  greenish  by  reflected  light 
as  I  shall  explain  more  fully  in  a  subsequent  chapter. 

When  fully  developed  glaucoma  becomes  combined  with  cataract,  which  is 
sometimes  suddenly  the  case,  there  is  not  merely  the  addition  of  a  whitish 
opacity  spread  over  the  dead  sea-green  or  olive-green  hue  of  the  lens;  but 
there  are  always  present  other  remarkable  appearances  in  the  eye,  denoting 
changes  in  the  organization  of  almost  all  its  tissues.  The  opaque  lens  is  vol- 
uminous, and,  in  some  cases,  seems  still  more  so  than  it  really  is,  being  pressed 
forwards  by  the  superabundant  fluid  which  occupies  the  place  of  the  vitreous 
humor.  At  last,  the  lens  is  pushed  in  some  degree  through  the  pupil.  The 
iris,  pale  and  discolored,  is  completely  motionless.  The  pupil  is  irregularly 
dilated,  the  iris  shrinking  chiefly  in  one  or  two  directions.  The  edge  of  the 
pupil  appears  rolled  back  into  the  posterior  chamber.  The  eyeball  feels  hard 
as  a  pebble,  and  is  covered  by  varicose  vessels.  Internal  flashes  of  light  are 
frequently  experienced  by  the  patient,  who  is  totally  deprived  of  any  power 
of  perceiving  light  from  without.  Chronic  choroiditis  or  arthritic  iritis,  with 
severe  and  long-continued  headache,  is  often  the  precursor  of  this  hopeless 
condition  of  the  eye.     (See  pp.  544,  554.) 

8.  As  for  general  and  remote  complications  of  cataract,  the  variety  is  end- 
less. Among  the  most  frequent  are  rheumatism,  scrofula,  gout,  and  syphilis, 
as  general  complications;  and  inveterate  ulcers  on  the  lower  extremities,  as 
a  remote  one.  It  is  highly  important  to  make  ourselves  acquainted  with  the 
existence  of  any  such  complications,  and  with  the  complete  history  of  the 
health  of  the  patient,  who  consults  us  on  account  of  cataract.  For  instance, 
if  an  individual  affected  with  cataract,  be  of  an  inflammatory  tendency,  subject, 
perhaps,  to  attacks  of  pneumonia  or  pleuritis,  great  care  will  be  required, 
both  before  and  after  an  operation,  to  avoid  the  causes  of  plethora  and  arterial 
action.  It  will  probably  be  only  by  repeated  bloodletting,  and  purging,  with 
an  abstemious  diet  both  before  and  after  removing  the  cataract,  that  the  eye 
will  escape  destructive  inflammation. 

A  person  with  any  serious  organic  disease,  such  as  diseased  heart,  is  an 
improper  subject  for  an  operation  for  cataract.     The  preliminary  abstinence, 


726  MEDICAL   TREATMENT   OF   CATARACT. 

with  such  depletory  treatment  as  may  be  required  after  the  operation,  is  not 
unlikely  to  lead  to  dropsy  and  irremediable  debility. 

A  healthy  eye,  except  that  it  is  aifected  with  cataract,  and  a  healthy  con- 
stitution, are  favorable  in  regard  to  the  result  of  an  operation.  If  the  eye 
and  the  constitution  are  sound,  the  half  of  the  cornea  may  be  incised,  for 
example,  and  the  lens  removed,  without  much  risk.  Xot  so,  if  the  eye,  or  the 
individual,  is  unhealthy.  In  this  case,  the  wound  is  apt  to  suppurate,  and  the 
eye  to  perish  from  inflammation. 

Age,  in  itself,  is  not  an  objection  to  extraction.  In  healthy  old  people, 
there  is  generally  sufficient  reparative  power  for  the  healing  of  the  wound ; 
but  if  the  progi'ess  of  life  has  been  attended  with  serious  diseases  of  the  sys- 
tem, so  that  the  general  tone  is  much  lowered,  the  influence  of  this  state  may- 
be very  unfavorable. 


Philosophical  Transactions;  Vol.  cxxxi.  p.  59;  London,  1S41. 


SECTION  V. — PALLIATIVE  TREATMENT  OF  CATARACT. 

Shading  of  the  eyes,  and  dilatation  of  the  pupils  by  a  drop  of  the  solution 
of  atropine  every  second  night,  constitute  the  palliative  treatment  of  cataract. 
Not  merely  in  the  incipient  stage,  but  even  in  the  advanced,  many  patients 
find  their  sight  so  much  improved  by  these  simple  means,  that  they  defer,  for 
months  or  years,  to  submit  to  any  surgical  operation.  All  patients,  however, 
do  not  derive  the  same  benefit;  and  some  are  so  dazzled  by  dilatation  of  the 
pupil  that  they  cannot  suffer  it.  Partial  cataracts,  whether  capsular  or  capsule- 
lenticular,  are  the  cases  in  which  the  benefit  is  most  remarkable. 


SECTION  VI. — MEDICAL  TREATMENT  OF  CATARACT. 

Three  different  modes  of  curing  cataract  without  operation,  have  been  pro- 
posed ;  viz :  the  antiphlogistic,  the  stimulant,  and  the  counter-irritant.  It  may 
fairly  be  questioned,  whether  such  means  have  ever  succeeded  in  any  case  of 
true  cataract,  in  restoring  the  natural  transparency  of  the  parts.  Many  of 
the  alleged  cures  have  been  either  instances  of  mere  lymphatic  effusions  on 
the  surface  of  the  capsule,^  or  else  cases  of  ruptured  capsule,  in  which  the 
removal  of  the  opaque  lens  has  been  affected  by  the  solvent  power  of  the 
aqueous  humor.  On  other  occasions,  it  can  scarcely  be  doubted,  that  no 
cataractous  affection  of  the  lens  or  its  capsule  existed,  but  that  glaucoma,  with 
incipient  amaurosis,  was  mistaken  for  cataract,  and  submitted  to  certain  modes 
of  treatment,  which  not  unfrequently  prove  efficacious  in  restoring,  to  a  cer- 
tain degree,  the  sensibility  of  the  retina. 

1.  Bloodletting  and  mercury  are  likely  to  be  attended  with  good  effects,  if 
inflammation  is  the  cause  of  the  opacity  of  the  lens  and  capsule.  The  efficacy 
of  these  remedies,  an  incipient  spurious  cataracts,  especially  those  of  the  fibrin- 
ous kind,  is  fully  ascertained,  but  in  true  cataract  they  are  seldom  or  never 
tried.  Yet  in  certain  cases  of  this  sort  they  might  perhaps  prove  beneficial; 
for  instance  in  the  very  commencement  of  Morgagnian  cataract,  a  disease 
which,  according  to  Beer,  results  chiefly  from  external  irritation. 

2.  Mr.  Ware  in  one  of  his  notes  to  Wenzel's  Treatise  on  Cataract,  ac- 
knowledges himself  "willing  to  hope,  that  means  may  hereafter  be  discovered 
by  which  an  opaque  crystalline  may  be  rendered  transparent,  without  the  per- 


CURE  OF  CATARACT  BY  OPERATION.  ^2*1 

formance  of  any  operation  whatsoever;"  adding,  that  "the  remedies  which 
have  appeared  to  him  more  effectual  than  others  in  these  cases,  have  been  the 
application  to  the  eye  itself  of  one  or  two  drops  of  ether,  once  or  twice  in 
the  course  of  the  day;  and  occasional  frictions  of  the  eye,  over  the  lid,  with 
the  point  of  the  finger,  first  moistened  with  a  weak  volatile  or  mercurial  lini- 
ment." 

M.  Gondret,  to  whom  I  shall  have  occasion  to  refer  as  recommending 
counter-irritation  as  a  means  of  curing  cataract,  makes  use  also  of  stimulants 
to  the  eye,  especially  electricity  or  galvanism,  and  ammoniacal  collyria.  Ma- 
gendie,  who  has  published'^  a  paper  by  M.  Gondret,  on  the  subject,  regards 
the  observations  of  this  practitioner  as  illustrative  of  his  own  views  of  the 
influence  of  the  fifth  nerve  on  the  nutrition  of  the  eye.  "When  that  nerve  is 
cut  across,  the  nutrition  of  the  eye  is  interrupted,  the  cornea  becomes  opaque, 
and  the  humors  are  transformed  into  a  substance  resembling  curd.  As  similar 
changes  are  found  to  arise  where  the  nerve  is  unable  from  disease  to  execute 
its  functions,  it  is  by  no  means  an  unwarrantable  conjecture,  that  cataract, 
which  is  generally  admitted  to  be,  in  most  instances,  an  effect  of  abnormal 
nutrition,  may  arise  as  well  from  a  faulty  action  of  the  nerve  which  controls 
the  nutrition  of  the  eye,  as  from  any  disorder  directly  affecting  the  source 
whence  the  lens  draws  its  nourishment.  If  this  be  correct,  then  it  is  probable 
that  by  stimulating,  or  otherwise  modifying  the  action  of  the  fifth  nerve,  the 
nutrition  of  the  lens  may  be  influenced  ;  so  that  if  want  of  nervous  influence 
leads  to  opacity,  excitation  may  remove  the  tendency  to  cataract,  or  even 
restore,  in  some  cases,  the  natural  transparency. 

3.  M.  Gondret's  paper,  on  the  Treatment  of  Cataract,  just  referred  to, 
contains  a  number  of  cases  not  undeserving  of  attention,  although  not  one  of 
them  is  a  satisfactory  instance  of  true  cataract,  cured  by  the  means  which  he 
recommends.  Sincipital  cauterization,  by  means  either  of  the  actual  cautery. 
or  of  an  ointment  formed  with  a  highly  concentrated  solution  of  ammonia,  is 
the  remedy  upon  which  he  chiefly  depends.  I  am  not  prepared  altogether 
to  deny  the  efficacy  of  powerful  counter-irritation,  in  changing  the  diseased 
action  upon  which  the  production  of  true  cataract  depends ;  but  in  most  of 
M.  Gondret's  cases,  especially  in  those  in  which  the  opacity,  visible  behind 
the  pupil,  was  preceded  by  inflammation,  the  suspicion  is  strong  that  the 
disease  was  spurious. 


'  Benvenuto  Cellini  tells  Clement  VII.,  that  lignum  vitae. — Memoirs  of  Benvenuto  Cellini; 

two  cataracts  had  fallen  upon  his  ejes.     These  Vol.  i  Chap.  11. 

appear  to  have  been   the    effects  of  syphilitic  ^  Journal   de    Physiologic;    Tome  v.  p.  41; 

iritis,  of   which  Benvenuto   cured    himself  by  Paris,  1825. 


SECTION  Vn. — PRELIMINARY  QUESTIONS  REGARDING  THE  REMOVAL  OF  CATARACT 

BY  OPERATION. 

Before  entering  on  the  methods  of  operating  for  cataract,  there  are  some 
questions  of  a  general  nature,  which  require  to  be  considered. 

1.  When  only  one  eye  is  affected,  ought  we  to  proceed  to  operate,  or  wait 
till  the  other  also  is  attacked  ?  Some  tell  us,  that  we  ought  not  to  operate 
under  such  circumstances,  on  account  of  the  difference  in  visual  power  which 
would  exist  between  the  two  eyes,  even  were  the  cataract  successfully  removed; 
a  difference  which,  to  a  certain  degree,  could  no  doubt  be  remedied  by  the 
use  of  a  double-convex  lens,  placed  before  the  eye  whence  the  cataract  had 
been  removed,  but  which,  without  this  assistance,  might  render  the  patient's 
vision  so  confused,  that  to  see  well  with  either  eye,  the  other  would  require 


t28  CURE   OF   CATARACT   BY   OPERATION. 

to  be  shut.  To  delay,  then,  is  the  practice  generally  followed  in  such  circum- 
stances. But  others  recommend  an  immediate  operation,  asserting,  that  by 
removing  the  cataract  from  the  one  eye,  the  disease  may  be  prevented  from 
attacking  the  other ;  or  that,  if  already  commencing  in  this  eye,  it  might  be 
cured  by  external  and  internal  remedies,  if  once  the  completely  cataractous 
eye  were  restored  to  its  office  by  an  operation.  The  sympathy  which  exists 
between  the  eyes  is  undoubtedly  strong,  and  we  can  easily  conceive  that  it 
may  operate  in  inducing  similar  affections  of  the  crystalline  lenses,  as  it  often 
appears  to  do  in  producing  similar  diseases  of  the  retinae,  and  still  less  equi- 
vocally similar  ophthalmias.  Were  it  established  that  cataract  was  thus  pro- 
duced sympathetically,  there  could  be  no  doubt  of  the  propriety  of  removing 
a  single  cataract,  even  when  not  the  slightest  appearance  of  the  disease  could 
be  detected  in  the  opposite  eye ;  but  the  fact  is  not  established.  Cataract 
in  old  people  generally  attacks  both  eyes  within  the  period  of  a  few  months ; 
but  in  middle  life,  we  often  meet  with  it  in  one  eye,  the  other  having  continued 
unaffected  for  many  years. 

2.  When  both  eyes  are  cataractous,  and  equally  affected,  ought  both  to  be 
operated  on  at  the  same  time  ?  To  this  question,  my  experience  leads  me  to 
answer  in  the  affirmative,  if  division  of  the  cataract  is  the  operation  to  be 
performed;  but  if  we  mean  to  extract,  I  regard  it  as  better  to  operate  on  one 
eye  only,  and  wait  the  result,  before  touching  the  other.  Double  extraction 
decidedly  exposes  the  eyes  to  greater  risk  of  inflammation.  If  we  operate 
only  on  one  eye,  and  allow  it  to  recover,  we  may  possil)ly  observe,  in  the 
course  of  the  operation  and  recovery,  some  particulars  which  will  be  essen- 
tially useful  to  us  in  conducting  the  second  operation,  or  will  even  lead  us  to 
select  a  different  and  more  suitable  mode  of  operating  for  the  second  eye. 
The  patient,  however,  who  has  recovered  from  a  first  operation,  either  well, 
or  indifferently,  or  ill,  is  often  unwilling  to  submit  to  a  second. 

The  confinement,  abstinence,  and  depletion,  used  after  a  first  operation, 
sometimes  cause  the  eye  not  operated  on,  to  fall  so  much  back  in  the  orbit, 
that  it  is  difficult  to  perform  extraction  on  it. 

3.  Does  the  patient  require  to  undergo  any  particular  course  of  prepara- 
tion, before  submitting  to  an  operation  for  cataract  ?  The  time  was,  when 
a  long  and  severe  preparation  was  deemed  necessary,  consisting  of  venesec- 
tion, cupping  and  scarifying,  purging,  and  low  diet.  Now-a-days,  we  have 
perhaps  fallen  into  an  opposite  error,  and  avail  ourselves  too  little  of 
the  precautions  fitted  to  prevent  inflammation.  As  it  is  of  the  highest 
importance  that  recovery  should  take  place  without  inflammatory  action,  it 
may  not  be  improper  to  bleed  the  patient  once  before  operating,  both  to 
moderate  the  impetus  of  the  circulation,  and  to  discover  by  the  appearances 
of  the  blood,  whether  there  may  not  be  inflammation  already  present  in  the 
system.  Should  the  blood  prove  sizy,  it  would  be  highly  imprudent  to  pro- 
ceed immediately  to  an  operation.  It  is  better  not  to  operate  on  pregnant 
females,  as  the  agitation  is  apt  to  cause  abortion. 

If  the  bowels  be  disordered,  with  foul  tongue,  deficient  appetite,  and  head- 
ache, a  dose  of  calomel  every  second  or  third  night,  followed  by  salts  and  senna 
next  morning,  ought  to  be  given  three  or  four  times,  or  till  the  symptoms  in 
question  are  removed.  Even  when  the  patient  appears  to  be  in  perfect  health, 
a  few  saline  purges  ought  to  be  administered  at  proper  intervals,  and  an  anti- 
phlogistic plan  of  diet  followed  for  at  least  eight  or  ten  days.  Rest  is  to  be 
observed  for  several  days  before  any  operation.  Catarrh,  or  cough,  debars 
an  operation,  especially  extraction. 

Immediately  before  any  operation,  the  patient  must  take  no  full  meal,  and 
carefully  avoid  all  articles  difficult  of  digestion. 

When  once  an  operation  is  resolved  upon,  it  ought  not  to  be  put  off,  with- 


MODES   OF   FIXING   THE   EYE.  729 

out  some  good  cause ;  for  the  patient's  anxiety  grows  with  every  hour,  and 
he  is  apt  greatly  to  magnify  the  dangers  to  be  apprehended.  It  proves  highly 
encouragiug  to  the  patient,  to  talk  with  one  who  has  been  successfully  operated 
on,  and  who  is  able  to  give  a  reasonable  account  of  the  operation. 

4.  Is  there  any  particular  season  of  the  year  more  suited  than  another  for 
operating?^  The  spring  was  formerly  selected  in  preference  to  any  other 
season.  Yet  from  the  prevalence  of  catarrhal,  rheumatic,  and  inflammatory 
affections,  at  that  period  of  the  year,  it  is  perhaps  the  worst.  Patients  who 
are  liable  to  suffer  from  such  complaints,  ought  to  be  operated  on  in  dry 
summer  weather  only;  but  a  purely  local  cataract,  occurring  in  an  individual 
otherwise  healthy,  may  be  removed  at  any  season,  provided  the  patient  is 
properly  sheltered  and  cared  for. 

5.  In  cases  of  congenital  cataract,  ought  the  operation  to  be  delayed  till 
the  patient  has  attained  an  age  sufficient  to  enable  him  to  understand  the 
importance  of  an  attempt  to  restore  sight,  or  ought  it  to  be  practised  during 
infancy?  The  answer  decidedly  is.  Operate  in  infancy,  and,  if  possible, 
before  teething  commences.  If  the  operation  is  delayed,  the  capsule  becomes 
opaque  and  tough,  and,  therefore,  much  more  difficult  to  remove,  while  the 
eyes,  having  no  distinct  perception  of  external  objects,  acquire  such  an 
inveterate  habit  of  rolling,  that  for  a  long  time  after  the  pupil  has  been 
cleared  by  an  operation,  no  voluntary  effort  can  control  this  irregular  motion.^ 
Speaking  of  the  results  of  Mr.  Saunders'  operations.  Dr.  Farre  states  that 
the  sensibility  of  the  eye,  "  in  many  of  the  cases  cured  at  the  ages  of  four 
years  and  under,  could  not  be  surpassed  in  children  who  had  enjoyed  vision 
from  birth;  but  at  eight  years,  or  even  earlier,  the  sense  was  evidently  less 
active;  at  12,  it  was  still  more  dull;  and  from  the  age  of  15  and  upwards, 
it  was  generally  very  imperfect,  and  sometimes  the  mere  perception  of  light 
remained."^ 


•  Consult  Hamilton,  London  and  Edinburgh  cident  disease,  namely  oscillation,  and  is  then 
Monthly  Journal  of  Medical  Science,  March,  not  likely  to  subside,  even  after  the  cataract 
1843,  p.  201.  is  removed. 

*  The  motion  referred  to  does  not,  in  every  '  Saunders'  Treatise  on  some  Practical 
case,  appear  the  result  of  the  eyes  being  Points,  relating  to  the  Diseases  of  the  Eye, 
affected  with   cataract;    but  is    often  a  coin-  p.  154;  London,  1811. 


SECTION  VIII. — POSITION  OF  THE  PATIENT  DURING  OPERATIONS  FOR  CATARACT 
MODES  OF  FIXING  THE  EYE — USE  OF  CHLOROFORM. 

In  operations  on  the  eye,  much  depends  on  the  position  of  the  patient, 
assistant,  and  operator,  and  on  each  understanding  what  he  is  to  do.  An 
ignorant  forwardness  on  the  part  of  the  assistant,  or  a  want  of  composure  in 
the  patient,  may  in  an  instant  defeat  the  most  perfect  dexterity  of  the  ope- 
rator. 

A  day  or  two  before  the  operation,  the  surgeon  should  examine  the  capa- 
bility of  the  patient  to  allow  his  eyelids  to  be  held  asunder  and  pressed  on 
by  the  fingers,  as  they  must  be  at  the  operation.  Some  bear  this  easily; 
others  fret  at  it.  The  latter  cannot  readily  turn  their  eye  into  the  position 
wanted  by  the  surgeon,  their  eye  is  seized  with  muscular  spasms,  and  at  the 
moment  of  completing  the  section  of  the  cornea,  the  lens  and  vitreous  humor 
are  apt  to  bolt  out  together.  The  impatience  of  pressure  may  be  such  as  to 
deter  the  surgeon  from  extracting. 

A  clear  and  steady  light  is  to  be  chosen,  entering  the  apartment  by  the 
window  near  to  which  the  patient  is  placed,  and  by  no  other. 


130  MODES   OF   FIXING   THE   EYE. 

Some  operators  place  the  patient  on  a  chair,  with  an  assistant  standing 
behind  him;  some  lay  him  on  his  back  on  a  table  with  his  head  on  a  pillow, 
and  employ  an  assistant  to  take  charge  of  one  or  other  eyelid ;  others  dispense 
with  an  assistant. 

1.  The  patient  being  seated  on  a  low  stool,  or  on  a  chair  without  a  back, 
leans  his  head  against  the  breast  of  the  assistant,  who  stands  behind  him. 
We  shall  suppose  that  the  left  eye  is  to  be  operated  on.  In  this  case,  the 
patient  is  to  turn  his  left  side  a  little  towards  the  widow.  With  his  hands  he 
may  lay  hold  of  the  seat,  and  he  must  be  cautioned  that  on  no  account  is  he 
to  raise  them  towards  his  eyes.  If  he  cannot  be  depended  on  for  this,  an 
assistant  at  each  side  must  watch  his  hands. 

To  the  assistant  is  committed  the  double  charge  of  preventing  the  head 
from  bending  suddenly  back,  and  of  supporting  the  upper  lid.  With  his 
left  hand  he  lays  hold  of  the  patient  by  the  chin,  while  with  the  extremities 
of  the  index,  or  of  the  index  and  middle  fingers  of  his  right  hand  applied 
upon  the  border  of  the  upper  lid,  he  raises  it  as  completely  as  possible,  presses 
it  against  the  edge  of  the  orbit,  and  thus  exposes  the  upper  part  of  the  eye- 
ball. He  allows  his  fingers  to  project  so  far  beyond  the  border  of  the  lid, 
that  should  the  patient  turn  his  eye  up,  it  would  come  into  contact  with  the 
fingers,  and  thus  be,  as  it  were,  scared  back  into  its  proper  position.  In 
general,  the  assistant  not  merely  does  not  require,  but  must  avoid,  to  make 
pressure  on  the  eye,  in  any  stage  of  the  operation. 

The  operator  sits  before  and  close  to  the  patient,  on  a  seat  of  such  height 
that  the  patient's  head  is  opposite' to  the  breast  of  the  operator,  who,  by  this 
means,  is  able  to  observe  with  ease  whatever  goes  on  in  the  eye,  and  is  not 
obliged  to  elevate  his  arms  too  much  during  the  operation.  The  operator 
now  tries  the  point  of  the  needle  or  knife,  by  passing  it  through  a  bit  of  very 
thin-  leather,  held  on  the  stretch.  If  it  produces  no  sound  on  piercing  the 
leather,  the  point  is  good.  Still,  supposing  that  it  is  the  left  eye  which  is  to 
be  operated  on,  he  takes  the  instrument  in  his  right  hand,  while  with  the  index 
finger  of  his  left  he  draws  down  the  lower  lid,  and  places  the  point  of  that 
finger  upon  the  border  of  the  lid,  so  as  just  to  touch  the  eyeball.  The  middle 
finger  he  places  on  the  caruncula  lachrymalis,  allowing  it  at  the  same  time  to 
touch  the  nasal  side  of  the  eyeball,  so  as  to  steady  it,  and  prevent  it  from 
turning,  as  it  is  very  apt  to  do,  towards  the  nose;  a  position  which,  if  as- 
sumed after  the  operation  has  commenced,  may  be  productive  of  serious 
mischief. 

By  the  fingers  of  the  assistant  and  the  operator,  placed  as  has  now  been 
explained,  the  eye  is  fixed,  yet  without  pressure.  To  whatever  side  it  turns, 
it  meets  with  the  point  of  a  finger,  except  towards  the  temple,  where  the 
needle  or  the  knife  is  about  to  enter. 

Various  sorts  of  specula,  spikes,  and  hooks,  have  been  invented  for  fixing 
the  eye ;  but  all  of  them,  except  the  bent  silver  wire  speculum  (Fig.  53,  p. 
372),  are  now  discarded.  It  is  occasionally  employed,  especially  in  opera- 
tions on  children,  for  supporting  the  upper  lid,  being  appliedsometimes  to 
its  outer  surface,  but  more  frequently  beneath  its  edge. 

[We  have  not  unfrequently  seen  the  want  of  more  secure  means  of  steady- 
iny  the  ball  during  the  time  the  counter  puncture  is  being  made  in  the  opera- 
tion of  extraction,  than  that  afforded  by  the  fingers  of  the  surgeon  and  his 
assistant.  At  this  stage  of  the  operation,  the  surgeon  has  but  little  or  no 
control  over  the  movement  of  the  ball  by  his  instrument,  and  his  efforts  to 
effect  the  counter-puncture  only  favors  the  disposition  of  the  ball  to  rotate 
inwards.  To  overcome  this,  he  is  deterred  from  opposing  firm  pressure  by 
his  finger,  lest  it  should  cause  the  evacuation  of  the  contents  of  the  ball. 


MODES   OF   FIXING   THE   EYE.  "731 

The  spirting  out  of  the  aqueous  humor,  the  author  tells  us,  is  one  of  the 
most  frequent  accidents  during  this  first  period  of  extraction  from  this  very- 
rolling  in  of  the  eyeball ;  an  accident  which  we  think  is  often  attributable  in 
part  also  to  the  efforts  of  the  surgeon  to  oppose  such  a  motion.  In  the 
operation  for  artificial  pupil  by  excision  or  separation  through  the  cornea, 
the  surgeon  frequently  meets  with  the  same  sources  of  annoyance,  not  only 
in  the  first,  but  also  in  the  subsequent  stages  of  the  operation. 

Under  such  circumstances,  we  would  recommend  the  employment  of  an  in- 
strument (Fig.  88)  proposed  by  M.  Nelaton  in  the  last  volume  of  his  Patho- 

Fig.  88. 


logie  Chirurgicale,  and  which  is  known  amongst  the  French  as  his  ophthalmo- 
stat. It  looks,  at  first  glance,  somewhat  like  the  ordinary  Pellier's  speculum 
or  elevator,  but  on  closer  inspection  it  will  be  found  to  differ  from  it  in  many 
points.  It  resembles  in  reality,  a  diminutive  scavenger's  hoe,  with  its  blade 
nearer  parallel  to  the  shank  of  the  instrument,  and  the  concavity  of  the 
blade  looking  from  rather  than  to  the  handle.  The  blade,  or  plate  of  the 
instrument,  is  oval  three-fourths  of  an  inch  by  little  less  than  half  an  inch, 
with  a  slight  concavity  to  make  it  fit  well  over  part  of  the  ball  of  the  eye, 
and  its  edge  blunt  and  rounded,  so  that  when  the  blade  is  placed  beneath 
both  lids  at  the  external  canthus,  and  pressed  on  the  outer  border  of  the 
orbit,  it  will  fix  the  eye  by  pressing  on  this  bony  edge  the  conjunctiva  as  it 
is  reflected  from  the  lids  to  the  ball. 

The  angle  at  which  the  blade  is  placed  to  the  shank  causes  the  latter  when 
the  instrument  is  adjusted,  to  pass  backwards  and  parallel  to  the  side  of  the 
face,  and  the  distance  of  the  handle  from  the  blade,  enables  the  assistant  to 
hold  it  steady,  and  is  entirely  out  of  the  way  of  the  operator. — H.] 

If  it  is  the  right  eye  which  is  to  be  operated  on,  the  patient  turns  his  right 
side  a  little  towards  the  window,  the  assistant  places  his  I'ight  hand  on  the 
chin,  and  with  his  left  raises  the  upper  eyelid,  while  the  operator  takes  the 
needle  or  knife  in  his  left  hand. 

2.  Some  operators  prefer,  in  all  cases,  that  the  patient  be  laid  along  upoik 
a  table  ;  alleging  that  the  head  is  thereby  kept  more  steady,  and  that  this 
position  is  found  greatly  more  convenient,  if  the  patient  should  grow  faint 
during  the  operation.  When  the  horizontal  position  is  adopted  and  the 
operator  is  ambidextrous,  he  sits  or  stands  at  the  end  of  the  table  and  behind 
the  head  of  the  patient,  supporting  the  right  upper  eyelid  with  the  forefinger 
of  the  left  hand,  placing  the  middle  finger  on  the  caruncula  lachryraalis,  and 
holding  the  instrument  in  his  right  hand,  while  the  assistant,  standing  by  the 
patient's  side,  depresses  the  lower  lid.  When  the  left  eye  is  to  be  operated 
on,  the  surgeon  takes  the  instrument  in  his  left  hand,  and  raises  the  upper 
eyelid  with  his  right.  The  patient  should  be  so  placed  that  the  eye  to  be 
operated  on  is  next  the  window.  If  the  operator  prefers  operating  with  his 
right  hand  on  the  left  eye,  he  stands  by  the  patient's  left  side,  and  depresses 
the  lower  eyelid  with  his  left  hand,  while  the  assistant  sitting  or  standing 
behind  the  patient  raises  the  upper  lid, 

3.  Some  operators  employ  no  assistant.  The  patient  being  seated  on  a 
low  chair,  the  back  of  which  is  furnished  with  a  hollow  cushion  upon  which 


'732  OPERATIONS  FOR  CATARACT. 

to  rest  the  head,  which  is  bent  a  good  deal  back,  the  surgeon  stands  behind 
him.  With  the  index  and  middle-finger  of  the  hand  which  does  not  hold 
the  knife,  placed  upon  the  upper  and  lower  eyelids  towards  their  nasal  ex- 
tremity, he  presses  them  against  the  upper  and  lower  edge  of  the  orbit, 
kee[)s  them  open,  and  fixes  the  eye.  If  not  ambidextrous,  he  operates  thus 
only  on  the  right  eye ;  when  he  operates  on  the  left  eye,  he  stands  by  the 
patient's  left  side,  and  separates  the  lids  by  means  of  the  index-finger  and 
thumb  of  the  left  hand.  I  understand  that  a  distinguished  operator,  in 
London,  who  uses  no  assistant,  still  stands  behind  the  patient,  even  when  the 
left  eye  is  to  be  operated  on,  and  makes  the  section  with  the  right  hand, 
while  with  the  fingers  of  the  left  he  supports  the  lids. 

The  same  method  of  fixing  the  lids  may  be  adopted  with  the  patient  laid 
on  a  table.  It  is  only  for  those  who  are  experienced  and  dextrous,  to  attempt 
operating  without  an  assistant,  and  even  with  them  the  practice  does  not 
always  answer.*  If  the  fingers  of  the  hand  which  does  not  hold  the  knife  be 
occupied  in  keeping  the  eyelids  asunder,  it  may  be  impossible  for  the  unaided 
operator  to  prevent  the  turning  of  the  eye  towards  the  nose. 

If  with  the  eye  which  is  not  to  be  operated  on,  the  patient  retains  any 
considerable  degree  of  vision,  I  generally  cover  it  with  a  monoculus,  or  tie 
it  up,  that  both  eyes  may  be  more  at  rest  during  the  operation.  There  is  no 
better  mode,  however,  of  fixing  the  eyes  than  by  desiring  the  patient  to  look 
at  the  operator,  who  seizes  that  moment  for  entering  the  instrument  into  the 
eye,  which  is  the  subject  of  the  operation.  Of  this  advantage  we  are  not  so 
certain,  if  the  other  eye  is  excluded  from  the  light. 

It  is  of  very  great  advantage  in  operating  on  children,  to  put  them  fully 
under  the  influence  of  chloroform.  If  this  is  not  done,  the  child  must  be 
wrapt  up  in  a  shawl  pinned  so  as  to  keep  the  legs  and  arms  at  rest.  Care 
must  be  taken  not  to  allow  the  lids  of  the  child  to  become  everted,  else  the 
conjunctiva  protrudes,  when  it  is  often  extremely  difficult  to  penetrate  it 
with  the  needle. 

Needle  ojierations  may  be  performed  on  timid  adults  also,  under  the  in- 
fluence of  chloroform.  In  extraction  I  have  not  ventured  to  use  it,  being 
afraid  lest  the  vomiting  which  is  apt  to  follow  its  anaesthetic  eflect,  might 
cause  rupture  of  the  internal  structures  of  the  eye.  I  have  received,  how- 
ever, from  others  who  have  used  it  in  extraction,  a  very  favorable  account  of 
the  complete  stillness  of  the  eye  which  it  affords.  To  obviate,  if  possible, 
its  sickening  effect,  it  ought  not  to  be  administered  till  five  or  six  hours  have 
elapsed  after  taking  food.  In  old  subjects  in  whom  there  is  any  suspicion 
of  organic  disease  in  any  of  the  splanchnic  cavities,  it  ought  not  to  be  em- 
ployed.^ 


'  See  account  of  an  operation  by  Earth,  who        '■"  See   AVhite    Cooper,    Association    Medical 
used  no  assistant,  in  Santerelli,  Delle  Cateratte,     Journal,  January  7,  185.3,  p.  G. 
p.  61;  Forli,  ISll. 


SECTION   IX. — GENERAL   ACCOUNT   OF   THE   OPERATIONS   FOR   CATARACT. 

There  are  three  kinds  of  operations  for  the  cure  of  cataract.  All  three 
have  undergone  many  modifications,  but  each  is  founded  on  a  principle 
totally  differing  from  that  of  the  others. 

1.  There  is  the  mere  removal  of  the  cataract  out  of  the  axis  of  vision, 
leaving  it  still  in  the  eye.  This,  formerly  called  Couching,  is  now  termed 
Displacement. 


OPERATIONS   FOR   CATARACT.  TSS 

2.  We  have  the  complete  Extraction  of  the  cataract. 

3.  There  is  the  Division  of  the  cataract  into  fragments,  which  being  dis- 
solved in  the  aqueous  humor,  disappear  by  absorption. 

Although  it  be  possible  to  perform  any  of  the  three  kinds  of  operation, 
either  through  the  cornea  or  through  the  sclerotica,  displacement  is  best 
effected  through  the  sclerotica,  and  extraction  through  the  cornea,  while  the 
advantages  of  the  anterior  and  posterior  operations  of  division  are  about 
equal. 

The  instruments  invented  for  the  performance  of  the  operations  for  cataract 
are  very  various,  almost  every  operator,  and  in  many  instances  those  who  have 
operated  little  or  none,  having  modified  the  old,  or  invented  new  ones.  The 
simpler  and  the  fewer  the  instruments  are,  the  better.  If  the  young  oculist 
attach  himself  to  the  simplest  modes  of  operating,  and  acquire  dexterity  and 
skill  in  their  performance,  he  will  think  little  of  the  complicated  contrivances 
with  which  some  have  tried  to  make  up  for  their  want  of  knowledge  and  their 
deficiency  in  mechanical  adroitness. 

I.  In  Displacement,  of  which  there  are  two  varieties,  viz :  Depression  and 
Reclination,  we  assign  a  new  situation  to  the  cataract,  at  the  expense  of  the 
vitreous  humor,  which  we  know  to  be  by  no  means  a  mere  gelatinous  mass, 
but  an  organized  part  intimately  connected  with  those  structures  of  the  eye, 
which  are  of  the  highest  importance  and  the  most  susceptible  of  reaction. 
We  conclude,  then,  that  to  extensively  lacerate  the  hyaloid  membrane,  as  must 
be  done  in  tearing  away  and  forcing  down  into  the  vitreous  humor  such  a 
body  as  the  lens,  is  likely  to  produce  serious  injury  to  the  internal  textures 
of  the  eye,  excite  inflammation  of  the  ciliary  body  and  iris,  disorganize  the 
vitreous  humor,  and  lead,  directly  or  indirectly,  to  insensibility  of  the  retina. 
The  displaced  lens,  also,  is  apt  to  come  in  contact  with  the  ciliary  processes, 
and  to  excite  iritis,  followed  by  closure  of  the  pupil ;  or  to  press  against  the 
retina,  which  must  necessarily  cause  amaurosis.  These  effects  may  follow  more 
or  less  quickly.  If  the  displaced  lens  is  firm  and  entire,  or  inclosed  within 
the  capsule,  it  will  not  dissolve  in  the  vitreous  humor,  but  contracting  adhe- 
sions to  the  neighboring  parts,  will  remain  as  a  permanent  cause  of  irritation 
and  chronic  inflammation. 

In  Depression,  the  lens  is  pushed,  as  far  as  this  can  be  done,  directly  below 
the  level  of  the  pupil.  It  will  follow,  of  course,  the  curvature  of  the  eye, 
sweeping  over  the  corpus  ciliare  towards  the  anterior 
edge  of  the  retina,  and  resting  in  such  a  position, 
that  its  anterior  surface  shall  still  be  directed  for- 
wards, and  somewhat  downwards.  (Fig.  89.)  If 
the  lens  is  hard,  and  the  depression  rudely  performed, 
the  retina,  and  even  the  choroid,  may  readily  be  lacer- 
ated in  the  operation,  and  the  eye  deprived  in  an 
instant  of  all  chance  of  recovering  the  power  of  sight. 
If  the  lens  is  left  resting  upon  the  retina,  it  is  reason- 
able to  conclude,  that  this  of  itself  will  prevent  vision. 
Should  it  become  loosened  from  its  new  situation, 

and  rise  a  little  from  the  retina,  the  sensibility  of  this  membrane  may  perhaps 
return  ;  but  in  other  cases,  even  after  the  pressure  is  thus  removed,  the 
amaurosis  may  continue. 

After  depression,  the  lens  is  very  partially  covered  by  vitreous  humor,  by 
the  elasticity  of  which,  if  this  part  be  healthy,  it  is  apt  to  be  pushed  up,  and 
thus  to  resume  its  original  situation,  forming  as  at  first  an  impediment  to 
vision,  and  again  requiring  to  be  displaced.  If  the  vitreous  humor  is  dis- 
solved, the  lens  will  gravitate  to  the  bottom  of  the  eye. 


T34  OPERATIONS   FOR   CATARACT. 

Reascension  of  the  cataract  is  not  so  apt  to  occur  after  RecUnation.     la 
this  operation,  the  lens  is  made  to  turn  over  towards 
Fig.  90.  the  bottom  of  the  vitreous  humor,  in  such  a  way  that 

the  surface  of  the  lens,  which  formerly  was  directed 
forwards,  now  looks  upwards,  and  what  was  the  upper 
edge  is  turned  backwards.  (Fig.  90.)  Over  the  lens, 
displaced  in  this  manner,  the  vitreous  humor  closes 
more  completely  than  over  the  depressed  lens,  so  that 
reascension  is  less  likely  to  happen.  Another  advan- 
tage of  reclination  is,  that  the  retina  is  not  so  liable 
to  be  pressed  on  by  the  cataract  as  after  depression, 
the  displacement  effected  by  the  former  operation 
carrying  the  lens  completely  below  the  level  of  the  i)upil,  leaving  it  there  in 
the  vitreous  humor,  but  not  pressing  it  into  contact  with  the  floor  of  the  eyeball. 
On  the  other  hand,  reclination  must  necessarily  break  through  and  destroy 
the  hyaloid  membrane  more  extensively  than  depression  ;  while  after  the  for- 
mer, as  after  the  latter  operation,  the  cataract  will  certainly  often  remain,  like 
a  foreign  body,  the  cause  of  continued  irritation  within  the  eye,  and  of  ultimate 
insensibility  to  light. 

II.  Extraction  is  a  removal  of  the  cataract  out  of  the  eye  at  once  ;  and  if 
easy  of  performance  and  not  very  dangerous  for  the  eye,  we  would  without 
hesitation  pronounce  it  the  operation  which  ought  to  be  preferred.  But  to 
perform  this  operation,  whether  through  the  cornea  or  sclerotica,  requires  no 
small  degree  of  dexterity,  and  is  attended  by  very  considerable  danger  to  the 
eye. 

If  the  cornea  is  the  part  to  be  opened  for  the  extraction  of  the  cataract, 
the  incision,  in  order  that  it  may  unite  without  inflammation,  and  without  any 
cicatrice  which  would  prevent  the  entrance  of  light,  must  be  an  exact  segment 
of  a  circle,  regular  and  smooth,  at  a  fixed  distance  from  the  sclerotica,  and  of 
sufficient  size  to  allow  the  easy  exit  of  the  cataract.  Both  in  making  the 
section  of  the  cornea,  which  is  the  first  period  of  the  operation,  and  in  the 
subsequent  one  of  opening  the  capsule,  the  iris  ought  to  remain  uninjured. 
One  of  the  chief  advantages  attending  a  successful  extraction,  is  its  leaving 
the  posterior  capsule  and  all  behind  it  untouched  ;  one  of  the  principal  dangers 
attached  to  the  operation  is  the  loss  of  vitreous  humor.  The  hyaloid  mem- 
brane, if  not  perfectly  sound,  is  apt  to  burst,  and  the  vitreous  humor  to  be 
ejected  from  the  eye,  either  before,  along  with,  or  after  the  opaque  lens. 
There  remains,  after  the  most  favorable  extraction,  an  extensive  wound  of  the 
cornea,  which  we  are  most  anxious  should  close  by  immediate  union,  and 
without  any  protrusion  of  the  iris.  The  latter  event,  one  of  the  most  unfor- 
tunate which  can  happen,  appears  in  some  cases  to  be  the  consequence,  and 
is  always  an  additional  cause,  of  inflammation.  Occasionally  violent  suppu- 
rative inflammation  attacks  the  eye  after  extraction,  so  that  the  natural  struc- 
ture of  the  organ  is  totally  changed.  In  less  severe  cases,  the  iris  suffers  in 
texture,  the  pupil  closes,  or  the  cornea  is  rendered  opaque. 

To  divide  circularly  with  a  knife  a  membrane  inclosing  a  fluid,  which  fluid 
is  not  to  be  evacuated  till  the  section  is  carried  to  the  extent  of  a  semicircle, 
and  within  which  fluid  is  suspended  another  and  a  movable  membrane, 
which  is  neither  to  be  allowed  to  be  displaced,  nor  is  in  any  way  to  be  injured 
in  the  execution  of  the  section,  is  a  mechanical  problem  necessarily  difficult. 
It  is  too  artificial  a  piece  of  surgery  to  be  trusted  to  the  hands  of  those  who 
have  not  made  themselves  masters  of  the  subject,  and  already  shown  a  certain 
share  of  natural  or  acquired  dexterity  in  operating  on  the  eye.  It  is  too  nice 
and  dangerous  an  operation  to  be  undertaken  without  the  utmost  precaution, 
composure,  and  steadiness. 


DISPLACEMENT   OF   THE   CATARACT,  135 

Nor  is  it  likely  that  extraction  through  the  sclerotica  is  less  difficult  or 
less  dangerous.  Indeed,  this  method  appears  to  be  universally  abandoned, 
as  exposing  the  eye  to  hemorrhage,  to  the  almost  certain  loss  of  a  large 
quantity  of  vitreous  humor,  and  consequently  to  destruction  of  the  organ. 
If  the  risk  is  so  great,  it  must  deter  us  from  this  mode  of  operating,  even 
while  it  possesses  the  advantage  of  leaving  the  cornea  untouched. 

III.  Division  is  founded  on  the  fact  that  the  aqueous  humor ;  acting  as  a 
menstruum  perpetually  absorbed  and  secreted,  has  the  power  of  completely 
dissolving  and  removing  the  crystalline  lens.  Reasoning  from  this  fact,  and 
from  the  anatomy  of  the  parts  concerned,  we  naturally  conclude  that  it  will 
be  easy  to  introduce  a  needle  either  through  the  cornea  or  through  the  sclero- 
tica, open  up  the  anterior  hemisphere  of  the  capsule,  so  as  to  admit  the 
aqueous  humor,  and  thus  procure  the  solution  of  the  cataract.  Accordingly, 
division  is  regarded  as  the  least  dangerous  mode  of  curing  cataract  by  opera- 
tion. It  is  not  exempt,  however,  from  disadvantages,  trifling  ones  indeed, 
when  compared  to  the  dangers  attendant  on  displacement  or  extraction.  The 
torn  capsule  is  apt  to  reunite,  so  that  the  aqueous  humor  is  excluded  from 
the  cataract,  and  the  solution  ceases.  In  such  a  case,  the  operation  must  be 
repeated,  the  lens  itself  divided,  and  the  fragments  brought  into  the  anterior 
chamber.  Ii'itis  is  not  an  unfrequeut  consequence  of  the  operation  of  division, 
and  is  apt  to  be  attended  by  opacity  of  the  capsule  from  inflammation.  This 
may  take  place,  even  when  the  iritis  is  slight ;  and  as  the  capsule  is  insoluble, 
there  is  no  way  of  removing  its  opaque  shreds  from  behind  the  pupil,  except 
by  displacement  or  extraction.  Rudely  performed  division,  by  injuring  the 
vessels  which  nourish  the  interior  of  the  eye,  induces  dissolution  of  the  hyaloid 
membrane,  the  effects  of  which  being  propagated  to  the  retina  bring  on 
amaurosis.  If  the  cataract  is  hard,  although  the  capsule  is  divided,  the  lens 
will  not  dissolve  for  a  very  long  period  of  time,  if  at  all :  and  to  divide  the 
hard  opaque  lens  of  an  old  person  is  impracticable  ;  but  in  subjects  about 
middle  life,  and  still  more  in  young  persons  and  children,  the  method  by 
division  is  not  merely  sufficient  for  the  cure  of  the  disease,  but  is  plainly  the 
operation  to  be  preferred. 

The  conclusions  to  be  drawn  from  a  general  review  of  the  operations  for 
cataract  ai'e,  that  each  possesses  advantages  and  disadvantages,  and  is  attended 
by  peculiar  dangers  ;  that  one  mode  of  operating  will  be  suitable  for  one  case 
of  cataract,  and  another  for  another ;  and  that  there  can  be  no  more  incon- 
testable proof  of  a  man's  ignorance  of  the  subject  than  his  asking  which  of 
the  operations  we  practice,  or  of  a  man's  being  a  charlatan  than  his  pretending 
to  cure  all  kinds  of  cataract  by  one  kind  of  operation  alone,  modified  by  some 
trifling  change  in  the  manipulations  or  the  instruments.  Each  of  the  opera- 
tions for  cataract  will,  in  certain  circumstances,  recommend  itself  to  our 
choice  ;  none  is  to  be  universally  adopted  and  practised,  to  the  entire  rejection 
of  the  others. 


SECTION  X. — DEPRESSION  AND  RECLINATION. 

In  depression,  the  cataract  is  pressed  down  by  the  needle  below  the  level 
of  the  pupil,  somewhat  into  the  vitreous  humor,  and  to  such  a  depth  as  no 
longer  to  form  an  obstacle  to  vision.  This  operation,  although  by  no  means 
the  best,  is  certainly  one  of  the  simplest,  as  it  is  the  most  ancient,  and  there- 
fore claims  to  be  first  described. 

If  we  examine  the  figure  of  the  eye  and  the  proportions  of  its  several  parts, 
it  will  be  evident  that  there  is  not  sufficient  room  for  the  lodgement  of  a  lens 


736  DISPLACEMENT    OF   THE   CATARACT. 

of  normal  size  directly  below  tbe  pupil.  If  merely  depressed  (  Fi^.  89,  p. 
133),  without  being  reclined  or  turned  over,  the  lens  will  not  be  sufficiently 
covered  by  the  vitreous  humor,  and  will  be  very  apt  to  reascend  into  its 
original  situation.  If  pressed  too  much  down,  it  will  be  lodged  upon  the 
ciliary  processes  and  retina,  or  will  be  thrust  between  the  retina  and  the 
choroid,  or  even  through  these  membranes,^  causing  excessive  pain  at  the 
moment  of  the  displacement,  pain  which  has  in  some  instances  been  known  to 
last  through  life  ;  inducing  vomiting  some  hours  after  the  operation,  scarcely 
to  be  calmed ;  and  bringing  on  inflammation  and  amaurosis.  These  appear 
to  be  the  unavoidable  effects  of  incautiously  depressing  a  large  lens.  They 
are  carefully  to  be  distinguished  from  other  bad  effects  which  are  apt  to 
attend  this  operation,  but  which  with  attention  may  be  avoided. 

The  frequent  complaints  made  against  the  operation  of  depression  led 
Willburg*  to  propose  that  modification  of  displacement  known  by  the  name 
of  reclination.  In  this  operation  the  needle  being  applied,  not  to  the  upper 
edge  but  to  the  anterior  surface  of  the  lens,  or  rather  of  the  capsule,  the 
cataract  is  pressed  backwards  and  downwards  into  the  lower  part  of  the 
vitreous  humor,  opposite  to  the  interval  between  the  external  and  inferior 
straight  muscles,  and  is  left  with  its  anterior  surface  directed  upwards,  its 
superior  edge  backwards.  (Fig.  90,  p.  134.)  This  operation  must  necessarily 
be  attended  with  much  disturbance  of  the  vitreous  humor  ;  yet  it  is  in  a  great 
measure  free  from  the  principal  objections  against  depression.  Even  a  large 
cataract  which  has  been  reclined,  may  lie  embedded  in  the  vitreous  humor, 
without  being  in  contact  with  any  other  part  of  the  eye,  and  consequently 
without  pressing  directly  against  the  retina  or  the  corpus  ciliare.  It  will 
also  be  so  impacted  in  the  vitreous  humor  that  it  will  not  be  likely  to 
reascend. 

§  1.  Depression  or  Reclination  through  the  Cornea. 

In  depression  and  reclination,  the  needle  is  generally  introduced  through 
the  sclerotica  and  choroid.  Some,  however,  have  preferred  passing  it  through 
the  cornea;  but  in  this  way  neither  operation  can  be  satisfactorily  performed. 
As  it  is  impossible,  through  the  cornea,  to  open  the  posterior  capsule,  the 
displacement  can  be  effected  only  by  forcing  the  cataract  through  that  mem- 
brane ;  a  violent  step  which  may  not  always  succeed.  In  attempting  dis- 
placement through  the  cornea,  it  is  extremely  difficult  to  separate  the  whole 
circumference  of  the  cataract  from  its  natural  connections,  even  although  the 
pupil  is  fully  dilated  by  belladonna.  It  will,  therefore,  not  be  put  quite  out 
of  sight,  and  will  be  very  apt  to  reascend.  If  the  operator,  observing  the 
operation  imperfectly  completed,  make  further  attempts  to  displace  the  cata- 
ract, he  will  probably  bruise  and  perhaps  lacerate  the  iris.  When  partial 
adhesions  exist  between  the  iris  and  capsule,  requiring  to  be  separated  before 
proceeding  to  displacement  of  the  cataract,  the  separation  can  with  difficulty 
be  effected  by  the  needle  passed  through  the  cornea. 

§  2.   Depression  or  Reclination  through  the  Sclerotica. 

On  the  evening  previous  to  the  operation,  extract  of  belladonna,  moistened 
to  the  consistence  of  cream,  is  to  be  smeared  on  the  eyebrow  and  eyelids,  and 
allo\fed  to  remain  till  about  half  an  hour  before  the  operation,  when  it  is  to 
be  washed  off  with  a  sponge  and  tepid  water.  If  the  pupil  is  not  by  this 
time  fully  dilated,  a  solution  of  atropine,  or  filtered  solution  of  extract  of 
belladonna  in  water,  is  to  be  dropped  upon  the  conjunctiva,  not  rudely  dashed 
in  with  a  hair  pencil. 

The  instrument  for  depression  and  reclination  is  a  bent  needle,  of  which 


DISPLACEMENT   OF   THE   CATARACT, 


Y3t 


\ 


^ 


A 


Fig.  91  is  a  lateral  view,  while  Fig.  92  shows  its  convex  surface.     The 

curved  part  measures  not  more  than  i  inch  in  length,  nor 

more  than  ^^^  inch  in  breadth  at  its  broadest  part.     The    Figs.  92,     91. 

neck  is  round,  so  that  after  the  instrument  is  introduced 

into  the  eye,  it  may  be  turned  in  any  direction,  without 

distorting  or  enlarging   the  wound  by  which  it  has  been 

passed  through  the  sclerotica  and  choroid. 

Depression  and  reclination  are  divided  each  into  four 
periods,  which  must  not  only  be  distinctly  understood  by 
the  surgeon,  but  carefully  observed  by  him  in  practice.  In 
thejirst  period,  the  needle  is  introduced  through  the  tunics, 
and  into  the  vitreous  humor.  In  the  second,  the  posterior 
hemisphere  of  the  capsule  is  divided.  In  the  third,  the 
anterior  hemisphere  of  the  capsule  is  divided.  In  the  fourlh, 
the  actual  displacement  is  effected.  It  is  only  in  the  fourth 
period  that  reclination  differs  from  depression. 

1st  Period. — The  needle  must  enter  the  eye  so  as  to 
wound  nothing  but  what  cannot  be  avoided,  else  we  may 
be  prevented  from  satisfactorily  executing  the  remaining 
parts  of  the  operation,  or  may  inflict  serious  and  irrepara- 
ble injury. 

The  parts  which  must  be  wounded,  are  the  conjunctiva, 
sclerotica,  choroid,  and  vitreous  humor.  The  parts  to  be 
avoided  are  the  ciliary  processes,  the  retina,  the  branches 
of  the  iridal  or  long  ciliary  artery,  and  the  lens.  The  ves- 
sels of  the  choroid  are  also  to  be  spared  as  much  as  possible. 
If  the  ciliary  processes,  the  branches  of  the  iridal  artery, 
or  several  of  the  choroidal  arteries  be  wounded,  hsemorrhagy 
is  likely  to  take  place  into  the  eye.  We  are  taught  to 
believe  that  the  retina  is  insensible  to  mechanical  irritation, 
so  that  the  wounding  of  it  with  the  needle  should  not  be 
productive  of  any  pain  ;  but  as  we  know  not  how  far  the 
violent  vomiting  which  not  unfrequently  follows  displace- 
ment, may  sometimes  be  owing  to  touching  the  retina  with 
the  needle,  or  how  far  its  sensibility  to  light  may  afterwards 
be  affected  from  being  wounded,  we  should  always  avoid  a 
part  of  the  eye  the  integrity  of  which,  it  is  reasonable  to 
conclude,  must  be  of  the  highest  importance.  If  the  nee- 
dle is  directed  towards  the  cataract  in  the  first  period,  it  is 
apt  to  enter  the  substance  of  the  lens,  so  that  on  attempting 
to  proceed  with  the  operation,  the  whole  cataract  moves  towards  the  pupil ; 
an  inconvenient  and  awkward  occurrence,  requiring  the  needle  to  be  withdrawn 
a  little  and  freed  from  the  lens,  before  the  operation  can  be  proceeded  with. 

All  these  errors  may  be  avoided  by  attending  to  the  following  rules  : — 

1.  Taking  the  needle  in  his  right  hand,  if  it  is  the  left  eye  which  is  to  be 
operated  on,  and  vice  versa,  the  operator  holds  it  with  the  convex  surface 
looking  upwards,  and  the  concave  surface  downwards,  in  order  that  in  pass- 
ing through  the  pars  non-plicata  of  the  corpus  ciliare,  it  may  divide  as  few 
of  the  choroidal  arteries  as  possible. 

2.  The  lids  being  fixed  by  the  fingers  of  the  assistant  and  operator,  in  the 
manner  specified  at  page  TSO,  the  operator  leans  with  his  little  finger  on  the 
cheek  of  the  patient  as  on  a  point  of  support,  in  order  to  prevent  the  needle 
from  sinking  suddenly  and  to  too  great  a  depth  into  the  eye. 

3.  The  point  of  the  instrument  is  to  be  directed  towards  the  centre  of  the 
vitreous  humor,  thus  completely  avoiding  the  lens. 

47 


738  DISPLACEMENT   OP   THE   CATARACT. 

4.  The  needle  is  to  be  entered  at  the  distance  of  one-sixth  of  an  inch 
behind  the  temporal  edge  of  the  cornea.  If  this  rule  is  not  attended  to,  but 
the  instrument  is  entered  either  much  nearer  to  the  cornea  or  much  farther 
from  it,  the  ciliary  processes  in  the  one  case,  and  in  the  other  the  retina,  can 
scarcely  escape  being  injured. 

5.  As  the  iridal  artery  divides  into  two  branches,  at  the  distance  of  about 
three  lines  from  the  edge  of  the  cornea,  in  order  to  avoid  these  branches  the 
needle  is  to  be  entered  in  the  equator  of  the  eye. 

6.  As  soon  as  the  needle  has  penetrated  to  the  depth  of  one-fifth  of  an 
inch,  or  in  other  words,  as  soon  as  the  lance-shaped  part  of  it  is  fairly  within 
the  choroid,  the  first  period  of  the  operation  is  completed. 

2c?  Period. — The  second  period  of  the  operation  commences  with  a  double 
motion  of  the  needle,  by  which,  in  the  first  place,  it  is  made  to  perform  a 
quarter  of  a  revolution  on  its  axis,  so  that  its  concave  surface  comes  to  be 
turned  forwards,  and  its  convex  surface  backwards,  while  at  the  same  time  its 
handle  is  carried  a  little  towards  the  temple,  and  its  point  forwards  and  in- 
wards to  the  back  of  the  lens.  The  extent  to  which  it  will  require  to  be 
introduced,  in  order  to  reach  the  centre  of  the  posterior  surface  of  the  lens, 
is,  as  is  shown  at  a,  Fig.  91,  about  /q  inch,  and  it  is  well  to  mark  this  length 
on  the  needle  by  gilding  the  portion  of  it  nearer  the  handle,  so  that  the 
operator  may  know  when  it  is  pushed  sufficiently  into  the  eye.  The  point  of 
the  needle  is  now  to  be  raised  to  the  middle  of  the  upper  edge  of  the  pos- 
terior hemisphere  of  the  capsule,  and  by  a  repeated  vertical  movement  of  the 
point,  the  posterior  hemisphere,  and  especially  the  lower  part  of  it,  is  to  be 
divided,  so  as  to  prepare  an  aperture  for  the  passage  of  the  lens.  The 
incision  may  now  be  prolonged  a  little  way  downwards  through  the  vitreous 
humor. 

3c?  Period. — As  soon  as  the  surgeon  considers  the  division  of  the  posterior 
hemisphere  of  the  capsule  to  be  accomplished,  he. brings  the  needle  slowly  over 
the  upper  edge,  or  under  the  lower  edge,  of  the  crystalline  body,  into  the 
posterior  chamber.  The  needle  will  then  appear  within  the  pupil,  and  in 
front  of  the  cataract.  Having  turned  the  point  of  the  needle  towards  the 
anterior  hemisphere  of  the  capsule,  by  alternate  elevations  and  depressions 
of  the  point,  the  surgeon  divides  that  membrane  to  the  extent  of  its  whole 
diameter. 

Uh  Period. — The  rest  of  the  operation  differs  according  as  the  cataract  is 
to  be  depressed  or  reclined. 

If  the  operator  chooses  to  depress,  he  elevates  the  point  of  the  needle  by 
lowering  its  handle,  till  the  point  reaches  the  superior  edge  of  the  lens.  The 
concave  surface  of  the  instrument  being  applied  to  the  top  of  the  cataract, 
the  handle  is  now  to  be  gradually  elevated,  and  the  point  depressed ;  the 
cataract  descends  from  behind  the  pupil ;  its  course  is  downwards,  and  a 
little  outwards  and  backwards;  it  is  to  be  depressed  till  it  is  no  longer  in 
sight.  If  in  cifecting  this  the  handle  is  raised  much  higher  than  the  horizon- 
tal position,  the  cataract  is  apt  to  be  pressed  through  the  retina,  and  vision 
extinguished  by  the  very  attempt  which  is  made  to  restore  it. 

For  the  space  of  a  minute  or  two,  the  needle  is  to  be  kept  in  contact  with 
the  depressed  cataract.*  The  needle  is  then  to  be  rotated  between  the  finger 
and  thumb,  so  as  to  free  its  point  from  the  lens.  Its  point  is  then  to  be 
slowly  raised,  the  operator  taking  notice  whether  the  cataract  reascends,  or 
remains  depressed.     If  it  reascends,  the  depression  must  be  repeated. 

In  this  operation,  and  also  in  reclination,  it  might  perhaps  be  deemed 
desirable  that  the  capsule  should  be  displaced  along  with  the  opaque  lens  ; 
but  as  this  cannot  be  easily  and  safely  accomplished,  we  content  ourselves 


DISPLACEMENT   OF   THE   CATARACT.  T39 

with  dividing  it,  leaving  its  shreds  attached,  through  the  medium  of  the 
zonula  Zinnii,  to  the  ciliary  processes.     These  shreds, 
being  highly  elastic,  will  shrink  or  roll  themselves  up,  Fig.  93. 

and  prove  no  impediment  to  vision,  unless  inflammation 
come  on  and  render  them  opaque,  in  which  case  they 
are  apt  to  coalesce,  and  will  form  a  secondary  capsular 
cataract.  The  annexed  figure  (Fig.  93)  shows  the  in- 
terior of  an  eye,  dissected  by  Dr.  W.  Soemraerring.* 
eight  years  and  a  half  after  reclination.  The  lens  had 
entirely  disappeared,  a  portion  of  the  centre  of  the 
capsule,  which  had  been  displaced  along  with  the  lens, 
appeared  curled  up  and  lying  on  the  lower  and  outer 

part  of  the  ciliary  body,  while  the  remainder  of  the  capsule  formed  two  trans- 
parent semilunar  flaps,  retaining  their  natural  situation,  the  one  behind  the 
upper,  and  the  other  behind  the  lower  part  of  the  iris.  It  is  probable  that 
in  this  case  no  particular  attention  had  been  paid  to  a  division  of  the  capsule, 
before  proceeding  to  the  displacement  of  the  lens.* 

After  the  displacement  is  accomplished,  and  just  before  withdrawing  the 
needle  from  the  eye,  it  is  recommended  to  turn  the  point  of  the  instrument 
towards  the  cornea,  and  to  move  it  three  or  four  times  round  within  the  pupil, 
so  as  to  lacerate  the  capsule,  if  it  had  escaped  being  fully  divided  in  the  third 
period.  This  may  be  the  means  of  preventing  secondary  capsular  cataract, 
and  should  the  lens  reascend,  will  insure  its  being  exposed  to  the  dissolving 
action  of  the  aqueous  humor.  The  needle  is  then  to  be  removed  from  the 
eye,  in  the  same  position,  as  to  its  surfaces,  in  which  it  was  introduced. 

If  the  surgeon  prefers  reclination,  he  commences  the  fourth  period  by 
raising  the  point  of  the  needle  not  more  than  the  tenth  of  an  inch  above  the 
transverse  diameter  of  the  lens ;  he  presses  the  concave  surface  of  the  needle 
against  the  cataract,  and  then  immediately  proceeds  to  recline  it,  by  moving 
the  handle  of  the  instrument  upwards  and  forwards,  while  its  point,  of  course, 
passes  downwards  and  backwards.  By  this  manipulation,  the  cataract  is 
made  to  fall  over  into  the  vitreous  humor,  and  is  then  pressed  downwards, 
backwards,  and  a  little  outwards.  The  position  of  the  needle,  at  the  end  of 
reclination,  is  very  different  from  its  position  at  the  end  of  depression.  In 
the  latter,  it  is  nearly  horizontal ;  in  the  former,  the  handle  is  pointing  upwards, 
outwards,  and  forwards,  nearly  in  a  line  with  the  temple  of  the  operator. 

Manner  of  using  the  needle. — 1.  The  instrument  is  to  be  held  very  lightly  in 
the  hand,  so  that  it  may  be  moved  easily  in  all  directions.  If  it  be  grasped 
firmly  by  the  fingers,  the  operator  has  comparatively  no  power  over  it,  and  is 
unable  to  execute  the  delicate  movements  required  in  the  operations  of  dis- 
placement. 

2.  When  once  the  needle  is  introduced  into  the  eye,  no  part  of  the  depres- 
sion or  reclination  is  to  be  executed  by  a  motion  of  the  whole  instrument  in 
one  direction  ;  but  the  point  is  always  to  be  moved  in  one  direction,  and  the 
handle  in  another,  so  that  the  needle  forms  a  lever  of  the  first  kind,  the  scle- 
rotica being  the  fulcrum.  Upon  this  fulcrum  the  instrument  ought  to  be 
moved  with  the  least  degree  of  pressure  possible,  and  without  any  dragging 
of  the  eye. 

Modifications  of  depression  and  reclination  according  to  iHirieties  of 
cataract. — 1.  When  the  cataractous  lens  is  found  to  be  friable,  and  breaks 
into  fragments  under  the  pressure  of  the  needle,  or  soft,  so  that  the  needle 
passes  through  it,  displacement  ought  to  be  altogether,  or  in  a  great  measure, 
abandoned,  and  the  operation  of  division  immediately  substituted  in  its  room. 
The  anterior  hemisphere  of  the  capsule  is  carefully  to  be  lacerated,  and  its 
central  part,  if  possible,  destroyed  ;  the  fragments  of  the  friable  lens  will  often 


T40  DISPLACEMENT   OF   THE   CATARACT. 

pass,  almost  of  themselves,  through  the  lacerated  opening,  and  through  the 
pupil  into  the  anterior  chamber,  where  they  will  speedily  be  dissolved.  If 
the  nucleus  of  the  lens,  however,  appears  to  be  hard,  we  have  our  choice  either 
to  displace  it,  or  leave  it,  in  situ,  exposed  to  the  action  of  the  aqueous  humor. 
The  pieces  into  which  the  soft  lens  may  be  divided,  are  not  so  easily  scattered 
by  the  application  of  the  needle  ;  and  in  such  a  case,  it  is  better  not  to  attempt 
too  much,  but  rather  confine  ourselves  to  the  comminution  of  the  anterior 
hemisphere  of  the  capsule,  reserving  for  a  subsequent  operation  the  division  of 
the  lens  and  dispersion  of  its  fragments.  If,  instead  of  abandoning  displacement, 
the  sui'geon  persists  in  it,  when  he  finds  the  cataract  to  be  soft,  he  must  not  be 
surprised  if  internal  inflammation  of  the  eye  should  ensue,  in  consequence  of 
the  swelling  which  the  soft  lens  is  likely  to  undergo  in  the  vitreous  humor. 

2.  If  displacement  be  attempted  in  advanced  cases  of  Morgagnian  cataract 
{cataracta  Jlaido-dura),  the  fluid  part  of  the  cataract,  the  instant  that  the 
anterior  capsule  is  opened,  is  poured  into  the  aqueous  humor,  so  as  to  render 
it  quite  turbid.  The  operator  should  now  endeavor  to  displace  the  hard 
nucleus  ;  and  as  the  opaque  fluid,  if  left  within  the  eye,  is  extremely  apt  to 
cause  vomiting  and  pain,  ])aracentesis  corneas  should  immediately  be  performed, 
so  as  to  evacuate  the  contents  of  the  aqueous  chambers. 

3.  A  similar  escape  of  the  disintegrated  lens  into  the  aqueous  humor,  will 
happen  in  many  cases  of  capsulo  lenticular  cataract.  If  the  plan  is  not  fol- 
lowed, of  immediately  puncturing  the  cornea  and  allowing  the  mixture  of 
aqueous  humor  and  fluid  lens  to  escape,  which  is  the  practice  to  be  recom- 
mended, in  the  course  of  some  days  the  aqueous  humor  may  again  resume  its 
natural  transparency,  the  fluid  lenticular  matter  having  been  absorbed ;  but 
unless  something  more  has  been  done  at  the  time  of  the  operation  than  merely 
puncturing  the  capsule,  vision  will  still  be  interrupted  by  the  capsular  part  of 
the  cataract.  When  we  observe,  therefore,  that  the  dissolved  lens  is  escaping 
into  the  aqueous  humor,  we  should  endeavor  as  completely  as  the  state  of 
matters  will  allow,  to  lacerate  and  destroy  the  anterior  hemisphere  of  the 
capsule ;  and  should  we  find  after  the  absorption  of  the  dissolved  lens  is 
effected,  that  the  central  aperture  in  the  capsule  is  insufficient,  either  another 
attempt  must  be  made  with  the  needle,  to  clear  away  as  much  of  the  opaque 
membrane  as  will  secure  the  transmission  of  the  rays  of  light  to  the  retina, 
or  the  capsule  must  be  extracted  through  a  small  incision  of  the  cornea  or 
sclerotica. 

4.  We  sometimes  have  to  do  with  cases  of  cataract,  in  which  the  edge  of 
the  pupil,  in  consequence  of  previous  iritis,  is  partially  or  completely  adherent 
to  the  capsule.  When  the  adhesion  embraces  the  whole  circumference  of  the 
pupil,  to  separate  the  capsule  is  almost  impossible,"  so  that  as  far  as  this  struc- 
ture is  concerned,  the  formation  of  a  central  opening  in  it  is  all  that  we  should 
attempt.  The  lens  we  displace  or  divide,  according  to  the  estimate  we  are 
led  to  form  of  its  consistence.  When  the  edge  of  the  pupil,  on  the  other 
hand,  is  bound  to  the  capsule  in  one  or  two  points  only,  as  will  be  rendered 
evident  on  bringing  the  iris  under  the  influence  of  belladonna,  we  endeavor, 
first  of  all,  to  tear  or  cut  across  the  adhesions  with  the  edge  of  the  needle, 
then  open  up  the  centre  of  the  capsule,  and  lastly  displace  the  opaque  lens. 
Before  withdrawing  the  needle,  the  central  aperture  of  the  capsule  may  be 
enlarged  or  completed,  unless  we  judge  that  enough  has  already  been  done, 
and  that  anything  farther  should  be  left  to  another  operation,  after  an  interval 
of  some  weeks  or  months.  The  division  of  the  adhesions  between  the  iris  and 
the  capsule  is  sometimes  attended  with  an  effusion  of  blood. 

5.  Cases  occur  in  which  the  cataractous  lens  instantly  reascends,  whenever 
the  needle  is  raised  in  order  to  be  withdrawn  from  the  eye.  Such  an  occur- 
rence has  been  ascribed  to  a  greater  degree  of  adhesion  than  is  natural  between 


V  DISPLACEMENT   OF   THE   CATARACT.  •  T41 

the  lens  and  the  capsule,  or  between  the  capsule  and  the  hyaloid  membrane, 
and  has  been  designated  as  elastic  cataract.  In  this  case,  if  we  are  sure  that 
the  second  and  third  periods  have  been  properly  executed,  we  allow  the  lens 
to  resume  the  situation  whence  it  had  been  forced  ;  we  then  carry  the  needle 
over  its  upper  edge,  and  down  behind  the  posterior  hemisphere  of  the  capsule  ; 
we  move  it  upwards  and  downwards,  so  as  to  destroy  the  adhesion  of  the 
capsule  to  the  hyaloid,  bring  up  the  needle  from  under  the  cataract  into  the 
posterior  chamber,  and  displace  the  lens  inclosed  in  the  capsule. 

After-treatment.' — 1  Experiments  on  the  degree  of  vision  recovered  by  means 
of  the  operation  which  has  just  been  performed,  are  not  advisable,  as  in  the 
endeavors  which  the  patient  makes  to  discern  the  objects  presented  to  him, 
the  muscles  of  the  eye  are  necessarily  called  into  action,  and  this  is  apt  to 
unsettle  the  cataract  from  its  new  situation. 

2.  The  eyes  are  to  be  shaded  by  means  of  a  light  linen  compress,  fixed  by 
a  roller  going  round  the  head,  or  pinned  to  the  nightcap. 

3.  Kest  is  to  be  enjoined,  both  of  the  eyes  and  of  the  head,  for  some  days ; 
the  patient  lying  in  bed,  or  sitting  in  a  chair.  The  room  is  to  be  kept  mode- 
rately dark.  The  food  is  to  be  of  an  easily  digested  kind,  not  too  nourishing, 
nor  of  such  a  sort  as  to  require  chewing. 

4.  After  three  or  four  days,  the  eyes  may  be  protected  from  the  light  by  a 
green  bonnet-shade;  but  ought  not,  for  eight  or  ten  days  longer,  to  be  em- 
ploj'ed  in  examining  objects.  After  this  period,  they  are  gradually  to  be 
brought  into  use,  the  patient  taking  care  to  avoid  whatever  excites  pain  or 
redness  of  the  eyes,  or  gives  rise  to  epiphora. 

Accidents  during  or  consequent  to  the  operations  of  displacement. — 1.  One 
of  the  least  considerable  of  the  accidents  which  are  apt  to  follow  these  opera- 
tions is  the  formation  of  a  small  thrombus  under  the  conjunctiva,  in  conse- 
quence of  one  of  the  visible  vessels  of  the  eye  having  been  wounded  by  the 
needle ;  a  thing  which  may  easily  be  avoided.  Should  such  a  thrombus  follow, 
it  is  to  be  left  to  itself;  the  blood  contained  in  it  will  speedily  be  absorbed. 

2.  A  small  fungous  excrescence  sometimes  rises  from  the  wound  made  by 
the  entrance  of  the  needle  through  the  coats  of  the  eye.  It  may  be  touched 
once  a-day  with  a  solution  of  nitrate  of  silver,  or  if  this  proves  ineffectual, 
with  the  same  substance  in  a  solid  state. 

3.  Effusion  of  blood  into  the  eye  is  not  a  frequent  occurrence  in  the  opera- 
tions of  displacement.  Even  when  the  iridal  artery  is  divided,  or  the  ciliary 
processes  touched,  the  bleeding  generally  tends  more  to  escape  by  the  wound 
than  to  flow  into  the  interior  of  the  eye.  At  the  same  time,  haemorrhagy  into 
the  aqueous  humor  suddenly  obscuring  the  field  of  operation,  does  occasion- 
ally occur.  In  the  majority  of  cases,  the  blood  may  safely  be  left  to  be  re- 
moved by  absorption.  Rarely  is  it  in  such  quantity  as  to  produce  pain  or 
distension,  or  render  necessary  an  opening  at  the  edge  of  the  cornea,  with  the 
extraction  knife,  for  its  evacuation. 

4.  If  the  operator  has  entered  the  needle  in  a  wrong  direction,  and  plunged 
it  deep  into  the  eye,  the  point  of  it  is  apt  to  be  buried  at  once  in  the  substance 
of  the  lens,  so  that  on  attempting  to  proceed  with  the  operation,  the  whole 
cataract  moves  forward  towards  the  cornea.  When  the  operator  observes 
that  this  is  the  case,  he  must  turn  the  needle  several  times  round  on  its  axis, 
and  withdraw  it  a  little,  so  as  to  free  it  from  the  lens,  and  then  proceed  to  the 
second  period  of  the  operation,  in  the  usual  manner. 

5.  It  can  happen  only  from  extreme  carelessness,  or  rudeness  of  manipula- 
tion, that  in  introducing  the  needle  into  the  posterior  chamber,  the  iris  is 
separated  from  the  choroid,  an  accident  which  is  attended  by  considerable 
discharge  of  blood  into  the  aqueous  humor.  In  this  case  it  is  proper  to  with- 
draw the  needle  and  postpone  the  operation.     The  iris,  if  healthy,  is  not 


T42  DISPLACEMENT   OF   THE   CATARACT. 

likely  to  return  to  its  place,  but  a  false  pupil  will  probably  remain  perma- 
nently. 

6.  It  sometimes  happens  that,  on  attempting  to  depress  or  recline  the  lens, 
it  is  suddenly  tilted  forwards  through  the  pupil.  When  this  is  the  case,  it 
may  be  possible,  with  some  difficulty,  to  harpoon  it  with  the  needle,  carry  it 
back  again  through  the  pupil  to  its  former  situation,  and  then  displace  it  as 
had  been  intended.  I  consider  it  better  practice,  hovvever,  immediately  to 
extract  the  lens.  For  this  purpose,  the  operator,  keeping  the  lens  steady  in 
the  anterior  chamber  by  means  of  the  needle,  should  make  a  section  of  some- 
what less  than  one-half  of  the  circumference  of  the  cornea,  with  the  extraction 
knife,  and  either  push  out  the  lens  with  the  needle,  or,  laying  hold  of  it  with 
a  hook,  remove  it  from  the  eye. 

Y.  There  sometimes  occurs,  an  hour  or  two  after  any  operation  with  the 
needle,  excruciating  nervous  pain  in  the  eye,  and  in  all  the  branches  of  the 
fifth  nerve  on  the  corresponding  side  of  the  head.  The  pulse  is  not  affected, 
and  the  pain  yields  to  doses  of  from  forty  to  fifty  drops  of  laudanum,  repeated 
every  three  or  four  hours.  Those  who  have  been  in  the  habit  of  dosing  them- 
selves with  opium,  are  most  liable  to  such  attacks. 

8.  Yioleut  bilious  vomiting  in  the  course  of  a  few  hours,  or  during  the  first 
night  of  the  operation,  is  a  frequent  consequence  of  depression  and  reclina- 
tion.  This  symptom,  which  is  generally  attended  by  severe  pain  in  the  eye 
and  head,  has  been  attributed  to  various  causes,  as  injury  of  the  ciliary  nerves, 
or  of  the  retina,  at  the  moment  of  entering  the  needle,  and  pressure  on  the 
retina,  or  laceration  of  it,  from  displacememt  rudely  and  iguorantly  performed. 
Fluid  lenticular  matter  mixing  with  the  aqueous  humor,  is  a  cause  well  ascer- 
tained. The  ordinary  means  for  checking  vomiting  are  to  be  adopted,  such 
as  bits  of  ice  swallowed  at  intervals  of  a  few  minutes,  eff'ervescing  draughts, 
and  small  laudanum  clysters,  frequently  repeated.  Bloodletting  ought  to  be 
had  recourse  to,  as  inflammation  scarcely  ever  fails  to  occur  in  such  cases. 
If  the  presence  of  dissolved  lenticular  matter  in  the  aqueous  chambers  is  the 
cause,  the  cornea  is  to  be  punctured,  so  as  to  allow  the  opaque  fluid  to 
escape. 

9.  Adhesion  of  the  lids  in  the  morning  is  a  usual  occurrence  after  any  opera- 
tion with  the  needle.  It  is  of  no  consequence,  and  is  to  be  preferred  to  an 
acrid  watery  discharge,  or  hot  dry  eye. 

10.  Inflammation  of  the  retina  and  of  the  iris  is  to  be  apprehended  after 
the  operations  of  displacement,  especially  when  the  manipulations  have  been 
unskilfully  executed,  the  suspensory  ligament  of  the  lens  torn  from  its  adhe- 
sion to  the  ciliary  processes,  or  the  needle  kept  long  in  the  eye.  Severe  pain 
in  the  eye  and  round  the  orbit,  coming  on  during  the  night,  is  generally  the 
first  symptom  indicative  of  internal  inflammation,  after  any  operation  on  the 
eye.  The  sclerotica  and  conjunctiva  become  red,  the  color  of  the  iris  changes, 
the  pupil  contracts,  lymph  is  effused,  the  remnants  of  the  capsule  coalesce, 
become  opaque,  and  adhere  to  the  edge  of  the  pupil;  vision  is  extremely  in- 
distinct; and  unless  proper  means  of  cure  are  adopted,  onyx,  hypopium,  and 
destruction  of  the  eye,  may  ensue.  Free  bloodletting,  both  general  and 
local;  opium,  internally  and  externally;  calomel,  so  as  speedily  to  affect  the 
mouth;  and  belladonna,  to  expand  the  pupil,  are  the  remedies  chiefly  to  be 
relied  on. 

Chronic  inflammation  of  the  internal  textures  of  the  eye  is  a  frequent  con- 
sequence of  depression  or  reclination.  It  is  not  attended  by  much  pain,  but 
prevents  the  eye  from  ever  attaining  a  degree  of  healthiness  sufficient  to 
render  it  useful.  The  patient,  perhaps,  retains  a  considerable  degree  of  re- 
covered sight,  for  some  weeks  after  the  operation ;  but  epiphora,  varicose 
dilatation  of  the  external  bloodvessels  of  the  eye,  and  in  general  a  contracted, 


DISPLACEMENT   OF   THE   CATARACT.  743 

but  sometimes  a  dilated  pupil  supervening,  the  sight  becomes  weak,  and  in  a 
few  months  is  extinguished.  The  true  remedy  for  this  state  of  the  organ 
would  be  the  entire  removal  of  the  lens,  which,  lying  in  the  vitreous  humor, 
operates  exactly  as  a  foreign  substance  would  do  in  the  same  situation. 

11.  Amaurosis,  with  dissolution  of  the  vitreous  humor,  irregularly  di- 
lated pupil,  haziness  of  the  cornea,  and  varicose  dilatation  of  the  external 
bloodvessels  of  the  eye,  is  a  common  result  of  the  operations  of  displacement. 
If  the  retina  is  pressed  upon  by  a  firm  lens  which  has  been  depressed  or 
reclined,  insensibility  to  light  is  the  necessary  consequence.  It  sometimes 
happens,  however,  that,  after  some  days  or  weeks,  the  lens  rises  a  little  in 
the  vitreous  humor,  the  retina  is  thereby  relieved,  and  the  power  of  vision 
returns.  Yet  this  result  does  not  always  follow;  the  lens  may  reascend,  and 
the  retina  remain  insensible.  If  the  practitioner  who  has  performed  depres- 
sion or  reclination,  sees  reason  to  suspect  that  the  very  means  which  he  had 
adopted  for  restoring  vision  threatens  to  destroy  it,  he  ought  not  to  hesitate 
about  withdrawing  the  displaced  lens  from  the  eye  entirely.  Introducing  a 
bent  needle  through  the  sclerotica,  the  cataract  is  to  be  raised  into  its  former 
situation,  pressed  forward  through  the  pupil,  and  kept  in  contact  with  the 
cornea  till  a  section  is  made,  a  hook  introduced,  and  the  lens  laid  hold  of,  so 
that  it  may  be  extracted. 

12.  If  a  lens  of  moderate  consistence  is  stripped  of  its  capsule  and  depressed 
or  reclined,  it  may  dissolve  partially  or  completely  in  the  vitreous  humor.' 
But  if  it  be  displaced  with  its  capsule  entire,  it  will  suffer  no  solution;  even 
stripped  of  the  capsule,  a  hard  lens  may  remain  unchanged  for  a  great  length 
of  time.  The  annexed  figure  (Fig.  94)  shows  the  in- 
terior of  the  eye  of  a  woman  of  seventy-three  years  of  Fig.  94. 

age,  in  which  the  lens,  along  with  its  capsule,  was  reclined 
by  Dr.  Emden.  The  cataract  reascended,  and,  three 
months  after  the  first  operation,  the  reclination  was  re- 
peated. A  segment  of  the  cataract  always  continued 
visible  behind  the  pupil,  notwithstanding  which  the  pa- 
ti^ent  saw  well  for  three  years,  when  she  died.  The  lens, 
contained  in  its  capsule,  was  found  entire,  in  the  situation 
represented  in  the  figure.  Two  bloodvessels  were  ob-  (From  so.mmtmng.) 
served  running  from  the  ciliary  body  into  the  capsule.^ 

Beer  saw  a  lens,  which  had  been  depressed  thirty  years  before  by  Hilmer, 
reascend  in  consequence  of  a  fall  upon  the  head ;  and,  in  many  instances,  he 
had  found  cataracts,  on  dissection,  lying  in  the  vitreous  humor,  firm,  and  only 
slightly  contracted,  the  lenticular  part  bearing  no  marks  of  solution,  and  the 
capsular  none  of  maceration.^ 

Reascension  of  a  depressed  or  reclined  cataract  is  so  common  an  occur- 
rence that  some  have  gone  the  length  of  speaking  of  the  operations  of 
displacement,  as  affording  only  a  palliative  cure.'"'  Reascension  may  take 
place  at  any  period  after  the  operation,  but  is  more  apt  to  happen  within  the 
first  fortnight  than  afterwards.  The  plan  usually  adopted  by  those  who  have 
practised  displacement,  has  been  to  repeat  the  same  operation  after  each 
reascension,  till  the  lens  has  fairly  settled  in  the  situation  which  they  assigned 
to  it.  Thus  we  find  Mr.  Hey  couching  some  of  his  patients  six  or  seven 
times."  I  shall  not  pretend  to  say  that,  in  all  cases  of  reascension,  extraction 
through  the  cornea  should  be  practised ;  but  of  this  there  can  be  no  doubt, 
that  it  is  proper  in  all  such  cases,  if  extraction  is  not  immediately  resolved 
upon,  to  wait  for  a  few  weeks,  and  watch  what  may  be  the  effect  of  the  aqueous 
humor  on  the  cataract.  It  is  quite  evident  that  many  of  the  cures  attempted 
by  displacement,  and  recorded  as  instances  favorable  to  the  plan  of  couching 
in  preference  to  extracting,  were  actually  accomplished  by  the  dissolution  of 


744  DISPLACEMENT   OF   THE   CATARACT. 

the  lens  after  reascension.  Thus,  Mr.  Hey  tells  us  that,  in  one  of  his  patients, 
"the  cataract  in  the  left  eye  appeared  again;  but  in  a  few  weeks  it  became 
sensibly  wasted. "^^  In  a  case  operated  on  by  M.  Lisfranc,  the  lens  reascended 
next  day  after  the  operation;  for  six  months  it  underwent  no  apparent 
change,  absorption  then  commenced,  and  in  six  weeks  the  third  of  the  lens 
disappeared,  so  that  a  considerable  share  of  vision  was  restored."  Should 
there  be  no  appearance  of  dissolution  after  some  weeks,  it  will  become  a 
question  whether  a  repetition  of  displacement  should  be  adopted,  or  an 
attempt  made  to  extract  the  cataract.  The  latter  cannot  be  safely  attempted 
in  the  ordinary  way;  that  is,  by  a  section  of  half  the  circumference  of  the 
cornea,  else  the  vitreous  humor,  in  consequence  of  what  it  has  suffered  from 
the  previous  displacement,  will  almost  certainly  be  evacuated;  but  the  needle, 
passed  through  the  sclerotica,  must  be  employed  to  place  the  cataract  in  con- 
tact with  the  cornea;  about  a  third  part  of  the  circumference  of  which  being 
opened,  the  cataract  is  to  be  pushed  out  with  the  needle,  or  extracted  with 
the  hook. 

[§  3.   Dhplacement  of  Cataract  hy  lateral  traction  tliroxigh  the  Sclerotic.'] 

[Professor  Paucoast,^*  of  Philadelphia,  has  proposed  to  remove  hard  cata- 
racts from  the  axis  of  vision,  by  drawing  them  "  horizontally  backwards  with 
a  curved  needle  introduced  through  the  sclerotica." 

For  this  purpose  he  employs  a  needle,  "modelled  after  that  of  Scarpa,  but 
with  a  longer  and  more  sudden  curve,  and  reduced  to  the  smallest  size  allow- 
able, in  order  to  have  it  pass  through  the  sclerotic  coat,  so  that,"  "  with  its 
diminished  bulk"  to  "disturb  as  little  as  possible  the  interior  structures  of 
the  ball."  He  deems  "  a  curve  of  the  needle,  almost  amounting  to  a  rect- 
angular turn,"  "indispensable." 

He  punctures  "the  sclerotic  coat  at  a  distance  nearly  equal  to  the  diameter 
of  the  lens  behind  the  margin  of  the  cornea,"  and  "the  needle,  after  it  has 
entered  the  hyaloid  humor,  is  carried  forward  in  the  usual  manner,  so  as  to 
break  between  the  edge  of  the  lens  and  the  ciliary  body  into  the  aqueous 
chambers."  "After  being  made  to  divide  the  capsule  of  the  lens  in  the 
usual  manner,"  it  "  is  to  have  its  hooked  part  sunk  into  the  centre  of  the 
lens,"  which  is  thus  "  to  be  gradually  drawn  horizontally  backwards,  through 
the  same  track  by  which  the  needle  has  passed,  to  the  place  of  puncture  made 
in  the  sclerotic  coat.  The  handle  is  then  to  be  depressed,  and  the  needle 
detached  from  the  eye."  "By  this  process,"  he  says,  "the  eye  is  as  little 
disturbed  as  possible,  and  the  lens  rests  in  the  interior  of  the  hyaloid  tunic, 
and  not  in  contact  with  either  one  of  the  more  delicate  structures  of  the  ball, 
the  iris,  the  ciliary  body,  or  the  retina,  and  with  no  tendency  to  resume  its 
old  position." 

This  method  of  operating.  Professor  Pancoast  had  employed  up  to  1849, 
"in  about  twenty  cases  of  liard  cataract,  without,"  he  says,  "  any  permanent 
failure,  and  with  surprisingly  little,  and,  in  most  instances,  no  apparent  pain 
or  inflammation." 

"  In  the  same  way,  and  with  the  same  success,"  he  says,  he  has  "  several 
times  displaced  secondary  capsular  cataracts." 

We  have  had  many  opportunities,  through  the  kindness  and  courtesy  of 
our  friend  and  former  preceptor.  Dr.  Pancoast,  of  witnessing  him  perform 
this  operation,  and  for  neatness  of  execution,  and  absence  of  consequent  in- 
flammatory irritation,  we  confess,  in  his  hands  at  least,  we  need  not  Avish  for 
any  operation  more  satisfactory. 

The  only  difficulty  we  have  ever  seen  attending  its  performance,  has  been 
in  the  introduction  of  the  needle  through  the  sclerotic,  when  that  tunic  was 
equal  to,  or  greater  in  thickness  than,  the  lengths  of  the  hooked  portion  of 


DISPLACEMENT   OE   THE   CATARACT. 


14:5 


the  instrument.  In  sucli  cases,  the  first  steps  of  the  operation  are  somewhat 
embarrassed,  and  if  great  care  be  not  observed,  the  point  of  the  needle  will 
break  off  in  the  tunic. 

Without  expressing  any  positive  opinion  of  the  advantages  which  this 
operation  may  be  deemed  to  possess  over  either  depression  or  reclination, 
and  with  the  profoundest  respect  for  the  opinions  of  one  whom  we  have  always 
esteemed  facile  princeps  in  all  matters  of  surgery,  we  feel  it  incumbent  upon 
us,  in  recording  the  operation,  to  state  that  we  do  not  think  it  should  be  the 
one  of  election  for  hard  cataract,  for  the  same  or  similar  reasons  that  this 
position  should  be  denied  to  either  reclination  or  depression.  A  cataractous 
lens  displaced  from  the  natural  position  of  that  structure,  whether  by  depres- 
sion, reclination,  or  horizontal  traction,  is  a  foreign  body,  and  as  such  will  be 
very  liable  to  produce  disorganization  of  the  vitreous  humor,  and  subse- 
quently chronic  inflammation  of  the  internal  tunics  of  the  ball.  In  the  case 
of  horizontal  traction,  the  fluidity  of  the  vitreous  consequent  on  the  presence 
of  such  a  foreign  body,  will  not  allow  it  to  remain  in  the  position  in  which 
it  was  left  by  the  operation.  The  lens  will  gravitate  to  the  most  dependent 
point,  and  assume  a  position  scarcely,  if  at  all,  different  from  that  w^hich 
would  be  given  to  it  by  the  operation  of  reclination. 

In  some  cases,  Dr.  Pancoast  states,  "where  the  lens  has  been  large,"  he 
has  "failed  in  drawing  it  horizontally  backwards,  in  the  gap  made  by  the 
needle,"  and  "has  been  obliged  to  couch  it  in  the  usual  manner." — H.] 


'  Speaking  of  the  situation  of  the  lens  in 
those  who  had  been  operated  on  by  depression, 
and  whose  eyes  ho  dissected  after  death,  Daviel 
says:  "  Entin  il  m'est  arrive  do  le  rencontrer 
place  entre  la  retine  et  la  choroide,  et  ces  deux 
membranes  dechirces  en  plusieurs  endroits." — 
Memoires  de  TAcadeniie  Royale  de  Chirurgie; 
12mo.  Tome  v.  p.  377;  Paris,  1787. 

°  Betrachtung  itber  die  bishero  gewiihnlichen 
Operationen  des  Staars;  NUrnberg,  1785. 

^  Guy  de  Chauliac,  who  composed  bis  work 
on  Surgery  in  1363,  gives  the  following  direc- 
tion to  the  operator,  regarding  the  time  during 
which  he  should  keep  the  needle  in  contact 
with  the  depressed  cataract:  "II  la  tiendra 
logee  avec  I'eguille  pendant  le  temps  qu'il  faut 
mettre  a  dire  trois  fois  le  Pater,  ou  une  fois  le 
Minerere." 

'  Beobachtungen  iiber  die  organischen  Ve- 
randerungen  im  Auge  nache  Staaroperationen, 
p.  17;  Frankfurt  am  Main,  1828. 

'  Very  difi'erent  views  have  been  entertained 
respecting  the  degree  of  interference  which 
should  be  followed  in  regard  to  the  capsule. 
1.  Some,  by  saying  nothing  about  it,  leave  us 
to.  infer  that  they  reckon,  either  on  the  cap- 
sule being  displaced  along  with  the  lens,  or  that 
it  will  be  torn  through,  and  its  shreds  left  at- 
tached to  the  zonula  Zinnii.  2.  Others  ex- 
plicitly recommend  the  plan  of  displacing  the 
capsule  along  with  the  lens.  The  attempt  will 
generally  fail;  or,  if  it  succeed,  the  eye  will 
probably  be  severely  injured  by  the  zonula 
Zinnii  being  torn  away  from  the  corpus  ciliare. 
The  lens  will  remain  without  undergoing  almost 
any  diminution  from  absorption  in  the  vitreous 
humor,  and  will  be  apt  to  reascend.  3.  Of 
those  who  advise  displacement  of  the  lens 
without  the  capsule,  some  c(;nfine  themselves 


to  opening  the  posterior  capsule  only,  leaving 
the  anterior  untouched.  By  this  plan,  the 
aqueous  humor  is  prevented  from  infiltrating 
the  lacerated  vitreous  body,  and  the  anterior 
capsule  serves  as  a  convex  boundary  to  the 
vitreous  lens.  Should  the  anterior  capsule  be- 
come opaque,  it  can  be  removed  by  a  subse- 
quent operation.  4.  Fearing  the  formation  of  a 
secondary  cataract,  by  the  anterior  capsule  be- 
coming opaque,  some,  without  interfering  with 
the  posterior  capsule,  but  leaving  it  to  burst 
under  the  pressure  necessary  for  displacing  the 
lens,  devote  themselves  to  a  careful  laceration 
of  the  anterior  capsule  before  proceeding  to 
displace  the  lens;  and  after  it  is  displaced, 
return  with  the  needle  to  the  pupil,  lest  the 
anterior  capsule  may  still  be  entire,  and  al- 
though from  its  transparency  it  maj' not  be  visi- 
ble, repeat  the  movements  calculated  to  tear 
it  into  fragments.  5.  Some,  both  open  the 
posterior  capsule  and  lacerate  the  anterior. 

'^  Mr.  Hey  relates  (Practical  Observations  in 
Surgery,  p.  82,  London,  1803)  a  case  in  which, 
after  twelve  operations  with  the  needle,  he 
succeeded  in  detaching  the  capsule  under  such 
circumstances,  and  restored  vision. 

'  Scarpa,  Trattato  delle  principali  Malattie 
degli  Occhi;  Vol.  ii.  p.  50;  Pavia,  1816; 
Soemmerring,  Op.  cit.  pp.  17.  22.  31. 

*  Soemmerring,  Op.  cit.  p.  35. 

'  Lehre  von  den  Augenkrankheiten;  Vol.  ii. 
p.  363;  Wien,  1817. 

'"  Ibid. 

"  Op.  cit.  pp.  79  and  81;  London,  1803. 

'^  Ibid.  p.  77. 

'^  Lancette  Fran^aise,  2  Mars.  1837. 

'*  Transactions  of  American  Med.  Associa- 
tion; Vol.  iii.  p.  365  et  seq.  for  1850. 


146  EXTRACTION   OF   THE   CATARACT. 

SECTION  XI. — EXTRACTION. 
§  1.  Extraction  through  a  Semicircular  Incision  of  the  Cornea. 

Extraction,  through  an  incision  of  the  cornea,  appears  to  have  been  first 
practised,  as  a  regular  method  of  curing  cataract,  by  Daviel,  a  French  navy 
surgeon  settled  at  Marseilles,  about  the  middle  of  last  century.  He  confesses 
that  he  took  the  hint  from  Petit,*  who,  in  1Y08,  opened  the  cornea  to  extract 
an  opaque  lens  which,  having  reascended  after  depression,  had  fallen  into  the 
anterior  chamber  ;  and  that  he  felt  himself  urged  to  devise  some  new  mode  of 
operating,  by  the  want  of  success  which  he  found  to  attend  couching,  and  the 
destruction  of  the  internal  textures  of  the  eye,  disclosed  upon  dissecting  the 
eyes  of  those  who  had  been  operated  on  in  that  way.^ 

Daviel  commenced  his  operation  of  extraction,  by  passing  a  small  lancet 
into  the  anterior  chamber,  close  to  the  lower  edge  of  the  cornea.  He  then 
enlarged  the  incision,  thus  made,  by  another  instrument  somewhat  similar  to 
the  former,  but  which,  being  sharp  on  the  edges  only,  and  blunt  at  the  point, 
could  with  less  danger  to  the  iris  be  introduced  into  the  anterior  chamber. 
He  completed  the  semicircular  section,  towards  each  side,  with  bent  probe- 
pointed  scissors.  The  inconveniences  arising  from  the  employment  of  so 
many  instruments  were  remedied  by  Palucci,  La  Faye,  Sharp,  and  others,  who 
substituted  a  single  knife,  which  being  entered  at  the  temporal  edge  of  the  cor- 
nea, passed  across  the  anterior  chamber,  made  its  exit  at  the  nasal  edge  of  the 
cornea,  and  either  by  its  progressive  motion,  or  by  being  pressed  downwards, 
completed  a  crescentic  incision  parallel  to  the  lower  edge  of  the  cornea. 

The  operation  of  extraction  divides  itself  into  three  periods.  In  the  first, 
the  cornea  is  laid  open  with  the  knife.  In  the  second,  the  anterior  hemisphere 
of  the  capsule  is  divided.  In  the  third,  the  exit  of  the  cataract,  or  the  ex- 
traction properly  so  called,  is  accomplished.  Some  dexterous  and  experienced 
operatoi's  have  attempted  to  run  these  different  periods  together ;  but  it  is 
absolutely  necessary  to  study  them  individually,  and  it  is  always  safer  to 
execute  each  of  them  deliberately  and  by  itself. 

I  do  not  generally  dilate  the  pupil  by  belladonna,  previously  to  performing 
extraction  ;  but  it  is  a  practice  strongly  recommended  by  some,  as  they  think 
it  tends  to  lessen  the  danger  of  wounding  the  iris  during  the  section  of  the 
cornea,  renders  the  capsule  more  accessible  when  it  is  to  be  opened,  aids  in  the 
easier  exit  of  the  lens,  and  by  enabling  us  to  avoid  injury  of  the  iris  in  these 
three  periods  of  the  operation,  diminishes  the  chance  of  subsequent  iritis.^  I 
believe,  however,  that  after  the  section  of  the  cornea  is  made,  and  the  aqueous 
humor  evacuated,  the  pupil  does  not  generally  continue  dilated. 

\st  Period. — In  laying  open  the  cornea,  care  must  be  taken  that  the  section 
be  of  sufficient  size,  of  a  proper  form,  and  at  a  specified  and  regular  distance 
from  the  sclerotica.  It  must  be  large  enough  to  allow  the  exit  of  the  lens 
without  hindrance,  and  without  the  application  of  much  pressure  on  the  eye  ; 
and  to  permit  of  this,  the  incision  will  require  to  extend  to  at  least  a  half  of 
the  circumference  of  the  cornea.  Mr.  Ware  supposes  the  whole  circumference 
of  the  cornea  to  be  divided  into  sixteen  equal  parts,  and  states  that  nine  of 
these  should  be  included  in  the  incision.  It  must  be  of  a  proper  form,  not 
angular  nor  indented,  but  regular,  smooth,  and  parallel  to  the  edge  of  the 
sclerotica,  that  it  may  heal,  if  possible,  by  the  first  intention,  and  leave  no 
cicatrice  to  prevent  the  entrance  of  light  into  the  eye.  It  ought  not  to  be 
close  to  the  sclerotica,  for  then  the  iris  is  left  insufficiently  supported,  and  is 
apt  to  protrude  ;  neither  ought  it  to  be  far  from  the  sclerotica,  for  then  the 
incision  will  be  too  small  (Fig.  95),  and  if  an  opaque  cicatrice  follow,  it  will 
impede  the  passage  of  the  light  towards  the  pupil.     A  rim  of  cornea,  at  least 


EXTRACTION   OF  THE   CATARACT.  T4T 

the  twentieth  of  an  inch  broad  (Fig.  96),  should  be  left  between  the  sclerotica 
and  the  incision.  Being  thus  fairly  an  incision  in  the  cornea,  it  heals  more 
readily  than  if  it  were  close  to  the  union  of  the  cornea  and  sclerotica. 

Fig.  95.  Fig.  96. 


For  a  long  time,  the  lower  half  of  the  circumference  of  the  Fig-  97 
cornea  was  chosen  for  the  incision.  Wenzel,  however,  entering 
the  knife  on  the  temporal  side,  45*^  above  the  horizontal  diameter 
of  the  cornea,  brought  it  out  below  the  equator  on  the  nasal  side,  and 
thus  effected  a  semicircular  section,  one-fourth  of  which  was  above 
and  three-fourths  below  the  equator.  The  upper  half  of  the  cir- 
cumference of  the  cornea  is  now  generally  preferred.  The  incision 
of  the  lower  half  is  the  more  easily  executed ;  and  through  such 
an  incision,  the  opening  of  the  capsule  and  the  exit  of  the  lens,  are 
accomplished  with  the  least  difficulty.  But  if  this  incision  does 
not  heal  by  the  first  intention,  and  especially  if  it  be  prevented 
from  healing  by  a  protruding  iris,  then  a  broad  unsightly  cicatrice 
will  remain,  very  much  impeding  vision  when  the  patient  looks  down- 
wards, or  even  altogether  preventing  vision  in  any  direction.  On 
the  other  had,  even  supposing  that  the  incision  at  the  upper  edge 
of  the  cornea  heals  only  after  suppuration,  and  that  in  consequence 
of  protrusion  of  the  iris  through  the  incision,  the  pupil  has  been 
dragged  very  much  upwards,  or  is  entirely  closed  or  hid  behind  the 
cicatrice,  still  the  lower  part  of  the  cornea,  which  is  the  most  val- 
uable part,  may  be  left  perfect,  and  by  opening  up  an  artificial  pupil 
behind  this  part  of  the  cornea,  the  patient  will  generally  see  as  well 
as  if  the  eye  had  a  natural  pupil.  Through  the  incision  at  the 
upper  edge  of  the  cornea,  it  is  somewhat  more  difficult  to  effect 
the  division  of  the  capsule,  and  to  conduct  the  removal  of  the  lens. 
Still,  for  the  reason  just  explained,  this  is  certainly  the  situation  to 
be  generally  chosen.  If  the  patient  appears  to  have  a  particular 
difficulty  in  turning  the  eye  down,  or  if  the  eye  seems  more  than 
ordinarily  irritable,  the  lower  edge  is  to  be  preferred.* 

Various  forms  have  been  given  to  the  cornea-knife  ;  but,  on  the 
whole,  the  best  is  that  now  generally  known  as  Professor  Beer's. 
(Fig.  97.)  The  cutting  edge  is  placed  at  an  angle  of  about  15° 
with  the  back,  which  is  continued  in  a  straight  line  from  the  handle. 
The  point  is  double-edged  for  the  length  of  a  line  ;  the  strength 
and  temper  of  the  instrument  such  that  the  point  is  unbending. 
The  blade  should  be  slightly  convex  on  both  surfaces.  To  be 
capable  of  exactly  filling  the  wound  it  inflicts,  it  should  also  grad- 
ually increase  in  thickness  as  it  does  in  breadth  ;  but  it  must  not 
be  too  thick,  lest  by  over-pressure  on  the  aqueous  humor,  and 
through  the  medium  of  the  aqueous  humor  on  the  lens,  the  hyaloid 
membrane  be  forced  to  give  way,  so  that,  on  completing  the  section 
of  the  cornea,  the  lens  bolts  out  of  the  eye  along  with  part  of  the 
vitreous  humor.     The  breadth  of  the  knife  should  not  be  increased 


t48        •  EXTRACTION   OF   THE   CATARACT. 

beyond  au  angle  of  15°,  as  a  broader  knife  than  this,  from  the  difficulty  with 
which  it  penetrates  the  cornea,  is  apt  to  lead  to  an  escape  of  the  aqueous 
humor,  and  a  falling  of  the  iris  upon  the  edge  of  the  instrument. 

Immediately  before  using  it,  the  surgeon  tests  the  point  of  the  knife,  in  the 
manner  already  (p.  130)  mentioned.  He  assures  himself  also,  that  its  edge 
is  perfectly  sharp.  If  it  is  not  so,  it  may  be  impossible  to  divide  the  cornea 
with  it ;  or,  if  that  part  be  torn  through  with  a  knife  not  very  sharp,  the  in- 
cision may  not  heal  as  it  would  probably  do,  if  cut  through  cleanly  with  a 
keen-edged  instrument. 

In  the  further  description  of  the  operation,  we  shall  suppose  the  left  eye  is 
to  be  operated  on,  and  the  upper  half  of  the  cornea  to  be  opened.  The  right 
eye  being  covered  by  a  monoculus  or  by  a  pledget  and  roller,  the  fingers  of 
the  assistant  and  operator  are  to  be  applied  as  has  been  directed  in  Section 
VIII.,  and  especial  care  is  to  be  taken  that  the  operator's  middle  finger  is 
placed  on  the  caruncula  lachrymalis,  and  pressed  well  in  between  the  eyeball 
and  the  angle  of  the  eye,  so  that  the  eye  shall  be  fixed,  and  prevented  from 
turning  towards  the  nose;  a  position,  which,  if  by  inattention  to  the  rule  here 
laid  down,  the  operator  permits,  he  may  find  it  impossible  to  complete  the 
section  which  he  has  commenced.  This  is  one  of  the  most  important  cautions 
in  the  whole  operation. 

The  patient  is  to  be  informed  that  the  operation  is  attended  with  little  pain, 
but  requires  perfect  composure  and  silence  on  his  part,  and  that  he  must  on 
no  account  attempt  to  close  his  eyes,  or  squeeze  them  with  his  eyelids,  but 
allow  them  to  be  as  if  he  had  no  power  over  them.  This  passiveness  is  per- 
fectly attainable  by  the  use  of  chloroform,  so  much  so  indeed  that  the  eye, 
from  the  powerless  state  of  its  muscles,  is  apt  to  be  pushed  before  the  knife. 

If  chloroform  is  not  employed,  the  surgeon  tells  the  patient  to  look  at  him. 
This  generally  brings  the  eye  into  the  central  position.  The  operation  ought 
not  to  be  commenced,  if  the  eye  is  turned  upwards  or  downwards,  inwards  or 
outwards.  The  surgeon  sometimes  requires  to  uncover  the  other  eye,  and 
desire  the  patient  to  look  at  him,  to  get  the  eye  which  is  to  be  operated  on 
into  the  central  position.  He  then  places  the  knife  across  the  cornea, 
measuring,  as  it  were,  the  distance  which  he  is  about  to  traverse,  and  touches 
the  eye  with  the  flat  side  of  the  instrument,  so  as  to  accustom  it  to  the  contact 
of  a  foreign  substance,  and  thus  render  it  less  apt  to  start,  when  he  proceeds 
to  make  the  section. 

In  making  the  section  of  the  cornea,  the  operator  should  observe  the 
following  rules: — 

1.  The  point  of  the  knife  is  to  be  entered  on  the  temporal  side  of  the  cornea, 
at  the  distance  of  -^^  inch  from  the  sclerotica  (see  Fig.  9*7);  and  care  is  to  be 
taken  that  the  cutting  edge  of  the  instrument  is  inclined  neither  towards  nor 
from  the  operator.  Should  he  enter  the  knife  with  its  edge  inclined  forwards, 
he  would  find,  as  he  proceeded,  that  the  middle  of  the  incision  would  be  at 
too  great  a  distance  from  the  sclerotica ;  if  inclined  backwards,  that  the 
incision  would  go  beyond  the  cornea,  and  into  the  iris  and  sclerotica. 

2.  The  instrument  is  to  be  directed  nearly  perpendicularly  to  the  lamellae 
of  the  cornea,  as  if  it  were  intended  to  go  into  the  iris,  in  order  that  the 
lamellffi  may  be  fairly  penetrated,  and  the  point  of  the  knife  arrive  in  the 
anterior  chamber.  If  this  rule  is  neglected,  and  the  instrument  introduced 
in  a  direction  parallel  to  the  plane  of  the  iris,  it  may  slip  between  the  lamellae 
of  the  cornea,  and  not  pass  into  the  anterior  chamber  at  all.' 

3.  As  soon  as  the  point  of  the  knife  has  entered  the  anterior  chamber,  or 
in  other  words,  as  soon  as  the  puncturation  of  the  cornea  is  performed,  the 
handle  of  the  instrument  is  to  be  carried  backwards,  so  that  the  flat  surface 
of  the  knife  becomes  parallel  to  the  plane  of  the  iris,  and  its  point  directed 


EXTRACTION   OF   THE   CATARACT. 


749 


towards  the  point  of  exit  on  the  nasal  side  of  the  cornea.  Fixing  his  eye 
on  this  point,  which  ought  to  be  at  the  same  distance  from  the  sclerotica  as 
the  point  of  entrance,  the  operator  carries  the  instrument  cautiously,  steadily, 
unhesitatingly  towards  it,  neither  too  quickly  nor  too  slowly,  and  inclining  the 
edge  of  the  knife  neither  forwards  nor  backwards,  but  keeping  it  perfectly 
parallel  to  the  iris.  In  traversing  thus  the  anterior  chamber,  let  the  operator 
bend  his  eye  on  the  point  of  counter-pimcturation ;  if  he  do  so,  the  point  of 
the  knife  will  be  sure  to  follow  ;  whereas,  if  he  allow  himself  to  be  diverted 
to  anything  else,  for  instance,  to  what  the  edge  of  the  knife  is  doing,  he  may 
miss  his  aim,  and  bring  out  the  instrument  at  a  wrong  place.  Having 
reached  the  point  of  exit,  he  still  carries  the  knife  onwards  till  the  counter- 
puncturation  (Fig.  98)  is  effected.     He  has  now  the  eye  completely  under 

Fig.  98, 


control.  The  middle  finger,  which  it  was  so  important  should  rest  till  now 
upon  the  caruncula  lachrymalis,  and  prevent  the  eye  from  turning  inwards, 
may  be  shifted  to  the  lower  lid  ;  and  if,  by  the  operator's  express  desire,  the 
assistant  has  been  making  pressure  on  the  upper  part  of  the  eye,  that  pressure 
is  to  be  discontinued. 

4.  The  counter-puncturation  being  effected,  the  section  of  the  cornea  is  to 
be  completed,  simply  by  the  progressive  motion  of  the  knife,  till  it  has  cut 
itself  out.  In  this  part  of  the  operation,  no  pressing  upwards  of  the  edge  of 
the  knife  is  allowable,  much  less  any  sawing  motion,  or  any  dragging  of  the 
eye  towards  the  operator,  Tlie  handle  of  the  instrument  is  to  be  kept  back, 
so  that  the  extremity  of  the  blade  may  pass  over  the  nose  as  it  advances. 
When  the  incision  is  nearly  completed,  the  operator  cannot  proceed  too  cau- 
tiously. If  the  aqueous  humor  has  been  entirely  retained  till  now,  the  knife 
should  be  turned  a  little  on  its  axis,  to  allow  it  to  escape.  If  this  is  neglected, 
the  pressure  of  the  knife  upon  that  fluid,  acting  on  the  lens,  is  apt  to  burst 
the  hyaloid  membrane,  particularly  if  it  is  weak,  as  it  often  is  in  old  age,  and 
thus  give  rise- to  ejection  of  the  vitreous  humor.  The  instant  that  the  section 
is  finished,  the  upper  eyelid  is  allowed  to  fall,  the  light  admitted  into  the 
room  ought  to  be  moderated,  the  patient  is  to  be  assured  that  the  worst  of 
the  operation  is  over,  and  recommended  to  compose  himself. 

Similar  rules  are  to  be  followed,  if  the  incision  is  made  downwards,  or  semi- 
laterally. 

When  from  the  history  of  the  case,  or  any  particular  symptom,  there  is  a 
likelihood  that  the  hyaloid  is  weak,  or  even  dissolved,  it  is  proper  to  stop 
before  the  incision  of  the  cornea  is  quite  finished,  withdraw  the  knife,  and 
proceed  to  the  second  period  of  the  operation.  After  the  capsule  is  opened, 
the  small  portion  of  the  cornea  remaining  undivided,  is  to  be  cut  across  with 
a  narrow  probe-pointed  knife,  or  with  scissors. 


750 


EXTRACTION  OF  THE  CATARACT. 


'id  Period. — Yarious  instruments  have  been  employed  for 
opening  or  destroying  the  anterior  hemisphere  of  the  capsule, 
which  is  the  object  of  the  second  period  of  the  operation.  Some 
employ  a  simple  needle,  like  a  common  sewing  needle,  fixed  in  a 
handle,  its  point  bent  at  a  right  angle  (A,  Fig.  99) ;  and  with 
this  they  make  a  single  scratch  through  the  capsule,  in  general 
quite  sufficient  to  allow  the  exit  of  the  lens.  Others  employ  a 
lance-shaped  straight  needle,  the  lance-shaped  part  being  broader 
and  shorter  than  that  of  the  straight  needle  sometimes  used  for 
depression.  The  edges  of  this  instrument  are  sharp,  and  one  of 
them  being  turned  against  the  capsule,  it  is  proposed  to  divide 
this  membrane  by  several  oblique  incisions  running  from  right  to 
left,  and  crossed  by  as  many  running  from  left  to  right,  so  as  to 
reduce  the  capsule  to  a  number  of  small  lozenge-shaped  portions, 
some  of  which  might  come  away  with  the  lens,  but  which,  if  left 
in  the  eye,  could  not  unite  to  form  a  capsular  cataract.  The 
former  is  the  easier  mode  of  opening  the  capsule ;  the  latter 
seems  the  more  satisfactory,  were  it  not  ascertained  that  it  is  im- 
possible to  divide  the  capsule  into  lozenges,  even  with  the  very 
sharpest  instrument.^ 

The  patient  being  directed  to  look  down  towards  his  nose,  and 
the  upper  eyelid  being  raised,  the  surgeon  introduces  the  instru- 
ment behind  the  loose  flap  of  the  cornea,  with  its  angle  foremost, 
as  far  as  the  pupil ;  the  point  is  then  turned  towards  the  surface 
of  the  capsule ;  and  gentle  pressure  being  exercised  on  the  eye, 
so  as  to  give  a  certain  degree  of  tension  to  its  contents,  the  divi- 
sion of  the  capsule  is  effected  by  one  or  by  several  incisions.  If 
one  incision  only  is  made,  it  should  extend  to  the  whole  diameter 
of  the  capsule,  but  not  go  beyond  this,  which  might  lead  to  open- 
ing the  hyaloid  by  the  edge  of  the  lens,  and  allow  a  discharge  of 
vitreous  humor.  The  instrument  is  now  cautiously  withdrawn 
with  its  angle  foremost,  to  prevent  it  from  catching  in  the  iris  or 
cornea  ;  and  the  lids  are  again  permitted  to  close.  The  patient 
ought  here  to  be  cautioned  not  to  squeeze  the  lids  together,  but 
merely  to  keep  them  shut,  as  if  he  were  asleep. 

3c?  Period. — If  the  gentle  pressure  exercised  upon  the  eyeball, 
during  the  second  period  of  the  operation,  were  continued  after 
withdrawing  the  instrument  with  which  the  capsule  was  divided, 
the  lens  would  immediately  follow.  The  experienced  operator 
may  run  in  this  way  the  second  and  third  periods  together,  but 
those  who  have  not  operated  frequently,  will  find  it  advanta- 
geous to  pause  for  a  few  minutes  before  proceeding  to  the  third 
period. 

It  is  usual  to  have  the  curette,  scoop,  or  (as  it  is  sometimes  called)  Daviel's 
spoon  (B,  Fig.  99),  attached  to  the  opposite  extremity  of  the  same  handle 
in  which  is  fixed  the  needle  for  opening  the  capsule.  Holding,  then,  the  cu- 
rette in  the  hand  which  formerly  held  the  knife  and  the  needle,  the  operator 
with  the  thumb  of  the  other  hand,  raises  the  upper  eyelid,  and  directing  the 
patient  again  to  look  down  towards  his  nose,  presses  gently  and  continuedly 
on  the  upper  and  anterior  part  of  the  eyeball.  The  pupil  is  seen  to  dilate, 
the  superior  edge  of  the  lens  advances  through  the  pupil,  the  whole  lens  pas- 
ses into  the  anterior  chamber,  and  makes  its  exit  through  the  incision  of  the 
cornea,  without  any  other  interference,  in  general,  or  any  other  means  of  ex- 
traction being  employed,  than  a  continuance  of  moderate,  not  forcible,  pres- 
sure.    The  curette  is  used  to  assist  the  extraction,  only  if  the  lens  is  arrested 


B 


EXTRACTION   OF   THE   CATARACT.  *751 

between  the  lips  of  the  incision  of  the  cornea,  or  if  it  appears  falling  into 
pieces. 

The  patient  is  desired  again  to  close  his  eyes  as  if  he  were  asleep,  while  the 
operator,  having  received  the  lens  on  his  finger  nail,  may  examine  whether  it 
is  entire. 

When  the  patient  has  recovered  a  little  from  the  confusion  arising  from  the 
admission  of  light  into  the  eye,  the  surgeon,  holding  up  his  hand  at  the  dis- 
tance of  about  eighteen  inches  from  the  patient's  face,  may  desire  him  to  open 
a  little  the  eye  from  which  the  cataract  has  been  removed,  the  other  eye  being 
still  covered  with  the  pledget  and  roller,  and  to  say  whether  he  sees  anything. 
It  were  better,  in  some  respects,  to  dispense  with  this ;  but  the  patient  who 
submits  to  extraction,  knows  that  such  experiments  are  made  and  expects 
them,  and  if  put  to  bed  without  having  ascertained  what  degree  of  vision  he 
is  likely  to  recover  by  the  operation,  is  apt  to  get  anxious,  and  to  make  trials 
of  his  own,  which  may  be  much  more  detrimental. 

The  operator  with  his  thumb  now  repeatedly  and  gently  rubr.  the  upper 
eyelid  over  the  surface  of  the  eyeball,  raises  the  lid,  and  rapidly  examines  the 
appearance  of  the  pupil  and  the  state  of  the  flap  of  the  cornea.  If  the  pupil 
is  circular  and  clear,  and  the  edges  of  the  incision  of  the  cornea  accurately  in 
contact,  he  desires  the  patient  to  look  upwards,  and  then  immediately  to  close 
his  eyes,  informing  him  at  the  same  time,  that  he  is  not  to  make  any  further 
attempt  to  open  them  till  he  is  desired  to  do  so,  but  to  keep  them  closed, 
without  squeezing  the  lids  together,  and,  in  fact,  exactly  as  if  he  were  asleep. 
A  strip  of  court-plaster,  about  an  inch  long  and  a  quarter  of  an  inch  broad, 
is  now  to  be  applied  from  the  middle  of  the  upper  lid  to  the  middle  of  the 
lower,  over  the  eye  which  has  been  operated  on,  and  the  same  over  the  other. 
The  eye  is  thus  protected  fron  the  intrusion  of  foreign  matters,  and  the  pa- 
tient is  prevented  from  using  it,  while  the  eyelids  gently  support  the  flap  of 
the  cornea,  and  close  the  wound.  A  ribbon,  with  a  fold  of  linen  attached  to 
it,  is  put  round  the  head,  outside  the  patient's  nightcap,  the  fold  hanging 
down  over  the  eyes,  and  the  ribbon  pinned  to  the  nightcap. 

Modifications  of  extraction  according  to  varieties  of  cataract  and  pecidiar 
states  of  the  eye. — 1.  In  eases  of  capsulo-lenticular  cataract,  it  is  proper  to 
attempt  the  extraction  of  the  capsule  as  well  as  of  the  lens.  Some  do  this 
before,  others  after  the  lens  is  removed. 

The  pupil  being  dilated  with  belladonna,  and  the  cornea  opened  in  the 
usual  way,  we  may  endeavor  with  the  needle  to  divide  the  capsule  circularly, 
as  near  its  edge  as  the  instrument  can  be  applied  without  injuring  the  iris. 
The  part  of  the  capsule  included  within  the  circular  division  may  sometimes 
be  brought  away  on  the  point  of  the  needle;  but  if  this  cannot  be  done,  it 
should  be  extracted  by  means  of  a  small  toothed  pair  of  forceps,  and  then  the 
lens  removed  as  in  ordinary  cases.  This  is  the  mode  recommended  by  Mr. 
Ware. 

Beer,  on  the  other  hand,  first  extracted  the  lens,  and  then  attempted  to  re- 
move the  shreds  of  the  opaque  capsule,  by  means  of  the  forceps.  The  instru- 
ment being  introduced  through  the  incision  of  the  cornea  and  through  the 
pupil,  is  to  be  opened  so  as  to  receive  one  of  the  shreds,  and  shut  so  as  to 
hold  it  without  any  possibility  of  its  escaping.  Then  with  a  twitch,  the  shred 
is  to  be  extracted;  and  this  is  to  be  repeated  till  the  whole  of  the  shreds  are 
removed. 

Some  surgeons  think  it  safer  to  defer  making  any  attempt  to  remove  the 
opaque  capsule  when  they  extract  the  lens.'' 

2.  We  sometimes  know  from  the  history  of  the  case,  that  the  posterior 
hemisphere  of  the  capsule  is  opaque ;  or  immediately  after  the  lens  is  removed, 
we  observe  that  there  still  remains  an  opacity,  impeding  vision.     If  we  are 


752 


EXTRACTION  OF  THE  CATARACT. 


satisfied  that  this  opacity,  consists  neither  in  opaque  shreds  of  the  anterior 
half  of  the  capsule,  nor  in  some  portion  of  the  soft  exterior  substance  of  the 
lens  retained  in  the  eye,  we  may  conclude  that  it  is  the  posterior  hemisphere 
of  the  capsule  in  a  cataractous  state.  Perhaps  the  better  plan  in  such  a  case, 
would  be  to  allow  the  eye  to  recover  from  what  has  already  been  done,  and 
by  a  subsequent  operation  to  endeavor  to  remove  the  opaque  membrane  out 
of  the  axis  of  vision,  or  out  of  the  eye.  Some,  however,  have  recommended 
that  we  should  immediately  proceed  to  destroy,  and  if  possible,  to  remove 
the  posterior  half  of  the  capsule.  This  they  have  attempted  by  means  of  a 
needle,  of  which  one  of  the  edges  forms  a  hook  or  barb,  so  that  it  enters 
easily  through  the  membrane  in  question,  and  being  then  turned  one  quarter 
round  on  its  axis  and  suddenly  withdrawn,  brings  along  with  it  a  portion  of 
the  diseased  capsule.  This  manipulation  is  to  be  repeated,  till  at  least  a  con- 
siderable aperture  is  formed  for  the  transmission  of  light  into  the  deeper  parts 
of  the  eye,  an  object  which  will  scarcely  be  effected  without  some  loss  of  vit- 
reous humor. 

Accidents  during  or  after  extraction. — 1.  The  spirting  out  of  the  aqueous 
humor  before  the  counter-puncturation  is  effected,  is  one  of  the 
Fig.  100.  most  common  accidents  during  the  first  period  of  extraction.  The 
patient  feeling  the  eye  suddenly  touched  with  the  knife,  perhaps 
turns  the  eye  inwards,  and  the  aqueous  humor  escapes.  I  have 
seen  it  occur  from  the  patient's  speaking  at  that  moment,  and  the 
eye  moving  as  he  spoke.  The  iris,  in  consequence  of  losing  its 
usual  support,  immediately  falls  forward,  and  folding  over  or  under 
the  edge  of  the  knife,  will  be  cut  across,  if  the  section  is  pursued. 
The  practice  to  be  followed,  is  diffel'ent  according  to  the  size  of 
the  opening  which  has  been  made  in  the  cornea.  When  the  knife 
has  little  more  than  entered  the  cornea,  the  common  practice  is  to 
withdraw  it,  and  defer  the  operation  till  a  future  day.  I  once  saw 
even  the  slight  injury  thus  inflicted  on  the  eye,  followed  by  severe 
and  destructive  inflammation.  M.  Desmarres  is  of  opinion,  that 
by  waiting  only  for  a  few  minutes,  while  the  patient  keeps  his  eyes 
closed,  the  aqueous  humor  may  be  sufficiently  regenerated,  to  re- 
place the  iris  in  its  natural  situation,  and  to  allow  the  operator  to 
resume  the  section  of  the  cornea.^ 

When  the  knife  has  perhaps  half  crossed  the  anterior  chamber, 
and  consequently  has  effected  a  large  aperture  in  the  cornea,  before 
the  loss  of  aqueous  humor  happens,  the  practice  usually  followed 
is  to  attempt  to  liberate  the  iris  by  pressure,  and  under  this  effect 
the  counter-puncturation.  Tliis  is  attempted  by  applying  the  point 
of  the  forefinger  forcibly  on  the  cornea,  over  the  entangled  part  of 
the  iris,  and  pressing  the  iris  upwards  and  away  from  before  the 
knife,  and  back  into  its  place.  The  finger  being  still  kept  on  the 
cornea,  so  as  to  press  it  against  the  blade  of  the  knife,  and  prevent 
the  iris  again  falling  forward,  the  knife  is  to  be  carried  quickly 
across  the  anterior  chamber,  and  the  counter-puncturation  effected. 
This  once  accomplished,  there  is  little  farther  danger  of  the  iris 
falling  upon  the  edge  of  the  knife,  and  the  section  is  to  be  com- 
pleted in  the  ordinary  way. 

If  the  iris  cannot  be  made  to  retire  by  pressure,  one  or  other  of 
the  following  plans  may  be  adopted.  The  common  extraction-knife 
being  withdrawn,  the  narrow-bladed  probe-pointed  knife  (Fig.  100) 
is  to  be  introduced  through  the  aperture  previously  made,  and  in- 
sinuated along  the  posterior  surface  of  the  cornea  avoiding  the  iris 
as  much  as  possible.  The  cutting  edge  being  carried  to  the  ex- 
tremity of  the  wound,  by  withdrawing  the  knife  a  little,  the  inci- 


EXTRACTION   OF   THE   CATARACT. 


15S 


101. 


sion  is  to  be  extended,  and  this  is  to  be  repeated  till  a  semicircle  of  the  cor- 
nea is  divided.  Another  plan  is  to  introduce,  through  the  aperture  already 
made,  a  double  knife,  somewhat  like  that  of  Mr.  Guthrie,  only  smaller  and 
thinner,  one  of  its  blades  blunt  and  the  other  sharp  pointed,  and  push  it  cau- 
tiously through  the  anterior  chamber  to  the  nasal  edge  of  the  cornea.  The 
sharp-pointed  blade  is  now  to  be  pressed  forward,  so  as  to  effect  the  counter- 
puncturation  and  finish  the  incision  in  the  usual  way.  If  the  double  knife  is 
not  at  hand,  a  probe-pointed  knife  may  be  used  instead,  and  when  it  has 
reached  the  nasal  side  of  the  cornea,  an  opening  may  be  made  over  its 
extremity  with  another  knife  so  as  to  allow  it  to  come  through,  after  which 
the  incision  is  to  be  finished  exactly  in  the  same  way  as  if  the  sharp-pointed 
knife  only  had  been  employed. 

By  some  all  these  plans  are  disregarded,  and  we  are  advised  rather  to  carry 
the  knife  on,  and  if  the  iris  does  not  recede  on  pressure,  to  incise  a  portion 
of  it,  than  have  recourse  to  expedients  much  more  likely  to  prove  destruc- 
tive than  the  accident  they  have  been  invented  to  remedy.  A  simply  incised 
wound  of  the  iris,  or  even  one  where  a  small  portion  has  been  cut  off  entirely, 
is  not  found  to  lengthen  the  period  of  recovery,  to  give  rise  to  iritis,  or  to 
produce  any  other  subsequent  inconvenience  than  an  enlarged  and  ill-shaped 
pupil. 

2.  When  the  point  of  the  knife  reaches  the  nasal  edge  of  the  cornea,  the 
operator  occasionally  finds  it  difficult  to 
bring  it  through,  in  which  case  he  may  derive 
advantage  from  pressing  the  cornea  against 
the  knife  with  his  finger-nail.  In  other  in- 
stances, the  point  of  the  knife  is  seen  to 
bend  to  one  side,  so  that  it  is  impossible  to 
perform  the  counter-puncturation  in  the  or- 
dinary way.  When  this  is  the  case,  the 
cornea  may  be  opened  on  the  nasal  side  with 
another  knife,  and  then  the  one,  which  is 
already  across  the  anterior  chamber,  may  be 
carried  through  the  opening,  and  the  section 
completed.  The  double  knife  may  also  be 
useful  in  such  a  case. 

3.  Should  the  point  of  the  knife,  instead 
of  being  brought  out  through  the  cornea  at 
the  proper  place,  appear  ready  to  penetrate 
through  the  sclerotica,  it  must  be  cautiously 
withdrawn  a  little,  and  then  pushed  through 
the  cornea  at  the  distance  of  ^V  i'^ch  from 
its  nasal  edge. 

4.  Too  small  a  section  of  the  cornea  is  a 
very  frequent  occurrence,  in  consequence  of 
the  operator  bringing  out  the  knife  at  too 
great  a  distance  from  the  nasal  edge,  and 
perhaps  considerably  above  the  equator  of 
the  cornea.  In  this  case,  the  incision  must 
be  enlarged  to  a  semicircle.  Thei'e  is  no 
practice  more  apt  to  prove  fatal  to  the  suc- 
cess of  the  operation,  than  that  of  forcing 
the  lens  through  a  small  section.  Loss  of 
viti'eous  humor,  severe  pressure  upon  the  iris, 
and  destructive  inflammation  are  among  the 
consequences  to  be  dreaded. 

48 


15i  EXTRACTION   OF   THE   CATARACT. 

The  enlargement  is  effected  with  a  knife  or  scissors,  and  the  latter  either 
straight  or  doubly  curved.  The  incision  made  with  scissors  is  not  very  apt 
to  heal  by  the  first  intention  ;  its  edges  are  liable  to  swell,  inflame,  gape,  and 
allow  the  iris  to  protrude.  In  cutting  with  the  knife,  the  eye  is  more  dragged, 
and  the  lens  and  vitreous  humor  are  apt  to  fly  out  of  the  eye.  The  knife 
(Fig.  100,  p.  752)  is  narrow,  straight,  and  rounded  at  the  point,  and  is  to  be 
used  in  enlarging  the  section  exactly  as  in  cases  of  premature  loss  of  the 
aqueous  humor.  Richter  recommends  straight  scissors,  as  cutting  better 
than  curved  ones.  Generally,  however,  Daviel's  scissors  are  preferred,  from 
their  cutting  in  a  curve  concentric  to  the  edge  of  the  cornea.  There  are  two 
pairs  of  them,  the  one  so  bent  that  it  serves  for  dividing  the  temporal  side  of 
the  right  cornea  and  nasal  side  of  the  left,  while  the  other  pair  serves  for  the 
temporal  side  of  the  left  cornea  and  nasal  side  of  the  right.  On  the  supposi- 
tion that  the  incision  is  at  the  upper  edge  of  the  cornea.  Fig.  99,  represents 
the  latter  pair.  Rarely  will  the  incision  require  to  be  enlarged  at  both  extrem- 
ities ;  but  upon  no  account  is  the  operator  to  proceed  to  the  second  and 
third  periods  of  extraction,  if  he  is  conscious  that  the  section  of  the  cornea 
is  less  than  a  semicircle.  Standing  behind  the  patient,  and  resting  the  scis- 
sors on  the  back  of  the  finger  which  raises  the  upper  eyelid,  the  surgeon 
opens  them  a  little,  and  passes  the  one  blade  behind  the  middle  of  the  flap 
of  the  cornea  into  the  anterior  chamber,  while  the  other  remains  external  to 
the  cornea.  The  instrument  is  then  to  be  carried  close  to  the  temporal  or 
nasal  edge  of  the  cornea,  according  to  circumstances,  and  with  a  single  stroke 
the  incision  is  to  be  enlarged  to  the  requisite  dimensions. 

5.  If  the  section  is  too  close  to  the  sclerotica,  the  conjunctiva  is  apt  to  form 
an  impediment  to  its  completion,  the  knife  not  dividing  but  stripping  off  a 
portion  of  conjunctiva  from  the  sclerotica.  When  this  happens,  the  knife  is 
to  be  withdrawn  and  the  conjunctiva  cut  through  with  scissors.  The  section 
being  so  close  to  the  sclerotica,  is  apt  to  give  rise  to  protrusion  of  the  iris, 
evacuation  of  the  vitreous  humor,  and  inflammation  of  the  eye. 

6.  Some  operators  make  it  a  constant  practice  not  to  complete  the  section 
of  the  cornea  with  the  usual  extraction-knife,  but  to  withdraw  that  instru- 
ment when  the  incision  is  nearly  finished,  and  to  divide  the  remainder  of  the 
cornea  with  the  scissors,  or  the  small  probe-pointed  knife.  To  the  straight- 
edged  knife  some  prefer  one  with  a  convex,  and  others  with  a  concave  edge. 
The  practice  is  decidedly  proper,  when  the  operator  observes  that  he  has  unfor- 
tunately so  inclined  the  edge  of  the  knife  first  employed  that,  if  he  continues 
to  press  it  onwards,  the  incision  will  probably  extend  beyond  the  cornea  and 
divide  the  iris  or  sclerotica.  When  he  sees  that  this  is  likely  to  happen,  he 
should  by  all  means  withdraw  the  knife  and  complete  the  incision  in  the  manner 
above  mentioned. 

Some  advise  the  same  practice  on  another  ground,  and  one  of  unquestion- 
able importance.  It  is  just  at  the  completion  of  the  incision,  when  the 
motion  of  the  knife  is  nearly  parallel  to  the  laminae  of  the  cornea,  the  re- 
sistance to  the  instrument  greatest,  and  the  pressure  on  the  eye  most  severe, 
that  the  hyaloid  is  apt  to  burst  and  the  vitreous  humor  to  be  ejected.  To 
prevent  this  it  is  recommended  that  the  knife  be  withdrawn,  and  the  eye  left 
for  a  minute  or  two  at  rest ;  after  which,  the  second  period  of  the  operation 
is  to  be  performed,  and  the  incision  finished  with  the  scissors  or  the  small 
probe-pointed  knife. 

7.  Some  patients  cannot  turn  the  eye  sufficiently  down  to  permit  the  upper 
section  to  be  made  ;  and  in  such,  it  is  proper  to  perform  the  lower  section. 
It  sometimes  happens,  however,  that  the  upper  section  has  been  accom- 
plished, when  we  find,  on  proceeding  to  open  the  capsule,  that  it  is  impossi- 
ble for  the  patient  so  to  command  his  eye  as  to  turn  it  down  sufficiently  to 


EXTRACTION   OF   THE   CATARACT,  155 

expose  the  upper  half  of  the  cornea.  In  one  case  of  this  kind  which  hap- 
pened to  me,  I  was  obliged  to  make  pressure  on  the  eye,  and  evacuate  the 
lens  without  having  had  it  in  my  power  to  open  the  capsule.  The  case  for- 
tunately did  well.  In  other  cases,  I  have  been  obliged  to  lay  hold  of  the 
conjunctiva  with  a  hook  or  pair  of  forceps,  and  draw  the  eye  down  till  I  ex- 
ecuted the  second  period  of  the  operation.  Such  a  procedure,  with  the 
cornea  open,  is  very  apt  to  give  rise  to  rupture  of  the  vitreous  humor,  or  to 
hemorrhage  from  the  interior  of  the  eye. 

8.  The  iris  is  apt  to  be  injured  in  all  the  stages  of  the  operation. 

It  is  sometimes  pricked  in  making  the  puncturation,  it  may  fall  in  the  way 
of  the  knife  as  the  latter  passes  through  the  anterior  chamber,  or  it  may  be 
transfixed  in  attempting  the  counter-puncturation.  Incisions  are  thus  mad^ 
in  the  iris,  and  sometimes  a  piece  of  it  is  fairly  cut  out,  especially  when  it 
falls  before  the  knife,  and  the  operator,  unsuccessful  in  pressing  it  back,  con- 
tinues the  incision.  A  cut  into  the  iris  generally  forms  a  permanent  false 
pupil.  If  it  be  the  edge  of  the  natural  pupil  which  is  cut  into,  or  if  a  por- 
tion of  the  iris,  including  the  edge  of  the  pupil,  be  removed,  we  have,  after 
the  case  recovers,  a  large  irregular  pupil,  which,  though  it  looks  ill,  does  not 
materially  affect  vision. 

If  the  wound  in  the  iris  does  not  communicate  with  the  pupil,  on  making 
pressure  to  promote  the  escape  of  the  lens,  the  pupil  may  not  dilate,  or  the 
lens  may  present  itself  at  the  accidental  aperture.  In  either  case,  it  is  pro- 
per to  divide,  with  Maunoir's  scissors,  the  fibres  intervening  between  the 
accidental  aperture  and  the  pupil,  thus  allowing  the  cataract  to  be  extracted. 

The  iris  is  sometimes  lacerated  during  the  process  of  opening  the  capsule, 
or  iu  withdrawing  the  needle  employed  for  this  purpose.  During  the  seeond 
period  of  the  operation,  the  eye  should  be  steadied  by  gentle  pressure,  and 
the  opening  of  the  capsule  finished  without  any  unnecessary  delay.  If  this 
is  not  attended  to,  the  patient  is  apt  to  turn  up  the  eye  suddenly,  so  that  the 
iris  is  torn,  and  the  aqueous  chambers  filled  with  blood.  In  some  cases,  the 
blood  is  absorbed  iu  a  few  days,  and  neither  acts  as  a  foreign  body  in  exciting 
inflammation,  nor  prevents  the  healing  of  the  -wound.  If  it  is  observed,  how- 
ever, before  closing  the  eye  after  the  removal  of  the  lens,  that  the  aqueous 
chambers  are  filled  with  blood,  it  ought  to  be  removed  with  the  curette.  I 
remember  a  case  in  which  only  a  very  little  blood  was  discharged  at  the 
moment  of  the  operation,  from  the  iris  having  been  touched  with  the  needle, 
but  for  nearly  a  week  blood  continued  to  ooze  from  the  eye,  so  as  to  tinge 
the  fold  of  linen,  and  to  dry  on  the  cheek  and  nose.  The  restoration  to 
vision  was,  in  this  case,  very  imperfect. 

I  have  not  met,  in  the  course  of  my  reading,  with  any  case  parallel  to  the 
following  : — 

Case  349. — Extracting  the  cataract  from  the  right  eye  of  a  spare  unmarried  woman, 
about  50  years  of  age,  4th  June,  1851,  I  had  occasion  to  introduce  the  hook  into  the 
pupil  to  \'Aj  hold  of  the  lens,  and,  in  -withdrawing  the  lens,  I  by  chance  caught  hold  of 
the  iris,  and  removed  the  whole  of  it.  It  came  away  so  easily,  that  the  patient  seemed 
to  feel  no  pain,  and  I  experienced  no  drag,  as  if  anything  extraordinary  was  happening. 
As  the  lens  came  out,  I  saw  something  black  hanging  to  its  edge  ;  and,  on  examining 
this,  I  found  it  to  be  the  iris  entire.  The  eye  instantly  filled  with  blood.  This  was 
slowly  absorbed ;  and,  contrary  to  any  hope  that  I  could  have  entertained,  the  case  did 
well.  On  the  26th  of  July,  the  patient  called  on  me,  with  the  eye  strong,  reading  the 
sign-boards  on  the  shops,  as  she  went  along,  without  a  glass ;  no  intolerance  of  light ; 
and  the  aqueous  humor  clear.  On  the  9th  of  August,  there  was  still  a  yellowish  clot  of 
blood  behind  the  lower  edge  of  the  cornea.  The  central  space  was  clear;  and,  with 
cataract-glasses,  she  saw  distant  objects  distinctly,  and  read  large  type.  On  the  11th 
of  October,  the  central  space  behind  the  cornea  continued  clear,  and  was  somewhat  of  a 
triangular  shape,  while  the  circumference  was  filled  with  whitish  threads  and  reddish  par- 
ticles.    On  the  3d  of  April,  1852,  her  sight  was  so  good  that  she  read  small  type.     The 


756 


EXTRACTION  OF  THE  CATARACT. 


central  space  continued  clear;  while  around  it  a  sort  of  substitute  for  an  iris  had  been 
formed  by  lymph. 

9.  When  the  operator,  proceeding  to  the  third  period  of  extraction,  makes 
pressure  on  the  upper  part  of  the  eyeball,  but  observes  that,  notwithstand- 
ing this,  the  cataract  does  not  advance  through  the  expanding  pupil,  he 
ought  to  desist,  and  ask  himself  whether  the  section  of  the  cornea  be  of  the 
proper  size,  and  whether  he  has  reason  to  think  that  he  has  in  a  sufBcient 
manner  opened  the  capsule.  If  the  answer  in  the  affirmative  is  well  founded, 
then  merely  by  waiting  a  few  minutes,  rubbing  the  eye  gently  through  the 
medium  of  the  upper  lid,  moderating  the  light  admitted  to  the  apartment, 
and  repeating  the  pressure  on  the  upper  part  of  the  eyeball,  the  lens  will 
probably  advance,  and  make  its  exit  in  the  usual  way.  But  if  the  smallness 
of  the  section  be  the  cause  of  the  cataract  not  coming  forward,  the  section 
must  be  enlarged  ;  or  if  the  capsule  has  been  imperfectly  divided,  the  second 
period  of  the  operation  must  be  repeated.  Pressure  is  then  to  be  employed 
as  before,  when,  in  general,  the  cataract  will  advance.  The  pressure  must 
be  at  once  moderate  and  sufficient.  If  it  is  too  forcible,  the  hyaloid  mem- 
brane is  very  apt  to  give  way,  and  the  vitreous  humor  to  be  ejected 
Fig.  102.  before  the  lens.  If  from  timidity  on  the  part  of  the  operator,  the 
pressure  be  too  light  or  too  soon  relaxed,  the  lens  may  not  ad- 
vance, and  the  operator  will  distress  himself  with  imaginary  diffi- 
culties. Yet  it  sometimes  happens  that  the  section  of  the  cornea 
is  sufficient,  the  capsule  sufficiently  opened,  and  due  pressure  made, 
without  the  lens  advancing,  although  the  pupil  may  expand.  This 
arises  from  an  unnatural  adhesion  between  the  lens  and  the  capsule, 
and  is  to  be  remedied  in  the  following  manner  :  The  operator  is  to 
continue  the  pressure  till  the  upper  edge  of  the  lens  appears  in  view, 
he  is  then  to  introduce  a  thin  sharp  curette,  or  small  silver  spatula 
(Fig.  35,  p.  251),  through  the  pupil,  and  loehind  the  lens,  and  by 
the  motion  of  this  instrument  from  right  to  left,  to  separate  the 
capsule  with  the  lens  inclosed,  from  the  hyaloid  membrane.  The 
cataract  hook  (Fig.  102)  is  then  to  be  introduced,  and  the  lens  and 
capsule  extracted.  This  will  scarcely  be  effected  without  some  dis- 
charge of  vitreous  humor,  but  certainly  less  risk  attends  this  mode 
of  procedure  than  that  of  forcing  out  the  cataract,  under  such  cir- 
cumstances by  continued  pressure. 

10.  The  lens  falling  in  pieces  at  the  moment  of  extraction,  part  of 
them  may  remain  behind  the  pupil.  In  this  case,  if  the  operator 
rubs  the  eye  gently  through  the  medium  of  the  upper  lid,  and  then 
opens  the  eye,  he  will  generally  find  that  the  fragments  have  advanced 
into  the  anterior  chamber.  If  they  do  not  escape  on  raising  the  flap 
of  the  cornea  with  the  curette,  they  may  be  withdrawn  with  the  cata- 
ract hook.  Small  particles  may  be  left  to  dissolve  in  the  aqueous 
humor. 

It  sometimes  happens  that,  pn  examining  the  eye  four  or  five  days 
after  the  operation,  we  find  the  patient  does  not  see  so  well  as  he  did 
Immediately  after  it  was  performed,  and  that  the  pupil,  which  then 
seemed  dear,  is  now  opaque.  If  there  has  been  no  pain,  nor  other 
signs  of  inflammation,  this  opacity  is  probably  owing  either  to  some 
portion  of  the  lens  which  had  remained  concealed  in  the  edge  of  the 
capsular  cavity,  or  to  an  effusion  of  unorganized  lenticular  substance, 
similar  to  what  has  been  called  by  experimenters  on  the  lower  ani- 
mals a  regeneration  of  the  lens,  and  which  will  clear  away  from 
behind  the  pupil  in  the  course  of  a  week." 

11.  The  operator,  on  opening  the  eye  to  proceed  to  the  third 


EXTRACTION  OF  THE  CATARACT.  15*t 

period,  sometimes  perceives  that  part  of  the  pupil  is  quite  clear,  or 
that  it  is  altogether  so.  The  lens  has  fallen  down  partially  or  entirely  into 
a  dissolved  vitreous  humor.  This  accident  may  happen  before  the  second 
period,  but  generally  follows  it.  No  pressure  must  be  used,  but  the  hook 
must  be  passed  quickly  down  to  the  back  of  the  lens,  so  that  it  may  be 
caught  and  brought  away.  Some  escape  of  fluid  vitreous  humor  generally 
attends  this  accident.  On  one  occasion,  finding  it  difficult  to  get  hold  of  the 
sunk  lens,  I  filled  the  eye  with  water,  which  assisted  in  bringing  the  lens  into 
view  so  that  I  hooked  it  out. 

12.  An  escape  of  vitreous  humor  may  take  place  before,  along  with,  or 
after  the  exit  of  the  lens.  This  accident  may  arise  from  one  or  other  of  a 
variety  of  causes ;  such  as  undue  pressure  on  the  interior  of  the  eye,  in  con- 
sequence of  too  great  thickness  of  the  knife,  or  retention  of  the  aqueous 
humor  during  the  whole  of  the  first  period  of  the  operation  ;  immoderate  or 
improperly  directed  external  pressure  on  the  eye;  pressure  with  too  small  a 
section  of  the  cornea,  or  an  imperfect  division  of  the  capsule  ;  any  quick 
motion  of  the  eyeball  while  the  capsule  is  being  opened,  or  afterwards  and 
before  the  exit  of  the  lens  is  accomplished,  with  perhaps  an  effort  to  wink ; 
spasm  of  the  recti  or  orbicularis  palpebrarum.  It  is  much  more  frequently 
the  result  of  weakness  of  the  hyaloid  membrane  from  age  or  from  disease, 
than  of  any  other  cause.  When  the  eye  is  known  to  have  been  glaucomatous 
before  becoming  affected  with  cataract,  when  the  iris  or  the  cataract  is  in  the 
least  degree  tremulous,  or  when  the  subject  is  advanced  in  life,  and,  in  the 
ophthalmological  sense,  arthritic,  we  may  expect  a  dissolved  state  of  the 
vitreous  tissue.  If  we  operate  by  extraction  in  such  cases,  and  at  once 
extend  our  incision  to  a  semicircle,  we  may  lay  our  account  with  an  injection 
of  vitreous  humor. 

If  the  capsule  has  been  opened  in  a  previous  operation  through  the  scle- 
rotica, with  the  view,  for  example,  of  softening  a  hard  cataract  previously  to 
attempting  to  divide  it,  or  if  displacement  has  been  ineffectually  performed, 
and  the  operator  proceeds  to  extraction,  he  will  almost  to  a  certainty  en- 
counter an  evacuation  of  vitreous  humor. 

If  the  escape  of  vitreous  humor  commences  before  the  lens  has  been  removed, 
no  farther  pressure  must  be  made  on  the  eye,  but  the  hook  is  to  be  introduced, 
so  as  to  lay  hold  of  the  cataract,  which  is  to  be  withdrawn  as  speedily  as 
possible.  The  eye  is  then  to  be  shut,  and  gently  rubbed  for  some  time  through 
the  medium  of  the  upper  lid,  in  order  to  replace  the  iris,  which  is  very  apt, 
when  there  has  been  any  escape  of  vitreous  humor,  to  protrude  through  the 
wound  of  the  cornea. 

It  not  unfrequently  happens,  that  the  instant  the  section  of  the  cornea  is 
completed,  the  lens  is  ejected  with  violence,  along  with  a  quantity  of  vitreous 
humor.  This  is  particularly  apt  to  occur,  when  the  fissure  of  the  eyelids 
being  short,  they  require  to  be  a  good  deal  dragged,  and  of  course  the  eye- 
ball considerably  pressed  upon  by  the  fingers  of  the  assistant  and  of  the  ope- 
rator, to  allow  the  cornea  to  be  sufficiently  exposed.  In  this  case  also,  we 
must  endeavor  as  much  as  possible,  to  replace  the  iris,  and  bring  the  edges 
of  the  wound  of  the  cornea  together.  This  is  effected  chiefly  by  continued 
gentle  friction  of  the  eyeball,  through  the  medium  of  the  upper  eyelid. 

The  same  practice  is  to  be  followed,  if  the  evacuation  of  vitreous  humor 
follows  the  exit  of  the  lens,  or  occurs,  as  it  sometimes  does  suddenly,  when 
we  direct  the  patient  to  look  at  any  object  held  before  him,  after  the  removal 
of  the  cataract.  In  this  case,  the  action  of  its  muscles  on  the  eye,  seems  to 
cause  the  accident. 

In  general,  after  a  loss  of  vitreous  humor,  the  cornea  heals  more  slowly 
than  usual,  the  cicatrice  is  broader,  the  pupil,  of  a  shuttle-shape,  is  drawn 


758  EXTRACTION   OF   THE   CATARACT. 

towards  the  cicatrice,  and  vision  is  less  perfect.  The  danger  resulting  from 
this  accident,  arises,  within  certain  limits,  not  so  much  from  the  loss  of  vit- 
reous humor  directly,  as  from  the  gaping  state  in  which  the  wound  of  the 
cornea  is  left,  the  hyaloid  membrane  probably  hanging  through  it,  keeping  it 
from  uniting,  and  causing  the  eye  to  inflame.  If  only  a  fifth,  or  even  a  fourth, 
of  the  vitreous  humor  is  lost,  vision  may  not  be  matei'ially  affected.  If  a 
third  is  lost,  we  cannot  calculate  on  distinct  vision.  If  more  than  a  third  is 
evacuated,  the  pupil  generally  closes,  and  the  eyeball  shrinks  to  a  small  size. 
Occasionally  it  happens,  in  consequence  of  the  loss  of  even  a  moderate  quan- 
tity of  vitreous  humor,  that  the  pupil  dilates,  and  the  eye,  although  previously 
sensible  to  light  and  shade,  is  found  on  recovery  from  the  operation,  to  be 
completely  amaurotic. 

13.  As  the  patient  closes  his  eye,  after  the  exit  of  the  cataract,  the  flap  of  the 
cornea  sometimes  turns  down,  so  that  its  internal  surface  is  in  contact  with 
the  eyelid.  It  must  immediately  be  pressed  up  into  its  place,  by  means  of  the 
scoop,  and  accurately  adjusted  by  friction  through  the  eyelid. 

14.  It  sometimes  happens,  immediately  after  the  exit  of  the  lens,  that  the 
cornea  sinks  backwards,  and  presents  a  concavity,  instead  of  its  natural  con- 
vexity. It  is  essential  to  remedy  this  mal-position,  as  it  is  by  no  means  cer- 
tain that  the  cornea,  when  the  aqueous  humor  comes  to  be  re-secreted,  will 
resume  its  proper  direction.  If  it  does  not,  protrusion  of  the  iris,  and 
destructive  inflammation,  seem  certain  to  ensue.  It  is,  in  general,  easy  to 
remedy  the  unnatural  state  of  the  cornea,  by  introducing  the  scoop  behind  it, 
and  pressing  the  centre  of  it  gently  towards  us. 

M.  Maunoir,  in  a  case  of  this  sort,  was  led  to  adopt  a  different  practice : — 
Case  350. — Having  performetl  extraction  upon  a  man  of  82  years  of  age,  he  perceived, 
to  his  regret,  that  although  the  pupil  was  perfectly  black,  and  the  iris  uninjured,  the  ante 
rior  and  posterior  chambers  of  the  eye  were  not  replenished,  the  cornea  became  sunk  and 
•wrinkled,  a  few  bubbles  of  air  penetrated  into  the  anterior  chamber,  and  the  patient  had 
no  vision.  In  these  circumstances,  M.  Maunoir  sent  immediately  for  some  distilled  water, 
warmed  it,  placed  the  patient  on  his  back,  and  poured  the  water  round  the  eye.  He  then 
opened  the  eyelids,  and  raised  the  flap  of  the  cornea.  The  water  penetrated  into  the 
aqueous  chambers,  the  wrinkles  of  the  cornea  disappeared,  and  its  convexity  was  restored. 
Having  kept  the  eye  shut  for  some  minutes,  he  then  directed  the  patient  to  open  it,  and 
found  it  in  the  most  satisfactory  condition.  The  patient  distinguished  all  the  objects  pre- 
sented to  him,  as  well  as  after  the  most  successful  operation.  A  slight  pain  was  felt  from 
the  introduction  of  the  water,  but  went  off  in  a  short  time.  The  eye  healed  without 
difficulty;  and,  when  opened  a  week  after  the  operation,  it  was  free  from  swelling  and 
inflammation;  the  cornea  was  perfectly  united,  but  the  pupil  was  a  little  obscure,  and  the 
patient  complained  that  he  did  not  see  so  well  as  immediately  after  the  operation.  Six 
days,  however,  after  the  bandage  was  removed,  the  dimness  of  the  pupil  was  much  dimi- 
nished, the  sight  grew  stronger  from  day  to  day,  and  no  doubt  was  entertained  that  the 
patient  would  soon  be  able  to  read  common  print. ^ 

The  practice  in  this  case  must  be  regarded  more  as  a  feat,  showing  what 
the  eye  will  bear,  than  an  example  to  be  followed  in  similar  circumstances. 
A  bubble  of  air,  getting  behind  the  coruea,  which  appears  partly  to  have  led 
M.  Maunoir  to  think  of  filling  the  aqueous  chambers  with  water,  is  an  acci- 
dent of  no  moment.  If  it  does  not  disappear  on  rubbing  the  eye  gently,  it 
may  be  left. 

15.  Immediately  after  the  lens  has  escaped  from  the  eye,  the  iris  may 
become  involved  in  the  wound  of  the  cornea,  or  protruded  through  it.  If 
there  is  no  escape  of  the  vitreous  humor,  this  accident  is,  in  general,  very 
easily  remedied,  merely  by  rubbing  the  eye  through  the  medium  of  the  upper 
lid,  and  then  suddenly  exposing  it  to  the  light.  Should  this  not  succeed,  we 
may  lay  a  wet  cloth  over  the  lids  for  a  few  minutes,  which  causes  the  pupil 
to  contract,  and  then  repeat  the  rubbing  with  the  upper  eyelid.  Should  the 
iris  still  remain  prolapsed,  we  may  endeavor  to  press  it  into  its  place  with  the 


EXTRACTION   OF   THE   CATARACT.  T59 

curette,  following  up  this  with  rubbing  of  the  eye  as  before ;  and  should  this 
also  fail,  a  small  snip  may  be  made  in  the  protruding  portion  of  iris,  when  it 
will  often  return  almost  of  itself  into  the  eye,  in  consequence  of  the  aqueous 
humor,  which  was  lodged  behind  it,  draining  away. 

It  is  very  difiTerent  with  a  protrusion  of  the  iris,  which  is  apt  to  take  place 
about  the  fourth  day  after  the  operation,  or  later,  and  which,  though  often 
attributed  to  some  accidental  blow  on  the  eye,  restlessness  on  the  part  of  the 
patient,  or  improper  attempts  which  he  may  have  made  to  use  the  eye,  ought, 
I  am  convinced  to  be  ascribed,  in  general,  rather  to  the  supervention  of  undue 
inflammation  of  the  cornea,  and  of  inflammation  within  the  eye,  than  to  any 
mere  mechanical  cause.  Not  denying  that  this  protrusion  is  favored  by 
making  the  incision  too  close  to  the  sclerotica,  it  appears  to  be  much  more 
frequently  the  consequence  of  too  small  a  section  of  the  cornea,  so  that  the 
lens  had  to  be  pressed  out  of  the  eye  with  force  ;  of  the  incision  being  made 
with  a  knife  not  perfectly  sharp,  so  that  a  good  deal  of  dragging  was  exer- 
cised in  completing  the  section  ;  or  of  the  cornea  being  squeezed  between 
the  operator's  nail  and  the  knife. 

This  protrusion  of  the  iris  does  not  take  place  suddenly.  We  first  of  all 
observe  the  wound  gaping  a  little,  and  its  edges  white,  swollen,  and  everted. 
Next,  the  iris  begins  to  show  itself  between  the  lips  of  the  wound,  and  as  the 
aqueous  humor  accumulates  behind  it,  this  staphyloma  indis  increases.  At 
the  same  time,  the  protruding  portion  of  the  iris  inflames,  and  is  united  by 
effused  lymph  to  the  edges  of  the  wound  of  the  cornea.  The  conjunctiva  and 
sclerotica  redden,  the  discharge  of  tears  is  frequent  and  irritating,  the  patient 
feels  as  if  some  foreign  substance  of  considerable  bulk  were  lodged  beneath 
the  eyelids,  the  eye  and  supra-orbital  region  become  painful,  the  skin  dry  and 
hot,  and  the  pulse  quick.  The  protrusion  is  apt  to  be  increased,  if  the 
patient  is  affected  with  cough. 

No  direct  attempt  need  be  made  to  reduce  the  protruding  portion  of  the 
iris ;  but  means  should  be  taken  to  prevent  its  increase,  and  to  abate  the 
inflammation  on  which  it  depends.  The  protrusion  should  be  touched,  from 
time  to  time,  with  the  ten  grains'  solution,  or  a  sharpened  pencil  of  lunar 
caustic,  which  both  tends  to  lessen  the  protrusion  and  to  excite  such  inflam- 
mation as  produces  adhesion  between  the  section  and  the  prolapsed  piece 
of  iris.  Should  the  prolapsus  continue,  it  should  be  punctured,  or  snipped 
off  with  the  scissors.  Unless  the  patient's  state  of  constitution  forbids,  a 
vein  of  the  arm  ought  to  be  opened ;  leeches  applied  to  the  temple  ;  and  a 
blister  behind  the  ear.  The  bowels  should  be  acted  on  by  a  purgative,  and 
calomel  with  opium  administered  till  the  mouth  is  affected.  These  are  the 
most  likely  means  to  abate  the  inflammatory  action  upon  which  the  protru- 
sion probably  depends.  If  the  protruding  piece  of  iris  has  not  been  snipped 
off,  belladonna  is  at  first  to  be  avoided,  as  rather  tending  to  favor  the  protru- 
sion ;  but  after  the  iris  is  united  to  the  cornea,  belladonna  aids  in  approxi- 
mating the  edges  of  the  wound  of  the  cornea,  by  causing  the  protruding 
portion  of  the  iris  to  contract. 

A  broad  cicatrice  of  the  cornea,  with  a  dragging  of  the  pupil  towards  the 
cicatrice,  is  the  necessary  consequence  of  this  accident,  even  when  the  most 
appropriate  means  of  cure  are  had  recourse  to.  The  pupil  may  be  so  much 
distorted,  as  to  be  completely  hid  behind  the  cicatrice,  with  the  lower  half  of 
the  iris  very  much  on  the  stretch,  and  the  lower  half  of  the  cornea  clear,  a  state 
of  matters  which  still  affords  a  chance  of  vision  being  restored  by  the  formation 
of  an  artificial  pupil.  In  more  unfortunate  cases,  however,  the  inflammation 
is  so  severe  and  extensive,  and  is  prolonged  for  such  a  length  of  time,  before 
the  prolapsed  portion  of  the  iris  shrinks  and  the  wound  of  the  cornea  unites, 
that  the  vessels  of  the  eye  are  left  varicose,  and  the  retina  insensible.     Some- 


'JQO  EXTRACTION    OF   THE   CATARACT. 

times  the  neighboring  part  of  the  sclerotica  partalies  in  the  tendency  to 
protrusion  and  staphyloma,  so  that  the  eye  remains  permanently  unsightly  and 
irritable. 

16.  Although  the  healing,  by  immediate  union,  of  such  a  wound  as  that  of 
the  cornea  after  extraction,  must  depend  chiefly  on  the  exact  coaptation  of 
the  wounded  surfaces,  and  the  absence  of  all  inflammatory  action,  we  meet 
with  old  or  enfeebled  individuals,  in  whom  the  wound  does  not  close  for  a 
considerable  length  of  time,  notwithstanding  the  apparent  fulfilment  of  both 
these  conditions.  In  such  cases  the  flap  of  the  cornea  is  apt  to  become 
nebulous,  and  the  aqueous  chambers  either  remain  empty,  or  from  time  to 
time  are  subject  to  sudden  evacuation  of  their  contents  through  the  ununited 
incision.  In  a  woman,  about  50,  on  whom  I  operated  at  the  Glasgow  Eye 
Infirmary,  the  cornea  did  not  unite  for  some  weeks.  She  had  long  been  in 
the  use  of  tobacco  and  spirits  in  small  and  frequent  doses,  and  kept  her  room 
in  the  Infirmary  excessively  warm  and  airless.  In  a  feeble  emaciated  old 
woman  on  whom  I  operated  in  private,  the  lips  of  the  wound  of  the  cornea 
continued  perfectly  close  for  14  days;  they  then  opened,  the  whole  aqueous 
humor  was  discharged,  and  the  cornea  became  flaccid.  In  the  afternoon  of 
the  same  day,  the  eye  was  again  plump,  and  ultimately  complete  union  was 
efi'ected,  and  good  vision  restored. 

Immediate  union  not  taking  place,  the  wound  must  close  either  by  the 
process  called  union  by  adhesive  inflammation,  or  by  that  of  secondary  adhe- 
sion or  granulation.  A  want  of  power,  or  an  indisposition  in  the  part,  or  in 
the  constitution,  to  take  on  inflammatory  action,  sometimes  seems  to  interfere 
even  with  these  processes,  and  especially  the  former.  Mr.  Raleigh  has 
recorded  three  cases  of  extraction,  in  natives  of  Hindostan,  in  whom,  from 
this  cause,  formidable  obstacles  presented  themselves  to  a  successful  issue. 

Case  351. — The  first  case  related  by  Mr.  Raleigh  is  that  of  a  person  about  55  years  of 
age,  rather  infirm,  from  one  of  whose  eyes  a  hard  lenticular  cataract  was  extracted,  without 
any  violence.  No  vitreous  humor  escaped;  the  pupil,  previously  dilated  by  belladonna, 
regained  its  circular  figure  ;  and  the  divided  edges  of  the  cornea  closely  adapted  themselves 
to  each  other.  The  eye  seemed  to  perish  for  want  of  action  ;  the  cut  edges  of  the  cornea 
continued  in  close  connection,  and  there  was  no  protrusion  of  vitreous  humor;  still  the 
aqueous  chambers  did  not  fill;  the  cornea  became  flaccid,  dim,  and  gradually  opaque ; 
after  a  time,  slight  chemosis  appeared,  which  a  few  leeches  removed.  The  case  ended  in 
a  sinking  of  the  whole  globe. 

In  his  second  and  third  cases,  Mr.  Raleigh,  observing  a  similar  want  of 
action  in  the  eyes  operated  on,  used  with  good  effect  stimulants  to  excite 
inflammation,  such  as  ground  pepper  applied  to  the  eye,  a  pepper  poultice 
over  the  brow  and  temple,  and  solution  of  nitrate  of  silver  to  the  eye.  At 
the  same  time,  he  gave  sulphate  of  quina  internally." 

n.  It  sometimes  happens,  perhaps  in  consequence  of  carelessness  in 
adjusting  the  flap  of  the  cornea,  that  the  edges  of  the  wound  unite  in  so  imper- 
fect a  manner,  as  to  be  unable  to  withstand  the  pressure  of  the  aqueous 
humor.  The  consequence  is,  that  there  is  protruded  from  between  the  lips  of 
the  wound,  a  thin  semi-transparent  membrane,  having  the  form  of  a  vesicle, 
distended  by  aqueous  humor,  and  giving  rise  to  the  sensation  of  a  foreign 
body  in  the  eye.  This  vesicular  protrusion  generally  makes  its  appearance 
in  the  course  of  a  few  weeks,  but  I  have  seen  it  occur  years  after  the  operation. 
If  the  membrane  which  forms  it,  and  which  has  generally  been  regarded  as 
the  lining  membrane  of  the  cornea,  be  punctured,  the  tumor  subsides ;  but 
speedily  reuniting,  the  membrane  is  protruded  as  before,  so  that  it  is  better 
to  snip  it  off,  touch  the  part  with  a  pointed  pencil  of  lunar  caustic,  and, 
keeping  the  eye  shut  for  several  days,  endeavor  thus  to  procure  a  more  perfect 
union.  The  cicatrice,  in  ordinary  cases  of  extraction,  slowly  disappears,  and 
in  the  course  of  a  few  months  is  sometimes  quite  invisible ;  but  in  every  such 


EXTRACTION   OF   THE   CATARACT.  T61 

case  as  has  just  now  been  described,  the  cicatrice  will  be  considerable  and 
indelible. 

18.  Haeraorrhagy  into  the  interior  of  the  eye,  from  the  choroidal  vessels  or 
the  centi-al  vessels  of  the  retina,  is  an  accident  which  always  proves  fatal  to 
vision.  It  generally  occurs  in  the  course  of  the  first  night  after  the  operation. 
The  patient  complains  of  severe  pain  in  the  eye  ;  and,  on  exposing  the  eye, 
blood  is  seen  oozing  from  between  the  lids,  and  the  flap  of  the  corneals  found 
to  be  raised  by  a  clot.  The  bleeding  is  perhaps  speedily  checked  by  cold 
applications,  but  the  mischief  is  already  done,  and  the  eye  suppurates. 

This  accident  is  more  apt  to  happen,  if  vitreous  humor  has  been  lost  in  the 
operation.  It  is  sometimes  brought  on  by  a  fit  of  coughing,  or  of  vomiting. 
Weakness  of  the  internal  vessels  is  probably  the  chief  cause,  and  as  this  state 
is  likely  to  exist  in  both  eyes,  should  an  eye  be  lost  in  this  way,  it  would  be 
proper  not  to  operate  on  the  second  eye  by  extraction. 

19.  Inflammation  is  the  consequence  most  to  be  apprehended,  after  the  ope- 
ration of  extraction.  It  attacks  one  or  several  of  the  textures  of  the  eye, 
occurs  with  various  degrees  of  severity,  and  comes  on  at  uncertain  periods  of 
time  after  the  operation.  1.  The  conjunctiva  is  frequently  its  seat,  and  then 
it  presents  symptoms  of  puro-mucous  ophthalmia ;  the  eye  feels  as  if  filled 
with  sand  ;  there  is  considerable  chemosis,  with  puriform  discharge,  and  adhe- 
sion of  the  lids.  2.  In  other  cases,  the  cornea  inflames  more  than  is  consist- 
ent with  the  healing  of  the  wound  ;  the  lips  of  the  incision  become  white, 
swell,  and  gape,  the  iris  is  apt  to  protrude,  and  a  broad  unsightly  cicatrice, 
with  anterior  synechia,  is  the  result.  Perhaps  as  much  clear  cornea  is  left, 
with  uninvolved  iris,  as  gives  the  chance  of  an  artificial  pupil  being  formed, 
after  some  months.  3.  In  many  instances,  the  sclerotica  and  iris  inflame  ;  the 
patient,  sometimes  so  soon  as  six  or  seven  hours  after  the  operation,  is  affected 
with  severe  pulsative  pain  in  and  round  the  eye,  aggravated  during  the  night, 
followed  by  effusion  of  lymph  from  the  iris,  opacity  of  the  shreds  of  .the  cap- 
sule, adhesions  of  the  iris,  and,  it  may  be,  closure  of  the  pupil.  A  fortnight 
may  elapse  before  iritis  sets  in  ;  the  wound  may  have  healed  perfectly,  and 
there  may  have  been  every  prospect  of  good  vision,  w^hen,  from  some  imprudent 
exposure,  exertion  of  the  eye,  or  error  in  diet,  this  kind  of  inflammation  is 
excited.  4.  In  other  cases,  and  especially  where  the  flap  of  the  cornea  has 
been  often  lifted,  and  numerous  instruments  introduced  into  the  interior  of  the 
eye,  the  inflammation,  although  internal,  does  not  partake  so  much  of  the 
adhesive  as  of  the  suppurative  character  ;  so  that  the  organ  is  in  still  greater 
danger  of  being  destroyed.  Pus  is  deposited  in  the  anterior  chamber,  and  in 
the  substance  of  the  cornea,  the  eyeball  has  the  appearance  of  being  greatly 
swollen,  and  is  frightfully  protruded  from  the  orbit.  Severe  pain  entirely 
prevents  sleep,  and  is  scarcely  moderated  by  any  kind  of  treatment.  The 
cornea  gradually  melts  away  under  a  process  of  ulceration,  till  scarcely  a  ves- 
tige of  it  remains.  Sometimes  it  sloughs,  at  least  I  have  seen  the  exterior 
lamellfe  separate  in  the  state  of  a  slough.  Gradually  the  eye  shrinks,  the 
whole  front  of  it  being  opaque.  5.  The  peculiar  inflammation  called  by  the 
Germans  arthritic,  and  which,  whatever  be  its  nature,  is  undoubtedly  a  specific 
inflammation,  is  extremely  apt  to  be  excited  by  the  operation  of  extraction. 

These  five  varieties  of  inflammatory  aflections,  following  the  operation  of 
extraction,  are  greatly  modified  by  the  age,  constitution,  and  previous  habits, 
of  the  patient. 

When  the  disease  is  limited  to  inflammation  of  the  conjunctiva,  with  some 
degree  of  puro-mucous  discharge,  the  danger  is  comparatively  inconsiderable, 
and  the  usual  treatment  for  catarrhal  ophthalmia  will  generally  suffice  for  its 
removal.  The  eye  is  to  be  fomented  several  times  daily  with  tepid  water,  or 
with  the  collyrium  of  the  bichloride  of  mercury  ;  the  edges  of  the  eyelids  are 


162  EXTRACTION    OF   THE   CATARACT. 

to  be  anointed  with  some  mild  salve,  or  the  unguentum  precipitati  rubri ;  and 
if  the  symptoms  do  not  yield  to  these  simple  applications,  the  solution  of 
nitrate  of  silver  is  to  be  dropped  once  or  twice  a  day,  upon  the  inside  of  the 
lower  eyelid. 

When  the  disease  assumes  the  form  of  iritis,  general  and  local  abstraction 
of  blood,  but  especially  venesection,  calomel  with  opium,  and  the  external  use 
of  belladonna,  are  the  means  of  cure  to  which  we  must  have  recourse. 

The  arthritic  variety  of  inflammation  will  require  moderate  depletion,  chiefly 
by  means  of  leeches,  along  with  purgatives,  opium  to  control  the  pain,  bella- 
donna, counter-irritation,  and,  if  the  disease  assumes,  as  it  is  very  apt  to  do, 
a  chronic  form,  the  internal  exhibition  of  tonics. 

It  is  chiefly  when  inflammation  affects  the  substance  of  the  cornea,  or  assumes 
the  shape  of  phlegmonous  ophthalmitis,  that  the  danger  becomes  greatly 
augmented,  and  a  difficulty  is  often  felt  as  to  the  choice  to  be  made  between 
a  depletory  and  a  stimulating  plan  of  treatment. 

In  healthy,  perhaps  plethoric,  subjects,  not  far  advanced  in  life,  and  whose 
eyes,  except  that  they  were  afi"ected  with  cataract,  were  in  a  sound  condition, 
it  often  happens,  that,  in  the  course  of  the  first  night,  or  even  within  a  few 
hours  of  the  operation,  inflammation  of  a  phlegmonous  character  sets  in,  with 
acute,  throbbing  pain  in  the  eye  and  head.  The  eyelids,  especially  the  upper 
eyelid,  soon  become  swollen,  of  a  florid  red  color,  and  are  extremely  tender  to 
the  touch.  Burning  tears  flow  from  the  eye,  succeeded  by  a  thick  yellow 
secretion  adhering  to  the  cilia.  The  conjunctiva  is  red  and  cheraosed.  There 
is  smart  symptomatic  fever,  with  general  excitement,  a  quick,  strong,  hard 
pulse,  flushing  of  the  face,  and  hot  skin. 

In  old  debilitated  subjects,  the  attack  does  not  occur  so  early ;  rarely  within 
30  or  40  hours  of  the  operation,  and  often  not  for  three  or  four  days,  during 
which,  although  the  patients  have  perhaps  made  little  complaint,  they  have 
often  not  slept.  The  attack  sets  in  with  severe  pain  in  the  eye  and  head  ;  the 
lids  are  swollen,  but  the  swelling  is  livid  or  cedematous  ;  there  is  a  thin  muco- 
purulent discharge  from  the  eye  ;  the  conjunctiva  is  considerably  chemosed, 
but  only  slightly  reddened  ;  the  pulse  is  generally  quick,  feeble,  and  irregular, 
but  in  some  cases  it  is  slow  ;  the  extremities  are  dry  and  cold;  and  there  is  a 
great  feeling  of  depression. 

Of  neither  of  these  sets  of  patients  can  we  judge  by  the  pain  alone,  for  in 
both  it  is  severe.  In  both  classes,  the  section  of  the  cornea  is  apt  to  gape, 
the  substance  of  the  cornea  becomes  dusky  and  semi-opaque,  and  suppuration 
and  ulceration  are  likely  to  destroy  the  eye. 

Experience  has  shown  that  a  totally  opposite  plan  of  treatment  requires 
to  be  adopted  in  these  two  classes  of  patients. 

In  the  former  class,  we  must  have  recourse  to  bleeding  from  the  arm,  cup- 
ping, and  leeches.  The  bleeding  from  the  arm  must  not  be  pushed  to  syncope, 
lest  this  bring  on  vomiting.  The  leeches  will  require  to  be  frequently  applied 
to  the  temple,  the  side  of  the  nose,  and  even  on  the  lids.  Abstinence  must 
be  observed,  and  the  bowels  opened  by  purgatives.  Calomel  with  opium 
ought  to  be  administered,  till  the  gums  exhibit  signs  of  being  affected. 
Counter-irritation  is  to  be  used.  The  eye  is  to  be  carefully  and  frequently 
fomented  with  warm  water. 

In  the  latter  class,  the  very  applications  which  would  aggravate  the  symp- 
toms in  the  former,  give  striking  and  often  immediate  relief;  namely,  a  dose 
of  laudanum,  with  carbonate  of  ammonia,  or  ether;  good  broth,  or  other 
nutritive  food  in  solution;  and  a  moderate  use  of  beer,  wine,  or  spirits.  Very 
soon  after  the  adoption  of  tl'iis  plan,  the  patient  feels  better,  falls  asleep,  and 
wakes  refreshed.  In  48  hours,  the  swelling  of  the  lids  has  been  known  to 
fall,  and  the  section  to  close.    As  often  as  the  pain  recurs,  warm  fomentations 


EXTRACTION   OF   THE   CATARACT.  Y63 

are  to  be  used.  Warmth  is  also  to  be  applied  to  the  extremities  and  surface 
of  the  body. 

The  almost  magical  effect  of  the  stimulating  plan,  in  such  cases,  is  well 
illustrated  by  Mr.  Tyrrell.'*  It  must  not  be  supposed,  however,  that  either 
depletion  in  the  plethoric,  or  stimulants  in  the  debilitated,  are  always,  or 
often,  to  succeed  in  rescuing  the  eye  when  destructive  inflammation  is  once 
set  up,  in  consequence  of  the  extensive  wound  inflicted  in  extraction.  Un- 
avoidable accidents,  or  undue  violence  in  operation,  an  unhealthy  condition 
of  the  eye,  an  artificial  state  of  the  constitution  from  the  long-continued  use 
of  spirits,  opium,  or  tobacco,  and  various  other  causes,  must  always  render 
the  risk  of  such  an  operation  greater,  in  many  instances,  than  any  human 
prudence  can  avert. 

20.  Inversion  of  the  lower  eyelid  is  an  occurrence  which  happens  not  un- 
frequeutly  after  extraction.  It  is  attended  by  a  considerable  degree  of  oedema 
of  the  eyelids,  of  which  it  is  probably  a  consequence.  The  inversion  excites 
inflammation  of  the  eye,  and  is  apt  to  prevent  union  of  the  wound  of  the 
cornea.  An  attempt  may  be  made  to  remedy  it  by  painting  the  external  sur- 
face of  the  lid  with  collodion.  If  this  should  prove  ineffectual,  recourse  must 
be  had  to  the  excision  of  a  fold  of  skin.   (See  p.  246.) 

After-treatment. — The  room  in  which  the  patient  is  to  sleep  after  the  ope- 
ration, should  be  large  and  well-aired,  with  a  temperature  of  from  50°  to  55° 
Fahr.  and  free  from  cold  draughts.  The  patient  ought  neither  to  be  loaded 
with  unnecessary  bedclothes,  nor  exposed  to  cold  from  their  deficiency.  He 
may  lie  either  upon  his  back,  or  on  the  side  opposite  to  that  of  the  eye  which 
has  been  operated  on.  He  should  be  put  to  bed  with  as  little  movement  of 
the  head  and  body  as  possible.  The  room  is  not  to  be  made  too  dark,  but 
is  to  be  kept  perfectly  quiet,  in  order  to  avoid  all  causes  of  sudden  alarm  or 
starting.  All  unnecessary  coughing  between  the  patient  and  those  about 
him  is  to  be  prevented.  A  careful  assistant  or  experienced  nurse  ought 
attentively  to  watch  the  patient  when  he  wakes,  taking  care,  especially,  that 
he  does  not  turn  suddenly  round  upon  the  eye  which  has  been  cut,  or  put  up 
his  hand  to  rub  the  eye.  If  there  is  any  particular  reason  to  dread  the  latter 
accident,  it  may  be  proper  to  muffle  the  patient's  hands,  and  pin  them  to- 
gether, or  down  by  his  sides. 

It  is  rarely  the  case  that  the  patient  complains  much  of  pain  during  the 
first  few  hours  after  the  operation.  If  he  does,  a  grain  of  opium  may  be 
given.     Sleep,  by  closing  the  pupil,  is  useful. 

The  length  of  time  during  which  the  patient  is  to  be  kept  in  bed,  is  a 
point  upon  which  there  has  been  a  wide  diversity  of  practice.  Wenzel  was 
at  one  time  in  the  habit  of  confining  his  patients  to  their  backs,  without 
change  of  posture,  for  a  fortnight  or  three  weeks ;  but  afterwards  he  shortened 
the  period  of  confinement  to  eight  or  ten  days.  Mr.  Phipps,  on  the  other 
hand,  examined  the  eye  on  the  morning  after  the  operation,  applied  a  shade, 
and  allowed  the  patient  to  rise.'^  A  middle  course  appears  the  most  judi- 
cious. The  patient  may  be  allowed,  in  the  course  of  the  second  day,  to  be 
raised  up  in  bed  for  a  short  time,  to  relieve  the  irksomeness  of  lying.  The 
incision  may  be  looked  at  on  the  third  or  fourth  day.  On  the  fifth  or  sixth 
day,  perhaps,  the  patient  may  be  allowed  to  be  out  of  bed  for  a  short  time. 
On  the  seventh  or  eighth,  the  eye  may  be  fairly  examined,  but  immediately 
afterwards  covered  with  the  shade.  In  ten  or  twelve  days,  the  patient  may  be 
allowed  to  look  at  large  olijects.  For  the  first  fortnight,  he  should  make  no 
use  of  the  eye,  nor  even  open  it,  unless  the  surgeon  be  present.  After  a  few 
days  more,  he  may  be  allowed  to  walk  about  his  room. 

It  is  desiraljle  that  the  patient's  bowels  should  not  be  disturbed  for  the 
first  24  or  even  48  hours  after  the  operation,  as  the  movements  of  the  body 


^Qi  EXTRACTION  OF  THE  CATARACT. 

in  getting  out  of  bed,  and  while  at  stool,  may  prove  injurious  to  the  eye. 
After  48  hours,  a  laxative  clyster  may  be  administered,  if  necessary.  In 
healthy  robust  subjects,  an  antiphlogistic  plan  of  diet  is  to  be  observed  for 
eight  days  or  more,  according  to  circumstances ;  after  which,  soup  may  be 
allowed,  and  in  about  a  fortnight  after  the  operation,  a  little  solid  animal 
food.  In  persons  of  advanced  life,  in  whom  it  is  important  that  the  repara- 
tive powers  should  be  well  kept  up,  good  beef-tea  may  be  given  from  the 
first,  in  a  day  or  two  meat  for  dinner,  and  after  live  or  six  days,  a  little 
porter. 

The  aqueous  humor  generally  continues  to  be  discharged  from  the  eye  for 
about  48  hours ;  in  some  cases,  however,  for  a  shorter  period,  and  often  for 
a  much  longer,  even  for  weeks.  Lest  the  discharge  of  the  tears,  and  also 
of  the  aqueous  humor,  if  it  flows  from  the  eye,  should  be  prevented,  it  is 
improper  to  cover  up  the  eye  too  closely,  and  still  more  improper  to  load  it 
with  dressings  and  bandages.  It  is  of  the  utmost  importance,  however,  to 
keep  the  eyelids  still,  and  prevent  any  attempt  to  use  the  eyes.  These  objects 
are  completely  obtained  by  the  strips  of  court-plaster,  from  the  employment 
of  which  I  have  never  witnessed  any  bad  consequences.  I  generally  allow 
those  which  are  applied  immediately  after  the  operation  to  remain  for  two 
or  three  days,  but  if  the  eyes  are  easy,  for  four  or  five  days;  after  which,  I 
remove  them,  and,  having  bathed  the  eyelids  with  warm  milk  and  water, 
without  opening  the  eyes,  replace  the  plasters  by  new  ones.  This  I  now 
repeat  every  day,  till  I  consider  the  wound  consolidated.  [See  p.  148. — H.] 

§  2.   Extraction  through  a  Small  Section  of  the  Cornea. 

When  treating  of  the  accidents  attendant  on  the  operations  of  displace- 
ment, I  mentioned  that  the  lens  occasionally  passes  through  the  pupil,  and 
lodges  between  the  cornea  and  the  iris.  It  is  not  quite  correct  to  say,  that 
in  this  situation  it  is  in  the  anterior  chamber  ;  for  as  the  axis  of  the  aqueous 
humor  is  to  that  of  the  lens  as  3  to  4,  it  is  evident,  that  after  the  lens  has  passed 
through  the  pupil,  it  will  occupy  not  only  the  anterior  chamber,  but  the  pos- 
terior also,  and  even  part  of  the  space  which  it  filled  while  in  its  natural 
situation.  The  iris  consequently  will  be  pressed  backwards  by  the  dislocated 
lens,  and  it  will  be  easy  to  lay  open  the  circumference  of  the  cornea,  without 
touching  the  iris.  A  hook  being  then  introduced,  the  lens  is  to  be  laid  hold 
of,  and  extracted.  In  such  a  case,  however,  whenever  the  lens  possesses  its 
normal  size  and  consistence,  the  section,  to  admit  of  its  easy  extraction,  will 
require  to  exceed  considerably  the  third  of  the  circumference  of  the  cornea. 

This  mode  of  removing  a  lens  which  has  fallen  in  front  of  the  iris,  has  led, 
in  a  variety  of  other  cases,  where  the  lens  is  either  soft,  so  as  to  permit  of 
its  being  moulded  through  a  small  aperture,  or  considerably  reduced  in  bulk, 
to  the  practice  of  opening  only  a  third,  or  less  than  a  third,  of  the  circum- 
ference of  the  cornea.  The  wound  in  this  way  being  less  extensive,  will  in 
general  heal  more  readily ;  and  even  should  it  inflame  in  some  degree,  and 
unite  but  slowly,  will  leave  less  deformity,  and  produce  less  impediment  to 
the  passage  of  light  into  the  eye,  than  the  broad  semilunar  cicatrice,  which 
sometimes  follows  the  common  operation  of  extraction.  The  lips  of  the 
incision,  when  only  a  third  of  the  circumference  of  the  cornea  is  opened, 
Avill  close  more  completely  immediately  after  the  operation  is  finished,  so  that 
we  need  not  be  afraid  of  prolapsus  of  the  iris,  and  may  therefore,  without  hesi- 
tation, dilate  the  pupil  by  belladonna,  before  proceeding  to  the  operation, 
which  will  both  enable  the  lens  to  be  more  easily  brought  forward  in  front  of 
the  iris,  and  render  injury  of  the  iris  less  liable  to  occur.  Through  a  small 
section,  also,  of  the  cornea,  especially  in  cases  of  dissolved  hyaloid  membrane, 
the  vitreous  humor  is  less  likely  to  be  evacuated  to  any  considerable  extent. 


EXTRACTION   OF   THE   CATARACT.  765 

Of  the  reality  of  some  of  these  advantages  I  am  able  to  speak  decidedly, 
as  I  have  employed  this  method  of  extraction  in  a  variety  of  cases.  I  pre- 
fer it,  when  it  is  my  object  to  extract  a  siliculose  or  secondary  capsular  cata- 
ract. 

1.  Siliculose  and  secondary  capsidar  cataracts. — The  following  plan  I  have 
successfully  adopted  in  cases  of  siliculose  or  secondary  capsidar  cataract,  the 
lens  having  been  absorbed,  either  spontaneously  or  in  consequence  of  an 
accidental  wound  of  the  capsule,  or  been  removed  by  previous  operation.  I 
place  the  patient  in  the  horizontal  position,  and  pass  a  curved  needle  through 
the  sclerotica,  with  which  I  gather  together  the  opaque  capsule  into  a  mass, 
which  I  then  push  through  the  pupil.  With  the  extraction-knife,  I  open  the 
upper  or  temporal  edge  of  the  cornea  to  about  a  third  of  its  extent,  if  the 
case  is  one  of  siliculose  cataract,  but  generally  much  less,  if  it  is  a  secondary 
capsular  one.  I  then  introduce  either  a  small  pair  of  forceps,  such  as  the 
canular  forceps,  or  Schlagintweit's  hook,  lay  hold  of  the  capsule,  and  either 
immediately  extract  it,  or,  if  I  find  this  opposed  by  any  adhesion,  turn  the 
instrument  round  on  its  axis  till  the  membrane  is  detached.  In  one  case, 
in  which  I  found  the  capsule  so  strongly  adherent  to  the  iris  that  I  was 
afraid  I  might  sooner  sever  the  latter  from  the  choroid  than  extract  the  cap- 
sule, I  contented  myself  with  prolapsing  the  capsule  through  the  wound  of 
the  cornea,  clearing  in  this  way  the  pupil,  and  restoring  a  very  useful  degree 
of  vision.  Under  such  circumstances,  iris-scissors,  either  common  or  canu- 
lar, might  be  advantageously  employed  in  dividing  the  half-detached  capsule. 

2.  Soft  cataracts. — Mr.  Gibson,  of  Manchester,  appears  to  have  been  the 
first  to  extract  soft  cataracts  through  a  small  incision  of  the  cornea.  He 
was  led  to  adopt  this  practice  from  the  great  length  of  time  which  soft  cata- 
racts sometimes  take  to  disappear  by  solution  in  the  aqueous  humor,  added  to 
the  fact,  that  not  only  is  the  patient  apt  to  grow  anxious  and  to  lose  his 
health,  but  the  eye  to  become  affected  with  chronic  irritability  and  inflamma- 
tion, under  this  prolonged  mode  of  cure.  Mr.  Gibson  first  of  all  freely  rup- 
tured the  anterior  hemisphere  of  the  capsule  with  the  needle,  and  after  two 
or  three  weeks,  proceeded  to  extract  the  pulpy  lens.  For  this  purpose  he 
punctured  the  cornea  near  its  temporal  edge  with  a  broad  extraction-knife, 
and  if  he  had  any  doubt  of  the  capsule  having  been  freely  lacerated  in  the 
former  operation,  he  directed  the  point  of  the  knife  obliquely  thi'ough  the 
pupil,  so  as  to  make  a  more  free  division  of  the  capsule.  On  withdrawing 
the  knife,  part  of  the  aqueous  humor  and  some  portion  of  the  cataract  were 
evacuated.  The  curette  was  next  introduced  through  the  incision,  and 
towards  the  pupil;  and  by  that  instrument  the  whole  of  the  cataract  was 
commonly  removed  by  degrees,  and  the  pupil  rendered  perfectly  clear.  Its 
removal  was  generally  much  facilitated  by  gentle  pressure,  towards  the  vitre- 
ous humor,  with  the  convex  surface  of  the  curette,  whilst  the  point  of  the 
instrument  was  inserted  through  the  pupil. 

Mr.  Gibson  observes  that  it  occasionally  happens,  upon  introducing  the 
curette,  that  a  considerable  part  of  the  cataract  appears  too  solid  for  removal, 
and  only  a  small  portion  escapes  in  a  pulpy  state.  The  nucleus  of  the  lens 
is  sometimes  much  more  solid  than  the  rest,  and  cannot  be  readily  extracted 
in  this  way ;  yet,  much  oftener  the  difficulty  arises  wholly  from  the  sraallness 
of  the  apertui'e  in  the  capsule,  so  that  it  allows  only  an  inconsiderable  part 
of  the  cataract  to  pass  out  at  a  time,  the  capsule  having  perhaps  been 
tougher  than  usual,  and  not  easily  lacerated  in  the  preparatory  operation 
with  the  needle.  In  such  a  case,  the  opening  into  the  capsule  may  be  ex- 
tended, either  by  means  of  the  curette,  or  by  the  needle  commonly  used  for 
lacerating  the  capsule  ;  or,  if  this  membrane  appears  uncommonly  firm,  it 
may  be  divided  with  iris-scissors. 


766  EXTRACTION   OF   THE   CATARACT. 

Mr.  Gibson  concludes,  that  by  this  operation,  the  repeated  use  of  the 
needle  may  be  safely  superseded,  and  the  eye  exposed  to  less  risk  of  injury 
and  iuflaramation.  He  adds,  that  in  many  instances  no  trace  of  inflammation, 
or  of  any  operation,  could  be  seen  on  the  eye  the  next  day ;  nor  had  the  iris 
ever  been  injured,  or  even  irritated  in  the  slightest  degree,  by  the  use  of  the 
curette." 

This  method  of  removing  soft  cataract  has  been  adopted  by  Mr.  Travers, 
with  the  difference,  that  instead  of  opening  the  capsule  vi^ith  the  needle  passed 
through  the  sclerotica,  and  then  waiting  for  two  or  three  weeks,  he  begins 
his  operation,  having  previously  dilated  the  pupil,  by  a  quarter  section  of  the 
cornea,  dipping  the  point  of  the  knife  into  the  pupil,  and  freely  lacerating  the 
capsule.  The  fluid  cataract,  he  states,  is  instantly  evacuated  with  the  aqueous 
humor;  the  flocculent  cataract,  taking  an  oblong  shape,  frequently  passes  out 
entire;  and  the  caseous  cataract  piecemeal,  through  the  hollow  of  the  scoop, 
on  gently  depressing  the  margin  of  the  pupil.'* 

3.  Firm  cataracts. — Mr.  Travers,"  Sir  William  Adams,*"  and  others,  have 
had  recourse  also  to  the  extraction  of  firm  cataracts  through  a  section  of  the 
cornea  less  than  a  semicircle. 

The  pupil  being  dilated  by  belladonna,  the  steps  of  the  operation  are,  to 
slit  open  the  anterior  capsule  with  a  small  bent  needle,  introduced  through 
the  sclerotica  ;  tilt  the  lens  forward  through  the  i)upil;  keep  it  fixed  by  means 
of  the  needle,  which  is  now  committed  to  the  charge  of  the  assistant ;  open  the 
circumference  of  the  cornea  to  fully  one-third  of  its  extent;  withdraw  the 
needle;  introduce  a  hook,  lay  hold  of  the  lens,  and  extract  it. 

The  opening  in  the  capsule  will  require  to  extend  to  its  whole  diameter, 
else  the  dislocation  of  the  lens  will  not  be  easily  accomplished.  The  disloca- 
tion is  usually  affected  by  pressing  with  the  needle  near  the  lower  or  upper 
edge  of  the  lens,  so  that  the  opposite  edge  from  that  which  is  pressed  upon 
is  tilted  forwards  through  the  pupil;  and  it  is  desirable  that  the  lens  should 
revolve,  so  that  its  posterior  surface  comes  to  be  applied  against  the  cornea. 
If  the  operator  is  satisfied  that  the  capsule  is  suflBciently  opened,  and  yet  fails 
in  bringing  the  lens  forwards  by  pressing  back  one  or  other  of  its  edges,  he 
may  withdraw  the  needle  from  the  posterior  chamber,  by  carrying  it  under, 
and  hence  behind  the  lens,  which  he  must  then  push  forwards  through  the 
pupil.  Retaining  the  needle  in  contact  with  the  lens  till  the  section  is  finished, 
or  even  keeping  it  in  the  eye  till  the  cataract  is  extracted,  is  no  doubt  of  use 
as  it  secures  us  against  the  lens  falling  back  into  its  former  situation,  which 
if  the  vitreous  humor  is  fluid,  is  very  apt  to  happen.  At  the  same  time,  un- 
less the  patient  be  very  still,  the  needle  is  apt  to  lacerate  the  iris,  and  cause 
bleeding  into  the  eye.  Some  operators,  therefore,  withdraw  the  needle  imme- 
diately after  the  lens  is  dislocated.  The  incision  of  the  cornea  is  to  be  exe- 
cuted exactly  as  the  semi-circular  incision,  namely,  by  carrying  the  knife  across 
the  anterior  chamber,  unless  there  is  reason  to  think  that  the  vitreous  humor 
is  dissolved,  in  which  case  it  is  better  to  make  an  opening  at  the  temporal 
margin  of  the  cornea,  and  enlarge  it  upwards  and  downwards  with  the  probe- 
pointed  knife.  If  this  plan  is  not  followed,  but  the  extraction-knife  carried 
across  the  anterior  chamber,  the  cataract  is  very  apt  to  be  forced  back  through 
the  pupil  into  the  vitreous  humor,  where  it  sinks  to  the  bottom.  The  incision 
being  made,  the  hook  is  to  be  introduced,  flat,  between  the  lens  and  the  iris 
as  far  as  the  centre  of  the  pupil;  the  point  of  the  instrument  is  then  to  be 
turned  forwards,  and  the  cataract  laid  hold  of  by  the  surface  which  happens 
to  be  towards  the  vitreous  humor.  The  extraction  is  accomplished  without 
any  pressure  on  the  eye,  which  constitutes  the  great  recommendation  of  this 
mode  of  operating,  in  cases  where  we  have  reason  to  suspect  the  hyaloid  mem- 
brane to  be  unsound. 


EXTRACTION   OF   THE   CATARACT.  76t 

§  3.  Extraction  through  the  Sclerotica. 

At  the  end  of  his  "Improved  Method  of  Opening  the  Temporal  Artery," 
published  in  1*783,  Dr.  Butter  describes  a  method  of  extracting  the  cataract 
through  the  sclerotica,  by  means  of  an  instrument,  similar  to  that  which  was 
afterwards  employed  for  the  purpose  by  Sir  James  Earle.  Dr.  Butter  had 
tried  the  method  he  describes  on  the  dead  body  only. 

O'Halloran  proposed'^  to  push  the  point  of  a  double  edged  knife  through 
the  sclerotica,  at  ^  line  from  the  cornea,  and  hence  through  the  ciliary  liga- 
ment into  the  anterior  chamber.  The  incision  was  then  to  be  enlarged  down- 
wards and  upwards  till  a  semicircle  of  sclerotica  was  divided  ;  the  anterior 
capsule  was  to  be  opened,  and  the  lens  extracted.  He  does  not  say  that  he 
ever  performed  the  operation. 

Mr.  B.  BelP^  suggested  extraction  through  the  sclerotica  as  a  mode  of 
operating,  not  only  practicable,  but  in  which  the  cornea  and  iris  would  be 
exempt  from  all  direct  injury.  His  experiments  on  the  lower  animals  led 
him  to  believe,  that  the  inflammation  induced  by  an  incision  through  the 
sclerotica  was  not  more  considerable,  nor  the  cure  in  any  respect  more  diffi- 
cult, than  when  extraction  was  performed  in  the  usual  manner.  He  recom- 
mended the  opening  to  be  made  in  the  upper  part  of  the  eye,  the  knife  being 
entered  about  Jq  inch  behind  the  cornea,  and  the  incision  to  be  of  sufficient 
size  for  allowing  the  cataract  to  pass.  A  sharp  curved  probe  was  to  be  intro- 
duced, the  point  of  which  was  to  penetrate  the  lens,  which  might  by  this 
means  be  removed  without  any  pressure  upon  the  eyeball. 

A  remarkable  case  of  wound  of  they  eye,  attended  with  evacuation  of  the 
lens,  led  Dr.  Lbbenstein-LobeP"  to  form  a  favorable  opinion  of  extraction 
through  the  sclerotica,  but  he  does  not  appear  to  have  ever  put  the  operation 
in  practice. 

I  have  already  (p.  406)  related  a  case,  in  which  I  extracted  a  crystalline  lens 
from  under  the  conjunctiva  ;  it  having  been  propelled,  by  a  smart  blow  on  the 
eye,  through  a  laceration  of  the  choroid  and  sclerotica.  The  opening  through 
these  tunics  was  already  healed,  the  pupil  clear,  and  the  retina  perfectly  sen- 
sible. Such  facts  as  this  would  lead  us  to  pause,  before  we  absolutely  reject 
the  operation  of  extraction  through  the  sclerotica. 

I  cannot  pretend  to  speak  with  much  precision  of  an  operation  which  I 
have  only  once  attempted  on  the  human  eye.  I  should  consider  it  proper, 
however,  to  divide  the  capsule  with  the  needle  before  opening  the  sclerotica 
and  choroid  with  a  double-edged  knife ;  to  select  the  upper  or  temporal  side 
of  the  eyeball  for  incision  ;  to  make  it  parallel,  not  perpendicular,  to  the  edge 
of  the  cornea  ;  to  introduce  the  knife  at  the  distance  of  a  line  behind  the  edge 
of  the  cornea,  so  that  it  may  leave  the  ciliary  ligament  untouched,  but  pass 
through  the  ciliary  muscle  and  ciliary  processes  into  the  lens,  without  wound- 
ing, if  possible,  the  suspensory  ligament  of  the  lens  or  the  Petitian  canal ; 
and  to  extract  the  lens  with  a  hook.  Of  course,  pressure  on  the  eyeball  in 
this  operation,  is  altogether  out  of  the  question. 

It  would  appear  from  the  testimony  of  WenzeP'  (which,  however,  is  given 
in  rather  an  unfriendly  spirit),  that  Janin  attempted  extraction  through  the 
sclerotica  on  seven  patients  in  the  Hotel  des  InvaEdes  at  Paris,  but  in  all  seven 
unsuccessfully. 

For  extraction  through  the  sclerotica,  Sir  James  Earle  employed  a  small 
lancet,  moving  backwards  and  forwards  between  the  blades  of  a  pair  of  forceps. 
This  instrument  being  introduced  through  the  sclerotica  and  choroid,  the  lancet 
is  withdrawn  by  means  of  a  spring  contained  within  the  handle,  while  the 
forceps  is  left  behind.  The  blades  are  then  opened,  and  the  cataract  seized 
and  brought  away.     Sir  James  entered  the  instrument  just  behind  the  iris. 


T68  EXTRACTION  OF  THE  CATARACT. 

In  the  first  three  operations  which  he  has  related,  he  introduced  it  in  such  a 
manner  that  the  incision  ran  parallel  to  the  edge  of  the  cornea,  and  of  course 
divided  a  considerable  number  of  the  choroidal  vessels  ;  but  in  his  fourth  ope- 
ration he  appears  to  have  introduced  the  instrument  in  such  a  manner  that  the 
incision  would  form  a  line  perpendicular  to  the  edge  of  the  cornea,  or,  in  other 
words,  run  parallel  to  the  course  of  the  choroidal  arteries.  Having  retracted 
the  lancet,  he  then  turned  the  forceps  round,  so  that  they  might  embrace  the 
cataract ;  a  mode  of  procedure  by  which  he  thinks  a  discharge  of  vitreous 
humor  less  likely  to  occur.  He  states,  also,  that  the  wound  which  is  made 
perpendicular  to  the  edge  of  the  cornea  heals  with  the  same  facility  as  the 
other.2=^ 

The  following  are  some  of  the  advantages,  mentioned  by  Sir  James,  as 
possessed  by  extraction  through  the  sclerotica.  The  wound  need  not  exceed 
a  fourth  of  the  size  of  the  incision  required  in  the  ordinary  operation  of  ex- 
traction through  the  cornea  ;  in  the  passage  of  the  forceps  through  the  vitreous 
humor  and  in  the  use  of  them  afterwards,  not  nearly  so  much  derangement  of 
the  interior  of  the  eye  is  produced  as  attended  the  employment  of  the  needle 
in  the  old  operation  of  couching  ;  as  the  part  through  which  the  incision  is 
made  performs  no  motion,  the  edges  of  it  remain  in  contact,  and  heal  with 
comparative  facility. ^^ 

Quadri""*  of  ^N'aples,  has  put  the  operation  of  extraction  through  the  scle- 
rotica more  completely  to  the  test  than  any  other  surgeon.  He  has  operated 
on  25  eyes,  and  on  11  of  these  successfully,  a  proportion  too  small  to  tempt 
any  one  to  think  of  abandoning  extraction  through  the  cornea,  for  the  opera- 
tion through  the  sclerotica. 

The  dangers  principally  to  be  feared,  in  extraction  through  the  sclerotica, 
are  bleeding  from  the  choroid,  to  such  an  extent  as  to  hide  the  cataract  from 
view,  atrophy  of  the  eye  from  a  profuse  loss  of  vitreous  humor,  and  amaurosis 
from  the  injury  which  the  retina  is  likely  to  sustain. 

I  have  seen  siliculose  and  secondary  capsular  cataracts  extracted  through  an 
incision  of  the  sclerotica,  of  about  2^  lines  long.  In  such  cases,  the  loss  of 
vitreous  humor  was  great,  and  the  eye  was  left  in  a  state  of  incomplete  amau- 
rosis, which  I  am  inclined  to  attribute  to  the  length  of  the  incision.  A  safer 
plan  is  to  extract  such  cataracts  through  a  smaller  incision  ;  indeed,  a  mere 
puncture  will  often  suffice.  A  bent  needle  being  first  of  all  to  be  passed 
through  the  sclerotica  at  ^  inch  from  the  edge  of  the  cornea,  the  opaque  cap- 
sule is  to  be  carefully  and  completely  detached  from  the  vitreous  humor  and 
zonula  Zinnii.  If  there  are  any  tags  between  the  iris  and  the  capsule,  they 
must,  if  possible,  be  divided.  The  needle  being  withdrawn,  a  pretty  broad 
iris-knife,  or  the  point  of  the  extraction-knife,  is  to  be  passed  through  the 
opening  left  by  the  needle,  and  the  wound  enlarged  to  the  length  of  a  line. 
Schlagintweit's  hook,  or  the  canular  forceps,  is  then  to  be  introduced,  and  the 
capsule  seized  and  extracted.  Any  common  forceps,  or  such  spring-forceps 
as  is  described  and  figured  by  Albinus,  is  improper  for  the  operation,  as  re- 
quiring much  too  large  an  incision. 

In  this  operation,  a  few  drops  of  blood  generally  escape  from  the  choroid. 
The  operator  should  place  the  extracted  capsule  in  water,  and  examine  whether 
it  is  entire.  If  any  portion  of  it  is  seen  remaining  in  the  eye,  the  hook  or  the 
forceps  should  be  re-introduced,  in  order  that  it  may  be  extracted  ;  but  the 
pupil,  although  previously  dilated  by  belladonna,  generally  contracts  so  much 
immediately  on  withdrawing  the  portion  of  the  capsule  first  seized,  that  the 
remains  of  it  may  escape  being  seen  till  next  day,  when  the  pupil  is  again  found 
widely  expanded.  I  have  seen  amaurosis  follow  also  this  method  of  operating  ; 
oftenest,  however,  when  there  was  reason  to  believe  the  retina  previously 
unsound.-^ 


EXTRACTION   OF   THE   CATARACT. 


^69 


'  Memoires  de  I'Academie  Roynle  des  Sci- 
ences, Annee  1708,  p.  311;  Arusterdam,  1750. 

^  Memoires  de  rAcademie  Royale  de  Chirur- 
gie:  12ino;  Tome  v.  p.  3G9;  Paris,  1787.  In 
1707,  Mery  had  seen  Saint-Yves  perform  extrac- 
tion in  a  case  similar  to  that  in  which  Petit  ope- 
rated in  the  following  year,  and  to  which  Daviel 
refers.  Mery  was  led  from  the  success  of  Saint- 
Yves'  operation,  to  recommend  extraction 
through  the  cornea  as  a  mode  of  removing  cat- 
aract worthy  of  being  generally  adopted,  re- 
marking, "qu'on  risque  moins  a  tirer  la  cata- 
racte  en  dehors  qu'  h  I'abattre  au  dedans  de 
I'oeil." — Memoires  de  rAcademie  Royale  des 
Sciences,  Annee  1707  ;  p.  686 ;  Amsterdam, 
1746. 

^  See  Raleigh,  Transactions  of  the  Medical 
and  Physical  Society  of  Calcutta  ;  Vol.  iv.  p. 
385  ;  Calcutta,  1829. 

*  It  is  mentioned  in  books,  thatWenzel,  Rich- 
ter,  and  B.  Bell  practised,  or  at  least  recom- 
mended the  upper  section.  The  first  Wenzel's 
common  operation  was  a  semi-lateral  section, 
parallel  to  the  temporal  and  lower  edge  of  the 
cornea;  but  in  certain  cases,  as  when  the  lower 
part  of  the  cornea  was  leucomatous,  he  made 
his  section  parallel  to  the  nasal  and  superior 
edge.  In  this  way  he  operated,  as  his  son  re- 
lates (Traitedela  Cataracte,pp.l32,135;  Paris, 
1786),  on  the  Duke  of  Bedford,  and  on  the  cele- 
brated Leonard  Euler.  All  that  Richter  says  on 
the  subject  (Treatise  on  the  E.xtraction  of  the  Cat- 
aract, p.  59;  London,  1791),  is,  thatthe  upper  sec- 
tion is  practicable.  B.  Bell  had  tried  the  upper  sec- 
tion only  on  some  of  the  lower  animals  ;  but  he 
states  (System  of  Surgery,  Vol.  iv.  p.  238 ; 
Edinburgh,  1801)  several  reasons  for  preferring 
it  to  the  common  method  of  making  the  incision 
parallel  to  the  lower  edge  of  the  cornea. 

Santerelli  was  the  first  (Delle  Cateratte,  p.  79  ; 
Forli,  1811),  as  far  as  I  know,  who  actually  made 
the  section,  not  semilaterally,  as  Wenzel  had 
done,  but  at  the  upper  edge  of  the  cornea.  This 
he  did  at  Berlin,  in  1795,  with  a  double-edged 
knife,  or  broad  lancet,  the  point  of  which  he  in- 
troduced directly  into  the  anterior  chamber, 
from  the  middle  of  the  upper  edge  of  the  cornea, 
in  the  expectation  of  forming  an  incision  of 
sufficient  extent  merely  by  pressing  the  instru- 
ment on  towards  the  lower  edge  of  the  cornea ;  a 
method  of  operating  in  which  it  would  be  impos- 
sible to  make  a  section  of  more  than  from  a 
quarter  to  a  third  of  the  circumference.  The 
method  of  Santerelli  is  abadone,and  is  entirely 
abandoned. 

The  best  operators,  both  of  this  country  and  of 
Continental  Europe,  are  at  present  following 
exactly  the  plan  recommended  by  B.  Bell,  who 
says,  "  The  upper  part  of  the  cornea  is  cut  with 
the  same  ease  as  the  under  part  of  it;  the  same 
instruments  being  employed,  and  the  surgeon, 
patient,  and  assistants  being  placed  in  the  same 
manner ;  only  in  this  ease  the  knife  must  bo  in- 
troduced with  the  cutting  edge  of  it  towards  tho 
upper  part  of  the  eye." 

'  See  case  by  Paget,  Edinburgh  Medical  and 
Surgical  Journal;  Vol.  ix.  p.  280;  Edinburgh, 
1813. 

^  "  Quand  une  ouverture  est  faite  dans  cette 
membrane,  I'aiguille  entraine  avec  elle  sous  la 
pression  qu'  elle  exerce,  la  levre  correspondante 
de  la  solution  de  coatinuite,  mais  ne  fait  pas  de 

49 


nouvelle  incision.  Je  me  suis  assure  de  co  fait 
sur  les  lapins,  en  introduisant  une  aiguille  e 
travers  la  cornee,  et  in  dissequant  I'oeil  appres 
avoir  sacrifie  Fanimal." — Desmarres,  Traite  des 
Maladies  des  Yeux,  p.  607;  Paris,  1847. 

''  Tyrrell  on  Diseases  of  the  Eye,  Vol.  ii.p.416; 
London,  1840. 

'  Op.  cit.  p.  618. 

'  Quoted  from  the  Bibliotheque  LTniverselle, 
for  October,  1829,  in  the  Journal  of  the  Royal 
Institution  for  November,  1830,  p.  191. 

'°  Transactions  of  the  Medical  and  Physical 
Society  of  Calcutta;  Vol.  iv.  p.  350 ;  Calcutta, 
1829. 

' '  Practical  Work  on  the  Diseases  of  the  Eye; 
Vol.  ii.  p.  427  ;  London,  1840. 

'^  On  the  Treatment  of  Patients  after  the 
Operation  for  the  Cataract;  by  Jonathan  Wathen 
Phipps;  published  as  an  Appendix  to  Wathen 
on  Fistula  Lachrymalis;  London,  1792. 

"  Practical  Observations  on  the  Formation 
of  an  Artificial  Pupil;  to  which  are  annexed. 
Remarks  on  the  Extraction  of  Soft  Cataracts, 
&c.  p.  103;  London,  1811. 

"  Further  Observations  on  the  Cataract; 
Medico-Chirurgical  Transactions,  Vol.  v.  p.  406; 
London, 1814. 

''  Ibid. 

"  Practical  Inquiry  into  the  Causes  of  the 
Frequent  Failure  of  the  Operations  of  Depression 
and  Extraction,  pp.  138,283;  London,  1817. 

'^  Lcibenstein-Lbbel  conjectured  that  extrac- 
tion through  tho  sclerotica  was  the  method 
adopted  by  Kerkringius,  Burrhus,  Taylor,  and 
Woolhouse,  when  they  boasted  of  having  re- 
stored a  young  and  acute  vision  to  aged  people, 
by  removing  the  corrupted  and  turbid  humors  of 
the  eye,  and  replacing  new  ones  in  their  stead; 
but  it  is  very  unlikely  that  extraction  through 
the  sclerotica  was  practised  by  any  of  these 
operators. 

"  Transactions  of  the  Royal  Irish  Academy, 
1788;  p.  139. 

'"  System  of  Surgery  ;  Vol.  iv.  p.  246;  Edin- 
burgh, 1796. 

^°  Edinburgh  Medical  and  Surgical  Journal; 
Vol.  xiii.  p.56;  Edinburgh,  1817. 

*'  Traite  de  la  Cataracte,  p.  33;  Paris,  1786. 

'^  From  some  experiments  which  I  have  made 
on  the  lower  animals,  I  am  convinced  that  an 
incision  through  the  sclerotica,  perpendicular 
to  the  edge  of  the  cornea,  gapes  less,  and  there- 
fore heals  sooner,  than  one  parallel  to  the  edge 
of  the  cornea.  At  the  same  time,  it  is  evident 
that  an  incision  5  lines  long,  which  will  be  ne- 
cessary for  the  extraction  of  the  lens,  the  mere 
diameter  of  which  measures  4  lines,  must,  if  per- 
pendicular to  the  edge  of  tho  cornea,  implicate 
the  retina. 

^^  Account  of  a  New  Mode  of  Operation  for 
the  Removal  of  Cataract;  London,  1801. 

^'  Annotazioni  Pratiche  sulle  Malattie  dcgli 
Occhi ;  Lib.  iii.  p.  107  ;  Napoli,  1827. 

^'  On  the  Extraction  of  Membranous  Cata- 
racts through  tho  Sclerotica,  see  Albinus  De 
Catarrhactft  (1G95),  Ilalleri  Disputatioues  Chi- 
rurgicaj,  Tom.  ii.  p.  61;  Lausaunaa,  1755:  Frey- 
tag,  De  Cataracts,  (1721),  lb.  p.  65:  Earle,  Op. 
cit.:  Brett,  Medical  Gazette,  Vol.  xx.  p.  415; 
London,  1837:  Middlemore,  lb.;  Vol.  xxii.  pp. 
56,  158;  London,  1838:  lb.  May  5, 1838,  p.  255. 


770  DIVISION   OF   THE   CATARACT. 


SECTION   XII. — DIVISION. 

§  1.   Division  through  the  Sclerotica} 

Syn. — Postei'ior  Operation  for  Absorption.     Hyalonyxis,  from  iaXoEtJ'rjf,  vitreous,  and  vd'tto;, 

/  puncture. 

In  the  days  of  Celsus,*^  breaking  down  the  cataract  into  fragments  with  the 
couching  needle,  was  regarded  as  a  proper  supplementary  step  to  displace- 
ment, when  this  could  not  be  satisfactorily  performed.  Barbette,  Read,  and 
Maitre-Jan,  all  availed  themselves  of  their  knowledge  of  the  fact,  that  a 
cataract  which  had  been  mei'erly  cut  up  and  left  in  its  ordinary  situation, 
would  after  a  certain  time  disappear.  Barbette^  states,  that  in  such  circum- 
stances, vision  would  be  restored  after  seven  or  eight  weeks  ;  Read*  employs 
the  words  consumed  and  dispersed  to  express  the  disappearance  of  the  pieces 
of  the  divided  cataract ;  Maitre-Jan*  observes  that  this  disappearance,  which 
he  styles  a  precipitation,  takes  place  as  well  in  the  anterior  as  in  the  posterior 
chamber,  and  notices  its  connection  with  a  laceration  of  the  capsule.  Pott^ 
appears  to  have  been  the  first,  not  merely  to  make  use  of  the  term  which  we 
now  employ  in  speaking  of  the  disappearance  of  the  cataract,  namely,  disso- 
lution, but  to  adopt  a  laceration  of  the  capsule  as  a  distinct  mode  of  operating, 
independent  of  depression. 

It  is  evident,  that  in  this  mode  of  operating,  the  object  is  not  to  remove 
the  cataract  immediately,  but  merely  to  expose  it  to  a  natural  means  of  cure, 
namely,  the  solvent  action  of  the  aqueous  humor.  This  may  be  done  in  two 
ways ;  viz.  first,  by  destroying  the  front  of  the  capsule,  so  that  the  aqueous 
humor  gains  admittance  to  the  lens ;  and,  secondly  by  dividing  the  lens  into 
fragments,  and  pushing  these  into  the  aqueous  humor.  Both  of  these  objects 
may  certainly  be  accomplished  at  one  operation  ;  but  it  is  better  to  operate 
twice,  or  oftener,  than,  by  doing  too  much  at  once,  to  endanger  the  safety  of 
the  eye.  I  have  long  made  it  a  rule  to  confine  myself  in  the  first  operation 
to  little  more  than  a  careful  comminution  of  the  anterior  hemisphere  of  the 
capsule.  The  caution  delivered  by  Mr.  Hey  is  peculiarly  applicable  to  the 
operation  of  division.  "One  principal  thing,"  says  he,  "to  be  kept  in  view 
by  the  operator  is,  to  do  no  harm.  If  he  secures  this,  he  will  almost  certainly 
do  some  good,  and  often  much  more  good  than  he  expects. "' 

Division  through  the  sclerotica  naturally  divides  itself  into  four  periods.  In 
the  first,  the  needle  is  introduced  through  the  tunics,  and  into  the  vitreous 
humor ;  in  the  second,  the  instrument  enters  the  posterior  chamber ;  in  the 
third,  the  anterior  hemisphere  of  the  capsule  is  divided ;  in  the  fourth,  the 
lens  is  scraped  or  cut  into  fragments,  and  these  are  pushed  into  the  anterior 
chamber. 

The  pupil  is  to  be  dilated  by  belladonna,  in  the  manner  directed  at  page  736. 

A  bent  needle  is  to  be  preferred  for  tearing  through  the  capsule  and  open- 
ing up  the  texture  of  the  lens;  a  straight  one,  if  our  object  is  to  cut  the  lens 
into  pieces.  These  two  methods  must  carefully  be  distinguished  from  one  an- 
other, as  well  as  from  a  third  kind  of  operation  with  the  needle,  in  which  the 
cataract  is  drilled  by  a  rotatory  motion  of  the  instrument  on  its  axis.  The 
first  of  these  methods  of  using  the  needle  may  be  called  laceration;  the 
second,  discission;  the  thii-d,  which  is  rarely  practised  except  through  the  cor- 
nea, terehration.  We  shall  first  direct  our  attention  to  the  method  by  lacera- 
tion. 

The  size  of  the  bent  needle  for  this  operation  ought  to  be  half  that  of  the 
needle  for  displacement,  the  measurements  of  which,  along  with  delineations 


DIVISION   OF   THE   CATARACT. 


ni 


of  its  form,  are  given  at  p.  737.  Its  neck  ought  to  be  round,  and  its  edges 
as  sharp  as  its  form  will  permit. 

1st  Period. — The  first  period  of  the  operation  is  exactly  the  same  as  in 
depression  and  reclination.   (See  page  737.) 

2d  Period. — The  second  period  commences  with  a  double  motion  of  the 
needle,  by  which  it  is  made  to  perform  a  quarter  of  a  revolution  on  its  axis, 
so  that  its  convex  surface  is  turned  forwards,  and  its  concave  surface  back- 
wards. At  the  same  time,  its  handle  is  to  be  carried  back  towards  the  temple, 
and  its  point  forwards,  to  the  interval  between  the  circular  edge  of  the  ciliary 
processes,  and  the  circumference  of  the  lens.  The  operator  now  slowly  pushes 
on  the  needle  between  these  parts  into  the  posterior  chamber.  He  sees  its 
point  advancing  from  behind  the  temporal  edge  of  the  pupil  (Fig.  103),  and 
carries  it  on  through  the  posterior  chamber,  till  its  point  reaches  the  centre 
of  the  anterior  hemisphere  of  the  capsule. 

od  Period. — The  operator  proceeds  by  numerous  touches  of  the  instrument 
to  tear  the  anterior  hemisphere  of  the  capsule  into  shreds,  to  an  extent  rather 
exceeding  than  falling  within  the  natural  size  of  the  pupil.  The  object  is 
entirely  to  annihilate  the  central  portion  of  the  capsule,  and  thus  allow  the 
aqueous  humor  free  access  to  the  lens.  Merely  to  pierce  the  capsule,  slit  it 
up,  or  tear  it  from  the  front  of  the  lens,  would,  in  all  probability,  not  answer 
the  purpose,  because  the  portions  of  the  capsule  thus  treated  would  speedily 
reunite,  and  the  absorption- of  the  lens  be  interrupted.  Neither  is  it  desirable 
to  open  the  capsule  in  the  whole  of  its  diameter,  because  this  would  most 

Fig.  103. 


likely  be  followed  by  dislocation  of  the  lens,  which  would  consequently  press 
against  the  iris,  or  pass  entire  through  the  pupil  into  the  anterior  chamber. 

"The  comminution  of  the  capsule  is  to  be  effected  without  exercising  much 
pressure  on  the  crystalline,  which  might  cause  separation  of  the  adhesion 
between  the  ciliary  processes  and  zonula  Zinnii. 

If  the  lens  be  soft  and  friable,  portions  of  it,  towards  the  end  of  this  period 
of  the  operation,  will  generally  be  observed  to  break  off,  and  float  forwards 
through  the  pupil.  If  it  be  partially  or  entirely  dissolved,  the  fluid  will 
escape  into  the  aqueous  humor  and  render  it  turbid  as  soon  as  the  capsule  is 
opened. 

If  it  be  the  first  operation  which  the  cataract  has  undergone,  the  needle 
should  be  withdrawn  as  soon  as  the  division  of  the  capsule  is  completed.     It 


'7'72  DIVISION   OF   THE   CATARACT. 

is  of  great  importance,  however,  that  this  part  of  the  operation  be  as  com- 
pletely executed  as  possible,  especially  in  cases  of  congenital  cataract,  both 
that  we  may  avoid  unnecessary  repetitions  of  the  operation,  and  because  the 
capsule  is  generally  much  less  tough  at  a  first  operation  than  in  any  succeed- 
ing one,  and,  therefore,  more  easily  divided.  If  mei-ely  punctured  in  a  first 
operation,  and  left,  in  an  almost  entire  state,  to  be  acted  on  by  the  aqueous 
humor,  admitted  through  the  puncture  of  the  capsule,  this  membrane  is  often 
found,  on  a  second  operation,  to  be  much  tougher  and  more  opaque,  or  now 
for  the  first  time  opaque,  having  formerly  been  transparent.  I  have  especially 
remarked  this  in  infants.  Hence  the  necessity  of  great  attention  to  the  com- 
minution of  the  anterior  hemisphere  of  the  capsule  at  the  first  operation. 

Uh  Period. — It  sometimes  happens  that  the  division  of  the  capsule,  in  the 
manner  and  to  the  extent  above  stated,  is  sufficient,  without  any  further  opera- 
tion, to  procure  the  absorption  of  the  lens,  and  the  restoration  of  vision. 
Much  oftener  the  operation  of  division  requires  to  be  repeated  after  the 
interval  of  two  or  three  months ;  and,  at  the  second  operation,  particular 
attention  requii*es  to  be  paid  to  the  breaking  up  of  the  lens  and  dispersion  of 
its  fragments. 

The  needle  being  introduced  as  before,  the  operator  begins  the  division 
exactly  as  he  began  the  former  operation,  lest  the  shreds  of  the  capsule  may 
in  the  interval  have  coalesced,  and,  therefore,  require  to  be  separated  and 
broken  down.  Having  assured  himself  of  the  existence  of  a  sufficient  central 
aperture  in  the  capsule,  he  next,  by  gentle  movements  of  the  needle  upwards 
and  downwards,  divides  the  lens,  pushing  the  pieces,  as  he  proceeds,  through 
the  pupil,  into  the  anterior  chamber.  In  breaking  up  the  lens,  it  is  sometimes 
necessary  to  move  the  edge  of  the  needle  backwards  or  towards  the  vitreous 
humor ;  but  this  direction  ought  rather  to  be  avoided,  in  order  that  the 
posterior  capsule  may  be  left  entire,  for  if  it  be  much  injured,  it  is  apt  to 
become  opaque,  an  occuri-ence  rendering  necessary  new  operations,  which 
endanger  the  organization  of  the  vitreous  humor. 

It  is  by  no  means  essential,  even  for  speedy  solution,  that  the  pieces 
of  the  divided  lens  be  brought  into  the  anterior  chamber.  Some  have 
been  led  to  think  that  solution  is  accomplished  fully  as  quickly,  when  the 
lens,  stripped  of  its  capsule,  is  left  in  its  natural  situation.  No  doubt,  the 
greater  quantity  of  the  menstruum  by  which  the  solution  is  to  be  effected  lies 
in  the  anterior  chamber,  and  therefore  a  comminuted  lens  will  there  be 
brought  more  thoroughly  into  contact  with  the  aqueous  humor ;  but,  on  the 
other  hand,  it  is  urged  that  probably  this  menstruum  is  secreted  chiefly  in 
the  posterior  chamber,  and  that  it  is  possible  it  may  possess  more  of  the  sol- 
vent power  when  just  flowing  from  the  capillaries  which  secrete  it,  than  after 
it  has  passed  forward  through  the  pupil,  and  is  about  to  be  absorbed.** 

[Dr.  R.  Frazer  Michel,**  of  Charleston,  South  Carolina,  has  reasoned  in  a 
very  ingenious  way,  on  the  influence  ])robably  exerted  by  the  ciliary  processes 
in  effecting  the  rapid  absorption  which  we  see  taking  place  in  the  chamber 
of  the  aqueous  humor.  From  contemplating  the  great  vascularity,  both 
arterial  and  venous,  of  this  structure,  and  its  total  want  of  lymphatics,  he  has 
inferred  that  the  function  of  this  body  is  both  to  secrete  the  humor  of  the 
aqueous  chamber,  and  to  carry  on  the  absorption  of  all  that  is  removed 
therefrom  by  such  means. 

The  opinion  that  the  aqueous  humor  is  derived  from  such  a  source,  derives, 
at  least,  some  support  from  the  rapidity  with  Avhich  it  is  renewed  after  evacu- 
ation from  the  anterior  chamber.  The  length  of  time  required  for  its  re- 
accumulation,  under  such  circumstances,  must  indeed  be  very  short  to  enable 
M.  Desmarres  to  say,  in  speaking  of  the  accident  of  prolapsus  of  the  iris 


DIVISION   OP   THE   CATARACT.  773 

in  making  the  section  of  the  cornea  for  extraction  :  "  Toutefois,  on  anrait 
lieu  d'esperer,  en  attendant  quelques  minutes  et  en  recommandant  au  malade 
de  tenir  les  yeux  fermes,  de  pouvoir  reprendre  I'operation  inachevee.  L'iris, 
en  effet,  ne  tarde  pas,  par  suite  de  la  rapide  reproduction  de  I'humeur 
aqueuse,  a  s'eloignes  de  la  cornee."^"  And  then  the  membrane  of  aqueous 
humor  lining  the  anterior  chamber  is  so  thin,  delicate,  and  devoid  of  vas- 
cularity, as  to  lead  us  to  seek  for  some  other  source  from  which  so  rapid  a 
product  can  be  derived.  The  part  must  be,  indeed,  highly  vitalized,  which 
can  so  rapidly  perform  such  a  function  of  secretion,  and  the  degree  of 
vitality,  in  a  secreting  organ  at  least,  is,  by  a  law  of  physiology,  in  direct 
ratio  with  its  vascularity.  Hence,  Dr.  Michel,  and  those  who  advocate 
with  him  such  a  source  for  the  aqueous  humor  as  that  of  the  ciliary  pro- 
cesses, have,  we  think,  a  very  fair  amount  of  reason  in  support  of  their 
doctrine. 

The  experiments  of  Magendie  and  others  on  the  facility  with  which  fluids 
are  taken  up  by  venous  radicles,  might  also  justify  the  belief  in  the  absorption 
of  substances,  such  as  fragments  of  a  broken-up  lens,  being  accomplished  by 
the  same  structures  here,  seeing  that  this  part  of  the  eye  at  least  is  almost, 
if  not  totally,  devoid  of  the  other  source  of  absorption.  But  pathologists 
are  as  yet  divided  in  opinion  as  to  the  manner  in  which  the  removal  of  a 
broken  up  lens  is  accomplished,  whether  by  direct  absorption  or  solution. 

Be  this  as  it  may,  and  even  admitting  that  the  removal  of  a  broken-up 
lens  is  more  rapidly  effected  in  the  anterior  than  in  the  posterior  chamber  (a 
fact  which  we  do  not  think  has  yet  been  conclusively  established),  we  can- 
not admit  that  the  advantages  thus  to  be  derived  from  throwing  the  frag- 
ments into  the  anterior  chamber  are  at  all  commensurate  with  the  evil 
consequences  of  such  a  procedure.  We  coincide  entirely  with  Dr.  Jacob 
in  the  opinion  that  the  nausea  so  invariably  following  this  operation  of 
division  is  to  be  attributed  "to  the  pressure  of  the  fragments  of  the  broken- 
up  lens  on  the  iris.  After  a  careful  consideration  of  all  the  cases  in  which 
we  have  had  an  opportunity  of  watching  the  effect  of  this  procedure,  whether 
under  our  own  care  or  in  the  practice  of  others,  at  home  and  abroad,  we 
feel  satisfied  of  the  fact  that  the  eady  supervention  of  nausea  and  of  vomiting, 
and  their  intensity  and  duration  were — making  all  due  allowance  for  suscep- 
tibility to  nervous  shock — in  direct  proportion  with  the  number  of  fragments 
of  the  lens  thrown  into  the  anterior  chamber.  We,  therefore,  do  not  think  it 
advisable,  or  even  necessary,  that  such  a  step  as  the  displacement  of  the 
fragments  should  be  taken,  and  feel  satisfied  that  the  complete  and  thorough 
discission  of  the  lens  and  its  capsule,  without  disturbing  either  from  their 
natural  position,  will  be  found  a  more  desirable  method  of  treating  the  affec- 
tion.—H.] 

The  facility  with  which  the  fragments  of  the  divided  lens  are  scattered  by 
the  needle,  does  not  depend  so  much  on  its  consistence  as  on  a  sort  of  coagu- 
lation which  it  has  undergone.  In  patients  about  the  age  of  25,  we  not 
unfrequently  find  the  lens  so  soft  that  the  needle  passes  through  it  in  every 
direction,  but  at  the  same  time  so  tenacious  that  the  fragments  can  be  separated 
with  difficulty;  whereas  in  patients  of  35,  the  lens  is  generally  more  friable, 
and  breaks  under  the  needle  into  scales  and  flocculi.  By- exposure,  however, 
to  the  aqueous  humor  for  a  few  weeks,  the  glutinous  lens  becomes  coagulated, 
and  then  its  fragments  prove  less  cohesive.  Even  the  hard  lens  of  an  old 
person,  if  exposed  for  some  time  to  the  influence  of  the  aqueous  humor,  occa- 
sionally becomes  brittle,  so  that  a  second  operation  with  the  needle  (the 
first  operation  having  been  devoted  to  the  comminution  of  the  anterior 
hemisphere  of  the  ca[)sule),  we  find  the  superficial  lamince,  at  least,  of  the 


11i 


DIVISION   or   THE   CATARACT. 


lens  to  scatter  into  fragments.  This  is  an  occurrence,  however,  too  rare  to 
vindicate  us  in  adopting  division  as  a  general  mode  of  operating  on  the  hard 
cataract  of  old  persons.  When  instead  of  merely  comminuting  the  anterior 
hemisphere  of  the  capsule,  or  scraping  down  the  surface  of  the  lens,  it  is  our 
object  to  cut  the  lens  in  pieces,  an  operation  which  is  termed  discission,  we 
require  to  employ  a  straight  needle,  such  as  is  represented  in  the  annexed 
figure  (Fig.  104),  its  breadth  being  2V  inch,  its  length  from  the  point  to  the 

Fig.  104. 


i 


Fiss.  105,  106. 


neck  I  inch,  and  its  neck  round.     Its  cutting  edges  must  be  made  as  sharp 
as  possible. 

[As  a  sharp  cutting  edge  cannot  be  given  to  a  needle  of  the  form  delineated 
in  Fig.  104,  above  the  shoulder  of  the  spear,  and  as  the  edge  of  such  an 
instrument  is  placed  on  either  side  at  too  great  an  angle  to  its  axis  to  allow 
of  its  being  brought  into  full  play  on  the  surface  of  the  lens,  when  introduced 
through  the  sclerotic,  it  is  conceivable  that  a  more  efficient 
instrument  might  be  produced  for  the  purpose.  Fully 
impressed  with  this  idea.  Dr.  Hays  has,  many  years  since, 
entertained  the  belief  that  an  instrument  made  somewhat 
after  the  form  of  an  iris-knife,  would  be  better  adapted  for 
the  division  of  cataract.  More  than  three  years  ago,  he 
had  one  of  the  kind  made,  and  has  figured  and  described 
it  in  his  last  edition  of  Mr.  Lawrence's  work,  p.  126.  It, 
however,  did  not  possess  the  precise  form  he  desired,  and 
after  having  had  a  great  variety  constructed,  he  has  at  last 
succeeded  in  obtaining  one  of  Mr.  Kolbe,  of  this  city, 
which  meets  with  his  approbation.  The  accompanying 
wood-cut  (Fig.  105)  may  be  received  as  a  faithful  repre- 
sentation of  the  instrument,  as  it  has  been  made  under 
Dr.  H.'s  immediate  supervision.  In  the  forthcoming 
number  of  the  American  Journal  of  Medical  Sciences  (see 
July  num1)er  for  1855,  p.  82),  Dr.  H.  thus  describes  his 
hiife-needle : — 

"  This  instrument,  from  the  point  to  the  bead  near  the 
handle  («  to  b,  see  Fig.  106),  is  six-tenths  of  an  inch,  its 
cutting  edge  (a  to  c)  is  nearly  four-tenths  of  an  inch. 
The  back  is  straight  to  near  the  point,  where  it  is  trun- 
cated, so  as  to  make  the  point  stronger,  but  at  the  same 
time  leaving  it  very  acute  ;  and  the  edge  of  this  truncated 
portion  of  the  back  is  made  to  cut.  The  remainder  of  the 
back  is  simply  rounded  off.  The  cutting  edge  is  perfectly 
straight,  and  is  made  to  cut  up  to  the  part  where  the 
instrument  becomes  round,  c  This  portion  requires  to  be 
carefully  constructed,  so  that  as  the  instrument  enters  the 
feye  it  shall  fill  up  the  incision,  and  thus  prevent  the  escape 
of  the  aqueous  humor.  In  the  diagram  (Fig.  106)  the  pro- 
portions of  the  blade  are  not  very  accurately  represented, 
the  rounded  part  being  rather  too  slender,  and  the  handle 
should  be  octagonal,  with  equal  sides,  and  of  the  same 
thickness  its  whole  length." — H.] 
\st  Period. The  pupil  being  dilated  by  belladonna,  the  needle  is  to  be 


DIVISION   OP   THE   CATARACT.  116 

passed  through  the  sclerotica,  at  the  distance  of  I  inch  behind  the  edge  of 
the  cornea,  in  the  equator  of  the  eye,  and  with  its  one  flat  surface  directed 
upwards  and  the  other  downwards. 

2d  Period. — The  second  period  commences  by  giving  to  the  instrument  a 
quarter-turn  on  its  axis,  at  the  same  that  its  point  is  directed  towards  the 
interval  between  the  ciliary  processes  and  the  circumference  of  the  lens.  Its 
one  flat  surface  looking  forwards,  and  its  other  flat  surface  backwards,  it  is  now 
advanced  through  the  posterior  chamber,  till  its  point  is  hid  behind  the  nasal 
portion  of  the  iris,  and  has  advanced  nearly  as  far  as  the  nasal  edge  of  the  lens. 
Sd  Period. — In  the  third  period,  one  of  the  cutting  edges  of  the  needle 
being  turned  towards  the  cataract,  by  a  steady  pressure  backwards,  accom- 
panied by  a  slight  withdrawing  motion  of  the  instrument,  the  lens,  enveloped 
'n  its  capsule,  is  to  be  fairly  cut  across,  and  divided  into  two.  Provided  the 
cipsule  is  not  thickened  and  opaque,  and  the  nucleus  of  the  lens  not  firm,  a 
moderate  pressure  of  the  needle  backwards  will  cause  it  to  sink  through  these 
stiuctures,  so  that  their  division  may  be  accomplished  by  pressure  alone ;  if 
th«  capsule,  on  the  other  hand,  is  thickened,  or  the  nucleus  of  the  lens  firm, 
mere  pressure  will  have  the  effect  only  of  carrying  them  back  towards  the 
vitieous  humor,  but  not  of  dividing  them.  The  combination,  then,  of  a  draw- 
ing motion  across  the  cataract,  along  with  pressure  backwards  through  its 
surfice,  is  necessary  to  accomplish  the  division. 

Sipposing  the  cataract  to  be  divided  into  halves,  the  needle  is  now  to  be 
broight  forwards  through  the  cut  it  has  made,  in  order  that  a  similar  discis- 
sion may  be  made  of  the  upper  and  lower  portions  of  the  lens  and  capsule. 
Havng  been  divided  into  as  many  pieces  as  possible,  the  smaller  poi'tions 
are  b  be  pushed  with  the  flat  side  of  the  needle,  through  the  pupil,  into  the 
anteiior  chamber. 

Wiat  length  of  time  is  generally  required  for  the  cure  of  cataract  by  ab- 
sorpton  ?  To  this  I  am  inclined  to  answer,  that  we  have  no  evidence  to 
prove  that  the  capsule  is  ever  absorbed,  whether  it  be  in  the  transpai'ent  or 
in  the  opaque  state ;  and  that  as  for  the  lens,  the  rapidity  with  which  it  is 
dissoked,  depends  partly  on  its  consistence,  and  partly  on  the  completeness 
with  vhich  it  is  exposed  to  the  aqueous  humor.  If  in  a  person  below  35 
years  of  age,  the  central  portion,  of  the  anterior  hemisphere  of  the  capsule 
be  ttoroughly  comminuted  with  the  needle,  and  if  no  inflammation  follow  the 
operition,  the  lens  may  be  completely  dissolved  in  six  or  eight  weeks.  Of 
coune,  the  soft  lens  of  the. child  will  be  absorbed  in  a  shorter  time,  while  the 
hare  lens  of  a  person  of  55  or  60  may  remain  unchanged  for  many  months. 
In  in  individual  of  about  30  years  of  age,  in  whom  I  freely  divided  the  anterior 
henisphere  of  the  capsule,  very  little  absorption  seemed  to  take  place  for  the 
firs  six  weeks.  In  the  course  of  the  next  two  weeks,  the  lens  was  completely 
dissolved.  Dr.  W.  Soemmerring  made  a  single  incision  into  the  opaque 
capule  of  a  boy,  of  four  years  of  age,  affected  with  congenital  cataract.  The 
len;  remained  without  apparent  change  for  half  a  year.  Absorption  then 
conraenced,  and  rapidly  proceeded." 

Ye  constantly  observe  that  solution  and  absorption  go  on  much  more 
rapdly,  when  the  eye  is  free  from  inflammation  or  irritation.  Indeed,  during 
anattack  of  pain,  with  redness  and  epiphora,  solution  and  absorption  seem 
to  cease,  but  are  renewed  whenever  the  irritation  subsides,  or  the  inflamma- 
ticn  is  overcome.  We  explain  this,  partly  by  the  well  known  fact  that  over- 
distension of  the  bloodvessels  is  found  to  be  inconsistent  with  a  free  action 
of  the  absorbents,  and  partly  by  the  circumstance,  that  although  there  may 
be  no  evident  effusion  of  lymph  behind  the  pupil,  there  is  always  a  tendency 
in  intei'nal  ophthalmia  to  such  an  effusion,  and,  of  course,  a  disposition  to 
close  up  and  repair  the  injured  capsule.     This  effort  of  nature,  however 


176  DIVISION   OF   THE   CATARACT, 

admirable  its  design,  we  must  in  this  instance  endeavor  to  counteract,  in  the 
first  place,  by  as  complete  a  division  of  the  capsule  as  is  possible,  and, 
secondly,  by  a  strict  antiphlogistic  after-treatment. 

The  opinion  above  stated,  that  the  capsule,  so  far  as  we  know,  is  insoluble, 
is,  I  am  aware,  in  contradiction  to  what  has  usually  been  maintained  upon 
this  point.  The  capsule  in  the  transparent  state  we  never  see  ;  its  shreds  are 
invisible,  from  the  very  circumstance  of  their  transparency.  The  membrane, 
too,  is  highly  elastic,  and  upon  being  divided,  rolls  itself  up  like  a  bit  of 
moistened  gold-beater's  leaf.  But  if  inflammation  occurs,  the  capsule  becomes 
opaque,  and,  unless  the  inflammation  is  speedily  subdued,  will  continue  per- 
manently so.  The  opaque  shreds  in  the  inflamed  state  tend  also  to  reunite, 
and  thus  give  rise  to  secondary  capsular  cataract.  Subdue  the  inflammation 
by  bloodletting,  mercury,  and  other  appropriate  remedies,  and  the  opaque 
state  of  the  capsule  subsides  or  disappears.  Neglect  it,  and  not  merely  do«s 
the  opacity  become  permanent,  but  however  much  the  capsule  may  afterwards 
be  divided,  its  shreds  never  disappear,  except  by  displacement.  They  nny 
be  pushed  aside,  a  central  aperture  cleared,  and  vision  restored  ;  but  portions 
of  opaque  capsule  will  be  visible  for  life  behind  the  edge  of  the  pupil,  wlen 
brought  under  the  influence  of  belladonna,  and  the  minute  shreds  whichfell 
down  into  the  anterior  chamber,  will  lie  there  without  undergoing  the  sligiest 
change.  It  is  probable,  that  the  return  of  transparency,  after  inflammrtion 
of  the  capsule  is  overcome,  has  given  rise  to  the  erroneous  opinion  thatthis 
membrane  is  .susceptible  of  solution  in  the  aqueous  humor.  I 

Modifications  of  division  through  the  sclerotica  according  to  var%eti\s  of 
cataract. — 1.  When  the  lens  is  fluid,  it  will  of  course  flow  through  the  w)und 
of  the  capsule  into  the  aqueous  humor.  This  renders  it  difficult  to  ezcute 
the  division  of  the  capsule  with  precision.  It  is  desirable,  however,  that  the 
centre  of  it  should  be  freely  lacerated.  The  turbid  aqueous  humor  is  gene- 
rally absorbed  in  a  few  days,  and  not  unfrequently  in  the  course  of  a  lingle 
day.  As  has  been  already  mentioned  (p.  *742),  the  eff'usion  of  the  dissolved 
lens  into  the  aqueous  chambers,  is  apt  to  excite  vomiting  and  inflammation. 

2.  The  appearances  of  the  opacity,  added  to  the  age  of  the  patient,  iiould 
in  general  be  sufficiently,  indicative  of  hard  cataract ;  and  in  cases  d"  this 
sort,  division,  and  especially  discission,  ought  not  to  be  tried.  ShouH  the 
operator,  however,  have  deceived  himself,  supposing  the  lens  to  be  sofi,  but 
on  touching  it  with  the  needle  discover  it  to  be  hard,  he  has  a  choice  of  ether 
performing  displacement,  or  of  bringing  the  lens  through  the  pupil,  opeiing 
one-third  of  the  circumference  of  the  cornea,  and  extracting. 

3.  In  capsulo-lenticular  cataract,  the  opaque  portion  of  the  capsule,  wrich 
generally  occupies  the  centre,  may  be  so  thick  and  tough,  that  it  cannot  be 
divided.  In  this  case,  the  lens  ought  to  be  cut  up,  and  the  transparent 
part  of  the  capsule  divided.  After  the  lens  has  dissolved,  the  opaque  porion 
of  the  capsule  may  be  extracted  through  a  puncture  of  the  cornea. 

4.  When  the  pupillary  edge  of  the  iris  is  partially  adherent  to  the  capsile, 
(which  in  this  case  is  always  more  or  less  opaque),  we  may  endeavor  vith 
the  point  or  edge  of  the  needle  cautiously  to  separate  the  adhesions,  partfcu- 
larly  if  they  are  but  few  in  number,  and  having  effected  this,  proceed  to  the 
division  of  the  capsule  in  the  usual  way.  If  the  whole  edge  of  the  pupil  is 
adherent,  separation  is  scarcely  to  be  accomplished ;  and  the  case  must  Ibe 
treated  either  by  drilling,  or  by  the  formation  of  an  artificial  pupil.  ' 

After-treatment. — Except  in  continued  dilatation  of  the  pupil,  the  aftff- 
treatment  does  not  diff'er  from  what  has  already  been  recommended  is 
advisable  after  the  operations  of  displacement.  If  the  pupil  is  kept  under 
the  influence  of  belladonna,  the  fragments  of  the  divided  lens  are  in  a  grea'. 
measure  prevented  from  irritating  the  iris,  and  thus  the  iritis  is  warded  off. 


DIVISION   OP   THE   CATARACT.  Ill 

It  is  daugerous  to  allow  the  pupil  to  contract,  before  the  cataract  is  dissolved. 
The  eyebrow  and  eyelids,  therefore,  are  to  be  smeared  with  the  extract  of 
belladonna  morning  and  evening,  till  all  redness  and  irritation  consequent  to 
the  operation  have  disappeared,  after  which  we  may  substitute  the  solution 
of  atropine,  of  which  a  little  is  to  be  dropped  into  the  inner  corner  of  the  eye, 
the  patient  opening  the  lids  and  allowing  the  solution  to  spread  over  the 
conjunctiva.  This  is  to  be  continued  once  a  day,  till  the  cataract  has  disap- 
peared, the  patient  meanwhile  shading  the  eyes,  lest  the  influence  of  the  light 
prove  hurtful. 

Accidents  during  and  after  division  through  the  sclerotica. — Many  of  these 
are  exactly  similar  to  those  which  attend  the  operations  of  displacement,  and 
need  not  again  be  particularly  insisted  on.     A  few  are  peculiar. 

1.  The  needle,  instead  of  entering  the  posterior  chamber,  sometimes  slips 
between  the  lens  and  capsule.  From  the  transparency  of  the  capsule,  this 
accident  may  escape  the  operator's  notice,  till  he  has  made  a  number  of 
movements  with  the  needle  through  the  lens,  and  finds  no  flocculent  substance 
passing  into  the  aqueous  humor.  Suspecting  what  is  wrong,  he  may  even 
press  the  point  of  the  needle  forwards  in  the  direction  of  the  pupil,  but  in  so 
doing,  carry  the  capsule  still  entire  before  the  instrument.  As  it  is  impossible, 
with  the  needle  in  this  situation,  to  divide  the  capsule  in  a  proper  manner, 
the  operator  ought  to  withdraw  the  instrument  a  certain  way,  and  then  repeat 
the  second  period  of  the  operation,  taking  care  to  bring  the  point  of  the  needle 
in  front  of  the  capsule.  It  is  bad  practice  to  proceed  to  divide  the  lens,  and 
leave  the  capsule  almost  untouched. 

2.  Should  it  happen,  in  consequence  of  an  improper  use  of  the  needle, 
that  the  lens  bursts  from  the  capsule,  and  passes  through  the  pupil  into  the 
anterior  chamber,  the  cornea  should  immediately  be  opened,  and  the  lens 
extracted.  This  accident  is  particularly  apt  to  happen,  in  the  operation  of 
discission,  if  the  cutting  edge  of  the  needle  is  not  placed  exactly  in  the 
equator  of  the  lens.  If  it  is  either  above  or  below  it,  as  soon  as  pressure  is 
applied,  with  the  intention  of  cutting  the  cataract  into  two,  the  lens  is  tilted 
into  the  anterior  chamber. 

3.  If  we  have  divided  the  capsule  in  a  case  of  hard  cataract,  the  surface  of 
the  lens  may  dissolve,  leaving  a  firm  nucleus.  This  gradually  diminishes  in 
bulk  ;  and  it  is  the  practice  of  some  operators,  in  cataracts  of  medium  consist- 
ence, first  to  reduce  the  size  of  the  lens  by  exposing  it  to  the  action  of  the 
aqueous  humor,  and  then  to  dispose  of  the  nucleus  by  displacement.^^  I 
have  known  a  hard  nucleus  undissolved  a  year  after  the  operation  of  division. 
Falling  forwards  into  the  anterior  chamber,  it  may  cause  great  irritation, 
neuralgia,  and  inflammation.  It  may  become  united  to  the  iris  by  inflamma- 
tion, so  that  if  we  delay  opening  the  cornea  for  its  extraction,  when  we  come 
at  last  to  do  this,  it  cannot  be  removed,  having  become  organized,  and 
incorporated  with  the  iris. 

4.  If  the  hyaloid  membrane  is  in  a  dissolved  state,  the  lens  and  capsule, 
hitherto  kept  in  their  place  by  the  adhesion  of  the  zonula  Zinnii  to  the  ciliary 
processes,  are  apt  on  being  touched  with  the  needle,  suddenly  to  sink  to  the 
bottom  of  the  vitreous  humor.  In  this  case,  the  cataract  ought  immediately 
to  be  laid  hold  of  with  the  needle,  brought  up  into  its  former  place,  pushed 
through  the  pupil,  and  extracted  through  a  small  section  of  the  cornea. 

5.  A  certain  degree  of  inflammation  may  always  be  expected  to  follow 
division  through  the  sclerotica.  A  soft  lens,  exposed  to  the  aqueous  humor, 
imbibes  that  fluid,  swells,  and  sometimes  presses  on  the  iris,  so  as  to  cause 
pain  and  vomiting,  and  to  bring  on  an  internal  inflammation  of  the  eye,  lead- 
ing to  a  contraction  of  the  pupil.  Reparative  inflammation  of  the  capsule, 
also,  must  always  ensue,  spreading  in  some  degree  to  the  iris,  and  if  not 


718  DIVISION   OP   THE   CATARACT. 

timely  checked,  producing  opacity  of  the  capsular  shreds,  closing  up  the  cen- 
tral aperture  which  has  been  formed  by  the  operation,  interrupting  in  various 
ways  the  process  of  dissolution  of  the  lens,  and  perhaps  going  the  length  of 
coarctation  of  the  pupil  and  adhesion  of  the  iris.  In  two  cases  in  which  I 
operated,  suppuration  within  the  capsule  took  place,  the  matter  exuding 
partly  into  the  anterior  chamber.  Belladonna,  bloodletting,  and  calomel  with 
opium  are  the  means  to  be  employed  to  avert  these  dangers.  In  one  of  the 
cases  just  referred  to,  I  opened  the  cornea,  and  allowed  the  matter  to  escape. 
The  other  case  was  greatly  benefited,  after  the  mouth  became  sore  with  mer- 
cury. 

6.  Has  the  process  of  solution  and  absorption  of  the  lens  no  exhausting 
effects  upon  the  internal  parts  of  the  eye  ?  Are  these  parts  left  as  sound, 
after  this  process  has  been  accomplished,  as  after  extraction,  in  neither  case 
inflammation  having  occurred  ?  To  these  questions  I  must  answer,  that,  after 
the  process  of  solution  and  absorption  is  completed,  we  frequently  observe 
undeniable  signs  of  the  internal  textures  of  the  eye  having  suffered,  not  from 
inflammation  apparently,  nor  from  irritation,  but  rather  from  exhaustion. 
The  nutritive,  or  regenerative  power  of  the  eye,  appears  to  be  weakened. 
The  iris  becomes  paler  and  more  flaccid  than  natural,  the  pupil  smaller,  and 
its  motions  less  vivid  :  according  to  the  testimony  of  one  observer,'^  the 
aqueous  humor  is  insufficiently  secreted ;  while,  in  some  cases,  the  wasting  of 
the  eye  extends  more  deeply,  the  vitreous  humor  shrinks,  and  the  retina 
loses  its  sensibility. 

§  2.   Division  through  the  Cornea. 

Syn. — Anterior  Operation  for  Absorption.     Keratonyxis,  from  xlpaj,  cornu,  wbence  cornea, 

and  vuTTfltf,  I  puncture. 

It  has  been  conjectured  that  this  is  a  very  ancient  method  of  curing  cata- 
ract. It  is  probable,  however,  that  the  puncturing  of  the  eye  of  which  the 
Greeks  spoke  familiarly  as  a  means  of  restoring  sight,"  as  well  as  the  opera- 
tion for  cataract  for  which  Galen  says  man  was  indebted  to  the  goat,  was 
depression  through  the  sclerotica,  not  division  through  the  cornea." 

Albucasis  tells  us,*^  that  he  had  been  informed  there  were  some  who  pumped 
out  the  cataract  through  a  hollow  needle.  Now,  in  cases  of  fluid  cataract, 
there  is  no  doubt  that  the  (iiitta  opaca,  in  which  the  Arabians  believed  cata- 
ract to  consist,  might  be  discharged  through  a  small  canula,  introduced,  I 
presume,  through  the  cornea ;  but  even  when  the  cataract  was  not  fluid,  and 
when  only  the  aqueous  humor  was  discharged,  a  very  slight  wound  through 
the  anterior  hemisphere  of  the  capsule  with  the  end  of  the  tube,  might  occa- 
sionally effect  a  cure,  by  the  admission  of  the  aqueous  humor.  We  shall 
presently  see  that  the  operation  proposed  by  Conradi  amounted  to  little  more 
than  such  a  perforation  of  the  capsule. 

There  is  an  insulated  case  recorded  by  Mayerne,  in  which  a  female  oculist 
appears  to  have  cured  a  cataract  in  a  young  person,  by  the  introduction  of  a 
needle  through  the  cornea.*''  This  case  is  generally  considered  as  the  earliest 
example  of  an  attempt  to  procure  the  solution  of  the  lens  by  puncturing  the 
capsule  through  the  cornea.  It  is,  however,  not  very  evident  what  was  the 
intention  of  the  operator,  and,  except  from  the  circumstance  of  its  being 
placed  in  a  chapter  De  Suffusione,  we  should  not  have  known  that  it  was  a 
case  of  cataract  at  all. 

Gleize  deserves  to  be  mentioned  in  a  history  of  the  operation  of  division 
through  the  cornea,  although  his  claims  have  been  strangely  exaggerated. 
It  happened  that  a  patient,  on  whom  he  was  about  to  perform  extraction, 
made  an  involuntary  motion  with  her  head,  just  as  the  knife  penetrated  the 


DIVISION   or   THE   CATARACT.  779 

cornea,  so  that  the  knife  slipped  out,  and  was  followed  by  the  aqueous  humor. 
It  occurred  to  the  operator,  that  he  might  depress  the  cataract  through  the 
wound  of  the  cornea,  which  he  accordingly  did.  He  says  nothing  about 
dividing  the  cataract,  or  exposing  it  to  solution  in  the  aqueous  humor.^^ 
His  successful  depression  in  this  instance  led  him,  however,  to  recommend  a 
similar  mode  of  operation  in  other  cases ;  namely,  that  having  dilated  the 
pupil  by  belladonna,  the  operator  should  make  an  incision  at  the  edge  of  the 
cornea,  introduce  a  needle  and  divide  the  capsule  circularly,  depress  the  lens 
if  hard,  extract  it  if  soft,  but  leave  any  fragments  which  might  be  detached 
from  it,  or  even  the  whole  lens  if  it  could  neither  be  depressed  nor  extracted, 
to  be  dissolved  by  the  aqueous  humor,  an  event  which  he  says  occupies  20 
or  30  days,  or  longer. 

The  merit  of  first  proposing  a  distinct  method  of  operating  by  division 
through  the  cornea  belongs  to  Conradi,  a  surgeon  at  Nordheim  in  Hanover. 
He  at  once  passed  a  needle,  or  very  small  lancet-shaped  knife,  through  the 
cornea,  opened  the  anterior  hemisphere  of  the  capsule,  and  withdrew  the 
instrument,  leaving  the  cataract  to  be  dissolved ;  an  operation  which  is  cer- 
tainly one  of  the  simplest  yet  proposed  for  the  cure  of  this  disease,  being 
executed  with  a  single  instrument,  and  interesting  only  the  cornea  and  the 
capsule. ^^ 

Conradi's  operation  was  put  to  the  test  in  different  parts  of  Germany.  In 
many  cases  it  proved  successful;  in  others,  the  punctured  incision  of  the  cap- 
sule was  found  to  heal  up,  and  thus  the  solution  of  the  cataract  to  be  inter- 
rupted. This  led  Buchhorn,  of  Magdeburg,  to  add  two  important  steps  to 
the  operation,  namely,  dividing  the  lens  as  well  as  the  capsule,  and  bringing 
forward  the  fragments  of  the  cataract  with  the  flat  side  of  the  needle.*"  The 
division  of  the  lens,  and  the  introduction  of  its  fragments  into  the  anterior 
chamber  were  supposed  directly  to  hasten  the  solution  of  the  cataract  and  the 
consequent  restoration  of  sight.  The  success,  however,  of  this  method  de- 
pends chiefly  upon  the  degree  in  which  the  anterior  hemisphere  of  the  capsule 
is  comminuted.  If  this  part  of  the  operation  be  so  completely  effected,  that 
the  remains  of  the  membrane  cannot  coalesce,  then  the  solution  of  a  cataract 
of  ordinary  consistence  is  certain,  even  should  it  be  left  entire,  and  in  its  natu- 
ral situation. 

Division  through  the  cornea,  which  partakes  much  more  of  the  nature  of 
laceration  than  discission,  comprehends  three  periods,  viz  :  first,  the  intro- 
duction of  the  needle;  secondly,  the  division  of  the  capsule;  and  thirdly,  the 
division  of  the  lens  and  scattering  of  its  fragments. 

Whatever  form  is  given  to  the  needle,  it  ought  to  be  smaller  than  that  used 
for  division  through  the  sclerotica,  as  in  the  present  case  it  has  to  operate 
through  the  pupil,  and  often  in  the  eyes  of  infants.  The  neck  must  be  round, 
and  of  such  a  degree  of  thickness  as  shall  fill  the  wound  made  by  the  bent 
part  of  the  instrument. 

I  consider  a  modification  of  the  needle  recommended  by  Dr.  Jacob^'  to  be 
the  best,  combining  the  advantages  of  a  small  blade,  with  great  strength  and 
fine  temper,  inflicting  so  minute  a  wound  that  no  mark  remains  in  the  cornea, 
capable  of  effectually  opening  up  the  texture  of  the  lens,  and,  from  its  conical 
form,  not  likely  to  permit  the  aqueous  humor  to  escape  during  the  operation. 

Dr.  Jacob's  needle  (Fig.  107)  is  made  out  of  a  common  sewing-needle 
of  the  size  known  as  No.  7,  being  about  ^^  inch  in  thickness.  The  point  is 
turned  to  the  requisite  curve  by  means  of  a  pair  of  pliers,  or  the  ward  of  a 
small  key ;  of  course  without  heat,  which  would  destroy  the  temper.  All 
needles  are  not  so  soft  as  to  be  bent  thus  cold ;  there  may  not  be  one  in  ten 
of  this  temper,  but  when  once  turned,  such  a  needle  retains  the  curve  with- 
out any  danger  of  bending  or  breaking,  and  possesses  a  degree  of  strength 


780 


DIVISION   OP   THE   CATARACT. 


Figs:  107,  108. 


t\ 


and  temper  rarely  observed  in  needles  separately  forged  and  finished  by  the 
cutler.  After  having  received  the  requisite  curve,  the  point  is  ground  flat 
on  each  side,  on  a  fine  hone,  and  carefully  examined  with  a 
magnifying  glass  to  ascertain  that  it  is  perfect.  (See  magni- 
fied view.  Fig.  108.)  The  needle,  held  in  a  pair  of  pliers,  is 
now  to  be  run  down  into  a  cedar  handle,  leaving  only  half  an 
inch  of  blade.  If  the  blade  be  left  longer,  it  will  yield  and 
spring  when  opposed  to  a  resistance.  A  needle,  thus  con- 
structed, is  neither  more  nor  less  than  a  shoemaker's  square 
awl  in  miniature,  and  as  this  tool,  when  dexterously  used, 
passes  readily  through  a  piece  of  thick  dense  leather,  so,  no 
doul)t,  will  this  needle  penetrate  the  cornea,  when  properly 
handled ;  that  is  to  say,  when  one  or  other  angle  of  its  edge  is 
entered  formost.  To  insure,  however,  a  ready  passage  through 
the  cornea,  even  in  the  hands  of  those  unacquainted  with  this 
manoeuvre,  the  square  edge  may  be  changed  into  a  single  point, 
as  is  represented  in  the  magnified  view  (Fig.  109).  Less  dex- 
terity and  less  force  are  needed  to  pass  this  form  of  needle 

Fig;.  110. 


Fio;.  109. 


through  the  cornea,  while  it  tears  up  the  capsule  and  lens 

better. 

1st  Period. — The  pupil  being  dilated  by  belladonna,  and  the 

patient  seated  on  a  low  chair,  or  laid  along  upon  a  table,  the 

surgeon  stands  behind  him,  raises  the  upper  eyelid,  and  brings 
the  point  of  the  needle  within  a  very  short  distance  of  the  eye.  When  the 
cornea  is  brought  into  an  advantageous  position,  and  completely  fixed  by  the 
fingers,  he  suddenly  strikes  the  needle  into  it  at  the  distance  of  not  less  than 
-Jo"inch  from  the  sclerotica,  directing  the  point  of  the  instrument  towards  the 
centre  of  the  pupil,  and  its  flat  side  towards  the  iris  (Fig.  110).  The  conical 
form  of  the  needle,  and  the  resisting  texture  of  the  cornea,  render  necessary 
considerable  degree  of  pressure  to  make  the  instrument  penetrate  into  the 
anterior  chamber. 

2d  Period. — The  needle  having  fairly  entered  the  anterior  chamber  so  that 
its  point  is  seen  at  the  opposite  side  of  the  pupil,  the  operator  turns  the  point 
directly  back,  and  proceeds  to  comminute  the  capsule,  picking  and  scratch- 
ing the  surface  of  the  crystalline  with  a  semi-rotatory  motion  of  the  instru- 
ment. This  he  should  do  with  the  needle  turned  first  in  one  direction  and 
then  in  another,  so  as  to  reduce  to  minute  fragments  the  central  portion  of 
the  capsule,  to  an  extent  equal  to  the  natural  size  of  the  pupil.  In  doing 
this,  he  takes  care  not  to  raise  the  capsule  on  the  point  of  the  needle,  which, 


DIVISION   OF   THE   CATARACT.  781 

by  rending  the  membrane  across,  might  give  rise  to  dislocation  of  the  lens, 
and  would  at  least  prevent  the  division  from  being  accomplished  in  a  satisfac- 
tory manner. 

3d  Period. — If  the  lens  is  soft  and  friable,  fragments  of  it  fall  like  snow 
into  the  anterior  chamber,  as  the  surgeon  comminutes  the  capsule.  When  he 
observes  this,  he  may  proceed  to  deal  more  freely  with  the  lens,  twirling  the 
needle  round  so  as  to  drill  away  its  substance.  A  cataractous  lens  is  some- 
times so  soft,  that  it  falls  almost  into  a  powder  under  the  needle.  In  such 
cases  the  fragments  necessarily  fall  into  the  anterior  chamber  so  as  to  fill  it 
half  way  up,  and  are  rapidly  absorbed  without  producing  inflammation.  Such, 
observes  Dr.  Jacob,  are  certain  lenticular  cataracts  of  a  blue  tint,  not  generally 
found  in  old  persons. 

As  the  operation  generally  requires  to  be  performed  more  than  once,  in  the 
second  and  subsequent  operations,  it  is  the  comminution  of  the  lens  which  is  to 
be  chiefly  attended  to,  unless  at  the  first  operation  the  formation  of  a  sufficient 
central  aperture  in  the  capsule  has  failed.  When  this  has  been  the  case,  the 
division  of  the  capsule  must  be  repeated,  then  the  lens  broken  up,  in  the 
manner  already  mentioned,  and  the  fragments  brought  forward  into  the 
anterior  chamber.  If  the  fragments  be  larger  than  the  head  of  a  common  pin, 
they  are  liable  to  produce  inflammation  by  pressing  on  the  iris,  which  pressure 
can  be  obviated  only  by  keeping  the  pupil  completely  dilated  by  belladonna. 
No  rule  can  be  given  regarding  the  periods  at  which  the  operation  should  be 
repeated.  Dr.  Jacob  observes,  that  "  while  the  broken  lens  lies  well  in  the 
posterior  chamber,  without  pressing  on  the  iris,  the  operator  has  reason  to 
congratulate  himself,  and  it  is  only  when  he  has  ascertained  Ihat  no  change  is 
taking  place  in  the  cataract,  that  he  is  called  upon  again  to  disturb  it.  He 
should  be  particularly  cautious  not  to  repeat  the  operation  while  any  trace  of 
inflammation  exists." 

As  in  division  through  the  sclerotica,  the  posterior  hemisphere  of  the  cap- 
sule and  the  vitreous  humor  ought  to  be  spared  as  much  as  possible.  In  the 
operation  through  the  cornea,  this  can  be  done  more  easily  than  in  division 
through  the  sclerotica. 

In  withdrawing  the  needle,  the  surgeon  has  to  encounter  the  same  descrip- 
tion of  difficulty  which  attends  its  introduction.  It  is  tightly  held  by  the 
cornea,  requiring  to  be  turned  on  its  axis  in  order  to  extract  it,  as  an  awl  is 
drawn  from  leather. 

The  after-treatment  is  the  same  as  when  division  has  been  performed  through 
the  sclerotica. 

Modifications  of  division  through  the  cornea^  according  to  varieties  of  cata- 
ract.— 1.  The  fluid  cataract  is  to  be  treated  as  has  already  been  recommended, 
(pages  740,  776)  on  other  occasions  ;  but  the  hard  cataract  cannot  be  man- 
aged so  easily  as  if  the  needle  had  been  passed  through  the  sclerotica.  Some 
of  the  German  operators  recommend  reclination  to  be  immediately  performed 
when  the  lens  proves  to  be  hard,  but  I  should  judge  it  better,  having  carefully 
comminuted  the  capsule,  to  withdraw  the  needle,  and  allow  the  lens  to  be  acted 
on  by  the  aqueous  humor.  After  six  or  eight  weeks,  we  shall  probably  find 
the  lens  softened,  and  fit  for  being  broken  up.  If  it  does  not  appear  so,  it 
may  be  displaced  through  the  sclerotica,  or  extracted  through  a  small  section 
of  the  cornea. 

2.  It  sometimes  happens  that  as  the  surgeon  is  comminuting  the  capsule, 
or  opening  up  the  texture  of  the  lens,  the  latter  falls  into  a  number  of  large 
fragments,  which  come  forward  into  the  anterior  chamber.  These  may  be 
taken  up  on  the  point  of  the  needle,  and  forced  back  out  of  the  way  of  the 
iris,  or  if  sufficiently  soft,  they  may  be  divided  by  pressing  them  against  the 
back  of  the  cornea  with  the  convex  edge  of  the  needle. 


782  DIVISION   OP   THE   CATARACT. 

3.  In  certain  cases  the  pupil  is  found  almost  closed,  and  adhering  to  a  small 
hard  cataract.  Dr.  Jacob  has  introduced  his  needle  in  such  cases,  and  with 
the  point  destroyed  the  adhesions  between  the  margin  of  the  pupil  and  the 
hard  mass,  which  he  has  then  placed  in  the  anterior  chamber,  and  removed 
through  an  opening  in  the  cornea. 

4.  The  operation  of  terebration,  already  referred  to  (p.  'ZTO),  is  a  variety 
of  keratonyxis,  which,  though  in  a  great  measure  superseded  by  the  formation 
of  an  artificial  pupil,  still  requires  a  short  notice. 

It  was  in  cases  of  capsular  or  capsulo-lenticular  cataract,  with  the  pupil 
reduced  to  a  small  size,  and  adherent  by  its  margin  to  the  capsule,  that  the 
operation  of  drilling  was  introduced  by  Mr.  Tyrrell. ^^  Having  passed  a  very 
fine  straight  needle  through  the  temporal  edge  of  the  cornea,  he  directed  its 
point  to  the  capsule,  close  to  the  nasal  margin  of  the  pupil,  and  having  pene- 
trated the  capsule,  and  entered  the  substance  of  the  lens  to  the  depth  of  about 
-Jg  inch,  he  rotated  the  needle,  so  as  to  make  its  point  act  as  a  drill.  Having 
thus  secured  an  opening  more  free  than  could  be  effected  by  a  simple  puncture, 
he  withdrew  the  needle. 

According  to  the  degree  of  supposed  absorption,  he  repeated  the  operation 
every  three,  four,  or  five  weeks,  taking  care  to  puncture  the  capsule  in  afresh 
place  at  each  operation,  till  at  length  he  was  enabled  so  far  to  weaken  or 
detach  the  portion  of  capsule,  occupying  the  pupil,  that  it  was  easily  displaced, 
after  the  lens  became  absorbed.  The  extent  of  the  loss  of  lens  he  ascertained 
by  the  increase  in  the  size  of  the  anterior  chamber,  and  by  the  diminished 
resistance  to  the  point  of  the  needle.  Upon  an  average,  he  had  to  repeat  the 
operation  seven  or  eight  times,  before  the  lens  was  removed.  In  most  cases, 
he  accomplished  the  clearing  of  the  pupil,  and  restoration  to  sight,  simply  by 
repeated  drilling  ;  but,  in  a  few  instances,  he  was  obliged,  after  all,  to  form  an 
artificial  pupil  with  Maunoir's  scissors. 

The  circumstance  already  referred  to  (p.  631),  and  of  which  Mr.  Tyrrell 
was  not  ignorant,  that  generally  the  lens  is  not  opaque,  in  the  cases  in  question, 
and  that  even  the  capsule  is  transparent,  except  within  the  area  of  the  pupil, 
has  led,  in  a  great  measure,  to  the  abandonment  of  this  mode  of  treatment, 
and  to  the  substitution  at  once  of  an  artificial  pupil,  by  the  removal  of  a  por- 
tion of  iris,  thus  both  securing  a  passage  for  the  rays  of  light  on  to  the  retina, 
and  preserving  the  crystalline. 

5.  From  the  firmness  of  its  point,  and  the  ease  with  which  it  can  be  turned 
in  every  direction,  the  bent  needle  for  division  through  the  cornea  sometimes 
enables  the  surgeon  to  deal  effectually  with  an  opaque  capsule,  the  lens  having 
previously  been  removed.  He  may  sometimes  succeed  in  picking  it,  with  the 
point  of  the  instrument,  from  any  attachment  it  may  have  to  the  iris,  or  if  it 
hangs  floating,  he  may  perhaps  entangle  and  detach  it,  by  pulling  or  twisting. 

Accidents  during  or  after  division  throxigh  the  cornea. — 1.  It  sometimes 
happens  that  just  as  the  needle  passes  through  the  cornea,  the  dilated  pupil 
suddenly  contracts.  This  is  not  unlikely  to  happen  if  the  anterior  surface  of 
the  iris  is  touched  with  the  needle,  but  it  sometimes  takes  place  before  the 
point  of  the  instrument  is  fairly  within  the  anterior  chamber.  After  a  minute 
or  two,  the  pupil  generally  expands  again,  so  that  the  operation  may  be  pro- 
ceeded with.  If  it  continues  much  contracted  after  some  minutes,  the  needle 
must  be  withdrawn  ;  and  on  some  future  day,  another  attempt  may  be  made, 
giving  the  pupil  every  chance  of  keeping  dilated,  by  both  using  belladonna  on 
the  day  previous  to  the  operation,  and  by  dropping  the  solution  of  atropine 
on  the  conjunctiva  about  an  hour  before  it  is  performed. 

2.  Should  the  eye  be  too  much  pressed  upon  by  the  fingers,  or  should  the 
needle  be  ill  adapted  for  filling  the  wound  of  the  cornea,  the  aqueous  humor 
is  apt  to  escape,  one  of  the  consequences  of  which  is  that  the  iris  advances 


DIVISION   OF   THE   CATARACT.  T83 

towards  the  cornea,  and  folds  itself  round  the  needle,  so  that  it  is  difficult,  if 
not  impossible,  to  proceed  with  the  operation.  In  this  case  the  operator 
should  either  immediately  withdraw  the  needle,  or  merely  open  the  front  of 
the  capsule  by  a  single  scratch  with  its  point,  and  then  withdraw  it,  taking 
care  to  supply  himself  with  a  more  cautious  assistant,  or  with  a  better  needle, 
before  attempting  the  operation  a  second  time.  Even  with  the  best  assistance, 
and  the  best  constructed  needle,  an  escape  of  aqueous  humor  is  apt  to  happen, 
and  forms,  from  its  serious  consequences,  a  weighty  objection  to  the  operation 
through  the  cornea. 

The  advancement  of  the  iris  is  not  the  only  bad  consequence  of  the  loss  of  the 
aqueous  humor.  The  lens  also  is  apt  to  start  forward,  and  sometimes  even 
bursts  from  the  capsule.  Under  these  circumstances,  it  is  immediately  advisable 
either  to  displace  the  lens  through  the  sclerotica,  or  to  extract  it  through  a 
small  section  of  the  cornea ;  for  when  left  in  this  state,  it  presses  against  the 
pupil,  and,  if  hard,  may  give  rise  to  severe  inflammation  of  the  iris,  and  even 
of  the  cornea. 

Even  a  soft  cataract,  in  a  young  person,  left  pressing  against  the  iris,  and 
the  latter  in  contact  with  the  cornea,  I  have  known  to  be  followed  by  severe 
inflammation,  ending  in  contracted  and  adherent  pupil.  In  such  circum- 
stances, it  may  be  weeks  before  the  iris  resumes  its  natural  place,  or  any 
aqueous  humor  occupies  the  anterior  chamber. 

3.  Dislocation  of  the  lens  occurs  under  various  circumstances,  during  or 
after  the  operation. 

If  a  hard  lens  be  dislocated  from  the  capsule,  in  consequence  of  the  needle 
sticking  in  it,  the  lens  may  be  placed  in  the  anterior  chamber,  and  immediately 
extracted. 

If  instead  of  a  central  aperture  only  having  been  formed  in  the  capsule,  its 
whole  diameter  has  been  slit  open,  dislocation  of  the  lens  may  happen  in 
the  course  of  some  days  after  the  operation.  The  exposed  lens,  imbibing 
aqueous  humor,  and  becoming  swollen,  may  not  only  press  against  the  iris, 
but  become  partially  dislocated,  coming  out  of  the  capsule  by  one  of  its  edges 
and  projecting  through  the  pupil.  This  accident  is  favored  by  too  great  a 
dilatation  of  the  pupil.  I  have  seen  the  cornea  take  on  ulceration-,  from  the 
irritation  caused  by  such  a  dislocation.  The  lens  should  be  extracted,  and 
the  inflammation  combated  by  venesection,  leeches,  and  calomel  with  opium. 

4.  Independently  of  any  dislocation,  division  through  the  cornea  is  some- 
times followed  by  corneitis,  generally  attended  by  inflammation  of  the  iris. 
The  cornea  loses  its  lustre,  and  its  internal  surface,  probably  from  effused 
lymph,  sometimes  becomes  of  a  yellowish  color.  The  aqueous  humor  also 
assumes  a  turbid  appearance,  so  that  the  state  of  the  iris  can  be  discerned 
with  difficulty.  When  the  inflammation  subsides,  and  the  cornea  and  anterior 
chamber  become  clear,  the  iris  is  observed  to  be  retracted,  the  pupil  irregular, 
and  its  edge  adherent  to  the  remnants  of  the  capsule,  which  are  of  a  whitish 
color,  forming  a  secondary  capsular  cataract.  It  is  a  very  common  result  of 
division,  either  through  the  cornea  or  through  the  sclerotica,  that  the  capsule, 
transparent  at  the  time  of  the  operation,  becomes  opaque,  requiring  to  be 
removed  out  of  the  axis  of  vision  by  a  subsequent  operation.  The  inflamma- 
tion of  the  cornea,  iris,  and  capsule,  must  be  treated  by  bloodletting,  calomel 
witli  opium,  counter-irritation,  and  belladonna.  The  attack  is  sometimes  so 
acute  as  to  require  repeated  venesection.  In  other  cases,  the  inflammation 
is  comparatively  slight,  continuing  for  months,  and  perhaps  scarcely  atti'acting 
attention,  except  from  those  who  have  been  put  on  their  guard  against  this 
chronic  form  of  corneitis  and  iritis."*  Scrofulous  iritis  in  young  persons  is 
sometimes  very  troublesome  after  division  through  the  cornea,  and  is  apt  to 
end  in  closure  of  the  pupil. 


Y84 


DIVISION   or   THE   CATARACT, 


If  the  operation  of  division  be  attempted  on  the  eyes  of  old  persons,  arth- 
ritic ophthalmia  is  liable  to  follow,  and  will  resist  almost  every  method  of 
cure.  The  pain  of  the  eye  and  head  continues  unabated,  notwithstanding 
depletion,  counter-irritation,  mercury,  and  opium.  The  patient  gets  little  or 
no  rest,  day  nor  night.  The  redness  is  not  intense ;  there  is  a  very  distinct 
bluish-white  ring  round  the  edge  of  the  cornea ;  the  lens  becomes  of  a  green 
color,  and  appears  swollen  ;  and  the  retina  is  soon  rendered  totally  insensible. 
In  such  a  case,  it  is  advisable,  even  as  a  mere  means  of  relief  from  pain,  to 
extract  the  lens. 

5.  A  very  singular  consequence  of  division  through  the  cornea  has  been 
described  by  Dr.  Ammon,-*  namely,  an  infiltration  of  fluid  cataractous  matter 
into  the  substance  of  the  cornea,  rendering  it  white  and  swollen,  and  ending 
in  its  ulceration  and  complete  destruction.  When  such  an  infiltration  takes 
place  (which  in  Dr.  Amnion's  case  it  did  in  the  course  of  the  day  on  which  the 
operation  was  performed),  he  recommends  opening  the  cornea  as  in  extraction. 


'  The  Germans,  feeling  no  wish  to  rob  Mr. 
Pott  of  his  fair  claims,  call  this  Die  Potte'che 
Opercttionsmcthode. 

*  "Si  subindfe  redit,  eadem  acu  magis  conci- 
denda,et  in  plures  partes dissipanda est."  Celsus 
deRe  Medicfi;  Lib.  vii.;  Parsii.;  Cap.  i.jSect.  ii. 

'  "  Etiamsi  sufRcienter  depressa  baud  erit 
cataracta,  visum  tamen  sfcpo  post  septimanas 
septem  vel  octo  rediisse,  in  variis  observavi, 
modo  in  partes  varias  divisa  fuerit."  Pauli 
Barbette  Opera  Chirurgico  Anatouiica,  p.  CO; 
Lugd.  Batav.  1672. 

*  Short  but  Exact  Account  of  all  the  Diseases 
incident  to  the  Ej-es ;  London  1706. 

'  Traite  des  Maladies  de  I'CEil,  p.  186;  Troyes, 
1711. 

'  "I  have  sometimes,  -when  I  have  found  the 
cataract  to  be  of  the  mixed  kind,  not  attempted 
depression;  but  have  contented  myself  ivith  a 
free  laceration  of  the  capsula;  and  having 
turned  the  needle  round  and  round  between  my 
finger  and  thumb,  within  the  body  of  the  crj's- 
talline,  have  left  all  the  parts  in  their  natural 
situation:  in  which  cases  I  have  hardly  ever 
known  them  fail  of  dissolving  so  entirely  as  not 
toleave  the  smallest  vestige  of  a  cataract."  Pott's 
Chirurgical  Works;  Vol.  iii.  p.  156;  London, 
1808.  jMr.  Pott  first  published  his  remarks  on 
the  Cataract  in  1775. 

'  Practical  Observations  in  Surgery,  p.  72; 
London, 1803. 

'  De  la  Garde's  Treatise  on  Cataract,  p.  51  ; 
London,  1821. 

°  Amer.  Journal  of  Med.  Sci.  for  Oct.  1817, 
p.  393. 

'°  Desmarres,  Traite  des  Mai.  des  Yeux; 
Paris,  1847,  p.  618.  Hays'  Lawrence,  p.  726. 
Phila.  1854. 

* '  Bcobachtungen  iiber  die  organischen  Ver- 
anderungen  im  Auge  nach  Staaroperationen,p. 
58:  Frankfurt  am  Main,  1828. 

'■'  Keturn  of  Operations  in  the  Calcutta  Eye 
Infirmary,  by  AV.  Martin  ;  Calcutta,  1853. 

"  Bonisson,  Archives  Generales  de  Medecine. 
Mai,  1847,  p.  1. 


o^Q^A^uci',  iv*iJ"));  Epicteti  Dissertationes  ab  ^Ir- 
riano  collectie;  i.  25. 

"  "Ttva.  <fi  in  7rtfiimd)(nm  aa.^1  i-rmvMT-^M  eoi 

•T0^7rdt.pa.lliVll7v  Tcic  ii7rcKiyu/jl.iVCli;  8X  rod  TTifllTririJv 

ctiya.,  li-ri;  Tripi-^xj^iiTO.  avsoAS^Sf)  c?uv^ciivoii  ifATnt- 
^«jV»?  tU  tcv  (.zbcL'Au'jv.  Galeni  Vj^uyotyii  j)  'Ist- 
■rpoc."     Opera,  Vol.  iv.  p.  371  ;  Basilese,  1538. 

"  Methodus  Medendi,  autore  Albucase,  p. 
68;  Easilea?,  1541. 

^  Praxeos  Mayernianas  Syntagma,  p.  84, 
Londini,  1690. 

'*  Nouvelles  Observations  pratiques  sur  les 
Maladiesde  I'CEil, p.  118;  Orleans,1812.  Either 
the  original  edition,  published  in  1786,  contains 
a  different  account  of  the  case  referred  to  in 
the  text,  or  Buchhorn  is  incorrect  in  stating 
that  through  the  wound  Gleize  divided  the  lens 
and  capsule,  that  the  lens  dissolved  in  20  days, 
and  that  Gleize  adopted  this  as  a  successful 
mode  of  operating.  On  the  contrary,  it  was 
depression  which  Gleize  performed  in  the  case 
referred  to ;  and  he  prefers,  when  the  cataract  is 
soft,  that  it  should,  if  possible,  be  extracted, 
"pour  eviter  la  longueur  de  sa  dissolution.'' 

"  Conradi  published  an  account  of  his  mode 
of  operating,  in  1797,  in  the  1st  volume  of 
Arnemann's  Magazin  fur  die  Wuudarzeney- 
kunst. 

^''  Buchhorn  de  Keratonyxide  ;  Ilala),  1806 
Die  Keratonyxis,  eino  neue  gefahrlosere  Me- 
thodo  den  grauen  Staar  zu  operiren ;  Von 
W.  II.  J.  Buchhorn  ;  Magdeburg,  1811.  Buch- 
horn was  the  first  who  gave  the  name  of  Jcera- 
tonyxis,  or  7>i()jf<i'o  cornea,  to  this  method  of 
operating. 

^'  Dublin  Hospital  Reports  ;  Vol.  iv.  p.  214  ; 
Dublin,  1827. 

*^  Practical  Work  on  Diseases  of  the  Eye; 
Vol.  ii.  p.  464  ;  London,  1840. 

*'  See  Schindler  do  Iritide  chronica  ex  Cera- 
tonyxide ;  VratislaviaJ,  1819. 

''  Zeitschrift  fiir  die  Ophthalmologie,  Vol. 
i.  p.  127;  Dresden,  1830. 


CHOICE   OP  AN   OPERATION  FOR  CATARACT.  T85 


SECTION  Xni. — CHOICE   OF  AN    OPERATION    FOR  CATARACT;    INDICATIONS  AND 
CONTRA-INDICATIONS  FOR  THE  DIFFERENT  MODES  OF  OPERATING. 

When  a  case  of  cataract  presents  itself,  the  honest  and  intelligent  practi- 
tioner will  ask  himself,  Is  this  a  case  for  division,  or  ought  I  to  venture 
extraction,  or  ought  I  to  content  myself  with  displacement  ?  He  will  be 
guided  in  his  answer,  partly  by  the  kind  of  cataract  before  him,  the  kind  of 
eye  in  which  the  cataract  exists,  and  the  age  and  constitution  of  the  patient, 
and  partly  by  the  degree  of  confidence  which  he  has  in  his  own  powers  and 
experience  as  an  operator. 

I  hold  it  unnecessary,  after  what  has  been  said  in  the  foregoing  sections, 
to  discuss  minutely  the  merits  of  each  of  the  operations,  but  the  following 
general  remarks  may  not  be  unworthy  of  attention. 

1.  As  the  success  of  division  depends  on  the  solution  of  the  fragments  to 
which  the  cataract  is  reduced,  and  that  within  a  moderate  space  of  time,  and 
without  any  injurious  irritation  of  the  eye,  this  method  of  operating  is  contra- 
indicated  when  the  lens  is  hard,  or  the  capsule  greatly  thickened  or  very 
tough.  Such  cataracts  are  either  incapable  of  being  divided  with  safety  to 
the  neighboring  parts,  or,  if  partially  broken  up,  are  incapable  of  being 
dissolved. 

It  is  only  where  the  lens  is  throughout  soft,  and  the  capsule  either  trans- 
parent, or  at  least  not  greatly  thickened,  that  we  can  with  propriety  have 
recourse  to  division.  Hence  it  is,  that  in  almost  all  cases  of  cataract  in  chil- 
dren and  young  persons,  this  is  the  operation  which  is  to  be  preferred,  while 
in  old  persons  it  rarely  answers. 

In  the  following  cases,  division  appears  to  be  peculiarly  indicated. 

1.  When  the  one  eye  is  blind  from  cataract,  and  in  the  other  the  disease  is 
merely  incipient.  By  the  time  that  the  cataract  is  fully  formed  in  the  second 
eye,  the  divided  lens  may  already  be  dissolved  in  the  other. 

2.  In  weakly,  timid,  or  irritable  persons,  and  in  those  who  are  subject  to 
convulsive  or  nervous  diseases,  extraction  or  displacement,  both  of  which  are 
severe  in  comparison  to  division,  would  be  improper. 

3.  When  the  surgeon  is  timid,  and  unaccustomed  to  operate  on  the  eye. 
The  errors  which  such  a  person  is  likely  to  commit  in  performing  extraction 
or  displacement,  may  be  fatal  to  the  patient's  sight,  but  in  division  he  can  do 
comparatively  little  harm,  and  if  his  first  attempt  fails  to  remove  the  cataract, 
the  operation  can  be  repeated. 

Division  must  be  regarded  as  an  excellent  mode  of  curing  those  varieties 
of  cataract  which  are  susceptible  of  solution ;  whereas  if  the  operator  employs 
division  in  cases  unfit  for  this  mode  of  cure,  disappointment  will  be  the  result, 
and  a  false  estimate  will  probably  be  formed  of  the  merits  which  the  operation 
really  possesses.  If  we  have  recourse  to  division  for  the  removal  of  the  hard 
cataract  of  old  people,  we  shall,  in  general,  not  merely  waste  time,  but  expose 
our  patients  to  such  evil  consequences  as  may  unfit  them  for  deriving  advan- 
tage from  any  other  mode  of  operating.  Nor  ought  it  to  be  concealed  that 
the  cure  of  cataract  by  division,  even  in  young  subjects,  not  unfrequently 
gives  rise  to  an  atrophic  state  of  the  eye,  unfavorable  to  a  healthy  resumption 
of  its  functions,  an  effect  very  uncommon  after  extraction.  The  labor  of 
absorption  necessary  to  remove  the  lens  seems  often  to  prove  injurious.  The 
vitreous  humor,  lacerated  probably  in  the  operation,  shrinks;  the  iris  becomes 
tremulous  ;  without  the  formation  of  any  adhesions,  the  pupil  becomes  con- 
tracted; and  the  retina  loses,  in  a  considerable  measure,  its  sensibility. 
We  often  see  eyes  after  extraction,  almost  perfect,  except  that  they  want  the 
lens ;  rarely  so  after  division, 

50  ,;^ 


T86  CHOICE  OF  AN  OPERATION  FOR  CATARACT. 

With  regard  to  the  comparative  merits  of  division  through  the  cornea  or 
through  the  sclerotica,  as  the  cornea  is  presumed  to  be  nearly  insensible,  the 
former  operation  is  supposed  to  be  the  less  painful.  It  requires,  however, 
more  force  to  penetrate  the  cornea  than  the  sclerotica  and  choroid ;  and  the 
latter  structures,  notwithstanding  their  vascularity,  are  more  tolerant  of  the 
injury  inflicted  in  division,  than  the  former.  There  is  of  course  no  danger  of 
injuring  the  ciliary  processes  or  retina  when  the  needle  passes  through  the 
cornea ;  the  anterior  hemisphere  of  the  capsule  is  also  certain  of  being  more 
or  less  completely  divided  in  this  method,  while  the  posterior  is  more  likely 
to  escape  being  destroyed  than  in  the  operation  through  the  sclerotica,  the 
hyaloid  membrane  is  left  entire,  and  the  sensibility  of  the  retina  is  less  liable 
to  be  endangered  by  the  violence  done  to  the  neighboring  textures.  These 
advantages  are,  in  some  measure,  counterbalanced  by  the  danger  of  injuring 
the  iris  with  the  needle  passed  through  the  cornea,  the  liability  of  corneitis 
to  occur  after  this  mode  of  operating,  the  danger  of  iritis  being  brought  on 
by  the  iris  advancing  into  contact  with  the  cornea  from  the  loss  of  aqueous 
humor,  and,  should  the  lens  unexpectedly  prove  hard,  the  difficulty  of  either 
displacing  it  or  of  bringing  it  forward  through  the  pupil  for  extraction. 

II.  That  extraction  is  the  proper  mode  of  removing  a  hard  cataract,  is  an 
assertion,  of  the  truth  of  which  those  who  have  had  any  considerable  experi- 
ence in  the  treatment  of  eye-diseases  appear  to  be  as  firmly  convinced,  as  they 
are  that  soft  cataract  may  safely  and  satisfactorily  be  cured  by  division.  The 
attempt  to  remove  hard  cataract  by  division,  besides  requiring  repeated 
operations  which  protract  the  cure  for  many  months,  exposes  the  eye  to  the 
danger  of  the  insoluble  nucleus  droi)ping  through  the  pupil,  so  that  at  last 
the  patient  must  submit  to  its  displacement  or  extraction.  When  no  par- 
ticular contra-indication,  therefore,  exists  to  extraction,  we  have  recourse  to 
that  operation;  and  there  only  remain  for  our  consideration  the  circumstances 
which  may  forbid  that  operation  even  when  the  cataract  is  hard,  and  the 
comparative  advantages  of  a  large  or  small  section  of  the  cornea. 

The  following  are  some  of  the  chief  contra-indications  to  extraction  through 
a  semicircular  incision  of  the  cornea.  They  of  course  may  be  regarded  so 
far,  as  indications  either  for  extraction  through  a  small  section,  or  for  dis- 
placement. 

1.  When  the  cornea  is  flat,  the  iris  convex,  the  eyeball  small,  and  deep  in 
the  orbit,  the  edge  of  the  orbit  prominent,  or  the  eyelids  short,  so  that  the 
palpebral  opening  is  contracted,  it  is  difficult,  or  even  impossible,  to  make  a 
semicircular  section  of  the  cornea  in  the  usual  manner. 

2.  I  have  already  (page  701)  noticed  the  objection  to  extraction,  founded 
on  the  presence  of  an  arcus  senilis.     I  do  not  consider  it  of  much  weight. 

3.  The  existence  of  adhesions,  either  between  the  cornea  and  iris,  or 
between  the  iris  and  crystalline  capsule,  generally  debars  the  operation  of 
extraction;  for  in  the  former  case,  it  is  not  likely  that  the  section  could  be 
executed  without  dividing  the  iris,  while  in  the  latter,  the  division  of  the  cap- 
sule and  exit  of  the  lens  are  prevented. 

4.  If  the  pupil  is  very  small  (m^ost's),  and  even  when  under  the  influence 
of  belladonna  dilates  to  ah  inconsiderable  extent,  the  last  mentioned  objec- 
tion will  still  occur  to  prevent  us  from  attempting  extraction. 

5.  A  fluid  state  of  the  vitreous  humor  is  a  very  sufficient  objection  to  the 
ordinary  operation  of  extraction,  which  ought  therefore  never  to  be  attempted 
unless  the  eyeball  presents  to  the  touch  nearly  its  natural  firmness.  If  soft 
and  boggy,  the  vitreous  fluid  is  deficient  in  quantity,  and  the  retina  unsound; 
but  much  more  frequently,  we  encounter  a  dissolved  state  of  the  hyaloid 
membrane,  attended  by  a  superabundant  quantity  of  vitreous  fluid,  and  an 
extraordinary  degree  of  hardness  of  the  eyeball.     In  this  case  the  cataract, 


CHOICE   OF   AN    OPERATION   FOR   CATARACT.  T8t 

clinging  through  the  medium  of  the  zonula  Zinnii  to  the  ciliary  processes, 
may  easily  be  displaced  by  the  needle.  The  least  touch  is  often  sufficient  to 
make  it  sink  to  the  bottom  of  the  eye,  and  even  without  any  operation,  a 
spontaneous  displacement,  or  sort  of  natural  cure  of  cataract,  sometimes 
occurs,  to  the  astonishment  and  delight  of  the  patient.* 

The  restoration  to  sight  in  such  cases,  whether  affected  by  the  needle,  or 
by  a  natural  solution  of  the  connection  between  the  cataract  and  the  ciliary 
processes,  is  seldom  of  long  continuance.  On  looking  into  the  eye,  the  cata- 
ract is  seen  bobbing  about  in  the  vitreous  fluid,  the  iris,  if  not  previously 
tremulous,  now  becomes  so,  and  in  the  space  of  a  few  weeks  or  months  the 
retina  is  found  to  be  insensible.  Once,  on  touching  such  a  cataract  with  the 
needle,  I  observed  that  it  separated  from  the  ciliary  circle,  except  towards 
the  nose,  where  it  continued  to  hang  as  if  on  a  hinge.  When  the  patient 
looked  upwards  he  saw  tolerably  well,  and  could  read  the  names  above  the 
shop  doors  with  facility,  for  in  such  a  position  of  his  head  the  cataract  floated 
back  into  the  vitreous  fluid  and  left  the  pupil  clear ;  but  the  instant  he 
attempted  to  examine  any  object  which  required  him  to  lean  foi'ward,  such  as 
reading  a  book  lying  on  the  table  before  him,  he  saw  none,  the  cataract  mov- 
ing forward  and  shutting  the  pupil  exactly  like  a  door  or  lid.  This  patient 
continued  for  some  time  to  show  himself  at  the  Glasgow  Eye  Infirmary,  but 
at  his  last  visit  he  was  totally  blind  ;  the  lens  had  separated  from  its  hinge, 
the  pupil  was  clear,  the  cataract -floated  behind  the  lower  edge  of  the  pupil, 
the  iris  was  tremulous,  the  eyeball  very  hard,  and  the  retina  insensible.  In 
all  such  cases,  cataract  is  preceded  by  a  glaucomatous  state  of  the  lens,  in 
which  it  reflects  the  green  rays  of  the  incident  light.  When  we  know,  then, 
that  tins  appearance  has  preceded  cataract,  or  when  we  find  the  eye  preter- 
naturally  firm,  we  cannot  proceed  with  confidence  to  extract  in  the  usual  way. 
Perhaps,  we  ought  to  extract  through  a  small  section,  as  the  only  mode  of 
operating  which  is  safe  and  proper  under  such  circumstances. 

6.  When  the  eyes  are  exceedingly  restless,  affected  perhaps  with  involun- 
tary, incontrollable,  or  convulsive  motions,  or  when  the  patient  is  under  the 
influence  of  excessive  fear,  or  exhibits  an  extreme  want  of  docility,  extraction 
is  out  of  the  question.  Previously  to  the  genei'al  use  of  ether  or  chloroform 
as  anaesthetic  agents,  it  sometimes  happened,  under  circumstances  such  as 
these,  that  even  displacement  was,  with  great  difficulty,  effected.  Thus  in 
Mr.  Wardrop's  first  attempt  to  operate  on  James  Mitchell,  a  blind  and  deaf 
boy,  then  about  15  years  of  age,  the  patient  at  first  yielded  readily,  and 
allowed  himself  to  be  placed  and  held  on  the  table.  The  uneasiness,  however, 
occasioned  by  the  pressure  necessary  to  keep  the  eyeball  steady,  and  the  lids 
open,  seemed  to  overcome  his  resolution,  and  his  exertions  became  so  violent 
that  it  was  quite  impossible  to  secure  even  his  head.  A  second  attempt  was 
made  the  day  following,  more  precautions  being  taken  to  secure  him  ;  but  so 
violent  were  his  exertions  and  cries,  and  so  irascible  did  he  become,  that  all 
present  were  glad  to  relinquish  their  posts.  Some  days  after,  a  wooden  box, 
the  sides  of  which  moved  on  hinges,  was  folded  round  his  body,  and  fixed  by 
circular  ropes ;  and  in  this  way,  notwithstanding  a  powerful  resistance,  he 
was  placed  on  a  table  and  kept  quite  steady.  Mr.  Wardrop  had  given  up  . 
all  hopes  of  extracting  the  cataract,  and  determined  to  try  couching.  Much 
difficulty  was  found  in  holding  open  the  lids,  and  keeping  the  globe  of  the 
eye  steady.  As  soon,  however,  as  the  needle  touched  the  eye,  he  remained 
quite  still,  and  his  dreadful  screaming  ceased.  AVith  the  sharp  edge  of  the 
instrument,  Mr.  Wardrop  cut  through  the  anterior  portion  of  the  capsule, 
and  with  its  point  dragged  the  lens  from  behind  the  pupil.  On  depressing 
the  point  of  the  needle,  the  lens  remained  out  of  view,  except  a  small  portion 
of  its  inferior  edge.    On  the  fourth  day  after  the  operation,  the  lens  was  found 


788  CHOICE   OP   AN   OPERATION   FOR   CATARACT. 

to  have  cliauged  its  place,  and  could  be  again  distinguished  covering  about 
one-fourth  of  the  upper  edge  of  the  pupil.-  Such  a  patient  could  now  be 
very  easily  managed,  by  making  him  inhale  the  vapor  of  ether  or  chloroform. 
The  more  violent  the  struggles  of  children,  the  more  speedily  do  these  agents 
take  effect. 

III.  With  regard  to  the  comparative  merits  of  a  large  or  small  section  of 
the  cornea,  it  must  be  acknowledged,  that  while  no  operation  disturbs  the 
internal  textures  of  the  eye  less  at  the  moment  of  performance  than  dexter- 
ously executed  extraction  through  a  semicircular  incision,  the  dangers  to  whicti 
the  safety  of  the  eye  is  exposed,  after  the  operation  is  finished,  are  of  the 
most  serious  description.  Extraction  through  a  small  section,  on  the  other 
hand,  causes  more  disturbance  within  the  eye  at  the  moment  of  operation, 
but  is  presumed  to  expose  the  organ  to  less  risk  after  the  cataract  is  removed. 
Extraction  through  a  small  section,  although  it  requires  fully  as  much  cau- 
tion, demands  less  dexterity  than  extraction  through  a  semicircular  section, 
endangers  the  iris  less,  is  rarely  followed  by  any  considerable  ejection  of 
vitreous  humor,  or  protrusion  of  the  iris,  and  cannot  produce  so  deforming 
or  so  mischievous  a  cicatrice,  unless  violent  and  disorganized  inflammation 
supervene.  Fragments  of  tlie  lens  are  apt  to  be  left  behind,  and  the  lining 
membrane  of  the  cornea  is  sometimes  excited  to  inflammation,  especially  when 
the  operation  has  been  clumsily  done ;  but  there  is  no  denying,  that,  after 
extraction  through  a  small  section,  the  operator  sends  his  patient  to  bed  with 
feelings  of  considerably  less  apprehension  for  the  coming  result,  than  after 
extraction  through  a  semicircular  incision. 

IV.  The  principle  on  which  the  operations  of  displacement  are  founded  is 
essentially  bad.  As  well  might  we  expect  to  lodge  an  entirely  foreign  body 
within  the  eye,  and  yet  no  continued  irritation  take  place,  no  disorganization 
follow  of  the  delicate  textures  with  which  it  remained  in  contact,  and  no 
interruption  happen  to  the  function  of  the  organ,  as  that  the  lens  could  be 
pressed  into  the  vitreous  humor,  and  lie  there  close  to  the  retina,  and  the 
eye  continue  healthy,  and  vision  be  preserved.  Reclination  or  depression  is 
to  be  thought  of  only  when  some  insuperable  objections  exist  to  division  and 
extraction.  I  assign  them  this  low  rank  in  the  scale,  not  because  the  lens  is 
apt  to  reascend  after  being  displaced,  for  that  I  consider  as  rather  a  favorable 
event,  from  the  chance  it  gives  of  the  cataract  dissolving  after  its  reascension, 
but  because  chronic  inflammation  within  the  eye,  dissolution  of  the  hyaloid 
membrane,  and  amaurosis,  are,  I  believe,  the  almost  invariable  results  of  a 
cataract  of  any  considerable  bulk  continuing  undissolved  in  the  situation 
assigned  to  it  by  displacement. 

As  to  the  choice  between  depression  and  reclination,  small  cataracts  should 
be  depressed,  large  ones  reclined. 


'  "  Dominus  Packer  passus  est  in  oculo  sin-  substantia  crassior  et  gravis  elevationem  im- 

istro   cataractam    confirmatissimam   ad   minus  pediat. 

per   annus   23,    quam   albissimara,   satis   com-  •'  Elapsis   diebus   15,  ad  mo  rediit,  ostendit 

pactam    ct  maturam  acu  deturbandam   s;iepiils  oculum  clarioreni,  et  facile  de  omnibus  objectis 

suasi;  una  nocte,  sine  ulla  causa  externa,  evan-  visibilibus    potuit    pronunciare.     Dixit    tamen 

uit  suffusio,  et,  licet  confuse,  mane   ccepit   et  uxorem    aliquoties    vidisse    partem    cataractac 

lucem  aspicere  et  colores  agnoscere.     Venit  ad  denuo    ascendentem    ad  pupillam,  quae  valida 

me,  et  oculum    ostendit    purum,  lucidum   sine  narium    emunctione  illico    ima   iterum   petiit. 

ulla   huinorum    perturbatione,  obscuritate,  aut  Proculdubio  recurret,  neque  enim  absumi   po- 

confusione.     Pupilla   minor  tantilm   fuit,  quas  test." — Praxeos  Mayernianae  Syntagma,  p.  S3; 

tamen    clause    altero    oculo  dilatabatur.     Non  Londini,  1690. 

credo  fuise  dissipatum  istud  coagulum,  sed  pen-  See  Cases  by  Beyer,  Traite  des  Maladies  Chi- 

dere  forsan  ab  uvea  divulsam  fundum  petiisse  rurgicalcs;  Tome  v.  p.  509,  Paris,  1816. 

aquei  bumoris  eo  loci  ubi  ab  acu  separata  cata-  °  Wardrop's  Hist,  of  James  Mitchell,  pp.  27, 

racta  deprimitur  et  subsidit.     Forsan  ascendet  .32  ;  London,  1813.     From  the  expressions  em- 

denuo,  ut   saepe   contingit    in   cataractis   male  ployed  by  Mr.  Wardrop,  one  is  led  to  suppose 

depressis   et  locatis   ab   operatore,  nisi  forsan  that  the  cataract  had  been  pressed  upwards,  not 

downwards,  in  the  operation. 


SECONDARY  CATARACT.  T89 


SECTION  XIV. — CONGENITAL   CATARACT. 

Fig.  Wardrop,  PI.  XL  Figs.  1,  2.     Ammon,  Thl.  III.  Taf.  XIV.  Figs   1-17.     Dalrymple,  PI. 
XXVIII.  Fig.  1.     Sichel,  PI.  XVIII.  Figs.  1,  2,  4. 

Oa  the  subject  of  congenital  cataract,  I  must  refer  the  reader  to  what  I 
have  ah-eady  said,  respecting  the  origin  of  the  disease  as  an  arrest  of  deve- 
lopment ;  its  being  often  lenticular  at  first,  afterwards  to  become  capsulo- 
lenticular ;  its  being  sometimes  central ;  sometimes  siliculose,  with  the  lens 
almost  entirely  absorbed ;  its  occasional  complication  with  oscillation,  amau- 
rosis, and  other  defects ;  and  the  advantages  of  an  early  removal  of  the  dis- 
ease by  operation.     (See  pages  109,  716,  U8,  Y29.)^ 

Diagnosis. — With  respect  to  the  diagnosis,  I  may  mention  that  congenital 
cataract  not  unfrequently  passes  undetected  till  the  subject  of  it  has  reached 
the  age  of  ten  or  twelve,  or  even  a  more  advanced  period  of  life,  the  defect- 
ive vision  being,  all  the  while,  ascribed  to  myopia.  This  is  particularly  apt 
to  happen  when  the  cataract  is  of  a  light  bluish-white  color,  when  the  lens  is 
either  small  in  size  and  surrounded  by  a  dark  zone  (p.  tlS),  or  when  the 
margin  of  the  lens  is  partially  or  entirely  transparent  (p.  711.)  In  such  cases, 
a  considerable  share  of  vision  is  obtained,  especially  of  near  objects,  when  the 
patient  turns  his  back  to  the  light ;  and  it  is  sometimes  only  after  artificial 
dilatation  of  the  pupil,  that  the  nature  of  the  affection  becomes  manifest  to 
the  parents,  or  even  to  the  practitioner. 

Operation. — It  is  of  great  advantage  to  place  the  child  under  the  influence 
of  chloroform,  when  we  are  about  to  operate  for  congenital  cataract.  The 
absence  of  resistance  enables  us  to  accomplish  the  operation  deliberately, 
while  the  restlessness  of  the  eye  is  overcome  more  completely  and  more  safely 
than  can  be  effected  by  the  pressure  of  the  fingers,  or  the  application  of  the 
speculum.  Division  through  the  cornea  can  then  be  performed  with  less  risk  of 
a  loss  of  the  aqueous  humor ;  and  we  avoid,  by  having  recourse  to  the  anterior 
operation,  the  difficulties  experienced  in  operating  through  the  sclerotica  in 
infants,  arising  from  the  smallness  of  the  space  between  the  edge  of  the  cor- 
nea and  the  external  commissure  of  the  eyelids,  and  from  the  resistance  offered 
to  the  needle  by  the  loose  conjunctiva,  thrown  into  a  state  of  protrusion, 
in  consequence  of  the  lids  becoming  everted,  in  the  attempt  to  expose  the 
eye. 


'  On  Congenital  Cataract,  consult  Ammon's  Darstellungen,  Theil  iii.  p.  63  j  Berlin,  1841. 


SECTION   XV. — SECONDARY   CATARACT. 

Fhj.  Saunders,  PI.  VI.  Figs.  1-4.  PI.  VII.  Figs.  2-6.  Warrdop,  PI.  XIII.  Fig.  5,  Soemmer- 
ring's  Beobachtungen.  Ammon,  Thl.  I.  Taf.  XII.  Figs.  30-35.  Taf.  XIII.  Dalrymple,  PI. 
XXVII.  Fig.  4.     Sichel,  PI.  XXI.  XXII. 

Secondary  cataract  consists  either  in  some  portion  of  the  cataract  which 
had  existed  previously  to  an  operation,  but  which  has  been  but  imperfectly 
removed  by  it,  or  in  some  new  production  which  first  began  to  exist  after  an 
operation.  Secondary  cataract  may  be  true,  or  spurious,  or  mixed.  It  may 
be  a  piece  of  lens,  a  piece  of  capsule,  a  lymphatic  effusion,  or  a  combination 
of  these. 

§  1.  Lenticular  Secondary  Cataract. 

With  regard  to  lenticular  fragments  remaining  behind  the  pupil  after  any 
of  the  operations  for  cataract,  if  productive  of  no  apparent  irritation,  it  is  the 


790  SECONDARY  CATARACT. 

best  practice  to  keep  the  pupil  dilated,  and  wait  for  some  time,  so  as  to  give 
them  a  chance  of  being  dissolved  by  the  aqueous  humor.  I  am  led  to  think, 
that  occasionally  a  thin  layer  of  lenticular  substance  is  left  adherent  to  the 
inside  of  the  capsule  after  extraction,  and  that  this  layer,  so  thin  and  trans- 
parent as  not  to  be  observed  at  the  moment  of  operation,  may  become  quite 
opaque,  and  form  an  obstacle  to  vision  after  the  wound  is  healed ;  but  as  it 
gradually  dissolves,  the  pupil  clears. 

Sometimes  a  large  nucleus  or  even  an  entire  lens,  which  has  reascended, 
may  be  allowed  to  remain,  and  will  gradually  be  removed  by  absorption.  In 
the  mean  time,  external  causes  of  irritation  are  to  be  carefully  guarded  against, 
and  the  pupil  kept  dilated  by  belladonna.  Should  solution  not  take  place 
within  a  reasonable  space  of  time,  we  have  our  choice  either  to  extract  through 
a  small  section,  or  again  to  displace. 

Attempts  to  cure  hard  cataract  by  absorption  are  apt  to  be  followed  by  per- 
sistence of  the  nucleus,  which,  in  various  ways,  may  prove  a  source  of  annoy- 
ance and  danger,  1.  Remaining,  perhaps  for  years,  behind  the  pupil,  it  may 
move  about  as  the  head  moves,  rendering  vision  obscure  and  confused,  but  not 
producing  much  irritation,  2.  It  may  sink  down  behind  the  iris,  and,  coming 
into  contact  with  the  ciliary  processes,  cause  pain  and  inflammation.  Effusion 
of  lymph  taking  place  around  it,  it  may  become  bound  down  in  its  new  situa- 
tion. The  irritation  it  produced  may  now  cease  ;  or  it  may  continue,  bringing 
on  lymphatic  deposition  into  the  pupil,  and  even  abscess  of  the  cornea.  3.  It 
may  drop  through  the  pupil,  and  down  into  the  angle  between  the  cornea 
and  the  iris,  producing  severe  neuralgia  in  some  cases,  and  in  others  iritis.  If 
it  is  left  there  for  weeks  or  months,  on  proceeding  to  extract  it,  it  may  be  found 
organically  adherent  to  the  iris  and  cornea. 

In  the  first  of  these  three  cases,  the  nucleus  may  be  displaced ;  but  in  the 
last  two,  extraction  through  a  small  section  should  be  attempted.  A  curved 
needle  is  passed  through  the  sclerotica,  with  which  the  nucleus  is  fixed  against 
the  cornea  till  the  incision  is  made,  and  then  the  nucleus  is  thrust  out  of  the 
eye  with  the  needle. 

§  2.    Capsular  Secondary  Cataract. 

Although  the  capsule  is  seldom  removed  from  the  axis  of  vision  along  with 
the  lens,  capsular  secondary  cataract  rarely  follows  the  operation  of  displace- 
ment ;  but  after  extraction,  and  still  more  after  division,  this  sort  of  secondary 
cataract  is  very  common. 

If  the  anterior  hemisphere  of  the  capsule  has  been  somewhat  opaque  before 
extraction  was  performed,  and  the  operator  has  not  removed  the  opaque 
membrane  when  he  extracted  the  lens,  or  if  with  a  transparent  capsule  the 
second  period  of  the  operation  has  been  carelessly  performed,  and  any  consi- 
derable degree  of  internal  inflammation  supervenes,  capsular  secondary  cataract 
will  certainly  occur,  and  may  be  so  complete  and  dense,  as  in  a  great  measure 
to  defeat  the  object  of  the  operation,  A  slight  opacity  of  the  torn  capsule 
is  a  very  frequent  event  after  extraction.  Indeed  it  rarely  happens  after  the 
patient  has  recovered,  that  on  concentrating  the  light  by  means  of  a  lens, 
and  allowing  its  focus  to  fall  on  the  pupil,  some  opaque  shreds  are  not  visible. 
Even  when  these  have  occupied  the  whole  field  of  the  pupil,  I  have  seen  the 
opacity  so  thin,  that  the  patient  could  see  to  read  and  write  through  it,  with 
the  aid  of  a  cataract-glass.  If  iritis  occurs  after  the  operation,  the  rem- 
nants of  the  capsule  not  only  become  white,  and  coalesce,  but  they  adhere  to 
the  iris,  the  pupil  becomes  small  and  angular,  and  although  immediately  after 
the  exit  of  the  lens,  the  patient  distinguished  objects  with  tolerable  precision, 
probably  a  mere  perception  of  light  and  shade  will  now  be  retained. 

It  is  difficult  to  prevent  the  formation  of  capsular  secondary  cataract  after 


SECONDARY   CATARACT,  "TGI 

division.  If  the  anterior  half  of  the  capsule  be  merely  rent  across  by  the 
needle,  or  stript  in  one  piece  from  the  front  of  the  lens,  it  is  very  apt  to  heal 
up  again  and  to  become  opaque,  so  that  it  both  prevents  the  process  of  solu- 
tion from  going  on,  and  forms  of  itself  a  new  obstacle  to  vision.  If,  in 
performing  division,  the  lens  and  capsule  be  separated  from  their  natural 
connections,  and  fall  back  into  the  vitreous  humor,  the  lens  may  dissolve, 
provided  the  capsule  is  sufficiently  lacerated,  but  the  capsule  itself  will  proba- 
bly be  seen,  deep  in  the  eye,  floating  about,  and  interrupting  distinct  vision. 

In  the  normal  state,  and  even  after  it  has  become  opaque,  the  capsule  is  of 
less  specific  gravity  than  the  aqueous  humor  of  the  vitreous  fluid,  and  hence 
it  tends  always  to  float  up  into  the  pupil,  a  fact  which  should  be  boinie  in 
mind,  as  well  in  the  ordinary  operation  of  division,  as  in  attempts  to  displace 
capsular  secondary  cataract.  A  piece  of  much  thickened  capsule,  if  com- 
pletely insulated,  will  sink,  but  if  still  connected  with  a  considerable  portion 
which  is  not  thickened,  the  whole  will  float.  Hence  the  propriety  of  dividing 
the  capsule  rather  from  below  than  from  above,  iii  order  that,  if  any  shreds 
remain  in  connection  with  the  circumference  of  the  capsule,  they  may  be 
attached  near  its  upper  rather  than  its  lower  edge,  and  thus  float  out  of  the 
axis  of  vision. 

It  is  proper  to  try  whether  we  cannot  form  a  sufficient  central  aperture 
with  the  needle,  when  a  capsular  secondary  cataract  occupies  a  great  portion 
of  the  field  of  the  pupil.  We  often  succeed  in  doing  so,  and  find  that  the 
shreds  into  which  we  tear  the  obstructing  membrane  retreat  behind  the  iris. 
But  in  many  cases,  the  capsule  resists  this  mode  of  treatment. 

In  the  transparent  state  the  capsule  is  easily  torn  through,  but  it  is  other- 
wise after  it  has  become  opaque  and  thickened  by  inflammation.  In  this  state 
it  is  so  tough  and  elastic,  that  we  cannot  divide  it ;  we  may  carry  it  on  the 
point  of  the  needle  almost  to  the  bottom  of  the  vitreous  humor,  whence  it 
instantly  springs  up  again  to  its  former  situation.  It  may  sometimes  be 
gathered  round  the  curved  needle,  separated  from  its  connections,  and 
depressed ;  but  it  seldom  remains  long  in  its  new  situation.  I  have  some- 
times succeeded  in  twisting  a  capsular  secondary  cataract  round  a  curved 
needle,  by  rotating  the  needle,  and  then,  drawing  the  capsule  towards  the 
aperture  in  the  sclerotica,  have  left  it  fixed  there,  as  I  withdrew  the  needle. 
The  iris  and  ciliary  body,  to  which  the  capsular  secondary  cataract  is  often 
attached,  are  liable  under  such  attempts  to  be  stretched  and  injured,  and 
sometimes  the  iris  is  detached  from  the  choroid.  Serious  inflammation  is  also 
prone  to  follow  such  operations. 

Mr.  Bowman  has  proposed'  to  clear  the  pupil  of  capsular  secondary  cata- 
ract, by  tearing  the  membrane  through  with  two  cataract  needles  used  simul- 
taneously. He  introduces  them  near  the  opposite  edges  of  the  cornea  down 
to  the  membrane ;  and  their  points,  having  penetrated  close  to  one  another, 
are  then  separated,  tearing  it  across,  and  carrying  it  in  fragments  to  opposite 
sides  of  the  pupil.  Thus,  there  is  no  drag  upon  the  vascular  parts,  the  only 
tissues  touched  being  the  cornea  and  the  opaque  membrane  itself.  One  of 
the  needles  may  be  made  to  furnish  a  fixed  point  of  resistance,  from  which 
the  other  can  act  with  advantage. 

Capsular  secondary  cataract  may  be  extracted  in  Freytag's  method,  through 
the  sclerotica,  as  I  have  already  (p.  168)  explained ;  but  the  safer  and  more 
satisfactory  mode  is  through  a  small  section  of  the  cornea,  as  described  at 
page  765.  In  this  way,  I  succeeded  on  one  occasion  in  removing  the  whole 
capsule  (Plate  II.  Fig.  1),  forming  an  entire  bag,  the  centre  of  the  anterior 
hemisphere  being  thickened  and  almost  cartilaginous,  whilst  the  rest  of  the 
capsule  was  transparent.  The  lens  had  been  removed  some  years  before  by 
absorption.^ 


792 


SECONDARY   CATARACT. 


Figs.  113.    112.  111. 


D 


E 


The  minute  instruments  which  recent  ingenuity  has  introduced  into  oph- 
thalmic practice  under  the  names  of  canula-forceps,  and  canula-scissors,  may 
often  be  used  with  good  eifect,  in  detaching  and  extracting  capsular  secondary 
cataracts,  especially  through  the  cornea. 

The  idea  of  converting  the  end  of  a  bit  of  steel  wire,  no  thicker  than  a  cataract  needle, 
into  a  pair  of  forceps,  the  blades  of  which  are  to  open  by  their  own  elasticity,  and  to  be 
shut  by  means  of  a  canula  pressed  forwards  on  the  wire,  belongs,  it  seems,  to  M.  Char- 
rifere,  a  well-known  surgical  instrument-maker  in  Paris.  To  Mr.  Wilde,  of  Dublin,  we 
owe  the  adaptation  of  the  same  mechanism  to  the  working  of  a  minute  pair  of  shears  or 
scissors.  The  same  handle  and  canula  serve  for  either  instrument;  and  the  surgeon  may 
provide  himself  with  forceps  and  scissors  of  various  sorts,  which  he  can  introduce  into 
the  canula  and  handle  at  pleasure.  Fig.  Ill  shows  the  canula-scissors  complete,  and  the 
scissors  open;  Fig.  112,  the  scissors  closed;  Fig.  118,  the  stem  of  the  forceps,  removed 
from  the  canula;  Fig.  114,  the  forceps  closed. 

When  the  surgeon  is  about  to  prepare  either  instrument  for  use,  he  passes  the  stem  of 
the  forceps  or  the  scissors  down  the  canula,  till  the  blades 
114.     begin  to  be  closed  by  its  pressure;   he  then  fixes  the 
stem  by  turning  she  screw  on  the  side  of  the  handle. 
Either  instrument,  when  about  to  be  passed  into  the  eye, 
is   to   be   shut,  which  is   done   by   pressing   down   the 
trigger  to  the  handle ;    the  trigger  projects  the  canula 
forwards  through  the  collar,  and  thus  brings  the  blades 
together.     On  allowing  the  trigger  to  rise,  the  canula  is 
-!.       brought  back  into  its  former  position,  and  the  blades  are 
I       allowed  to  divaricate.     If  it  is   the  forceps  which  are 
being  used,  the  membrane  within  the  eye,  be  it  iris  or 
capsule,  is  seized,  by  again  pressing  down  the  trigger  and 
closing  the  blades.     Keeping  them  so,  the  membrane  is 
drawn  out  through  the  wound  of  the  sclerotica  or  cornea. 
If  it  is  the  scissors  which  are  being  used,  by  pressing 
down  the  trigger  the  membrane  is  clipped,  and  the  inci- 
iJB  sion  of  it  to  the  required  extent  is  eflFected  by  repeated 

movements  of  the  same  sort. 

The  two  instruments  are  employed  chiefly  in  the  ex- 
traction of  capsular  secondary  cataracts,  either  through 
the  cornea  or  through  the  sclerotica  ;  and  in  the  forma- 
tion of  artificial  pupil,  chiefly  through  the  cornea.  The 
scissors  are  used  to  cut  across  bands  of  tough  opaque 
capsule  or  false  membrane,  in  the  one  case,  and  in  the 
other,  to  incise  the  iris.  The  forceps  are  used  to  take 
hold  of  the  capsule,  and  withdraw  it  from  the  eye  ;  or  to 
lay  bold  of  the  iris,  and  either  detach  it  from  the  choroid, 
or  prolapse  its  pupillary  margin  through  an  incision  of 
the  cornea. 

The  common  canula-forceps  (Fig.  113),  are  formed  so 
that  the  one  blade  ends  in  a  single  tooth,  which  is  re- 
ceived, when  the  instrument  is  made  to  close,  between 
two  teeth  in  the  opposite  blade ;  and  when  shut  (Fig. 
114),  they  form  an  obtuse  point,  so  that  they  cannot  be  passed  into  the  eye  without  a 
previous  puncture.  One  of  the  blades  of  another  pair,  long  and  sharp-pointed,  is  perfo- 
rated to  receive  the  tooth  of  the  short  blade,  and  is  sufi&ciently  keen  to  enter  the  cornea 
or  the  sclerotica  without  any  preliminary  incision. 

The  blades  of  the  common  canula-scissors  are  pointed,  the  one  projecting  beyond  the 
other,  and  their  external  edges  sharp,  so  that  they  are  capable  of  piercing  the  cornea  or 
sclerotica  in  the  closed  state  (Fig.  112).  The  canala  and  scissors  are  so  adapted  to  each 
other,  that  the  canula  quite  fills  up  the  wound  made  by  the  scissors  ;  so  that  if  the  cor- 
nea be  the  part  penetrated,  the  aqueous  humor  is  prevented  from  escaping,  while  the 
scissors  are  at  work  within,  clipping  the  iris  or  the  capsule,  by  the  opening  and  shutting 
of  their  blades. 

iSIr.  Bowman,  to  adapt  the  scissors  for  snipping  the  border  of  the  pupil  at  a  given  point, 
without  risking  the  lens,  has  had  the  short  blade  made  blunt  instead  of  sharp-pointed, 
so  that  it  might  be  passed  behind  the  iris,  and  not  wound  the  capsule  if  it  touched  it. 
In  conical  cornea,  as  a  plan  attended  with  less  risk  than  Mr.  Tyrrell's  operation  for 
extending  the  pupil  by  prolapsus  (see  p.  659),  Mr.  B.  proposes  to  pass  such  modified 
canula-scissors  at  once  through  the  cornea,  and  incise  the  pupillary  border  at  such  a  point 


SECONDARY   CATARACT. 


193 


as  to  enlarge  the  pupil  by  the  resulting  gaping  of  the  incision,  behind  a  part  of  the  cornea 
more  fitted  to  transmit  a  true  refraction  than  the  apex  of  the  cone. 

It  is  well  to  be  provided  with  different  pairs  of  scissors;  one  with  the  blades  long, 
another  with  them  short;  one  with  both  blades  sharp-pointed,  another  with  the  one  blade 
sharp  and  the  other  blunt-pointed,  and  a  third  with  both  blades  blunt-pointed. 

Great  nicety  is  required  in  the  workmanship  both  of  the  canula-forceps  and  scissors ; 
especially  of  the  scissors,  which  are  meant  to  be  self-penetrating.  Unless  their  blades  be 
thin,  and  the  canula  accurately  adjusted  to  the  size  of  the  wound  which  the  blades  make, 
the  instrument  will  not  only  not  answei-,  but  is  likely  to  inflict  severe  injury  on  the  eye. 

Each  time  the  forceps  or  scissors  is  used,  the  instrument  requires  to  he  taken  to  pieces 
and  carefully  wiped  dry,  the  canula  by  means  of  threads  drawn  through  it  by  a  fine 
twisted  wire ;  for  if  the  least  moisture  is  left,  the  stem  rusts  in  the  canula,  and  the 
mechanism  is  at  once  disarranged.  After  being  wiped,  the  forceps  or  scissors  may  be 
drawn  through  leather  smeared  with  tallow  or  suet.^ 

§  3.   Spurious  Secondary  Cataract. 

As  for  spurious  secondary  cataract,  that  which  arises  from  the  effusion  of 
coagulable  lymph,  in  consequence  of  iritis,  is  the  most  frec^uent.     It  may  be 
very  slight,  fringing  merely  one  edge  of  the  pupil, 
impeding  its  motions  on  that  side,  giving  rise  to  a  Fig.  115. 

sensation  similar  to  what  is  styled  a  musca  volt- 
tans,  but  not  otherwise  affecting  vision.  It  may, 
on  the  other  hand,  appear  very  considerable,  form- 
ing a  network  occupying  the  whole  pupil,  as  is 
represented,  after  extraction,  in  Figure  115;  or 
the  pupil  may  be  much  contracted,  perhaps  almost 
closed,  and  adherent  to  the  remains  of  the  capsule. 

The  reticulated  variety  is  generally  of  a  very 
delicate  texture,  especially  when  it  originates,  as  (From  Beer.) 

was  the  case  in  the  instance  represented  in  Fig.  115, 

in  a  sanguineous  effusion,  so  that  if  we  attempt  to  extract  it,  it  gives  way 
when  touched  with  the  knife  passed  through  the  cornea,  or  is  ruptured  in 
consequence  of  the  loss  of  the  aqueous  humor.*  It  is,  therefore,  advisable 
to  try  to  break  it  up  with  the  needle,  rather  than  attempt  its  extraction. 
When  the  pupil  is  much  contracted,  and  filled  by  lymphatic  exudation  which 
firmly  connects  it  to  the  capsule,  the  only  method  of  restoring  vision  is  to 
form  an  artificial  pupil,  in  one  or  other  of  the  ways  hereafter  to  be  described. 

§  4.  Mixed  Secondary  Cataract. 

A  great  proportion  of  the  cases  of  secondary  cataract  which  present  them- 
selves, is  of  this  class.  Opaque  capsxile  is  generally  combined  with  some 
degree  of  false  membrane,  binding  it  more  or  less  to  the  iris.  Even  apiece 
of  hard  lens,  remaining  after  an  operation  or  repeated  operations  with  the 
needle,  often  proves  intimately  connected  to  a  portion  of  capsule,  and  this 
attached  by  false  membrane  to  the  iris. 

By  far  the  most  effectual  mode  of  cleaning  the  pupil  in  such  cases  is 
extraction,  either  through  the  sclerotica  or  through  the  cornea.  For  this 
purpose,  the  pupil  should  be  dilated  to  the  utmost  by  belladonna,  the  patient 
laid  supine,  and  brought  under  the  influence  of  chloroform. 

Through  the  sclerotica,  the  operation  is  generally  commenced  by  the  intro- 
duction of  the  curved  needle,  and  an  attempt  made  to  break  open  a  large 
central  aperture  in  the  secondary  cataract.  If  this  succeeds,  the  fragments 
of  the  capsule  shrink  immediately  towards  or  behind  the  iris,  leaving  sufficient 
space  for  good  vision,  and  the  needle  is  withdrawn.  If  the  texture  is  tough, 
so  that  the  needle  makes  no  impression  on  it,  an  attempt  is  immediately  to 
be  made  with  the  needle  to  gather  the  cataract  into  a  mass,  and  to  detach  it 
from  the  vitreous  body  and  from  the  iris.     This  being  accomplished,  the 


194  CATARACT   GLASSES. 

punctured  wound  of  the  sclerotica  must  be  enlarged  a  little  with  the  iris-knife, 
or  the  point  of  the  extraction-knife.  Schlagintweit's  hook  or  the  blunt- 
pointed  canula-forceps  is  introduced,  the  cataract  is  seized,  the  instrument 
is  turned  once  or  twice  round  on  its  axis  to  make  sure  of  the  complete  sepa- 
ration of  the  cataract,  which  is  then  slowly  extracted. 

Through  the  cornea,  if  the  cataract  appears  a  thin  pellicle,  the  sharp-pointed 
forceps  may  be  used.  Held  with  the  short  blade  anterior,  this  instrument  is 
carried  through  the  cornea  near  its  margin,  and  on  to  the  edge  of  the  pupil. 
The  blades  are  opened,  the  sharp  one  passed  through  and  behind  the  cataract, 
the  short  one  in  front.  The  cataract  being  seized  by  closing  the  blades,  the 
instrument  is  rotated  so  as  to  separate  any  adhesions,. and  the  extraction  is 
effected.  If  the  capsule  appears  much  thickened,  it  is  in  vain  to  attempt  its 
extraction  through  so  small  a  puncture  as  that  made  by  the  sharp-pointed 
forceps.  With  the  iris-knife,  a  wound  about  a  line  in  length  is  made  through 
the  cornea  near  its  margin,  and  at  the  same  time  the  point  of  the  instrument 
is  passed  into  the  cataract  close  to  the  edge  of  the  pupil.  The  instrument  is 
then  suddenly  withdrawn,  so  as  to  save  as  much  as  possible  of  the  aqueous 
humor.  The  blunt-pointed  forceps  is  introduced  into  the  anterior  chamber, 
the  blades  are  opened,  one  of  them  is  passed  into  the  aperture  already  made 
in  the  cataract,  and  carried  behind  it,  while  the  other  blade  embraces  it  in 
front,  the  instrument  is  closed,  rotated,  and  removed  along  with  the  opaque 
substance.  If  it  is  the  nucleus  of  the  lens  which  requires  to  be  removed, 
the  incision  of  the  cornea  will  require  to  be  more  considerable  ;  in  which  case 
the  aqueous  humor  is  in  a  great  measure  evacuated,  and,  as  it  flows  out,  is 
generally  followed  by  an  advance  of  the  cataract  toward  the  cornea. 

The  extraction  of  membranous  cataracts  through  the  cornea  was  accom- 
plished by  Gibson  with  a  simple  hook,  or  with  a  pair  of  small  forceps,  which 
shut  by  a  spring.  The  closing  of  the  canula-forceps  requires  the  trigger  to 
be  pressed  down,  which  renders  it  inconvenient  to  rotate  the  instrument,  the 
fingers  not  being  sufficiently  at  liberty  for  that  purpose. 

The  canula-scissors  may  be  used,  either  through  the  sclerotica  or  the 
cornea,  for  cutting  across  the  capsule,  or  the  false  membrane  by  which  it  is 
connected  to  the  iris.  If  this  is  effected  where  the  opaque  pellicle  is  firmest, 
so  as  to  leave  it  attached  only  at  one  point,  and  by  a  slender  thread,  a  great 
object  is  gained.  If  it  does  not  immediately  shrink  out  of  the  field  of  the 
pupil,  an  attempt  must  be  made  to  lay  hold  of  it  with  the  canula-forceps, 
and  extract  it. 


'  Medical  Times  and  Gazette,  Oct.  30,  1852,  xxvi.  p.  166;  Bruxelles.  1851:  Wilde,  Medical 

p.  438.  Times,   December  7,   1850,   p.  592:    Bowman, 

'  See  Gibson's  Practical  Observations  on  the  Medical  Times  and  Gazette,  January  10,  and 

Formation  of  an  Artificial  Pupil,  &c.,  p.  117;  31,  1852,  pp.  34,  108. 

London,  1811.  *  Gibson,  Op.  cit.,  p.  126. 

^  Desmarres,    Annales   d'Oculistique;    Tome 


SECTION  XVI. — CATARACT  GLASSES. 


The  crystalline  lens  diminishes  a  little  the  image  on  the  retina,  but  so  little, 
that  the  cataract  patient,  after  a  successful  operation,  and  before  using  glasses, 
does  not  complain  of  seeing  objects  larger,  only  dimmer  than  he  did,  before 
becoming  affected  with  cataract.  As,  after  the  cataract  is  removed  by  opera- 
tion, its  place  is  filled  up  by  aqueous  fluid,  the  loss  of  the  crystalline  produces 
only  a  slight  diminution  in  the  refractive  power  of  the  eye,  but  affects  much 
more  the  faculty  which  this  organ  possesses  in  the  natural  state,  of  accom- 


CATARACT   GLASSES.  195 

moclating  itself  to  the  different  distances  of  objects.  We  endeavor  to  com- 
pensate for  the  diminished  refraction,  and  the  lost  power  of  accommodation, 
by  the  use  of  double-convex  or  plano-convex  glasses,  or  menisci,  of  different 
foci.  The  nearer  the  object  to  be  viewed,  the  more  convex  the  lens  to  be 
used,  or  in  other  words,  the  shorter  its  focus.  An  infinite  number  of  lenses, 
of  different  focal  lengths,  would  be  necessary  to  make  the  patient  see  perfectly 
at  all  distances;  but  as  this  is  practically  out  of  the  question,  he  generally 
contents  himself  with  two,  one  for  reading  and  seeing  near  objects,  and  the 
other  for  viewing  things  at  a  distance.  Objects  at  his  feet  such  as  the  steps 
of  a  stair,  are,  therefore,  what  he  sees  worst.  The  lenses  generally  employed 
are  of  the  focus  of  2^  inches  for  reading  and  of  4^  inches  for  distant  objects; 
I  have  known  individuals  of  50  years  of  age  read  with  3  inch,  and  see  distant 
objects  very  distinctly  with  5  inch  glasses.  Of  course,  glasses  of  the  longest 
focus,  which  answer  the  purpose,  are  to  be  preferred;  shorter  ones  may  be 
necessary  as  life  advances.  Menisci  are  preferable,  in  so  far  as  they  allow  a 
greater  range  of  vision.  Small  oval  lenses,  surrounded  by  a  dark  border  of 
tortoise-shell,  are  to  be  preferred,  as  lighter  and  productive  of  less  glare,  than 
large  circular  lenses,  inserted  immediately  into  the  spectacle  frame. 

The  glasses  are  employed  for  the  purpose  of  rendering  the  vision  of  those 
who  have  been  operated  on  for  cataract,  perfect  as  well  as  distinct;  for  there 
is  a  distinction,  perhaps  not  a  very  accurately  expressed  one,  admitted  by 
optical  authors,  between  distinct  and  perfect  vision.  Cataract  patients  after 
operation  often  possess  the  former  without  the  aid  of  glasses,  but  never  the 
latter.  From  want  of  the  crystalline,  the  rays  of  the  luminous  pencils,  which 
diverge  from  visible  objects,  are  no  longer  collected  to  absolute  points  of  the 
retina,  as  in  the  perfect  eye,  yet  these  pencils  occupy  portions  of  the  retina  so 
small,  as  to  allow  such  persons  to  discern  objects  placed  at  a  certain  distance 
with  tolerable  clearness.  Even  at  other  distances  than  that  at  which  they 
see  best,  they  still  discern  objects,  being  enabled  to  do  this  chiefly  from  the 
changes  which  take  place  in  the  size  of  the  pupil,  according  as  the  object 
viewed  is  more  or  less  distant;  but  they  are  totally  deprived  of  the  control 
over  the  refractive  powers  by  which  the  eye,  in  the  normal  state,  is  enabled 
to  see  perfectly  at  all  distances,  and  which  depends  either  on  a  change  of 
place  in  the  lens,  a  change  in  its  figure,  or  both,  or  on  other  changes  along 
with  these,  suSicient  to  shorten  the  focal  length  of  the  refractive  media  of  the 
eye  when  near  objects  are  regarded.  From  inattention  to  the  above  distinc- 
tion, several  authors  have  fallen  into  the  error  of  supposing  that  the  eye 
retained  the  power  of  changing  its  focal  distance,  after  being  deprived  of  the 
crystalline  lens. 

Not  only  do  patients  who  have  been  operated  on  for  cataract  see,  with 
various  degrees  of  distinctness,  and  at  very  different  distances,  without  the 
aid  of  any  glass,  or  with  one  glass  only  for  all  distances,  the  changes  in  the 
size  of  the  pupil  assisting  them  much  in  doing  so,  but  their  sight  is  capable, 
by  exercise,  of  very  considerable  improvement. 

Haller  mentions'  the  case  of  a  nobleman  who  appears,  immediately  after  the  cataract 
"was  removed  from  the  axis  of  vision,  to  have  seen  distinctly  at  various  distances.  Miss  H., 
a  young  lady  of  about  20,  whose  vision  Dr.  Young  examined,  used,  for  distant  objects,  a 
glass  of  4h  inches  focus,  and  with  this  she  could  read  as  far  off  as  12  inches,  and  as  near 
as  5.  Hanson,  a  carpenter,  aged  63,  who  had  had  a  cataract  extracted  a  few  years  before, 
and  was  also  examined  by  Dr.  Young,  saw  well  to  work  with  a  lens  of  2|  inches  focus,  and 
could  read  at  8  and  at  15  inches,  but  most  conveniently  at  11.  Mrs.  Maberly,  aged  about 
30,  who  had  had  both  lenses  extracted,  walked  without  glasses,  and,  with  the  assistance 
of  a  lens  of  about  4  inches  focus  could  read  and  work  with  ease.^  M.  Gabriel,  cured  of 
cataract  by  division  under  the  care  of  Maunoir,  read  a  book  printed  in  a  very  small  type 
with  the  aid  of  the  same  glass  with  which  he  viewed  the  pictures  hung  round  a  room ; 
engaged  in  the  chase ;  and  won  a  prize  at  shooting,  the  distance  being  200  paces. ^  A 
boy  of  12  years  of  age,  operated  on  by  Dr.  Rainy  at  the  Glasgow  Eye  Infirmary,  saw  dis- 


TOG  CATARACT   GLASSES. 

tant  objects  distinctly,  and  read  easily  with  glasses  of  4J  inches  focus.  Mr.  W.  J.,  aged 
60,  ujion  whom  I  operated  by  extraction,  wrote  without  glasses  and  read  what  he  had 
written,  but  required  glasses  of  2^  inches  focus  to  read  a  printed  book.  Mr.  T.  S.  T.,  a 
patient  of  mine,  whose  left  lens  was  absorbed  in  consequence  of  an  injury,  read  with  a 
5-inch  glass,  at  from  10  to  27  inches,  but  best  at  from  17  to  20  ;  and  with  a  4-inch  glass 
at  from  8  to  18  inches,  but  best  at  from  12  to  14. 

The  following  is  a  good  example  of  the  capability  for  improvement  which 
the  eye  possesses  after  removal  of  the  crystalline  lens  : — 

Case  352. — Sir  W.  Adams  operated  on  a  postilion  who  had  been  blind  nine  years  in 
one  eye,  and  three  in  the  other.  Both  cataracts  were  removed  by  division  ;  and  when 
the  patient  resumed  his  employment  as  a  postilion,  he  was  from  necessity  obliged  to  wear 
spectacles,  not  being  able  even  to  walk  without  them ;  but  finding  that  his  passengers 
were  frequently  apprehensive  of  their  safety,  from  being  driven  by  a  person  requiring 
spectacles,  he  by  degrees  left  them  off  altogether  in  the  day ;  and  in  the  course  of  twelve 
months  could  drive  quite  as  well  without  as  with  them.'* 

In  such  instances  of  distinct  and  improving  vision  after  the  removal  of  the 
crystalline  lens,  Dr.  Young  has  shown  that  the  use  of  the  optometer  at  once 
demonstrates  that  perfect  vision  is  wanting,  or  in  other  words,  that  the  eye 
has  lost  all  internal  control  over  its  refractive  powers.^ 

The  too  hasty  employment  of  cataract-glasses  after  the  most  successful 
operation,  may  soon  bring  the  eye  to  a  state  of  weakness,  which  will  render 
it  unfit  even  for  those  employments  which  require  but  a  moderate  degree  of 
sight.  No  cataract-glasses  ought  to  be  given  to  a  patient  so  long  as  his 
vision  appears  to  be  improving  without  their  use.  This  generally  continues 
to  be  the  case  for  several  months  after  the  operation.  If  we  allow  our  patient 
to  use  cataract-glasses  during  this  period,  he  will  no  doubt  be  very  glad  to 
find  that  he  can  return  immediately  to  almost  all  his  ordinary  pursuits  ;  but 
he  will  soon  begin  to  observe  that  he  does  not  see  so  well  as  he  did,  and  this 
he  will  probably  remedy  by  a  new  pair  of  glasses  of  greater  convexity,  and 
consequently  of  greater  magnifying  power,  than  those  he  had  at  first.  He 
will  go  on  in  this  way,  changing  his  glasses  as  his  power  of  vision  becomes 
less,  till  at  last  he  ends  in  finding  none  which  enable  him  to  see  so  well  as  he 
did  with  those  which  he  first  used.  On  the  other  hand,  if  our  patient  does 
not  begin  to  try  cataract-glasses  till  he  has  completely  recovered  from  the 
operation,  and  the  eye  has  as  much  as  possible  habituated  itself  to  the  absence 
of  the  crystalline  lens,  if  he  then  select  proper  glasses,  and  use  them  for  a 
while  only  occasionally,  his  sight  will  still  continue  to  improve,  and  his  first 
glasses  will  probably,  if  he  be  an  old  man,  serve  him  all  his  life,  and  if  he  be 
a  man  of  30  or  40,  he  will  not  require  to  change  them  till  he  be  50  or  60. 
He  will  be  able  to  return  to  the  finest  kind  of  work  in  which  he  had  been 
employed,  such  as  drawing,  or,  if  the  person  be  a  female,  to  sewing  and  the 
like. 

The  operative  means  for  the  cure  of  cataract  may  have  perfectly  succeeded, 
but  from  want  of  proper  glasses  the  patient  may  derive  but  a  small  amount 
of  benefit.  Thus,  the  widow  of  Drelincourt  was  operated  on  by  depression 
by  Rau,  but  for  fifteen  or  sixteen  years  she  derived  comparatively  little 
advantage  from  the  operation,  till  Haller  told  her  to  look  through  a  small 
glass  globe,  or  very  thick  lens,  when  she  found  that  she  was  able  to  read.^ 

The  best  test  of  a  cataract-glass  is,  that  when  placed  immediately  in  front  of 
the  eye,  it  enables  the  person  to  see  objects  perfectly,  at  that  distance  at 
which  he  could  see  them  before  he  became  affected  with  cataract.  If  he 
chooses  glasses  of  too  long  a  focus — for  example,  of  five  inches  focus  instead 
of  four,  and  three  instead  of  two  and  a  half — he  will  by  and  by  discover  that 
he  sees  ill  with  such  glasses,  unless  he  moves  them  an  inch  or  two  forward 
from  his  eyes,  when  he  finds  that  they  enable  him  to  see  distinctly.  In  this 
case,  he  must  be  furnished  with  glasses  of  shorter  focus  than  those  he  had  at 


INTRODUCTORY   VIEW   OF   ARTIFICIAL  PUPIL.  797 

first  selected,  so  that  the  images  of  objects  may  be  formed  exactly  on  the 
retina.  If  cataract-glasses  of  too  short  a  focus  have  been  chosen,  they  will 
bring  the  object  too  near,  so  that  the  patient  will  be  apt  to  mistake  the  dis- 
tance at  which  it  is  placed  from  him,  and  on  trying  to  grasp  it,  his  hand  will 
fall  short  of  it.  When  this  is  the  case,  glasses  of  longer  focus  must  be  selected. 
If  the  pupil  of  the  eye  which  has  been  operated  on  still  remains  dilated  by 
belladonna,  the  patient  will  fall  into  the  error  of  choosing  a  glass  of  shorter 
focus  than  what  will  suffice  after  the  pupil  has  contracted  to  its  natural 
size. 

It  is  said  that  those  who  have  been  short-sighted  previously  to  the  forma- 
tion of  cataract  can,  after  a  successful  operation,  lay  aside  their  concave 
glasses,  without  having  occasion  for  any  convex  ones  ;  and  that  some  require 
even  concave  glasses  after  the  operation  for  cataract,  but  less  concave,  of 
course,  than  those  which  they  formerly  used.  But  such  statements  are  pro- 
bably incorrect.  Having  operated  by  extraction  on  a  man  all  his  life  short- 
sighted, I  found  that  for  the  vision  of  distant  objects  he  required  the  usual 
glasses  of  four  and  a  half  inches  focus.  Mrs.  N.,  whom  I  cured  of  cataract 
by  division,  and  who  had  been  originally  short-sighted,  read  with  a  2^,  but 
saw  distant  objects  best  with  a  10-inch  glass. 

If  a  patient  from  whose  eye  a  cataract  has  been  successfully  removed,  had 
been  originally  a  little  short-sighted,  but  never  used  a  concave  glass,  on 
supplying  him  with  a  convex  glass  after  the  operation,  he  will  sometimes 
mention  that  he  sees  objects  much  more  beautifully  than  they  ever  appeared 
to  him  before.  In  fact,  he  had  never  seen  objects  with  the  distinctness  and 
brilliancy  with  which  they  appear  to  an  ordinary  eye,  or  to  a  myopic  eye 
armed  with  a  concave  glass. 

Short-sighted  persons,  before  becoming  affected  with  cataract  having  been 
able  to  read  at  perhaps  18  inches  with  the  aid  of  concave  glasses,  after  being 
successfully  operated  on  for  cataract,  expect  probably  to  be  able  again  to 
read  at  that  distance,  a  convenient  one  for  clergymen  and  others  ;  but  this 
they  cannot  accomplish.  Their  convex  glasses  will  enable  them  to  read  only 
at  the  distance  at  which  they  could  read  without  concave  glasses,  before  they 
became  cataractous,  say  6  inches. 


'  Elementa,  PhysiologiaB ;  Tom.  v.  Lib.  xvi.  *  Journal  of  Science  and  the  Arts ;  Vol.  ii. 

Sect.  iv.  ^  25,  p.  514;  Lausannje,  1763.  p.  409  ;  London,  1817. 

'^  On  the  Mechanism  of  the  Eye,  by  Thomas  '  Porterfield's  Treatise  on  the  Eye;  Vol.  i.  p. 

Young,  M.  D. ;  Philosophical  Transactions  for  434;  Edinburgh,  1759:  Young,  Op.  cit. 

ISOl,  p.  65.  "  Boerhaave,  Prteleetiones  Academicas;  Tom. 

^  Annales  des  Sciences  Naturelles,  Seconde  vi.  p.  145;  Venetiis,  1751. 
Serie,  Tome  v.  p.  190  ;  Paris,  1836. 


CHAPTER   XXI. 
ARTIFICIAL  PUPIL. 

SECTION  I. — INTRODUCTORY  VIEW  OF  THE  METHODS  OF  FORMING  AN  ARTIFICIAL 

PUPIL. 

I.  The  first  attempt  to  restore  vision,  in  cases  in  which  the  natural  pupil 
had  closed,  or  at  least  the  first  that  was  attended  with  success  (see  p.  632), 
was  made  by  Cheselden,  some  time  previous  to  1728.  In  that  year,  he  pub- 
lished a  short  account  of  two  cases,  in  which  the  natural  pupil  having  closed 


798  INTRODUCTORY   VIEW   OF   ARTIFICIAL   PUPIL. 

after  the  operation  of  couching,  he  formed  an  artificial  pupil.  He  did  this 
by  introducing  a  small  one-edged  knife  or  needle,  through  the  temporal  side 
of  the  sclerotica,  and  through  the  iris  into  the  anterior  chamber ;  he  then 
turned  the  cutting  edge  of  the  instrument  towards  the  iris  (Fig.  116),  and  as 
he  withdrew  the  knife,  divided  the  iris  transversely,  so  as  to  leave  an  incision 
in  that  membrane,  or  an  artificial  pupil,  extending  to  two-thirds  of  its  diame- 

Fig.  117. 


ter.  (Fig.  111.)  In  his  first  case,  he  formed  the  artificial  pupil  above  the 
centre  of  the  iris  or  place  of  the  natural  pupil,  because  he  did  not  know  how 
low  he  might  have  lodged  the  cataract  in  the  operation  of  couching,  which 
had  led  to  the  closure  of  the  natural  pupil.  In  his  second  case,  for  what 
reason  he  does  not  mention,  he  formed  the  artificial  pupil  below  the  middle 
of  the  iris.  His  account  of  the  whole  is  so  brief,  that  we  are  left  in  doubt 
how  far  the  first  patient  recovered  sight.  The  second,  he  states,  thought 
every  object  at  first  further  from  him  than  it  was  in  reality,  but  soon  learned 
to  judge  the  true  distance.* 

Such  was  the  original  method  of  forming  an  artificial  pupil.  As  other 
methods  have  since  been  invented,  we  may  distinguish  this  as  an  artijidal 
pupil  by  incision. 

II.  In  the  hands  of  the  first  Wenzel,  Cheselden's  operation  failed,  and  this 
led  him  to  invent  another  method  of  opening  up  an  artificial  passage  for  the 
rays  of  light  through  the  iris,  in  cases  similar  to  those  in  which  Cheselden  had 
operated,  namely,  closed  pupil  after  an  operation  for  cataract.  Having 
pierced  the  cornea  with  the  point  of  the  extraction-knife,  as  in  the  operation 
of  extraction,  he  next  plunged  it  through  the  iris  between  its  temporal  edge  and 

the  contracted  pupil ;  then  carrying  the 
^ig-  118.  handle  of  the  instrument  backward,  he 

brought  out  its  point  through  the  iris  on 
the  nasal  side  of  the  contracted  pupil, 
and  through  the  cornea,  as  in  the  opera- 
tion of  extraction.  Carrying  the  knife 
onwards,  he  divided  at  once  both  the  iris 
and  the  cornea,  only  that  he  necessarily 
completed  the  semicircular  section  of  the 
former  before  that  of  the  latter.  (Fig. 
118.)  He  then  introduced  a  small  pair 
of  scissors  through  the  incision   of  the 

cornea,  and  cut  off  the  flap  of  the  iris. ^     This,  then,  is  what  we  term  an  arti- 

Jicidl  ■pupil  hy  excision. 

III.  The  facts  that  occasionally  even  a  slight  blow  on  the  eye  will  separate 
a  portion  of  the  circumference  of  the  iris  from  the  choroid  (Fig.  55,  p.  400), 
that  in  operating  for  cataract  with  the  needle  similar  separations  sometimes 
happen,  and  that  the  false  pupils,  as  they  may  be  called,  which  are  thus  formed, 
often  continue  permanently  open,  were  the  means  of  suggesting  to  different 
operators  the  idea  of  a  third  method  of  forming  an  artificial  pupil.  Scarpa, 
for  instance,  having  passed  a  needle  through  the  temporal  side  of  the  sclerotica, 
advanced  its  point  as  far  as  the  upper  part  of  the  nasal  margin  of  the  iris, 
which  he  pierced  so  that  the  point  of  the  needle  became  just  perceptible  in 


INTRODUCTORY   VIEW   OF   ARTIFICIAL   PUPIL.  *r99 

the  anterior  chamber,  close  to  the  edge  of  the  cornea.  He  then  with  the  nee- 
dle pressed  upon  the  iris  from  above  downwards  and  from  within  outwards,  so 
that  a  portion  of  its  edge  might  be  separated  from  the  choroid.  Placing  the 
point  of  the  needle  upon  the  inferior  angle  of  the  commenced  fissure,  at  the 
same  time  drawing  the  iris  towards  the  temple,  he  continued  the  pressure  till 
the  separation  (Fig.  119)  was  of  sufficient  extent.     Scarpa  first  employed  a 

Fig;.  119. 


straight  needle,  but  afterwards  recommended  one  which  was  bent,  as  better 
calculated  for  the  formation  of  this  artificial  pupil  hy  separation.^ 

There  are  three  original  kinds  of  operation,  then,  for  the  formation  of  an 
artificial  pupil,  viz:  incision,  excision,  and  separation;  and  all  three  were 
invented  for  the  purpose  of  restoring  vision,  when  the  natural  pupil  had  closed 
after  an  operation  for  cataract. 

IV.  There  are  other  cases,  besides  closure  of  the  pupil  after  an  operation 
for  cataract,  in  which  the  formation  of  an  artificial  pupil  becomes  necessary, 
and  as  an  example  of  these,  I  may  mention,  opacity  of  the  centre  of  the  cor- 
nea. Supipose  that  the  central  portion  of  the  cornea,  to  the  extent  of  |  inch 
in  diameter,  is  occupied  by  a  dense  leucoma,  even  although  the  natural  pupil 
is  open  and  movable,  and  the  iris  perfectly  healthy,  the  patient  will  be  de- 
prived of  any  useful  degree  of  sight.  If  he  turns  his  back  to  the  light,  indeed, 
he  may  perhaps  see  a  little  past  the  edge  of  the  speck,  he  may  also  discern 
objects  obscurely  in  the  twilight,  when  the  pupil  dilates,  in  consequence  of 
the  moderate  light  to  which  the  eye  is  exposed  ;  but  in  bright  light  he  sees 
nothing.  We  sometimes  find  that  artificial  dilatation  of  the  pupil  by  bella- 
donna sufi&ces  in  such  a  case  to  restore  a  considerable  share  of  useful  vision. 
I  have  known  patients  affected  with  partial  opacity  of  the  cornea,  continue  for 
many  years  the  daily  application  of  a  filtered  solution  of  belladonna  to  the 
conjunctiva,  for  the  purpose  of  dilating  the  pupil,  so  that  the  light  might  enter 
the  eye  between  the  edge  of  the  speck  and  the  pupillary  edge  of  the  iris.  In 
many  cases,  however,  of  partial  opacity  of  the  cornea,  the  speck  is  so  broad, 
that  dilatation  of  the  pupil  to  the  utmost  extent  attainable  by  belladonna,  or 
by  atropine,  cannot  restore  any  useful  degree  of  vision.  In  these  cases,  then, 
and  also  when  the  frequent  application  of  the  belladonna  proves  irksome,  we 
are  naturally  led  to  the  expedient  of  withdrawing  a  portion  of  the  iris  from 
behind  the  lucid  part  of  the  cornea.  It  would  evidently  be  impossible,  how- 
ever, to  do  this  by  incision,  excision,  or  separation,  according  to  the  modes 
already  described  as  having  been  adopted  by  Cheselden,  Wenzel,  and  Scarpa, 
without  injuring  the  crystalline  lens,  and  thereby  producing  cataract.  This, 
of  course,  must  be  avoided,  and  hence  have  arisen  certain  necessary  changes 
in  the  methods  of  forming  an  artificial  pupil,  according  to  the  condition  of 
the  cornea  and  crystalline  lens.  In  the  cases  operated  on  by  Cheselden, 
Wenzel,  and  Scarpa,  the  whole  cornea  being  transparent,  and  the  lens  no 
longer  occupying  its  natural  place,  an  aperture  for  the  transmission  of  light 
was  the  whole  object  of  their  solicitude,  it  being  of  little  consequence  where 
or  how  the  new  pupil  was  obtained.  It  is  very  different,  when  the  artificial 
apei'ture  must  be  placed  behind  a  particular  portion  of  the  cornea,  and  when 
the  lens  being  transparent  must  not  be  touched  during  the  operation.  Wen- 
'zel's  e.xcisiou  of  a  central  portion  of  the  iris,  was  originally  adapted  for  cases 


800  CASES   REQUIRING   AN   ARTIFICIAL   PUPIL. 

of  closed  pupil,  after  the  operation  of  extraction,  although  he  afterwards  ex- 
tended it  to  cases  of  closed  pupil  in  which  the  lens  had  not  been  removed  ; 
but  it  could  be  of  no  service  when  the  natural  pupil  was  open,  and  the  en- 
trance of  light  into  the  eye  impeded  merely  by  opacity  of  the  centre  of  the 
cornea.  For  this  sort  of  case,  the  plan  is,  to  extend  the  natural  pupil  to  one 
side,  in  such  a  way  that  the  extended  portion  shall  be  behind  the  transparent 
edge  of  the  cornea.  This  may  be  done  by  making  a  small  opening  through 
the  cornea  close  to  its  edge,  and  simply  bringing  out  a  portion  of  the  iris 
through  the  opening,  leaving  it  to  unite  to  the  wound,  an  operation  which  is 
called  extension  of  the  pupil  by  prolapsus  ;  or  by  snipping  off 
Fig.  120.  the  portion  of  iris  which  protrudes,  which  is  styled  artificial 
pupil  by  lateral  excision.  The  portion  of  iris  to  be  fixed  in 
the  wound,  or  to  be  cut  off,  either  protrudes  with  the  gush  of 
aqueous  humor,  as  we  make  the  incision  of  the  cornea,  or  is  to 
be  drawn  out  with  a  small  hook  or  pair  of  forceps.  Whichever 
plan  is  adopted,  whether  extension  of  the  pupil  by  prolapsus,  or 
artificial  pupil  by  lateral  excision,  the  appearance  of  the  eye  after  recovery 
will  be  similar  to  what  is  represented  in  Fig.  120. 

The  operations  for  artificial  pupil,  although  founded  on  the  three  simple 
plans  of  cutting  through  the  iris,  cutting  out  a  piece  of  it,  or  separating  part 
of  its  circumference  from  the  choroid,  have,  like  the  operations  for  cataract, 
undergone  an  endless  variety  of  modifications,  suggested  partly  by  the  great 
diversity  of  the  diseased  states  of  the  eye  requiring  an  artificial  pupil,  and 
partly  originating  in  the  peculiar  notions  of  different  operators.  Even  com- 
binations of  the  operations  in  question  have  sometimes  been  found  available. 
Two  of  the  modifications  referred  to,  I  must  here  shortly  notice, 
Cheselden's  incision  through  the  sclerotica  is  in  a  great  measure  superseded 
by  incision  with  scissors  through  the  cornea,  a  method  of  operating  which 
we  owe  to  Janin,  but  which  was  much  improved  by  M.  Maunoir,  of  Geneva. 
Separation  of  a  portion  of  the  iris  from  the  choroid,  by  means  of  a  curved 
needle  introduced  through  the  sclerotica,  is  also  almost  entirely  laid  aside. 
Separation  is  now  effected  by  a  hook,  passed  through  an  incision  of  the 
cornea ;  and  in  order  to  prevent  the  separated  portion  of  iris  retreating  to 
its  former  place,  and  the  artificial  pupil  thus  closing,  the  separated  bit  of  iris 
is  drawn  through  the  incision  of  the  cornea,  and  left  there  to  be  fixed  by 
adhesion. 


•  Philosophical  Transactions  for  172S  ;  Vol.         °  Saggio  di  Osservazioni  e  d'Esperienze  sullo 
XXXV.  p.  451.  principali  Malattio  degli  Occhi;  Pavia,  ISOl. 

^  Traite  de  la   Cataracte,  par  M.  de  Wenzel, 
fils,  pp.  190,  198;  Paris,  1786. 


SECTION  II. — DISEASED  STATES  OF  THE  EYE   REQUIRING  THE   FORMATION  OF  AN 

ARTIFICIAL  PUPIL. 

The  diseased  states  of  the  eye,  requiring  that  an  artificial  pupil  should  be 
formed  for  the  restoration  of  vision,  are  almost  entirely  the  effects  either  of 
some  of  the  ophthalmins,  or  of  inflammation  consequent  to  injury  or  opera- 
tion. According  to  the  parts  affected  in  different  cases,  they  may  be  grouped 
under  the  seven  following  heads  : — 

I.  Partial  opacity  of  the  cornea. — This  includes  those  cases  in  which  there 
is  such  a  degree  of  opacity  of  the  central  portion  of  the  cornea  as  to  cover 
the  pupil,  while  the  whole  or  at  least  a  part,  of  the  circumferential  portion 


CASES   REQUIRING   AN   ARTIFICIAL  PUPIL.  801 

remains  transparent.  The  pupil  itself  is  open  ;  the  iris  unadherent  ;  every 
part,  in  fact,  is  supposed  to  be  healthy  but  the  cornea.  Through  the  trans- 
parent portion  of  the  cornea  the  light  enters,  but  is  arrested  by  the  iris  ;  let 
a  part  of  this  opaque  membrane  be  drawn  aside  or  removed,  the  light,  then 
allowed  to  pass  through,  will  be  transmitted  to  the  retina,  and  vision  restored. 
Should  the  opaque  portion  of  the  cornea  be  so  limited  in  extent  that  dilating 
the  natural  pupil  by  belladonna  suffices  to  restore  a  considerable  share  of  use- 
ful vision,  it  would  be  wrong  to  hazard  an  operation ;  but  should  the  opacity 
be  so  extensive  that  dilatation  by  belladonna  adds  little  or  nothing  to  the 
patient's  perception  of  objects,  we  require,  behind  the  lucid  portion  of  the 
cornea,  either  to  clip  through  the  iris  from  its  pupillary  to  its  ciliary  margin, 
to  extend  the  natural  pupil  by  prolapsus,  or  to  remove  a  part  of  the  iris  by 
the  operation  either  of  lateral  excision  or  of  separation.  When  there  is  a 
considerable  field  of  transparent  cornea,  the  plan  most  frequently  followed 
has  been  to  open  its  circumference,  in  a  certain  extent,  close  to  the  sclerotica, 
allow  the  iris  to  protrude,  or,  if  it  does  not  do  so,  draw  a  portion  of  it  out, 
and  snip  off  as  much  with  the  scissors  as  shall  form  a  sufficient  aperture  in 
the  iris,  to  serve  as  an  artificial  pupil.  On  the  other  hand,  if  the  lucid  por- 
tion of  the  cornea  is  small  in  extent  (not  more  or  perhaps  less  than  a  line's 
breadth),  it  would  be  unsafe  to  cut  into  that  portion,  in  order  to  extract  a 
part  of  the  iris  for  excision ;  for  should  the  wound  inflame,  the  whole  of  the 
transparent  segment  of  the  cornea  might  thus  be  rendered  opaque,  and  all 
chance  of  restoring  sight  destroyed.  In  such  a  case,  the  operation  of  separa- 
tion must  1)6  had  recourse  to,  not,  however,  in  the  manner  practised  by  Scarpa, 
and  shortly  described  in  the  preceding  section,  but  by  means  of  a  hook  intro- 
duced through  an  incision  of  the  cornea,  the  incision  being  made  at  a  distance 
from  the  lucid  segment, 

II.  Partial  opacity  of  the  cornea,  ivith  partial  adhesion  of  the  iris  to  the 
cornea. — The  cases  falling  under  this  head  are  generally  the  results  of  pene- 
trating wound  or  of  ulcer  of  the  cornea.  Like  the  cases  of  uncombined  opacity 
of  the  cornea,  those  belonging  to  this  class  vary  remarkably  in  regard  to  the 
extent  of  the  opacity.  The  central  portion  only  may  be  opaque,  or  the 
opacity  may  leave  but  a  small  segment  of  lucid  cornea  close  to  the  sclerotica. 
The  iris  also  is  involved  in  these  cases,  in  very  different  degrees.  The  pupil- 
lary edge  of  the  iris,  in  a  single  point  merely,  may  be  adherent  to  the  cornea, 
without  almost  any  distortion  of  the  pupil.  In  other  cases,  although  the  edge 
of  the  pupil  has  not  been  directly  involved  in  the  ulcer  which  has  ended  in 
the  opacity  of  the  cornea,  the  pupil  is  distorted,  contracted,  and,  though 
partially  open,  is  so  hid  behind  the  leucoma,  that  vision  is  completely  impeded. 
In  a  third  set  of  cases,  almost  the  whole  pupillary  edge  of  the  iris  has  been 
involved  in  the  ulcer,  and  is  therefore  adherent  to  the  cicatrice,  while  the 
anterior  chamber  is  nearly  obliterated  by  the  advancement  of  the  iris  towards 
the  cornea.  In  a  fourth  set,  the  united  cicatrice  and  iris  may  have  protruded, 
so  as  to  form  a  partial  staphyloma,  while  a  portion  of  the  cornea  and  iris 
continue  uniuvolved. 

The  same  rule  will  guide  us  in  the  choice  of  an  operation  for  artificial 
pupil  in  cases  of  this  class,  as  in  those  of  the  former;  namely,  that  when 
there  remains  only  a  small  segment  of  the  cornea  transparent,  this  is  too 
valuable  to  be  tampered  with,  no  incision  is  to  be  risked  into  that  transparent 
segment,  lest  it  should  thereby  be  rendered  permanently  opaque,  but  an 
incision  must  be  made  at  a  distance,  and  the  iris  withdrawn  from  behind  the 
transparent  part  by  separation  from  the  choroid.  When,  on  the  other  hand, 
there  is  a  considerable  field  of  cornea  transparent,  extension  of  the  pupil  by 
prolapsus,  or  artificial  pupil  by  lateral  excision,  will  in  general  be  had  recourse 
51 


802  CASES   REQUIRING   AN   ARTIFICIAL   PUPIL. 

to ;  not,  indeed,  with  the  same  facility  as  if  there  was  no  adhesion  between 
the  iris  and  cornea,  but  still  without  any  insurmountable  difficulty.  The  iris 
will  probably  not  be  protruded  by  the  mere  pressure  of  the  aqueous  humor 
rushing  through  the  incision  of  the  cornea,  but  the  hook  or  the  forceps  will 
in  general  serve  easily  to  extract  the  portion  of  iris  which  is  to  be  prolapsed 
or  to  be  removed  by  the  scissors. 

III.  Closure  of  the  pupil,  the  lens  and  capsule  being  presumed  transparent. — 
Closure  of  the  pupil  from  inflammation  of  the  iris,  without  any  opacity  of  the 
capsule,  or  any  adhesion  between  it  and  the  iris,  if  it  ever  happens,  is  certainly 
a  very  rare  occurrence,  and,  from  the  appearances  presented,  must  be  exceed- 
ingly liable  to  be  taken  for  a  case  of  closure  with  adhesion,  the  capsule  being 
opaque,  at  least  within  the  area  of  the  contracted  pupil.  As  it  is  a  rule  to 
which  there  is  no  exception,  that,  in  forming  an  artificial  pupil,  if  the  lens  and 
capsule  are  transparent  before  the  operation,  they  must  be  left  untouched,  it 
would  evidently  be  wrong,  in  any  case  in  which  there  was  reason  to  suppose 
that  closure  of  the  pupil  was  the  whole  amount  of  the  disease,  or  that  the 
capsule  was  opaque  merely  within  the  area  of  the  contracted  pupil,  while 
the  rest  of  it,' along  with  the  lens,  was  transparent,  to  have  recourse  to  the 
operation  of  the  incision,  or  to  perform  any  operation  except  in  the  most 
cautious  manner.  Extension  by  prolapsus  or  lateral  excision  is  indicated  in 
such  a  case.  After  laying  hold  of  a  portion  of  the  iris  and  extracting  it 
through  the  incision  of  the  cornea,  a  clot  of  unorganized  lymph  may  be  found 
to  occupy  the  posterior  chamber,  without  adhering  to  the  capsule,  and  is  to 
be  removed.  Mnch  more  frequently,  the  closed  pupil  is  found  adherent  to 
the  centre  of  the  capsule,  which  is  opaque,  the  circumference  being  transpa- 
rent ;  while  in  other  cases,  we  discover,  on  removing  a  portion  of  the  iris, 
that  our  great  caution  has  been  unnecessary,  as  the  whole  front  of  the  capsule, 
or  the  entire  lens,  is  opaque  ;  or  on  attempting  to  extract  a  portion  of  the  iris, 
we  find  so  firm  an  adhesion  between  that  membrane  and  the  capsule,  that  it  is 
impossible  to  effect  our  object,  so  that  the  ciises  will  require  to  be  treated  like 
those  of  the  next  class.  No  evil,  however,  can  arise  from  our  having  entei'- 
tained  a  more  favorable  view  of  the  case  than  we  find  to  be  warranted  by  the 
state  of  the  parts,  when  we  come  to  operate.  The  capsule  being  opaque  only 
within  the  area  of  the  contracted  pupil,  extension  by  prolapsus  or  lateral  ex- 
cision is  the  operation  most  likely  to  restore  vision.  Should  the  whole  field  of 
the  capsule  or  the  lens  prove  opaque  through  the  artificial  pupil  formed  by 
lateral  incision,  we  may  immediately  introduce  the  needle  and  divide  the  cata- 
ract. Sometimes  we  may  succeed  in  extracting  the  lens  in  fragments,  and 
perhaps  the  capsule  also  ;  in  other  cases,  the  safer  plan  will  be  to  delay  till  the 
eye  has  recovered  from  what  has  been  done,  and  afterwards  proceed  to  remove 
the  cataract  from  behind  the  new  pupil. 

lY.  Closure  of  the  pupil,  with  firm  and  extensive  adhesion  of  the  iris  to  the 
capsule,  or  the  capsule  or  the  lens  known  to  he  opaque. — In  this  case,  something 
requires  to  be  done  for  the  removal  of  the  lens,  either  at  the  moment  of  forming 
the  artificial  pupil,  or  subsequently.  For  the  formation  of  the  artificial  pupil, 
incision  with  the  scissors  is  sometimes  chosen,  and  performed  through  an 
opening  of  the  cornea  sufficiently  extensive  to  allow  the  lens  to  be  extracted. 
Cheselden's  method  has  also  been  practised  in  such  cases,  the  lens  being 
divided  by  the  iris-knife,  and  its  fragments  thrust  forwards  through  the  new 
pupil  into  the  anterior  chamber  for  solution.  Some  have  preferred,  in  such 
circumstances,  forming  first  an  artificial  pupil  by  lateral  excision,  or  by  sepa- 
ration, and  afterwards  have  disposed  of  the  lens  by  division  or  displacement. 
Others  have  chosen  central  excision,  and  immediately  proceeded  to  extract  the 
cataract  through  the  artificial  pupil. 


GENERAL  RULES   REGARDING   ARTIFICIAL   PUPIL.  803 

Y.  Closure  of  the  pupil  after  an  operation  for  cataract. — As  it  was  in  cases 
of  this  kind  that  Cheselden,  with  such  signal  success,  had  recourse  to  a  simple 
incision  of  the  iris  for  the  purpose  of  forming  an  artificial  pupil,  it  may  appear 
strange  that  Wenzel,  when  he  tried  the  same  operation,  was  so  disappointed, 
that  he  laid  it  aside,  and  adopted  that  of  central  excision.  The  cases,  how- 
ever, in  which  Cheselden  succeeded,  and  those  in  which  Wenzel  failed,  in 
forming  a  permanent  artificial  pupil  by  incision,  differed,  probably,  in  a  most 
material  circumstance,  namely,  the  healthy  or  unhealthy  state  of  the  iris ;  for, 
as  I  shall  have  occasion  in  a  following  section  to  explain  more  particularly, 
an  incision  through  an  iris,  the  texture  of  which  has  suffered  but  little  from 
inflammation,  is  likely  to  remain  permanently  open,  while  one  through  the  same 
membrane  after  it  has  become  thickened  and  otherwise  changed  in  texture, 
almost  invariably  closes,  and  its  edges  reunite.  Hence,  it  is  necessary  to  lay 
it  down  as  a  rule  regarding  the  cases  falling  under  this  head,  that  if  the 
appearance  of  the  iris  and  the  history  of  the  case  lead  to  the  conclusion  that 
the  closure  of  the  pupil  has  taken  place  without  any  severe  or  long-continued 
inflammation  of  the  iris,  simple  incision  may  be  practised,  either  according  to 
Cheselden's  method,  or  some  other,  more  recently  devised  ;  but  that  if  the  iris 
appears  to  be  much  altered  in  texture,  or  if  the  history  of  the  case  declares 
that  severe  and  long-continued  iritis  has  attended  the  closure  of  the  pupil, 
excision  or  separation  ought  to  be  adopted. 

VI.  Closure  of  the  pupil  from  protrusion  of  the  iris  after  extraction. — 
This  is  a  very  peculiar  case,  inasmuch  as  the  fibres  of  that  part  of  the  iris 
which  is  unconnected  with  the  cornea  are  completely  on  the  stretch,  so  that 
they  are  easily  divided,  and  the  artificial  pupil  formed  by  incision  instantly ^ 
expands.  From  these  circumstances,  this  case  is  by  far  the  best  suited  for 
the  operation  of  incision.  While  in  many  other  cases,  there  may  be  room . 
for  deliberation  between  the  different  kinds  of  operation,  in  this  there  is  none. 
YII.  Partial  opacity  of  the  cornea,  closure  of  the  pupil,  adhesion  of  the 
iris  to  the  cornea  or  to  the  capsule,  and  opacity  of  the  capside  or  lens. — So 
complicated  a  case  as  this  might  appear,  on  first  enunciation,  as  altogether 
beyond  relief.  Yet  some  of  the  most  striking  recoveries  of  sight,  by  means 
of  an  artificial  pupil,  have  taken  place  under  circumstances  of  this  unfavorable 
nature.  There  is,  we  shall  say,  a  lucid  segment  of  cornea,  from  behind  which, 
by  means  of  lateral  excision  or  separation,  we  remove  a  portion  of  the  iris; 
this  reveals  an  opaque  lens  and  capsule,  which  after  some  time  we  remove  by 
the  needle,  and  thus  restore  vision. 


SECTION  III. — GENERAL  RULES  REGARDING  ARTIFICIAL  PUPIL. 

1.  As  in  every  instance,  those  states  of  the  eye  which  require  the  formation 
of  an  artificial  pupil,  originate  partly,  if  not  entirely,  in  inflammation,  th,e  re- 
newal of  which  might  prove  fatal  to  the  success  of  the  operation,  it  is  to  be 
received  as  a  general  rule,  that  no  artificial  pupil  be  formed,  unless  the  patient's 
general  health  is  good,  and  the  eye  has  for  a  considerable  space  of  time  been 
perfectly  free  from  every  symptom  of  inflammation,  except  those  irremovable 
ones,  to  counteract  the  effects  of  which  the  operation  is  undertaken. 

2.  An  artificial  pupil  ought  never  to  be  formed  in  the  one  eye  so  long  as 
the  individual  retains  useful  vision  in  the  other;  for  to  see  well  with  the  sound 
eye  he  would  require  to  shut  that  in  which  the  artificial  pupil  had  been  formed, 
and  contrariwise;  the  axis  of  vision  in  the  two  eyes  seldom,  if  ever,  in  such- 
circumstances,  being  correspondent. 


804  GEXERAL   RULES   REGARDING   ARTIFICIAL   PUPIL. 

3.  We  ought  not  to  attempt  tlie  formation  of  an  artificial  pupil  in  an  eye 
with  which  the  patient  discerns  common  objects  with  tolerable  distinctness, 
such  as  a  pen,  knife,  scissors,  &c.,  lest  by  the  operation  we  deprive  him  of  the 
degree  of  vision  he  enjoys. 

4.  It  is  of  no  use  to  form  an  artificial  pupil,  unless  the  portion  of  cornea 
behind  which  it  will  be  placed,  is  tolerably  clear.  If  it  be  nebulous,  little  or 
no  accession  of  vision  will  be  gained.  Cases  occur  not  unfrequently  of  cen- 
tral leucoma,  with  anterior  synechia,  the  circumferential  portion  of  the  cornea 
being  so  nebulous  that  the  fibres  of  the  iris  are  not  visible.  It  is  needless  to 
attempt  the  formation  of  an  artificial  pupil  under  such  circumstances.  If  we 
are  left  in  doubt  as  to  the  degree  of  transparency  of  the  circumferential  por- 
tion of  the  cornea,  and  the  existence  of  adhesion  between  it  and  the  iris,  we 
may  make  a  puncture  through  the  cornea,  and  try  to  pass  an  Anel's  probe 
between  the  cornea  and  iris,  thus  ascertaining  whether  they  be  adherent,  and 
testing  the  transparency  of  the  cornea.  If  the  probe  is  clearly  seen  through 
the  cornea,  we  may  proceed  with  the  operation  of  separation. 

5.  That  condition  of  the  eye  in  which  the  aqueous  humor  is  supplanted  by 
a  coagulable  yellowish  fluid,  resembling  the  serum  of  the  blood,  is  an  un- 
favorable complication,  marking  the  existence  of  long-continued  disease  in 
the  iris  and  neighboring  parts.  On  puncturing  the  cornea,  the  inflammatory 
or  dropsical  fluid  in  question  escapes,  and  the  iris,  previously  of  a  yellowish 
or  greenish  hue,  assumes  more  of  its  natural  color;  but  on  proceeding  to  lay 
hold  of  the  membrane,  or  to  make  any  incision  into  it,  it  will  generally  be 
found  in  such  a  softened  state,  that  we  shall  be  unable  to  accomplish  our 
purpose,  while  inflammatory  reaction  is  almost  certain  to  follow  the  operation. 

6.  An  operation  for  artificial  pupil  ought  not  to  be  undertaken  if  there 
be  present  granular  conjunctiva,  vasculo-nebulous  cornea,  varicose  dilatation 
of  the  external  bloodvessels,  attenuatiou  of  the  sclerotica,  bogginess  of  the 
eyeball,  preternatural  hardness,  dropsy,  atrophy,  microphthalmos,  strabismus, 
or  the  like. 

Y.  Neither  would  we  operate  where  the  retina  was  not  tolerably  sound. 
Should  the  diseased  state  of  the  eye  be  a  speck  of  the  coi'nea,  and  should  the 
patient,  on  the  pupil  being  dilated  with  belladonna,  see  no  better  than  before, 
it  is  probable  the  vitreous  humor  and  retina  are  unsound,  so  that,  on  attempt- 
ing to  form  an  artificial  pupil,  the  vitreous  humor  would  burst  and  be 
evacuated,  or,  after  even  the  most  successful  formation  of  a  pupil,  the  amau- 
rotic state  of  the  retina  would  prevent  any  accession  of  vision.  If  the  pupil 
is  obliterated,  and  the  dull  discolored  iris  bulges  much  towards  the  cornea, 
and  especially  if  this  state  is  the  result  of  syphilitic  inflammation,  the  retina 
is  probably  unsound.  The  iris,  in  such  cases,  is  generally  much  thickened, 
and  bleeds  more  than  usual  on  being  cut. 

8.  Although  operating  in  such  a  case  must  be  a  mere  experiment,  yet  it 
may  sometimes  occur  that  the  formation  of  an  artificial  })upil  will  restore 
vision  to  an  eye  which  seemed  unable  to  distinguish  light  and  shade.  Gene- 
rally, indeed,  it  is  regarded  as  an  indispensable  condition  for  the  performance 
of  the  operation,  that  the  eye  be  able  to  discriminate  between  different  grada- 
tions of  light;  yet  it  is  a  conceivable  case,  that  from  the  natural  pupil  being 
completely  obliterated,  the  iris  at  the  same  time  thickened,  and  lymph  accu- 
mulated in  the  posterior  chamber,  added  perhaps  to  opacity  of  the  lens  and 
capsule,  the  patient  shall  be  slow  and  doubtful  in  his  discrimination  of  light 
and  shade,  although  the  retina  is  still  susceptible  of  resuming  its  office,  were 
the  impediments  now  enumerated  removed  by  operation.  Ponitz,  the  German 
translator  of  Assalini  on  Artificial  Pupil,  states  that  in  two  cases  he  operated 
with  success,  although  the  patients  were  previously  unable  to  distinguish  even 


GENERAL   RULES   REGARDING   ARTIFICIAL   PUPIL.  805 

the  brightest  light.  As  such  success  is  contrary  to  general  experience,  one 
cannot  help  suspecting  that  the  previous  testing  of  the  sensibility  of  the  eye 
had  not  been  instituted  with  suflBcient  care  ;  for  even  through  the  sclerotica, 
with  the  cornea  totally  staphylomatous  and  lined  by  the  adhering  iris,  light 
can  be  distinguished  when  the  retina  is  sound. 

9.  Patients  sometimes  present  themselves  with  both  eyes  apparently  in  a 
condition  demanding  the  formation  of  an  artificial  pupil  ;  but  the  one  with 
fewer  external  morbid  changes  than  the  other,  and  therefore  likely  to  be  fixed 
on  as  the  one  for  operation.  On  careful  examination,  however,  I  have  known 
the  worse  looking  eye  to  prove  distinctly  sensible  to  light  and  shade,  and  the 
better  looking  one  to  be  totally  amaurotic. 

10.  The  formation  of  an  artificial  pupil  ought  rarely,  if  ever,  to  be  attempted 
in  a  scrofulous  subject  under  the  age  of  puberty,  more  especially  if  the  dis- 
eased state  of  the  eye,  rendering  this  operation  necessary,  has  originated  in 
scrofulous  ophthalmia,  independent  of  injury.  After  an  operation  in  such  a 
subject,  inflammation  of  the  scrofulous  character  is  almost  sure  to  follow,  and 
will  probably  destroy  the  eye.  In  the  course  of  a  few  years  after  puberty,  the 
operation  may  be  performed  with  less  danger. 

11.  The  failure  of  the  operation  for  artificial  pupil  is  more  frequently  owing 
to  the  bad  selection  of  cases,  than  to  any  other  cause.  Performed  on  account 
of  morbid  changes  in  the  cornea  or  iris,  resulting  from  specific  diseases,  as 
scrofula,  syphilis,  or  gout,  it  is  generally  unsuccessful.  The  case  is  more 
hopeful,  if  the  diseased  state  of  the  eye  is  the  result  of  one  of  the  puro-mucous 
ophthalmia  ;  and  still  more  so,  if  it  be  directly  of  traumatic  origin.  If  sym- 
pathetic ophthalmitis  has  brought  the  eye  to  a  condition  in  which  only  an 
artificial  pupil  can  afford  a  hope  of  vision  being  restored,  the  chance  of  suc- 
cess is  very  slendei*. 

12.  The  artificial  pupil  should  be  formed  as  nearly  behind  the  centre  of  the 
cornea,  or,  in  other  words,  as  much  in  the  situation  of  the  natural  pupil  as 
possible.  "  So  important,"  says  Mr.  Bowman,  "  do  I  regard  a  central  po- 
sition, that  I  would  rather  make  a  pupil  near  the  centre,  behind  a  portion 
of  the  cornea,  somewhat  nebulous,  than  at  the  margin,  behind  a  part  perfectly 
clear.  "^ 

13.  If  the  artificial  pupil  cannot  be  formed  in  or  near  the  centre  of  the  iris, 
and  if  the  operator  has  a  choice  of  placing  it  behind  either  the  nasal  or  the 
temporal  edge  of  the  cornea,  he  ought  to  prefer  the  former  of  these  two  situ- 
ations, both  as  affording  a  more  useful  degree  of  vision,  and  as  causing  less 
deformity.  Often,  however,  the  operator  has  no  choice,  but  must  form  the 
artificial  pupil  behind  the  only  portion  of  the  cornea  which  remains  lucid, 
whether  that  be  at  the  temporal  or  nasal  edge,  at  the  upper  or  the  lower.  It  is 
easier,  in  general,  to  form  an  artificial  pupil  at  the  temporal  edge  than  at  the 
nasal ;  and  it  is  urged  by  Mr.  Gibson,  that  the  patient  enjoys  a  greater  field 
of  vision  when  the  pupil  is  towards  the  temple.  This,  however,  may  be 
doubted  ;  and,  at  any  rate,  there  is  a  much  greater  degree  of  awkwardness  in 
the  appearance  and  employment  of  an  eye  in  which  the  pupil  is  behind  the 
temporal  edge  of  the  cornea,  the  patient  evidently  finding  it  difficult  to  turn 
the  eye  so  as  to  bring  the  pupil  into  the  necessary  direction,  and  embrace  with 
it  the  usual  range  of  objects. 

14.  If  an  artificial  pupil  is  to  be  formed  in  each  eye,  some  direct  us  to 
make  the  one  behind  the  temporal  side  of  the  one  cornea,  and  the  other  behind 
the  nasal  side  of  the  other  cornea,  alleging  that  in  this  way  there  is  a  greater 
degree  of  correspondence  between  them  than  if  they  were  formed  in  any  other 
situations  except  in  the  centre  of  the  eyes.  If  both  pupils  are  towards  the 
temple,  as  in  Maunoir's  patient,  the  Marquis  de  Beaumanoir,^  the  appearance 
is  far  from  being  natural  or  agreeable. 


806 


INCISION,    EXCISION,    AND    SEPARATION   COMPARED. 


Fiff.  121. 


15.  As  au  artificial  pupil  generally  possesses  no  power  of  contracting  or 

dilating,  care  must  be  taken  that  it  is  made 
neither  too  large  nor  too  small.  It  is  re- 
markable, indeed,  how  useful  a  very  small 
artificial  pupil  may  prove,  as  is  well  illus- 
trated in  the  celebrated  instance  (Fig.  121) 
of  a  man  of  the  name  of  Sauvages,  operated 
on  by  Demours,  by  excision.^  In  general, 
however,  so  small  a  pupil  does  not  prove 
very  serviceable  ;  while,  on  the  other  hand, 
an  artificial  pupil  much  above  the  medium 
size  of  the  natural  one,  exposes  the  eye  to 
be  constantly  dazzled,  and  is  thus  rendered 

comparatively  useless. 

16.  Shape  is  of  less  consequence  than  position  and  size.  "A  large  orifice," 
remarks  Mr.  Bowman,  "if  it  take  the  direction  of  a  radius  in  front  of  the  lens, 
allows  of  better  sight  than  a  circular  pupil  of  the  same  area.  In  fact,  I  have 
found  a  long,  narrow,  elliptical  slit,  extending  from  the  situation  of  the  natural 
pupil  to  the  very  border  of  the  lens,  sufficient  to  permit  almost  perfect  vision."* 

IT.  In  all  cases  in  which  the  lens  and  capsule  are  either  evidently  trans- 
parent, or  are  thought  likely  to  be  so,  the  artificial  pupil  must  be  formed  in 
such  a  way  as  to  leave  these  parts  untouched. 

18.  In  general,  the  operation  should  be  performed  through  the  cornea 
rather  than  the  sclei'otica,  and  by  means  of  a  puncture  rather  than  an  exten- 
sive incision,  as  inflicting  less  injury  on  the  structure  of  the  eye,  and  as  at- 
tended with  less  risk  of  hemorrhage  and  of  subsequent  inflammation. 


'  Medical  Times  and  Gazette,  January  3, 
185.3,  p.  12. 

'^  Medico-Chirurgical  Transactions  ;  Vol.  vii. 
pp.  305,  309  ;  London,  181G. 


'  Traite  des  Maladies  des  Yeux;  Tome  iii.  p. 
426  :  Planehe  46,  Fig.  1;  Paris,  1818. 
*  Op.  cit.  p.  13. 


SECTION  IV. — INCISION,    EXCISION,    AND    SEPARATION    COMPARED. 
NECESSARY  FOR  THESE  OPERATIONS. 


CONDITIONS 


I.  The  least  complicated,  but  not  always  the  easiest,  mode  of  forming  an 
artificial  pupil,  consists  in  one  or  more  incisions  through  the  substance  of  the 
iris,  made  in  expectation  that  the  opening  so  formed  will  gape,  and  continue 
permanent.  If  the  opening  through  the  iris  is  formed  by  one  incision,  it  may 
run  horizontally,  so  as  to  produce  a  pupil  resembling  that  of  the  ruminating 
animals,  or  perpendicularly,  so  as  to  form  one  resembling  the  pupil  of  the 
cat  tribe.  The  artificial  pupil  may  be  oblique  in  its  direction,  and  may  occupy 
the  superior,  inferior,  nasal,  or  temporal  portion  of  the  iris ;  it  may  run,  not 
in  a  straight,  but,  as  Janin  preferred  it,  in  a  curved  line ;  or  it  may  be  formed, 
as  Maunoir  has  recommended,  by  two  incisions  meeting  each  other  at  an  acute 
angle.  The  formation  of  an  artificial  pupil  by  incision  may  be  accomplished 
by  passing  the  needle  or  knife  through  the  cornea,  and  thus  commencing 
upon  the  anterior  surface  of  the  iris,  or  the  instrument  may  be  entered  through 
the  sclerotica,  and  then  pass  through  the  iris  into  the  anterior  chamber. 
These  particulars  will  be  determined  partly  by  the  views  of  the  operator,  and 
partly  by  the  state  of  the  eye  upon  which  he  is  to  operate. 

It  must  be  evident,  that  it  is  an  indispensable  condition  for  the  success  of 
incision,  that  the  iris  be  in  such  a  state  as  shall  secure  the  dilatation  of  the 


INCISION,    EXCISION,    AND    SEPARATION   COMPARED.  801 

new  pupil,  as  soon  as  the  operation  is  completed.  If  the  artificial  pupil  do 
not  dilate,  the  iris  will  very  soon  heal,  and  the  patient  will  be  just  where  he 
was.  In  order  that  the  new  pupil  may  dilate,  it  is  necessary  that  the  sub- 
stance of  the  iris  be  in  a  tolerably  healthy  state.  If  that  membrane  has  sus- 
tained violent,  long-continued,  or  frequently  repeated  inflammation,  its  fibres 
are  rendered  incapable  of  contracting,  and  consequently  if  such  attacks  have 
ended  in  closure  of  the  natural  pupil,  the  iris  is  unfit  to  be  operated  on  by 
incision.  Whenevei*,  then,  the  history  of  the  case  and  the  appearances  of 
the  eye  lead  us  to  believe  that  there  has  been  severe  iritis,  we  ought  to  choose 
some  other  method  of  operating.  It  is  not,  however,  in  every  case  of  closure 
of  the  natural  pupil  from  iritis,  that  the  fibres  of  the  iris  are  rendered  incapa- 
ble of  contracting,  but  only  when  the  inflammation  of  the  iris  has  been  severe 
and  long-continued,  ending  in  thickening  of  that  membrane,  with  sanguine- 
ous or  lymphatic  deposition  in  its  substance,  or  on  its  posterior  surface. 

It  is  interesting  to  inquire  how  those  differences  of  opinion  have  arisen, 
which  have  existed  in  the  minds  of  operators  regarding  incision,  and  how 
this  operation  has  occasionally  succeeded,  and  at  other  times  completely 
failed.  The  explanation  will  be  found  in  the  difference  of  cases ;  in  the  fitness 
of  some  and  unfitness  of  others,  for  this  operation.  In  proof  of  this,  we  may 
refer  to  the  testimony  of  Janin.  The  first  case  in  which  he  performed  inci- 
sion was  one  of  obliteration  of  the  pupil  from  inflammation  after  extraction  ; 
and  the  second,  obliteration  from  severe  ophthalmia.  In  both,  he  made  a 
horizontal  incision  to  the  extent  of  two-thirds  of  the  diameter  of  the  iris,  and 
in  both,  on  opening  the  eye  some  days  after  the  operation,  he  found  the  arti- 
ficial pupil  completely  closed,  and  the  incision  healed.^  I  believe  that  we  are 
warranted  in  asserting,  that  the  closure  of  these  two  artificial  pupils  would 
not  have  taken  place,  had  the  substance  of  the  iris  been  in  a  natural  state  ; 
and  the  proof  of  this  may  be  taken  from  Janin  himself.  In  several  instances, 
while  performing  extraction  of  the  cataract,  this  operator  happened  accident- 
ally to  wound  the  iris.  Reasoning  from  his  experience  in  the  two  cases  of 
artificial  pupil,  he  expected  that  these  accidental  wounds  would  heal.  Here, 
however,  he  was  disappointed.  These  incisions  had  been  made  in  healthy 
irides,  and  on  opening  the  eyes  some  days  afterwards,  he  found  the  incisions 
more  dilated  than  at  the  moment  of  operation.'-^  Had  he  been  led  from  these 
striking  facts  to  compare  his  failures  in  the  operation  of  incision  with  the 
success  which  had  attended  this  method  of  operating  in  the  hands  of  Chesel- 
deu,  he  might  have  discovered  the  true  cause  of  the  diversity  of  results ; 
namely,  the  different  states  in  which  the  substance  of  the  iris  must  have  been 
at  the  moment  of  operating.  Instead  of  this,  Janin  was  led  to  attribute  his 
want  of  success  to  something  faulty  in  the  form  and  direction  of  his  incision. 
The  true  cause  unfortunately  escaped  him,  as  it  did  many  of  his  successors, 
who,  omitting  a  careful  examination  of  the  whole  facts,  bestowed  their  atten- 
tion chiefly  on  the  most  eflfectual  mode  of  dividing  two  sets  of  muscular  fibres 
of  the  iris.  It  was  not  in  fact  till  the  publication^  of  Sir  William  Adams's 
cases  of  artificial  pupil  by  incision,  that  the  objections  thrown  out  against 
this  operation  by  Scarpa  and  others  were  in  some  measure  removed  ;  although 
even  Sir  William  missed  the  true  secret  of  his  own  success,  attributing  it, 
not  to  the  condition  of  the  iris  upon  which  he  operated,  but  to  the  form  of 
his  knife,  and  the  extent  of  his  incision.  We  need  not  hesitate  to  assert, 
that  in  every  case  in  which  the  substance  of  the  iris  is  not  greatly  altered  by 
inflammation,  we  may  confidently  expect  the  artificial  pupil  formed  by  incision 
to  continue  patent,  in  whatever  direction  or  in  whatever  part  of  the  iris  the 
incision  is  made  ;  above  or  below,  or  in  the  line  of  the  natural  pupil ;  whether 
it  divides  the  radiating  fibres  only,  the  sphincter  only,  or  both ;  and  whether 
it  is  a  mere  pinhole,  or  extends  to  two-thirds  of  the  diameter  of  the  iris. 


808  INCISION,    EXCISION,    AND    SEPARATION   COMPARED. 

On  one  occasion  I  formed  an  artificial  pupil  by  an  incision  which,  a  priori, 
we  should  have  expected  to  have  produced  a  mere  slit  between  the  radiating 
fibres,  as  in  the  operation  neither  they  nor  the  sphincter  was 
divided.  The  closed  pupil  was  eccentrically  situated  towards 
the  temporal  side  of  the  eye,  and  I  therefore  divided  the  iris 
towards  its  nasal  side.  The  pupil  assumed  the  rhomboidal  shape 
shown  in  Fig.  122,  and  permanent  vision  was  restored. 

Besides  a  tolerably  healthy  state  of  the  iris,  of  which  we  can 
judge  pretty  accurately  from  its  color,  as  seen  through  the  cornea, 
there  are  other  conditions  necessary  for  incision.  Among  these  we  may 
mention  a  considerable  field  of  transparent  cornea,  opposite  to  that  portion 
of  iris  which  is  to  be  divided.  We  should  never  think  of  incision,  if  there 
were  merely  a  narrow  segment  of  cornea  transparent,  and  all  the  rest 
opaque  ;  for  in  such  a  case  an  artificial  pupil  by  incision  could  be  little  more 
than  a  mere  fissure,  whereas  a  more  considerable  and  more  useful  pupil  might 
be  formed  by  separating  the  iris  from  the  choroid,  and  removing  it  completely 
from  behind  the  lucid  portion  of  the  cornea. 

Another  condition  reckoned  necessary  for  incision,  previously  at  least  to 
the  invention  of  the  canula-scissors,  was,  that  the  iris  should  possess  a  certain 
degree  of  tension,  and  be  actually  fixed  in  some  measure,  either  by  closure  of 
the  natural  pupil,  or  by  partial  adhesion  to  the  cornea.  This  condition 
exists  in  a  very  striking  manner  in  those  cases  of  closure  of  the  pupil  and 
dragging  of  the  iris,  which  occur  from  prolapsus  of  this  membrane,  after 
extraction  of  the  cataract.  Not  merely  is  the  iris  easily  divided  in  these 
cases,  but  the  new  pupil  instantly  gapes  and  rarely  afterwards  contracts,  so 
that  they  are  actually  the  best  cases  for  the  operation  of  incision.  If,  on  the 
other  hand,  the  pupil  is  perfectly  free,  the  iris  will  glide  from  before  the  point 
of  any  instrument  in  the  shape  of  needle  or  knife,  with  which  we  might 
attempt  to  divide  it ;  and  even  were  the  iris  transfixed,  it  would  be  dilBcult 
to  give  the  incision  the  form  and  extent  required.  In  all  cases,  then,  in 
which  partial  opacity  of  the  cornea  merely  is  the  occasion  of  our  having 
recourse  to  the  formation  of  an  artificial  pupil,  incision  with  any  single  cut- 
ting instrument,  on  account  of  the  danger  of  wounding  the  crystalline  capsule, 
as  well  as  for  the  reason  now  stated,  would  be  improper.  To  incise  the  iris, 
from  its  pupillary  edge  towards  its  ciliary  edge,  even  when  the  membrane  is 
perfectly  free,  it  has  been  proposed  to  use  the  self-penetrating  canula-scissors, 
the  blade,  which  is  to  pass  between  the  iris  and  the  lens,  being  blunt-pointed. 
II.  As  excision  is  the  cutting  out  and  completely  removing  from  the  eye 
of  a  portion  of  the  iris,  this  operation  can  be  performed  conveniently  and 
safely  only  through  the  cornea.  It  will  require  also  a  considerable  opening 
in  the  cornea,  in  order  to  allow  either  a  spontaneous  protrusion  of  the  por- 
tion of  iris  to  be  removed,  or  the  introduction  of  such  instruments  as  are  to 
drag  that  portion  forth,  or  be  employed  within  the  eye  in  snipping  it  out. 
As  to  the  situation,  form,  and  dimensions  of  an  artificial  pupil  by  excision, 
these  must  depend  partially  on  the  fancy  of  the  operator,  but  chiefly  on  the 
incontrollable  circumstances  in  which  the  iris,  cornea,  and  other  parts  impli- 
cated in  the  operation  are  placed.  Above  all,  the  situation  and  dimensions 
of  the  new  pupil  must  depend  on  the  extent  and  place  of  the  transparent  part 
of  the  cornea. 

The  cases  in  which  the  pupil  is  open  and  the  iris  free,  and  which  we  have 
already  mentioned  to  be  totally  unfit  for  the  ordinary  operations  of  incision, 
are  the  very  best  for  excision  ;  for  it  is  evident,  that  it  is  only  in  such  cases 
that  the  protrusion  of  the  iris  through  the  wound  of  the  cornea  will  take 
place  with  that  degree  of  facility,  and  to  that  extent  which  will  enable  us  to 
finish  the  operation  simply  by  laying  hold  of  the  prolapsed  portion  of  iris 


INCISION,    EXCISION,    AND    SEPARATION   COMPARED.  809 

with  the  forceps,  and  snipping;  it  ofT  with  the  scissors.  If,  on  the  other  hand, 
the  natural  pupil  is  completely  closed,  and  the  posterior  surface  of  the  iris 
glued  to  the  parts  behind  it,  excision  in  this  easy  way  is  impracticable,  as  a 
protrusion  of  the  iris  through  the  wound  of  the  cornea  will  neither  take  place 
spontaneously,  nor  can  it  be  readily  effected  by  means  of  the  hook  or  forceps 
introduced  into  the  anterior  chamber. 

In  those  cases  in  which  the  iris  is  only  in  a  small  extent  adherent  to  the 
cornea,  excision  may  in  general  be  performed  with  ease,  a  very  limited  adhe- 
sion seldom  preventing  a  spontaneous  protrusion  of  the  iris  through  the 
wound  of  the  cornea.  But  if  the  adhesion  between  the  iris  and  the  cornea  is 
extensive,  involving  perhaps  the  whole  circumference  of  the  pupil,  it  is  often 
difficult  and  sometimes  impossible,  to  effect  a  sufficient  protrusion,  even  with 
the  aid  of  the  hook  or  forceps.  These  instruments  are  apt,  however,  to 
tear  away  a  bit  of  the  iris,  and  thus  an  artificial  pupil  may  be  formed  by 
laceration. 

Vision  may  occasionally  be  restored  in  cases  of  very  limited  adhesion  of 
the  iris  to  the  cornea,  simply  by  separating  the  adherent  portion,  or,  if 
this  cannot  be  accomplished,  by  cutting  across  the  adherent  part,  thus  free- 
ing the  iris,  and  allowing  the  natural  pupil  (in  the  latter  instance  a  little 
enlarged)  to  resume  its  functions.*  A  quarter-section  being  made  at  the 
edge  of  the  cornea,  a  small  probe  may  be  introduced,  and  an  attempt  made 
to  separate  the  adhesion,  which  will  sometimes  succeed,  if  the  adhesion 
has  been  consequent  merely  to  inflammation,  without  any  ulceration  of  the 
cornea  or  prolapsus  of  the  iris.  If  it  does  not  succeed,  we  may  either,  with 
Beer,  introduce  Cheselden's  iris-scalpel,  and  cut  the  adherent  point  of  the 
iris  across,  or,  as  Assalini  recommends,  use  a  very  small  pair  of  scissors  (the 
canula-scissors,  for  instance)  for  the  same  purpose.^  Should  this  abscission 
of  the  iris,  as  it  may  be  called,  seem  insufficient  to  restore  the  natural  pupil 
to  its  office,  the  opaque  part  of  the  cornea  still  covering  it  too  much  to 
permit  the  necessary  quantity  of  light  to  enter  the  eye,  we  may  immediately 
enlarge  the  pupil  by  the  excision  of  a  portion  of  the  iris.  Cases  of  this  sort 
are  capable  of  being  improved,  however,  simply  by  prolapsing  a  portion 
of  the  iris,  and  thus  dragging  the  pupil  from  behind  the  opacity ;  a  method 
of  operating  successfully  practised  by  Himly,"  and  extensively  used  by 
Tyrrell.7 

III.  Separation  is  an  operation  which  by  some  has  been  deemed  applicable 
in  almost  every  case  requiring  the  formation  of  an  artificial  pupil,  but  which 
I  am  inclined  to  employ  less  frequently  than  either  incision  or  excision.  It 
is  undeniable  that  there  is  no  case  in  which  separation  might  not  be  performed, 
let  it  be  one  of  partial  opacity  of  the  cornea  merely,  of  closure  of  the  natural 
pupil,  or  some  of  the  complicated  consequences  of  injury  or  of  inflammation  ; 
but  it  is  also  true,  that,  on  account  of  the  laceration  of  bloodvessels  and  nerves 
with  which  it  is  attended,  sepai'ation  is  more  severe  and  painful,  accompanied  by 
greater  danger  to  the  eye,  and  followed  by  a  more  tedious  recovery,  than  either 
of  the  other  modes  of  operating.  The  artificial  pupil  formed  by  separation, 
unless  very  particular  precautions  are  adopted,  and  the  parts  are  in  a  tolerably 
healthy  state,  is  also  extremely  apt  to  close,  lymph  filling  up  the  new  pupil,  and 
the  portion  of  iris  which  has  been  separated  returning  to  its  former  situation, 
and  re-adhering  to  the  choroid.  For  these  reasons,  we  should  always  seek  to 
attain  our  object  by  excision  or  incision,  and  only  when  these  are  unlikely  to 
fulfil  our  intention,  ought  we  to  have  recourse  to  separation. 

There  is  one  advantage  which  separation  possesses  over  incision,  and  which 
may  therefore  serve  in  certain  cases  to  recommend  it ;  namely,  that  with 
proper  care  the  lens  and  capsule  may  be  left  untouched  in  separation,  which 
in  the  ordinary  methods  of  incision,  it  is  difficult  or  impossible  to  accomplish. 


810  ARTIFICIAL   PUPIL   BY   INCISION. 

By  separation,  also,  we  are  ablei  to  form  the  largest  possible  pupil  admitted 
by  the  state  of  the  parts,  which,  when  the  lucid  segment  of  cornea  is  very 
small,  is  an  advantage  of  no  mean  importance. 

It  has  been  stated  in  a  previous  section,  that  Scarpa  practised  separation 
simply  by  introducing  a  curved  needle  through  the  sclerotica,  and  with  its 
point  dragging  away,  on  the  nasal  side,  the  ciliary  edge  of  the  iris  from  the 
choroid.  This  might  no  doubt  be  done  with  impunity  in  cases  of  closure  of 
the  natural  pupil  after  an  operation  for  cataract,  but  would  be  quite  inappli- 
cable if  the  lens  and  capsule  were  sound.  Hence  another  method  of  perform- 
ing separation  has  been  adopted,  namely,  opening  the  cornea,  and  introduc- 
ing a  hook  through  the  anterior  chamber,  avoiding  thus  the  lens  and  capsule. 
Separated,  however,  even  by  the  hook  introduced  in  this  manner,  the  iris, 
unless  perfectly  healthy,  and  its  fibres  quite  contractile,  would  speedily  return 
to  its  former  place,  and  the  new  pupil  be  thus  obliterated,  were  not  some 
means  adopted  for  preventing  this.  To  Langenbeck,  we  owe  the  additional 
step  of  bringing  out  through  the  incision  of  the  cornea  a  portion  of  the  sepa- 
rated iris,  allowing  it  to  remain  strangulated  between  the  lips  of  the  wound 
till  adhesion  takes  place,  and  thus  rendering  it  impossible  for  the  new  pupil 
to  close. 

The  situation  and  dimensions  of  an  artificial  pupil  formed  by  separation, 
whether  it  is  to  be  behind  the  nasal  or  the  temporal,  the  superior  or  the 
inferior  edge  of  the  cornea,  and  whether  it  is  to  be  merely  a  small  chink,  or 
a  triangular  opening,  each  side  measuring  a  couple  of  lines,  will  be  deter- 
mined by  the  state  of  the  eye  in  which  the  operation  is  to  be  performed.  In 
the  most  favorable  cases,  an  artificial  pupil  by  separation  assumes  the  form 
of  a  triangle,  its  base  being  circular  and  formed  by  the  ciliary  processes,  and 
the  two  other  sides  straight  lines.  But  in  many  instances,  we  employ  this 
method  of  operating,  when  merely  a  small  segment  of  the  cornea  remains 
transparent,  and  the  iris  is  everywhere  else  united  to  the  opaque  poi'tion  of 
the  cornea,  so  that  the  pupil  must  necessarily  be  small,  and  it  may  be  impos- 
sible to  produce  the  prolapsus  above  recommended  for  preventing  the  iris 
from  retreating  towards  the  choroid. 


'  Mcmoires   et  Observations  sur  I'ffiil,  pp.  '  See  a  Case  of  Abscission  by  Dr.  Ryan,  Dub- 

182,  184;  Lyon,  1772.  lin  Hospital  Reports;  Vol.  ii.  p.  370. 

-  Ibid.  pp.  185,  186,  187.  °  Wagner  de  Coremorphosi,  p.  22  ;  Gottingae, 

^  Practical  Observations  on  Ectropium,  &o.:  1818. 

London,  1812.  ■"  Practical  Work   on   the    Diseases    of    the 

*  Mauchart  de    Synechia,  Halleri    Disputa-  Eye ;  Vol.  ii.  p.  499  ;  London,  1840. 
tiones   Chirurgicaj  Selectaj ;    Tom.  i.   p.   447; 
Lausannse,  1755. 


SECTION  V. — ARTIFICIAL  PUPIL  BY  INCISION. 

Syn. — Corotomia ;  from  xipri,  pupil,  and  riy.viu,  I  cut. 

It  is  advantageous,  in  all  operations  for  artificial  pupil,  to  lay  the  patient 
on  his  back,  with  his  head  raised  on  a  pillow ;  and  the  assistant  should  be 
aware,  that  he  will  require  to  support  one  or  other  of  the  eyelids,  or  both, 
according  as  he  is  directed  by  the  operator.  In  excision,  particularly,  both 
hands  of  the  operator  are,  at  a  certain  stage  of  the  operation,  occupied  with 
the  instruments,  and  cannot  therefore  be  spared  for  holding  open  the  eyelids. 

Although  belladonna  has  in  general  little  or  no  power  over  an  iris  which 
has  suffered  such  a  degree  of  inflammation  as  to  end  in  closure  of  the  pupil, 
there  can  be  no  harm  in  applying  the  solution  of  atropine  to  the  eye,  an  hour 


ARTIFICIAL   PUPIL   BY   INCISION. 


811 


or  two  before  the  operation  of  incision.     In  any  of  the  other  operations  for 
artificial  pupil,  belladonna  would  be  improper. 

Chloroform  should  be  administered,  unless  the  patient  seems  likely  to 
preserve  a  perfect  self-command  during  the  operation.  By  its  influence  the 
eye  is  rendered  perfectly  quiet,  and  the  rolling  of  it,  which  is  so  apt  to  prove 
annoying,  is  avoided.  If  the  eye  proves  restless,  chloroform  not  being  used, 
it  may  sometimes  be  controlled  by  fixing  a  fine  hook  in  the  cornea,  if  it  hap- 
pens to  be  partly  opaque,  or  in  the  tunica  tendinea. 

§  1.  Incision  through,  the  Sclerotica. 

The  instrument  for  dividing  the  iris  through  the  sclerotica,  is  a  small  knife 
(Fig.  123),  about  two-thirds  of  an  inch  in  length,  and  the  twentieth  of  an 
inch  in  breadth,  with  a  straight  back,  sharp  point,  and  curved 
edge,  cutting  for  the  length  of  about  three-tenths  of  an  inch.  Fig-  123. 

Being  single-edged,  this  instrument  can  be  made  to  cut  much 
keener  than  any  sort  of  cataract  needle  ;  while,  from  its  small 
size,  it  passes  through  the  coats  of  the  eye  and  the  iris  with 
facility. 

The  operation  divides  itself  into  three  periods  ;  namely, 
Jirst,  The  introduction  of  the  iris-scalpel  through  the  sclerotica 
and  pars  non-plicata  of  the  ciliary  body  ;  secondly,  The  pas- 
sage of  the  instrument  through  the  iris  into  the  anterior 
chamber ;  and  thirdly,  The  division  of  the  iris. 

1st  Period. — The  cutting  edge  being  directed  backwards,  the 
operator  passes  the  iris-knife  through  the  sclerotica  and  cho- 
roid, exactly  in  the  equator  of  the  eye,  at  the  distance  of  \ 
inch  behind  the  temporal  edge  of  the  cornea,  and  to  the  depth 
of  i  inch  into  the  vitreous  humor. 

2c?  Period. — He  now  carries  the  handle  of  the  instrument 
back  towards  the  temple,  and  at  the  same  time  advances  its 
point  towards  the  union  of  the  temporal  with  the  two  nasal 
thirds  of  the  iris  ;  pressing  forward  its  point,  he  sees  it  appear 
between  the  fibres  of  the  iris,  and  project  into  the  anterior 
chamber.  He  now  brings  the  handle  forwards,  which  has  the 
effect  of  directing  the  point  of  the  instrument  towards  the 
nasal  edge  of  the  cornea,  and  he  pushes  it  cautiously  on 
through  the  anterior  chamber,  as  far  as  he  can  without  touch- 
ing the  cornea.     (Fig.  118,  p.  798.) 

3c?  Period. — It  is  now  by  a  double  motion  of  the  instrument, 
namely,  backwards  and  outwards,  that  the  iris  is  to  be  divided 
transversely,  to  the  extent  of  two-thirds  of  its  diameter. 
This  will  sometimes  be  effected  by  merely  pressing  on  the 
iris,  the  knife  suddenly  starting  through  that  membrane,  and 
thus  forming  an  artificial  pupil  of  the  required  extent ;  but 
more  frequently  neither  mere  pressure  on  the  iris,  nor  one 
rapid  stroke  of  the  edge  of  the  iris-scalpel  will  suffice,  but  we 
must  employ  repeated  strokes,  as  if  we  were  dividing  the 
membrane  fibre  by  fibre,  and  by  a  drawing  motion  of  the  in- 
strument as  well  as  pressure  with  its  edge.  All  this  must  be  done  gently 
and  cautiously,  lest  we  separate  the  iris  from  the  choroid. 

If  our  first  attempt  has  not  divided  the  iris  to  a  sufficient  extent,  the  point 
of  the  scalpel  is  to  be  again  carried  forward,  and  again  withdrawn,  until  the 
incision  is  of  the  proper  length.  (Fig.  lit,  p.  798).  Before  finally  removing 
the  instrument,  we  ought  to  notice,  unless  the  flow  of  blood  from  the  wounded 
iris  prevents  us,  whether  the  artificial  pupil  expands ;  and  if  the  edges  of  the 


812  ARTIFICIAL   PUPIL   BY   INCISION. 

incision  do  not  immediately  separate  from  each  other,  in  consequence  of  the 
contraction  of  the  fibres  of  the  iris,  we  should  open  up  the  pupil  a  little  by 
touching  its  edges  with  the  flat  sides  of  the  instrument.  The  iris-scalpel  is 
then  to  be  withdrawn,  in  the  same  line  of  direction  as  that  in  which  it  was 
introduced. 

This  method  of  operating  was  adopted  by  Cheselden,  in  cases  of  closure  of 
the  pupil  after  an  operation  for  cataract,  but  it  has  also  been  occasionally  had 
recourse  to,  especially  by  Sir  W.  Adams,*  when,  along  with  closure  of  the 
pupil,  an  opaque  lens  or  capsule  still  occupied  the  axis  of  vision.  When  this 
kind  of  complication  exists,  the  preliminary  steps  of  the  operation  are  such  as 
have  been  already  described.  In  dividing  the  iris,  the  capsule,  and  probably 
the  lens  also,  will  be  cut  across,  and  before  withdrawing  the  scalpel,  the  ope- 
rator must  endeavor  to  complete  the  division  of  the  cataract  as  far  as  he  can. 
The  aqueous  humor  will  by  this  means  be  admitted  to  act  upon  the  fragments 
of  the  lens,  but  should  the  absorption  of  these  afterwards  appear  retarded,  so 
that  they  continue  to  form  an  obstacle  to  vision,  in  the  course  of  two  or  three 
months  after  the  formation  of  the  artificial  pupil,  the  operation  of  division 
may  be  repeated,  as  in  ordinary  cases  of  cataract. 

If  the  iris  is  adherent  to  a  much  thickened  capsule,  it  will  be  difiicult  to 
perform  incision  in  the  manner  above  described,  and  even  were  the  iris  and 
capsule  cut  through,  it  is  almost  certain  that  the  new  pupil  would  not  expand, 
but  its  edges  speedily  unite.  If  we  have  proceeded  to  operate  by  incision 
through  the  sclerotica  in  such  a  case,  it  is  needless  to  attempt  the  separation 
of  the  iris  from  the  capsule.  It  is  preferable  to  withdraw  the  scalpel,  and  at 
a  future  period  proceed  to  the  formation  of  an  artificial  pupil  by  some  other 
method,  better  adapted  to  the  circumstances  of  the  case. 

§  2.    Incision  through  the  Cornea. 

I.  With  the  knife. — At  one  period  of  his  practice,  and  in  a  particular  set 
of  cases.  Beer  adopted  a  very  simple,  and,  at  the  same  time,  sufficiently  suc- 
cessful mode  of  performing  incision  through  the  cornea.  The  cases  in  ques- 
tion were  those  in  which,  in  consequence  of  prolapsus  of  the  iris  after  the 
operation  of  extraction  performed  at  the  lower  edge  of  the  cornea,  the  natural 
pupil  was  closed,  or  at  any  rate  so  distorted  and  hid  behind  the  cicatrice  of 
the  cornea,  as  to  be  incapable  of  serving  for  useful  vision,  while  at  the  same 
time  the  upper  half  of  the  iris  was  dragged  down  toward  the  cicatrice,  and  its 
fibres  put  very  much  on  the  stretch. 

In  such  cases.  Beer  introduced  a  double-edged  knife,  about  \  inch  in 
breadth,  and  shaped  exactly  like  a  lancet,  through  the  upper  part  of  the  cor- 
nea, and  carrying  it  a  little  way  through  the  anterior  chamber,  he  then  pene- 
trated the  iris  (Fig.  124).  He  thus  formed  a  transverse  incision  directly  be- 
hind the  middle  of  the  lucid  portion  of  the  cornea,  and  which,  from  the  tense 
state  of  the  fibres  of  the  iris,  instantly  gaped.^  The  same  operation  may  be 
practised  through  the  lower  part  of  the  cornea,  when  extraction  at  the  upper 
edge  has  been  followed  by  prolapsus  of  the  iris ;  or  the  incision  may  be  made 
in  a  vertical  direction  by  introducing  the  knife  at  the  temporal  edge  of  the 
cornea.^ 

In  cases  of  extensive  leucoma,  with  anterior  synechia,  the  result  of  traumatic 
inflammation,  with  a  crescent  of  clear  cornea,  and  an  apparently  healthy  portion 
of  iris  behind  it,  the  iris-knife,  or  a  broad  cataract  needle,  may  be  passed 
through  the  edge  of  the  cornea,  and  cautiously  insinuated  between  the  surfaces 
of  the  iris  and  cornea  till  its  point  has  reached  the  centre  of  the  exposed 
piece  of  iris;  the  instrument  is  then  to  be  rotated,  and  its  cutting  edge  being 
directed  against  the  iris,  as  much  of  it  is  to  be  divided  as  shall  leave  a  suflScieut 
artificial  pupil.* 


ARTIFICIAL   PUPIL   BY  INCISION. 


813 


Mr.  Estlin  mentions  his  having  seen  Mr.  Alexander  perform  this  operation 
many  years  ago,  in  cases  in  which  chronic  inflammation  of  the  iris  had  ac- 

Fig.  124. 


Operation  for  artificial  pu[iil  by  incision  through  cornea.  (From  TTalton.) 


companied  the  formation  of  cataract,  where  only  a  little  pupillary  aperture 
was  left,  and  that  of  an  irregular  shape,  the  iris  being  apparently  thinned,  and 
its  posterior  surface  glued  down  to  the  opaque  capsule.  "  The  cataract  be- 
hind," says  he,  "is  often  solid,  and  affords  a  good  resistance  to  the  knife  in 
cutting  the  fibres  of  the  iris.  It  is  uncertain  what  will  be  the  effect  of  the 
sudden  incision.  I  have  sometimes,  by  one  cut,  divided  the  fibres  of  the  iris, 
and  displaced  the  cataract,  so  that  a  clear  pupil  was  instantly  produced,  and 
a  sudden  blaze  of  light  let  in  upon  the  retina,  quite  astounding  to  the  delighted 
patient.  At  other  times,  a  permanent  aperture  in  the  iris  will  be  made,  of 
sufficient  extent  to  allow  of  a  thorough  view  of  the  opacities  behind  the  pupil, 
and  to  admit  of  future  operations  with  the  needle  for  their  removal,  either 
through  the  cornea  or  sclerotica."^ 

2.  With  the  scissois. — This  method  of  operating,  which  originated  with 
Janin,"  but  was  greatly  improved  by  Maunoir,' although  more  complicated  in 
its  manipulations  than  the  methods  of  Cheselden  and  Beer,  insures  more 
effectually  the  desired  result ;  and,  compared  with  the  operation  through  the 
sclerotica,  is  actually  more  easy  of  performance.  To  divide  the  iris  with 
Cheselden's  scalpel,  has  often  been  found  extremely  difficult  or  even  impossi- 
ble, whereas,  with  the  scissors,  the  iris,  in  whatever  state  it  may  be,  whether 
thin  and  unsupported  except  by  aqueous  humor  in  the  posterior  chamber,  or 
thickened,  and  perhaps  adherent  to  the  capsule,  is  divided  with  ease  and  cer- 
tainty. Even  in  cases  where  the  iris  projects  so  as  nearly  to  touch  the  cor- 
nea, M.  Maunoir's  operation  can  be  performed  with  comparative  facility. 
There  is  also  much  less  risk  of  tearing  the  iris  from  the  choroid  than  in  Che- 
selden's method. 

1st  Period. — An  incision,  comprehending  fully  a  fourth  of  the  circumfer- 
ence of  the  cornea,  is  made  at  the  distance  of  jV  i"c'^  ^o™  its  edge,  and 
generally  towards  the  temple.  If  the  case  is  one  in  which  the  lens  has  pre- 
viously been  removed,  the  incision  need  not  exceed  a  fourth ;  but  if  we  con- 


814 


ARTIFICIAL   PUPIL   BY   INCISION. 


template  the  removal  of  a  cataract  through  the  artificial  pupil,  a  greater 
extent  of  the  cornea  must  be  laid  open.  This  may  be  done  with  the  extrac- 
tion-knife, or  a -small  scalpel,  of  the  same  form  as  the  iris-scalpel,  but  twice 
its  size.  The  latter  instrument  is  to  be  passed  through  the  cornea  at  the 
point  intended  to  form  the  upper  extremity  of  the  incision,  and  directed 
across  the  anterior  chamber  ;  then,  as  it  is  withdrawn,  the  cornea  is  to  be 
ripped  open  to  the  requisite  extent.  If  the  extraction-knife  is  used,  the 
incision  is  made  in  a  similar  way  as  in  opening  the  cornea  in  the  operation  of 
extraction. 

2c?  Period. — The  scissors,  with  which  the  incision  of  the  iris  is  to  be  per- 
formed, must  be  made  with  blades  so  thin  and  narrow,  that  when  closed  (Fig. 
125)  they  do  not  exceed  the  thickness  of  a  small  probe,  the  blades  being 

Fig.  125. 


about  f  inch  long,  and  bent  so  as  to  form  an  angle  of  160°  with  the  middle 
line  of  the  handles.  The  blade,  which  is  to  pass  between  the  iris  and  the 
cornea,  is  probe-pointed ;  that  which  is  to  penetrate  the  iris  is  sharp-pointed, 

(Fig.  126.) 


and  about  ^V  i^ch  shorter  than  the  other 


Fig.  126. 


The  scissors  are  to  be  introduced,  flat,  through  the  wound  of  the  cornea, 
till  they  reach  the  part  of  the  iris  where  the  incision  ought  to  commence. 
They  are  then  to  be  turned  one-quarter  round  on  their  axis,  the  handles 
brought  a  little  forwards,  the  blades  opened,  the  sharp-pointed  blade  passed 
through  the  iris,  and  the  instrument  worked  across  the  eye,  with  the  probe- 
pointed  blade  before  and  the  sharp-pointed  one  behind  the  iris,  as  near  to  the 
nasal  edge  of  the  cornea  as  it  is  meant  to  extend  the  incision. 

od  Period. — The  scissors  are  now  to  be  sharply  closed,  and  the  iris  will  be 
divided.     Such  is  the  method  of  operating  with  the  scissors,  when  the  radiat- 


ARTIFICIAL   PUPIL   BY   INCISION. 


815 


ing  fibres  of  the  iris  are  upon  the  stretch,  as  in  cases  of  prolapsus  after  the 
operation  of  extraction  ;  but  in  other  cases,  and  especially  when  we  suspect 
the  substance  of  the  iris  to  be  thickened,  or  adherent  to  the  capsule,  it  is  pro- 
per to  make  two  incisions  (Fig.  127),  commencing  at  the  same  point,  and 
divaricating  from  one  another  at  an  acute  angle.     The  triangular  flap  thus 


Fig.  127. 


Fis;.  128. 


formed  shrivels  up  towards  its  base,  leaving  a  permanent  artificial  pupil, 
generally  of  sufficient  size,  preserving  sometimes  a  three-sided,  but  more  fre- 
quently assuming  a  quadrilateral  figure.     (Fig.  128.) 

When  closure  of  the  pupil  is  combined  with  cataract,  the  incisions  above 
described  will  lay  open  the  capsule,  and  may  even  divide  the  lens,  the  frag- 
ments of  which  the  operator  ought  to  endeavor  by  gentle  pressure  to  bring 
forward  through  the  artificial  pupil  into  the  anterior  chamber,  whence  they 
are  to  be  extracted  by  means  of  the  scoop,  if  they  are  soft,  or  the  hook,  if 
hard.  It  may  sometimes  be  possible  to  extract  even  the  capsule  through  the 
artificial  pupil.  If  a  portion  of  the  capsule  is  firmly  adherent  to  the  triangular 
flap  of  the  iris,  it  will  shrink  along  with  this,  and  form  no  obstacle  to  vision. 
Any  fragments  of  the  lens  which  may  be  left  will  gradually  dissolve  in  the 
aqueous  humor. 

It  is  by  no  means  indispensable  that  two  incisions  should  be  made,  to  per- 
mit the  extraction  of  a  cataract  through  the  artificial  pupil,  formed  by  the 
scissors ;  nor  is  it  necessary  that  the  incision  of  the  iris,  in  cases  of  closed 
pupil  combined  with  cataract,  should  be  transverse.  Maunoir  has  recorded 
a  case  of  capsulo-lenticular  cataract  with  closed  pupil,  in  which,  having  opened 
the  lower  part  of  the  cornea,  he  penetrated  the  iris  with  the  sharp-pointed 
blade  of  his  scissors,  at  the  distance  of  a  line  from  its  circumference,  carried 
that  blade  behind  the  lens,  closed  the  scissors,  and  thus  cut  through  the  lens, 
its  capsule  and  the  iris  in  a  vertical  direction.  The  pupil  immediately  be- 
came larger.  The  two  segments  of  the  capsule  were  separated,  and  showed 
a  broken  lens  of  a  bluish-gray  color,  the  capsule  being  yellowish-white. 
The  lens  was  easily  extracted,  piece  by  piece,  with  the  scoop.  The  larger 
segment  of  the  capsule  was  then  removed  with  forceps.  The  pupil,  in  form 
like  that  of  a  cat,  now  appearing  of  good  size,  the  other  fragment  of  the  cap- 
sule was  left,  lest  the  taking  of  it  away  might  have  made  the  pupil  too  large.^ 

In  cases  of  closure  of  the  pupil  from  iritis,  after  an  operation  for  cataract, 
Maunoir^  opened  the  cornea  at  its  lower  edge,  and,  passing  his  scissors  into 
the  anterior  chamber,  directed  the  sharp-pointed  blade  into  the  closed  pupil, 
and  behind  the  iris,  the  blunt-pointed  one  between  the  iris  and  the  cornea ; 


Fiff.  129. 


Fig.  130. 


he  then  divided  the  iris  by  two  radiating  incisions,  as  is  represented  in  Fig. 
129,  whence  immediately  resulted,  by  the  contraction  of  the  sphincter  and  of 
the  radiating  fibres,  a  pupil  of  a  quadrilateral  form,  as  in  Fig.  130. 


816  ARTIFICIAL   PUPIL   BY   INCISION. 

The  same  method  he  also  followed,  in  cases  of  closure  and  displacement  of 
the  pupil,  from  prolapsus  of  the  iris  after  extraction,  making  the  incision  for 
the  introduction  of  the  scissors  through  the  cicatrice,  and  passing  the  sharp- 
pointed  blade  through  the  secondary  cataract  which  occupied  the  pupil.  On 
one  occasion,  he  extracted  the  opaque  capsule,  partly  in  an  ossified  state,  with 
forceps,  after  making  the  first  incision  through  the  iris  ;  but  the  incision  not 
expanding,  he  then  made  a  second,  and  thus  obtained  a  large  pupil  in  the 
form  of  a  parallelogram. 

Incision  with  the  scissors  may  also  be  practised  when  the  iris  is  partially 
adherent  to  the  cornea,  as  is  often  the  case,  in  consequence  of  prolapsus 
through  a  penetrating  ulcer,  the  natural  pupil  remaining  partially  open,  and 
the  lens  and  capsule  transparent.  Having  supplied  ourselves  with  a  pair  of 
scissors  of  the  same  dimensions  as  those  above  described,  but  with  both  blades 
probe-pointed  and  equal  in  length,  we  introduce  them  through  a  small  section 
of  the  cornea,  pass  one  of  the  blades  within  the  contracted  natural  pupil, 
and  conduct  it  behind  the  iris  until  we  see  that  the  other  blade  has  reached 
the  angle  between  the  cornea  and  the  iris.  The  latter  is  then  to  be  divided 
by  one  or  two  incisions,  running  from  its  pupillary  towards  its  ciliary  edge. 
If  one  incision  only  is  made,  it  will  cut  across  the  sphincter,  and  then  pass 
between  the  radiating  fibres,  giving  rise  to  a  triangular  extension  of  the 
pupil,  as  in  Fig.  132.  If  two  incisions  are  made,  they  will  form  a  triangular 
flap,  the  apex  of  which  is  in  the  natural  pupil,  and  the  basis  behind  the  edge 
of  the  cornea,  and  which,  by  the  shrinking  at  once  of  the  sphincter  and  of 
the  radiating  fibres,  will  leave  a  large  quadrilateral  artificial  pupil,  similar  to 
that  represented  in  Fig.  130.  In  this  operation  the  capsule  and  lens  ought 
to  remain  untouched  ;  but  it  must  be  confessed,  that  there  is  more  risk,  in 
this  way,  of  injuring  those  parts,  than  in  the  operation  of  lateral  excision, 
which  has  therefore  been  generally  preferred  in  such  cases. 

Similar  incisions  of  the  iris  to  those  above  described,  through  the  sclerotica 
or  through  the  cornea,  may  be  accomplished  with  the  canula-scissors,  and,  if 
the  self-penetrating  pair  be  used,  without  auy  preliminary  incision.  Mr. 
Bowman  remarks,  that  as  "they  enable  us  to  make  the  pupil  as  central  as 
possible,  to  define  its  extent,  and  to  save  the  lens  while  present,  and  all  this 
with  a  mere  puncture  of  the  cornea,  they  must  supplant  altogether  the  iris- 
scissors  of  Maunoir,  which  require  a  large  incision  in  the  cornea,  do  not 
enable  the  surgeon  to  limit  the  pupil  as  he  desires,  and  are  very  apt  to  wound 
the  lens."" 

Case  353. — Mr.  Bowman  records  a  case  in  -wbich  a  dense  leucoma  occupied  the  greater 
part  of  the  right  cornea ;  the  lower  edge  of  the  pupil  being  adherent  to  the  leucoma,  its 
upper  edge  free  and  just  visible  above  the  leucoma.  The  cornea  was  slightly  hazy  above 
the  leucoma,  to  nearly  its  upper  margin.  The  lens  appeared  to  be  in  situ,  and  perfectly 
clear. 

Atropine  having  been  applied  so  as  to  dilate  the  pupil  a  little,  Mr.  B.  introduced  the 
canula-scissors  at  the  outer  side  of  the  cornea,  and,  pushing  them  on  as  far  as  the  pupil, 
passed  the  short  or  blunt-pointed  blade  behind  the  upper  edge  of  the  pupil,  and  the  long 
or  sharp-pointed  blade  in  front  of  the   iris.     The   trigger 
Fig.  131.       Fig.  132.  being  pressed  down,  the  blades  closed  and  cut  the  upper 

margin  of  the  pupil  to  the  extent  of  about  -j'g  inch.     Figure 
131  shows  the  appearance  of  the  eye  before  operation,  the 
dark  line  near  the  edge  of  the  cornea  is  the  site  of  the  punc- 
ture ;   and  that  extending  from  the  pupil  shows  the  incision 
by    the    scissors.     Figure    132   represents   the   consequent 
enlargement  of  the  pupil. 
No  blood  flowed  to  discolor  the  aqueous  humor  ;  and  the 
patient,  on  sitting  up,  could  at  once  see  the  trees  and  distant  houses  through  the  window. 
No  inflammation  ensued. 

About  a  month  after,  sight  continued  much  improved  ;  but  as  the  patient  stated  that 
he  saw  more  distinctly  when  the  eye  was  shaded,  and  it  was  found  that  the  pupil  enlarged 


EXTENSION   OF   THE   PUPIL   BY   PROLAPSUS. 


81t 


slightly  upwards  when  that  took  place,  Mr.  B.  repeated  the  operation,  dividing  the  iris 
to  a  slightly  greater  extent,  so  as  to  place  the  pupil  permanently  in  the  condition  in  which 
it  was  thus  found  to  serve  most  efficiently  the  purposes  of  vision. 


'  Practical  Observations  on  Ectropium,  &c., 
p. 38;  London,  1812. 

*  Beer's  Ansicht  der  staphylomatosen  Meta- 
morphosen  des  Auges,  p.  105,-  Wien,  1806. 

"  Walton's  Operative  Ophthalmic  Surgery, 
Fig.  153,  p.  589;  London,  1853. 

■*  Dixon,  Lancet,  June  25,  1853,  p.  578; 
Estlin,  Provincial  Medical  Journal;  Vol.  vi.  p. 
443:  London,  1843. 

*  Op.  cit.  p.  444. 

^  Mumoires  et  Observations  sur  I'ffiil,  p. 
191 ;  Lyon,  1772. 


'  Memoires  sur  I'Organization  de  I'lris  et 
rOperation  de  la  Pupille  Artilicielle ;  Paris, 
1812  :  Scarpa,  Trattato  dello  principali  Malat- 
tie  degli  Occhi;  Vol.  ii.  p,  118;  Pavia,  1816. 

'  Medico-Chirurgical  Transactions  ;  Vol.  ix. 
p.  287  ;  London,  1818. 

°  Meiuoires  sur  les  Amputations,  &c.,  p.  155; 
Geneve,  1825. 

'"  Medical  Times  and  Gazette,  January  10, 
1852,  p.  35. 


SECTION  VI. — EXTENSION  OF  THE  PUPIL  BY  PROLAPSUS. 

Si/7i. — Corectenia,  from  xrp»,  piipil,  U,  out,  and  tei'kw,  /  stretch. 
The  case  just  quoted  is  an  example  of  extension  of  the  natural  Fig.  133. 


pupil  by  incision.  Move  frequently,  extension  has  been  effected  by 
prolapsus,  a  method  of  operating  founded  on  the  fact,  that  in  punc- 
tured wounds  of  the  cornea  (see  p.  394),  the  instantaneous  escape 
of  a  portion  of  the  aqueous  humor  is  apt  to  be  attended  by  a  pro- 
lapsus of  the  iris,  and  a  permanent  diversion  of  the  pupil  in  the 
direction  of  the  wound. 

When  he  purposes  extending  the  natural  pupil  to  behind  some 
lucid  portion  of  the  cornea  by  prolapsus,  the  surgeon  does  not  trust 
to  the  chance  of  a  spontaneous  protrusion  of  the  iris,  as  soon  as  he 
makes  a  puncture  near  the  margin  of  the  cornea ;  but  he  provides 
himself  with  instruments  with  which  he  may,  if  necessary,  extract  a 
portion  of  the  pupil.  Of  these,  Tyrrell's  blunt  hook  (Fig.  133), 
and  the  canula-forceps  (Figs.  Ill  to  114,  p.  T92)  are  the  most 
employed.  As  an  extemporaneous  substitute  for  Tyrrell's  in- 
strument, an  Anel's  probe  may  be  converted  into  a  hook,  and 
has  the  advantage  of  taking  any  particular  bend  we  choose  to 
give  it. 

Neither  belladonna  nor  chloroform  should  be  used  in  this  opera- 
tion, they  being  likely  to  counteract  a  protrusion  of  the  iris. 

If  the  iris  is  perfectly  free,  the  cornea  being  punctured  at  the 
distance  of  -^^^  inch  from  the  sclerotica,  and  at  its  inner-lower  edge 
rather  than  at  any  other  part  of  its  circumference,  the  broad  cutting 
needle,  or  the  extraction  knife,  with  the  point  of  which  the  punc- 
ture is  made,  should  be  turned  a  little  on  its  axis,  so  as  to  favor  a 
sudden  and  considerable  gush  of  aqueous  humor,  and  thus  cause  a 
protrusion  of  a  portion  of  the  iris.  The  extended  pupil  will  gene- 
rally take  the  shape  of  a  triangular  slit,  its  basis  communicating 
with  the  natural  pupil,  and  its  apex  extending  to  the  puncture  in 
the  cornea. 

A  limited  adhesion  of  the  edge  of  the  pupil  to  the  cornea  may 
not  interfere  with  the  extension  of  the  pupil  in  the  manner  de- 
scribed, but  if  anterior  synechia  exists  in  a  more  considerable  degree, 
or  if  the  edge  of  the  pupil  be  tagged  to  the  capsule  of  the  lens,  a 
spontaneous  prolapsus  of  the  iris  is  not  likely  to  happen,  so  that 
the  hook  or  the  forceps  will  be  required  to  draw  out  a  portion  of 
the  membrane. 
52 


A^ 


818  ARTIFICIAL   PUPIL   BY   EXCISION. 

Case  354. — Figure  134  shows  the  appearance  of  an  eye  affected  with  leucoma,  and  the 
pupil  almost  entirely  adherent  to  the  internal  surface  of  the 

Fig.  184.      Fig.  135.  cornea.     In  the  middle  of  the  small  part  of  the  pupil  which  is 

free,  there  is  a  tag  of  adhesion.  The  patient  was  admitted  at 
the  Glasgow  Eye  Infirmary;  and  on  the  22d  of  July,  1853, 
Dr.  A.  Anderson,  having  made  a  puncture  through  the  cornea 
at  its  outer  margin,  passed  Tyrrell's  hook  behind  the  tag, 
and  formed  an  artificial  pupil,  of  an  oval  form  (Fig.  135),  by 
prolapsus,  through  which  the  patient  enjoyed  excellent  vision. 

If  the  original  pupil  is  quite  obliterated  by  adhesion  to  the  cornea,  the 
needle  used  to  puncture  the  cornea  must  be  carried  onwards  within  the  ante- 
rior chamber,  so  as  to  pierce  the  iris  close  to  its  adhesion  to  the  cornea.  The 
needle  is  then  to  be  suddenly  withdrawn,  without  any  rotation,  in  order  to 
save  as  much  as  possible  the  aqueous  humor,  which  aids  us  in  conveying  the 
hook  through  the  anterior  chamber  without  its  being  entangled  in  the  iris. 

The  hook  having  entered  the  wound  of  the  cornea,  and  being  carried  as  far 
as  the  pupil,  its  bend  is  to  be  directed  backward,  and  the  margin  of  the  pupil 
is  to  be  caught  by  pressing  the  point  gently  towards  the  surface  of  the  lens, 
at  the  same  time  that  the  instrument  is  cautiously  withdrawn  till  it  reaches  the 
wound  of  the  cornea.  Here  its  exit  would  be  impeded  were  we  not  to  give 
it  a  quarter  turn  on  its  axis ;  but  in  doing  this,  it  must  not  be  allowed  to 
recede  from  the  wound,  lest  the  iris  should  thereby  slip  from  its  grasp.  It  is 
then  to  be  brought  through  the  wound,  and  by  its  means  a  sufficient  portion 
of  the  iris  drawn  out  to  effect  the  desired  extension  of  the  pupil.  The  pro- 
lapsed piece  of  iris  is  left  to  adhere  to  the  lips  of  the  cornea,  and  shrinks  gradu- 
ally so  as  not  to  be  perceptible. 

In  cases  of  anterior  synechia,  the  hook  must  lay  hold  of  the  iris  at  the  place 
punctured  with  the  needle,  in  the  first  period  of  the  operation.  In  cases  of 
posterior  synechia,  any  part  of  the  pupil  which  is  open  must  be  caught  with 
the  hook,  the  previous  incision  of  the  cornea  being  made  in  such  a  direction 
as  shall  be  favorable  for  this  being  accomplished. 

If  no  part  of  the  pupil  remains  open,  but  the  whole  is  adherent  to  the 
capsule,  a  small  sharp  hook,  or  the  canula-forceps,  may  be  used  for  laying 
hold  of  the  iris  at  the  margin  of  the  contracted  jiupil,  and  an  attempt  made 
to  separate  a  portion  of  it  from  the  capsule,  and  extract  it.  This  can  some- 
times be  accomplished  only  by  tearing  out  a  strip  of  iris. 


SECTION   VTI. — ARTIFICIAL   PUPIL   BY   EXCISION. 
Syn. — Corectomia;  from  xopn,  ptipil,  Ix,  out,  and  TBfxvai,  I  cut. 

Excision  is  either  lateral  or  central.  The  latter,  the  invention  of  Wenzel, 
is  now  rarely  practised ;  the  former,  first  had  recourse  to  by  Beer,  and  after- 
wards by  Gibson,  is  one  of  the  most  common  modes  of  forming  an  artificial 
pupil. 

§  1.    Lateral  Excision. 

It  is  a  common  practice,  not  to  be  content  to  leave  the  piece  of  iris,  by  the 
prolapsus  of  which  an  extension  of  the  natural  pupil  has  been  effected,  as 
described  in  the  last  section,  to  adhere  to  the  wound  of  the  cornea  ;  but  im- 
mediately to  snip  it  off  with  the  scissors,  thus  terminating  the  oj^eration  in  a 
lateral  excision.  The  operation  of  Beer  and  Gibson  differed  from  that  of 
extension  of  the  pupil  by  prolapsus,  ending  in  snipping  oft"  the  prolapsed  bit  of 
iris,  chiefly  in  their  setting  out  with  the  intention,  not  of  effecting  a  narrow 
chink  merely,  which  they  were  afraid  might  close,  but  a  pupil  nearly  circular. 


ARTIFICIAL  PUPIL  BY   EXCISION,  819 

and  of  very  considerable  size,  and  this  not  through  a  puncture,  likely  to  ren- 
der difficult  the  subsequent  manipulations,  but  a  pretty  free  incision  of  the 
cornea,  calculated  to  facilitate  the  completion  of  the  operation.  That  too 
large  a  pupil  is  apt  to  be  formed  in  this  way,  is  undeniable.  At  the  same 
time,  the  easiness  of  the  process  is  likely  always  to  recommend  it,  especially 
to  those  of  limited  experience  in  operating  on  the  eye. 

The  necessary  instruments  are  a  knife,  a  hook  or  pair  of  small  forceps,  and 
a  pair  of  scissors.  The  cataract-knife  is  the  one  generally  employed,  but  I 
have  often  used  a  broad  iris-scalpel  for  ripping  open  about  a  fourth  of  the 
circumference  of  the  cornea,  close  to  its  edge.  If  the  cataract-knife  is  em- 
ployed, the  incision  is  made  as  in  opening  the  cornea  in  the  operation  of  ex- 
traction. The  hook  or  forceps  is  employed  for  dragging  out  a  portion  of  the 
iris  through  the  wound  of  the  cornea,  unless  that  membrane  protrudes  spon- 
taneously, when  the  forceps  is  generally  used  for  laying  hold  of  the  protruding 
portion,  till  it  is  snipt  off  with  the  scissors.  Tyrrell's  hook,  from  the  length 
of  its  bend,  seizes  too  much  of  the  iris,  and  is  therefore  not  suitable  for  the 
operation  of  excision.  The  cataract-hook  (Fig.  102,  p.  156),  or  a  blunt  hook 
of  similar  curve  (Fig.  143),  answers  better. 

[Jager's  keratome,  a  spear-shaped  blade,  inserted  at  an  angle  to  the  shaft  of 
the  instrument,  will  be  found  a  more  convenient  means  for  making  the  open- 
ing in  the  cornea  than  the  cataract  knife,  for  with  it  there  is  much  less  risk  of 
premature  evacuation  of  the  aqueous  humor,  and  wounding  of  the  iris,  than 
there  is  with  the  latter.  Efficient  aid  will  also  be  derived  in  this  operation 
for  artificial  pupil  from  such  a  pair  of  forceps  as  those  represented  in  Fig. 
136.     We  obtained  a  pair  some  years  since  of  Mr.  Luer,  in  Paris,  and  we 

Fis.  136. 


believe  he  attributed  their  invention  to  Professor  Maunoir,  of  Geneva.  They 
are  exceedingly  delicate,  and  have  a  couple  of  teeth  placed  at  an  angle  on  the 
one  side  of  each  blade,  so  that  when  these  blades  are  closed,  they  will  readily 
embrace  anything  on  a  plane  immediately  beneath  them  by  means  of  their 
teeth.  To  prevent  any  vertical  sliding  of  the  blades  on  each  other,  which  so 
frequently  happens  with  the  ordinary  forceps,  to  the  annoyance  of  the  ope- 
rator, the  extremities  are  curved,  each  one  twice  across  the  other,  so  as  to 
assume  the  form  of  an  italic/,  and  their  two  opposed  surfaces  are  so  flattened 
that  when  the  blades  are  closed  the  end  of  the  instrument  will  not  occupy 
more  space  than  that  of  the  form  usually  recommended. 

Fig.  131  represents  an  instrument  known  on  the  Continent  as  Fischer's  for- 

Fig.  137. 


ceps,  and  is  employed  by  our  friend  Mr.  Wilde  in  preference  to  all  others.  It 
is  certainly  a  very  convenient  instrument,  its  exceeding  minuteness  giving  one 
much  more  facility  and  accuracy  in  manipulating  than  is  enjoyed  with  any 
other  form  of  forceps. — H.] 

The  operation  divides  itself,  then,  into  three  periods. 


820  ARTIFICIAL   PUPIL   BY   EXCISION. 

1st  Period. — The  incision  of  the  cornea  rarely  requires  to  exceed  one-fourth 
of  its  circumference.  The  nasal  and  lower  edge  of  the  cornea  is  to  be  pre- 
ferred, when  the  state  of  the  parts  permits  the  operator  to  choose  the  situa- 
tion for  the  artificial  pupil ;  but  the  temporal  edge,  being  the  most  accessible, 
has  been  oftenest  selected.  Introducing  the  point  of  the  iris-knife  through 
the  edge  of  the  cornea,  and  as  much  across  the  anterior  chamber  as  the  state 
of  the  parts  permits,  the  operator,  as  he  withdraws  the  instrument,  enlarges 
the  incision  to  the  requisite  extent.  If  this  is  done  so  as  to  allow  the  aque- 
ous humor  to  issue  at  once  from  the  eye,  the  removal  of  the  knife  will  gene- 
rally be  followed  by  a  portion  of  the  iris,  projecting  through  the  wound  like 
a  small  bag.  The  incision  must  be  close  to  the  edge  of  the  cornea,  else  it 
will  be  difficult  to  effect  a  prolapsus  of  the  iris. 

2d  Period. — If  no  spontaneous  prolapsus  takes  place,  the  operator  with  the 
point  of  the  scoop  should  open  a  little  the  wound  of  the  cornea,  at  the  same 
time  making  gentle  pressure  with  the  finger  on  the  opposite  side  of  the  eyeball, 
when  the  iris  will  frequently  appear  between  the  edges  of  the  wound,  and  may 
be  laid  hold  of  with  the  forceps.  What  is  laid  hold  of  is  to  be  cautiously 
drawn  out,  care  being  taken  to  include  the  edge  of  the  natural  pupil  in  the 
portion  thus  prolapsed. 

Should  no  protrusion  of  the  iris  take  place  on  pressure,  or  should  the  edge 
of  the  natural  pupil  be  adherent  to  the  cornea  in  a  considerable  part  of  its 
extent,  so  that  the  iris  is  prevented  from  protruding,  it  becomes  necessary  to 
introduce  either  the  hook  or  the  forceps,  lay  hold  of  the  iris,  and  cautiously 
drag  out  as  much  as  may  be  sufficient  for  the  formation  of  an  artificial  pupil 
of  medium  size  In  doing  this,  care  must  be  taken  to  avoid  touching  the 
crystalline  capsule,  which,  in  the  cases  where  we  have  recourse  to  the  opera- 
tion of  lateral  excision,  is  generally  transparent.  We  must  also  calculate 
with  care  the  extent  of  iris  which  we  are  to  extract ;  for  if  a  very  small  por- 
tion only  is  drawn  out,  the  operation  may  prove  almost  fruitless,  from  the 
minute  size  of  the  artificial  pupil  which  will  be  formed ;  on  the  other  hand, 
if  a  large  portion  is  grasped  by  the  forceps  or  extracted  with  the  hook,  the 
object  of  the  operation  may  be  equally  frustrated  by  the  weakness  of  sight 
attendant  on  too  wide  a  pupil.  The  latter  error  is  perhaps  that  into  which 
the  operator  is  more  apt  to  fall.  The  snipping  out  of  a  flaccid  bit  of  iris, 
apparently  not  larger  than  an  ordinary  pin's  head,  will  sometimes  form  an  arti- 
ficial opening  much  beyond  the  medium  size  of  the  natural  pupil.  Removing 
too  much  of  the  iris  is  by  far  the  more  serious  error  of  the  two,  inasmuch  as 
it  scarcely  admits  of  any  remedy,  whereas,  if  the  operator  sees  that  at  the 
first  snip  he  has  removed  too  little,  he  can  either  drag  out  and  cut  off  an 
additional  portion,  or  enlarge  the  pupil  by  incision  with  the  scissors. 

Sd  Period. — The  operator,  holding  with  the  one  hand  the  piece  of  iris 
grasped  between  the  blades  of  the  forceps,  with  the  other  employs  the  scissors 
for  snipping  it  off.  During  this  period  of  the  operation,  it  is  evident  that 
the  lids  must  be  committed  entirely  to  the  charge  of  the  assistant.  The  ope- 
rator should  take  care  to  have  the  scissors  close  at  hand  before  laying  hold 
of  the  piece  of  iris  with  the  forceps,  that  he  may  not  be  obliged  to  search  for 
them,  in  doing  which  he  might  readily  drag  out  too  much  of  the  iris,  or  even 
separate  a  portion  of  it  from  the  choroid.  One  of  Beer's  pupils  invented  an 
instrument  for  this  operation,  in  which  a  hook  and  pair  of  scissors  were  com- 
bined, but  which  proved  too  complicated  to  be  easily  managed. 

If  any  portion  of  the  iris  remains  protruding  through  the  wound,  it  is  to 
be  reduced  with  the  scoop  or  the  point  of  a  small  probe.  The  operator  is 
now  to  rub  gently  the  front  of  the  eye  through  the  medium  of  the  upper  eye- 
lid, and  then  expose  it  to  a  pretty  bright  light,  so  as  to  ascertain  somewhat 
of  the  form  and  size  of  the  new  pupil.     (Fig.  120,  p.  800.) 


ARTIFICIAL  PUPIL   BY   SEPARATION.  821 

§  2.      Central  Excision. 

It  is  unnecessary  to  add  anything  to  the  account  of  Wenzel's  operation, 
given  at  page  798.  Both  it,  and  its  modifications  by  more  modern  operators, 
being  objectionable  on  account  of  the  extensive  incision  of  the  cornea  which 
they  require,  are  but  seldom  attempted.  Mr.  Travers,  however,  tells  us,  that 
he  has  repeatedly,  and  with  perfect  success,  opened  the  cornea  by  a  semicir- 
cular incision,  raised  the  centre  of  the  iris  with  forceps  introduced  under  the 
flap  of  the  cornea,  and  clipped  off  as  large  a  piece  of  the  iris  as  could  be 
embraced  by  the  convex  scissors.  He  adds,  that  through  such  an  opening, 
there  will  be  no  impediment  to  the  passage  of  the  lens.^ 

Dr.  Stroraeyer  has  invented  a  needle-knife,  for  making  at  once  a  section  of 
the  cornea,  and  cutting  out  an  artificial  pupil,  which  he  describes  in  a  pam- 
phlet, entitled  "Das  Korektom,"  published  at  Augsburg,  in  1842.  The 
needle  having  transfixed  the  cornea,  and  permitted  the  aqueous  humor  to 
escape,  the  knife  is  pushed  on  and  at  once  makes  a  section  of  the  cornea,  and 
cuts  out  a  piece  of  the  iris. 


■  Synopsis  of  the  Diseases  of  the  Eye,  p.  339 ;  London,  1820. 


SECTION  VIII. — ARTIFICIAL  PUPIL  BY  SEPARATION. 

Syn. — Corodialysis  ;  from  xipu,  pupil,  and  ita'Kvoi,  I  loosen. 
§  1.   Separation  through  the  Sclerotica. 

The  operation  of  forming  an  artificial  pupil  by  separating  a  portion  of  the 
iris  from  the  choroid,  by  means  of  a  curved  needle  introduced  through  the 
sclerotica,  is  now  almost  entirely  laid  aside  Even  when  merely  a  small  seg- 
ment of  the  cornea  remains  transparent,  with  the  iris  adhering  to  the  opaque 
part,  and  scarcely  any  anterior  chamber  existing,  a  case  in  which  it  is  impos- 
sible to  bring  out  any  part  of  the  iris  through  an  incision  of  the  cornea,  it  is 
not  unusual  to  pass  the  needle  with  which  the  separation  is  to  be  attempted, 
not  through  the  sclerotica,  but  through  the  opaque  part  of  the  cornea. 

§  2.   Separation  through  the  Cornea. 

Assalini*  and  Buzzi^  appear  to  have  performed  separation  through  the 
cornea,  the  former  as  early  as  ITS'!,  with  a  small  pair  of  forceps,  and  the 
latter  with  a  needle,  in  1788.  In  1801,  Schmidt*  performed  separation  by 
means  of  a  pair  of  forceps  introduced  through  an  opening  in  the  cornea,  but 
afterwards  adopted  separation  through  the  sclerotica,  as  not  endangering  the 
transparency  of  the  cornea.  Himly*  with  a  curved  needle,  and  BonzeP  with 
a  hook,  also  performed  separation  through  the  cornea.  None  of  these  ope- 
rators, however,  attempted  to  prevent  by  any  particular  means  the  return  of 
the  separated  iris  towards  the  choroid,  an  event  which  is  extremely  apt  to 
happen,  if,  as  is  often  the  case,  when  an  artificial  pupil  is  required,  the  iris 
has  previously  suffered  much  from  inflammation. 

Langenbeck''  was  the  first  to  whom  it  occurred  to  drag  out,  through  the 
wound  of  the  cornea,  the  portion  of  iris  which  is  separated  from  the  choroid, 
and  by  allowing  the  protruded  piece  to  unite  to  the  lips  of  the  wound,  to 
prevent  in  this  way  the  obliteration  of  the  new  pupil.  For  effecting  the 
separation,  he  at  first  employed  a  simple  hook.  On  the  ground,  however, 
that  a  simple  hook  is  apt,  instead  of  separating  the  iris  from  the  choroid,  to 


822 


ARTIFICIAL  PUPIL   BY   SEPARATION. 


tear  it  throngb,  or  to  let  it  go  after  the  separation  is  commenced,  a  variety 
of  complicated  instruments  have  been  invented.  One  of  these  we  owe  to  Dr. 
Reisinger/  consisting  of  two  delicate  hooks  laid  side  by  side,  which,  when 
shut  (Fig.  138),  are  no  thicker  than  a  common  single  hook.  In  this  state 
they  are  introduced  into  the  anterior  chamber,  but  by  their  elasticity  they 
separate  from  one  another  (Fig.  139),  and  thus  serve  to  lay  hold  of  the  iris 
at  two  different  points,  and,  being  again  brought  together,  seize  that  mem- 
brane also  as  a  pair  of  forceps. 

In  1817,  Langenbeck^  invented  an  instrument  for  effecting  the  separation 


Figs.  139,     138. 


Fig.  140. 


Figs.  141,       142. 


Fig.  143. 


of  the  iris,  consisting  of  a  steel  wire,  terminating  in  a  fine  hook,  which  slides 
within  a  slender  gold  tube,  the  latter  being  fixed  into  one  end  of  a  thick  silver 
tube,  within  which  is  a  spiral  spring.     By  means  of  a  knob,  the  hook  is  pro- 


ARTIFICIAL   PUPIL   BY   SEPARATION.  823 

traded  (Fig.  140)  in  the  same  way  as  a  pencil  is  pushed  out  of  a  pencil  case. 
When  the  pressure  on  the  knob  is  withdrawn,  the  spiral  spring;  serves  to 
retract  the  hook.  The  iris  being  laid  hold  of  where  it  is  attached  to  the 
choroid,  the  spiral  spring  is  allowed  to  operate  in  effecting  the  separation, 
till  the  concave  side  of  the  hook  presses  the  piece  of  iris,  which  it  has  trans- 
fixed, into  contact  with  the  end  of  the  small  gold  tube.  Thus  the  iris  is 
fixed,  so  that  it  cannot  escape  during  the  rest  of  the  operation,  nor  till  it  is 
fairly  prolapsed  between  the  lips  of  the  wound  of  the  cornea.  This  instru- 
ment requires  a  very  small  incision  for  its  introduction,  and  is  not  apt  to 
catch  in  the  cornea  as  it  is  withdrawn. 

Upon  a  similar  principle,  Grafe  formed^  his  coreoncion  or  iris-hook,  which, 
as  improved  by  Dr.  Schlagiutweit,^"  is  represented  open  in  Fig.  141,  and 
shut  in  Fig.  142.  The  hook  is  of  steel.  The  sliding  pinch  of  silver,  being 
moved  forwards  by  the  thumb  applied  on  the  ferrule  which  surrounds  the 
handle  of  the  instrument,  comes  in  contact  with  the  concavity  of  the  hook, 
and  so  fixes  the  piece  of  iris  which  is  laid  hold  of,  that  it  cannot  escape. 

To  act  within  the  eye,  Reisinger's  hook-forceps  require  a  larger  incision ; 
they  are  apt  to  separate  too  great  a  portion  of  the  iris;  and  are  sometimes 
difficult  to  bring  out  of  the  eye,  from  catching  in  the  cornea.  In  all  these 
respects,  Schlagintweit's  hook  is  preferable. 

Dr.  Jiingken,  who  took  the  trouble  to  publish  a  work  on  Griife's  coreon- 
cion, in  a  later  publication"  renounces  the  use  both  of  it  and  of  all  other  com- 
plicated instruments  for  effecting  the  separation  of  the  iris,  and  recommends 
in  cases  where  the  texture  of  the  membrane  is  healthy,  a  simple  hook,  and 
where  it  is  changed  by  disease,  a  small  pair  of  toothed  forceps,  such  as  that 
represent  in  Fig.  32,  p.  241,  but  reduced  in  size.  In  either  case,  the  canula- 
forceps  might  answer  well. 

The  operation  of  separation  divides  itself  into  four  periods  ;  viz  :  first,  the 
incision  of  the  cornea ;  secondly,  the  introduction  of  the  hook  and  laying  hold 
of  the  iris  ;  thirdly,  the  separation,  properly  so  called  ;  a\idfoy7'tIily,  the  stran- 
gulation of  the  separated  piece  of  iris  between  the  lips  of  the  wound  of  the 
cornea. 

1st  Period. — The  situation  of  the  incision  through  the  cornea  will  of  course 
vary  with  circumstances  ;  but  care  must  always  be  taken  that  it  be  neither 
too  near  nor  too  far  from  the  edge  of  the  cornea  behind  which  the  artificial 
pupil  is  to  be  formed.  We  shall  suppose  that  this  is  to  be  done  behind  the 
nasal  edge  of  a  cornea,  the  transverse  diameter  of  which  measures  2%  inch. 
In  this  case,  the  incision  should  be  made  in  a  vertical  direction,  at  the  dis- 
tance of  -2^0  inch  from  the  nasal  edge,  or  at  any  rate  not  nearer  to  that  edge 
than  the  centre  of  the  cornea.  Were  the  incision  nearer  than  this  to  the 
nasal  edge,  behind  which  we  have  supposed  that  the  artificial  pupil  is  to  be 
formed,  the  separation  of  the  iris  would  be  too  limited  to  form  a  pupil  of 
sufficient  size  ;  and  should  an  opaque  cicatrice  result  from  the  incision  of  the 
cornea,  this  would  probably  extend  over  the  new  pupil,  and  frustrate  the 
object  of  the  operation.  On  the  other  hand,  were  the  incision  much  further 
from  the  nasal  edge,  the  artificial  pupil  would  be  enormously  large,  in  con- 
sequence of  our  continuing  to  detach  the  iris  till  a  sufficient  portion  of  it  was 
drawn  through  the  incision.  But  by  making  the  incision  at  the  distance  of 
2?o  inch  from  the  edge  of  the  cornea  behind  which  the  separation  is  to  be 
effected,  the  result  is  likely  to  be  a  triangular  pupil  of  moderate  size. 

The  incision  will,  in  some  cases,  require  to  be  made  through  a  lucid  portion 
of  the  cornea,  and  in  others  through  one  which  is  opaque.  This  is  a  matter 
of  indifference,  except  only  that  we  see  better  how  to  continue  the  operation 
when  the  part  of  the  cornea  which  is  opened  is  transjiai'ent.  If  Schlagint- 
weit's hook  or  a  simple  hook  be  used,  the  length  of  the  incision  should  ecigial 


824  ARTIFICIAL   PUPIL   BY    SEPARATION. 

2='o  inch  ;  for  if  smaller  it  will  be  difficult,  or  even  impossible,  to  effect  througb 
it  the  necessar)^  protrusion  of  the  iris.  If  Reisinger's  double  hook  is  used, 
unless  the  incision  measure  fully  four-twentieths,  it  will  not  allow  the  instru- 
ment to  open  so  as  effectually  to  lay  hold  of  the  part  to  be  separated.  If, 
on  the  other  hand,  the  incision  is  too  extensive,  the  piece  of  iris  which  is 
protruded  will  not  be  strangulated  with  sufficient  force  by  the  lips  of  the 
incision,  but  will  be  apt  to  escape  again  into  the  anterior  chamber,  and 
return  towards  the  choroid. 

A  double-edged  knife  has  been  recommended  for  making  the  incision,  being 
pushed  obliquely  through  the  lamelljB  of  the  cornea,  and  across  the  anterior 
chamber,  till  its  point  reaches  the  edge  of  the  iris  which  is  to  be  separated 
from  the  choroid.  To  make  the  incision  of  sufficient  length,  the  knife,  enter- 
ing at  the  distance  of  -^^  inch  from  the  edge  of  the  cornea  behind  which  the 
artificial  pupil  is  to  be  formed,  should  have  its  cutting  edges  divaricating  at 
an  angle  of  40°.  Pushing,  then,  the  point  of  the  instrument  slantingly 
through  the  cornea,  it  is  to  be  carried  through  the  anterior  chamber,  till  it 
reaches  the  angle  between  the  cornea  and  iris,  on  that  side  of  the  eye  where 
the  artificial  pupil  is  to  be  formed,  and  be  immediately  withdrawn.  The 
incision  will  generally  be  vertical  in  its  direction,  when  the  pupil  is  to  be 
either  at  the  nasal  or  temporal  edge  of  the  cornea  ;  and  horizontal,  if  it  is  to 
be  at  the  upper  or  lower  edge ;  but  it  is  not  necessary  that  it  should  be 
always  so,  or  parallel  to  the  basis  of  the  intended  pupil.  It  may  be  oblique, 
as  is  shown  in  Fig.  144,  where  a  simple  hook  is  represented  as  introduced 
through  an  oblique  incision,  the  lower  edge  of  the  iris  being  about  to  be 
separated. 

The  incision  must  not  be  made  perpendicularly  to  the  lamella;  of  the  cornea, 
but  slantingly  ;  else  it  will  be  difficult,  if  not  impossible,  to  effect  the  protru- 
sion of  the  separated  piece  of  the  iris. 

2(1  Pei'iod. — It  is  desirable  that  the  sudden  withdrawiug  of  the  knife,  aided 
by  the  obliquity  of  the  incision,  should  prevent  the  aqueous  humor  from  being 
discharged  till  the  hook  is  introduced,  which  the  operator  slides,  flat,  with  its 
point  turned  downwards,  along  the  surface  of  the  eye,  till  it  slips  into  the 
incision.  He  then  carries  it  rather  rapidly  through  the  anterior  chamber,  till 
it  reaches  the  angle  between  the  cornea  and  iris,  and  is  even  a  little  way  be- 
hind the  sclerotica,  so  that  it  may  be  applied  to  that  part  of  the  iris  which 
covers  the  ciliary  processes.  Pressing  its  convexity  towards  the  cornea,  and 
turning  its  point  round  towards  the  iris,  the  operator  lays  hold  of  the  ciliary 
edge  of  the  membrane  with  the  hook,  which  he  then  turns  on  its  axis,  till  its 
point  is  directed  upwards. 

If  Schlagintweit's  hook  is  used,  it  is  introduced  shut ;  when  it  has  reached 
the  angle  between  the  cornea  and  iris,  the  pinch  is  drawn  back,  the  iris  is 
seized,  and  the  pinch  is  pushed  on,  so  that  the  instrument  is  again  shut.  The 
iris  is  thus  firmly  grasped  at  a  single  point. 

If  Reisinger's  double  hook  be  used,  the  two  branches  of  the  instrument  are 
to  be  pressed  together,  so  that  it  is  like  a  single  hook.  In  this  state,  it  is 
introduced  as  far  as  the  edge  of  the  iris,  which  is  to  be  separated  from  the 
choroid.  Having  turned  it  round  so  that  its  points  look  towards  the  iris,  the 
operator  slowly  relaxing  his  grasp  of  the  instrument,  allows  its  two  branches 
to  expand,  and  immediately  lays  hold  of  the  edge  of  the  iris  with  the  two 
hooks,  thus  separated  from  each  other.  He  next  closes  the  instrument,  so 
that  the  two  hooks  again  approach  each  other,  carrying  the  iris  with  them, 
and  laying  hold  of  it  as  with  a  pair  of  forceps.  He  then  turns  it  on  its  axis 
till  its  points  are  directed  upwards. 

3c?  Period. — Yery  slowly  the  operator  now  draws  the  hook  through  the 
anterior  chamber  towards  the  incision  of  the  cornea,  carrying  with  it  the  iris, 


ARTIFICIAL  PUPIL  BY   SEPARATION.  825 

between  which  and  the  edge  of  the  cornea  he  perceives  the  artificial  pupil 
gradually  formed.  During  this  period,  the  instrument  must  be  kept  as  close  to 
the  cornea  as  possible,  in  order  to  avoid  any  injury  of  the  crystalline  capsule  ; 
and  as  this  is  the  most  painful  part  of  the  operation,  care  must  be  taken  to 
keep  the  patient's  head  steady,  and  to  guard  against  his  raising  his  hand  to 
his  eye.  The  pupil,  as  it  is  formed,  fills  with  blood,  so  that  it  is  often  im- 
possible to  discern  the  state  of  the  lens  and  capsule. 

Uh  Period. — The  operator  now  requires  to  move  the  handle  of  the  instru- 
ment, so  that  the  convex  edge  of  the  hook  or  hooks  may  slip  easily  out  of 
the  incision  ;  for  if  any  difficulty  occurs  in  bringing  out  the  instrument,  the 
operator  is  apt,  in  attempting  to  obviate  it,  to  lose  hold  of  the  piece  of  iris 
which  he  has  separated.  The  portion  to  be  protruded  rarely  requires  to 
exceed  the  size  of  a  pin's  head.  (Fig.  145).  This,  however,  must  vary  in 
particular  cases;  for  it  sometimes  happens,  from  the  great  extensibility  of 

Fig.  144.  Fig.  145. 


the  iris,  that  the  pupil  will  not  be  of  sufficient  size,  unless  the  separation  is 
continued  even  after  the  hook  is  brought  out  of  the  eye ;  while  in  cases  where 
the  iris  is  diseased  in  texture,  and  its  extensibility  thereby  diminished,  it  is 
sometimes  found  difficult  to  effect  a  protrusion  at  all.  The  operator  must 
be  cautious  of  allowing  the  branches  of  the  double  hook  to  separate,  or  of 
letting  go  his  hold  of  the  iris,  till  he  sees  that  he  has  fully  accomplished  this 
part  of  the  operation,  and  that  the  protrusion  appears  to  be  retained  by  the 
lips  of  the  incision  ;  which  will  be  done  more  effectually  by  carrying  the  pro- 
truded portion  of  the  iris  from  the  middle  of  the  incision  towards  either  of 
its  extremities.  The  instrument  is  then  to  be  freed  from  the  protruding  part 
of  the  iris. 

The  portion  of  iris  separated  from  the  choroid  when  Schlagintweit's  hook, 
or  a  simple  hook,  is  used,  is  much  less  extensive  than  the  portion  separated 
by  Reisinger's  double  hook.  The  form,  therefore,  of  the  artificial  pupil, 
when  the  latter  instrument  is  used,  is  that  of  an  equilateral  triangle ;  when 
the  former  is  employed,  the  angle  towards  the  incision  is  acute,  or  the  arti- 
ficial pupil  may  Ibe  little  more  than  a  chink,  with  its  basis  turned  towards  the 
margin  of  the  cornea,  a  shape  just  the  opposite  of  the  pupil  formed  by  pro- 
lapsus, and  not  nearly  so  favorable  for  vision. 

The  eye  should  instantly  be  shut,  as  soon  as  the  hook  is  disengaged,  in 
order,  by  the  pressure  of  the  lids,  to  assist  in  retaining  the  protruding  por- 
tion of  the  iris.  After  a  few  minutes,  the  eye  may  again  be  opened,  in  order 
to  ascertain  the  state  of  the  prolapsus.  Should  this  have  disappeared,  by 
the  iris  having  retracted,  which  is  not  likely  to  happen  unless  the  incision  of 
the  cornea  is  too  large,  the  canula-forceps  ought  to  be  introduced,  the  sepa- 
rated part  again  brought  out,  and,  to  insure  the  object  of  the  operation,  the 
protruding  portion  snipt  off  with  the  scissors,  thus  combining  excision  with 
separation. 

Should  the  application  of  the  hook,  single  or  double,  not  effect  a  satisfac- 
tory separation,  but  rather  tear  the  iris,  which  is  likely  to  happen  only  when 
its  texture  is  softened  by  disease,  the  portion  which  is  protruded  will,  in  all 
probability,  be  too  small  to  remain  fixed  in  the  wound  of  the  cornea,  and 
will  be  apt  therefore  to  recede,  the  consequence  of  which  will  be  that  the 


826  FORMATION   OF   AN   ARTIFICIAL  PUPIL. 

pupil  will  be  too  small,  and  will,  in  general,  be  soon  filled  up  by  effused 
lymph.  Reisinger  recommends,  therefore,  under  such  circumstances,  the  ex- 
cision of  the  protruded  part  of  the  iris. 

When  the  fibres  of  the  iris  are  in  a  state  of  unnatural  tension  previous  to 
the  operation,  as  may  happen  from  there  having  been  a  former  protrusion  of 
that  membrane  through  a  wound  of  the  cornea,  or  through  a  penetrating 
ulcer,  the  protruding  of  a  portion  of  the  separated  iris  may  sometimes  be 
dispensed  with ;  as,  in  such  a  case,  there  is  little  or  no  danger  of  the  iris 
returning  towards  the  choroid. 

When  cataract  coexists  with  such  changes  in  the  cornea,  or  iris,  as  may 
demand  the  formation  of  an  artificial  pupil,  and  when  we  attempt  this  by 
the  operation  of  separation,  it  will  in  general  be  useless,  or  even  improper, 
to  attempt  anything  for  the  removal  of  the  cataract  at  the  time  of  forming 
the  artificial  pupil.  Extraction  is  plainly  out  of  the  question,  and  it  would 
be  better  to  defer  division  or  displacement  till  the  eye  has  recovered  from  so 
severe  an  operation  as  the  separation  of  the  iris  from  the  choroid.  Indeed, 
the  flow  of  blood  into  the  aqueous  chambers  is  in  general  so  great  as  to  make 
it  impossible  for  us  to  discern  the  parts  behind  the  iris  with  sufficient  dis- 
tinctness to  attempt  any  operation  on  the  lens  or  capsule  till  that  blood  is 
absorbed. 

'  Ricerche   sulle  Pupille  Artificiali,  -p.  11  ;  '  Neue    Bibliothek  fiir    dio  Chirurgie    und 

Milano,  1811.  Ophthalmologie  ;    Vol.   i.   p.   454;    Vol.  ii.   p. 

^  Ibid.,  p.  15.  lOG  :  Hannover,  1818,  1819. 

'  Ophthalmologisclie   Bibliothek  von   Himly  '  Das   Coreoncion  ;    eia  Beitrag   zur  kiinst- 

iind  Schmidt,  Vol.  ii.  p.  .31 ;  Jena,  1803.  lichen    Pupillenbildung,  von   Ch.  JUngken,  p. 

'  AVaguer  do   Coremorphosi,  p.  36  ;  Goettin-  61  ;  Berlin,  1817. 

g£e,  1818.  "  Ueber   den    gegenwartigen    Zustand    der 

'  Journal    der  practiscben    lleilkunde,    von  kiinstlichen  Pupillenbildung    in  Deutschland; 

Hufeland  und  Harles,  .Tanuar,  1815,  p.  47.  Miinchen,  1818.     GrUfe,  after   some  time,  en- 

^  Wenzl   Uber  den  Zustand   der  Augenbeil-  deavored   to   improve  his  coreoncion,  by  split- 

kunde  in  Frankreich  und  Deutscbland,  p.  107;  ting  the  hook  into   two,  so  as   to  resemble  in 

Niirnberg,  1815.  some    degree    Ileisinger's    double    hook.     See 

^  Darstellung    einer    leichten    und    sichern  Langenbeck's  Neue  Bibliothek  ;  Vol.  ii.  p.  58. 

Methode  kiinstliche  Pupillen  zu  bilden,  p.  29 ;  "  Lehro  von  den  Augenoperationem,  p.  656; 

Augsburg,  1816.  Berlin,  1829. 


SECTION  IX. — COMPOUND  OPERATIONS  FOR  THE  FORMATION  OF  AN  ARTIFICIAL 

PUPIL. 

1.  I  have  already  mentioned  the  combination  of  separation  with  excision, 
which  has  been  recommended,  when  the  separated  portion  of  the  iris  is  found 
to  recede  towards  the  choroid,  or  when  it  is  too  small  to  remain  fixed  in  the 
wound  of  the  cornea.  In  such  cases,  there  can  be  no  question  of  the  pro- 
priety of  bringing  out  the  separated  portion  of  iris  through  the  incision  of 
the  cornea,  and  removing  it  with  the  scissors. 

2.  Another  compound  operation  was  proposed  by  Donegana,*  namely,  sepa- 
ration with  incision,  but  which  scarcely  deserves  to  be  particularly  noticed. 
The  instrument  employed  by  him  was  a  falciform  needle,  with  which,  intro- 
duced through  the  sclerotica,  he  first  separated  a  portion  of  the  iris  from  the 
choroid,  and  then  endeavored  to  divide  the  iris  from  its  circumference  towards 
its  centre.  The  latter  part  of  the  operation  it  must  be  difficult  to  accomplish. 
Indeed,  it  is  hardly  possible,  by  the  pressure  even  of  the  sharpest  instrument, 
to  effect  a  division  of  the  iris,  after  separation  has  once  commenced. 

3.  It  is  sometimes  found  advantageous  to  add  incision  to  excision.  Thus, 
in  a  case  of  extensive  opacity  of  the  cornea,  with  adherent  iris,  a  segment  at 


ACCIDENTS   IN   FORMING   AN   ARTIFICIAL   PUPIL.  82? 

the  lower  edge  of  the  cornea  remainino;  transparent,  I  first  formed  an  artificial 
pupil  towards  one  extremity  of  the  segment  by  excision,  but  regarding  it  as 
too  small,  instead  of  attempting  an  additional  excision,  I  introduced  Mau- 
noir's  scissors,  and  divided  the  iris  transversely,  so  as  to  enlarge  the  artificial 
pupil  to  a  medium  size. 

4.  In  a  very  interesting  case  recorded  by  Mr.  Dixon, ^  he  first  formed  an 
artificial  pupil  by  penetrating  the  cornea  with  a  broad  cutting  needle,  drawing 
out  a  small  piece  of  iris  with  Tyrrell's  hook,  and  removing  it.  The  pupil 
turned  out*  very  small — a  mere  slit  in  the  iris.  In  a  subsequent  operation,  he 
therefore  enlarged  it,  by  catching  its  upper  edge  with  the  blunt  hook,  thus 
adding  extension  by  prolapsus  to  excision. 


'  Delia  Papilla  Artificialo ;  Milano,  1809.  ^  Lancet,  June  25,  1853,  p.  577. 


SECTION   X. — ACCIDENTS   OCCASIONALLY   ATTENDING   THE   FORMATION   OF   AN 
ARTIFICIAL   PUPIL  ;    AFTER-TREATMENT. 

Many  of  the  accidents  which  are  apt  to  attend  the  formation  of  an  artificial 
pupil  are  similar  to  those  which  accompany  or  follow  the  operations  for  cata- 
ract, and  need  not  be  particularly  insisted  on.     A  few,  however,  are  peculiar. 

1.  On  making  a  section  of  the  cornea,  for  the  purpose  of  forming  an  arti- 
ficial pupil,  by  excision  or  by  separation,  a  portion  of  the  vitreous  humor  is 
sometimes  instantly  evacuated  through  the  wound,  the  hyaloid  being  in  a 
weak  state.  This  may  happen  even  when  the  lens  is  transparent.  Umler 
such  circumstances,  it  is  not  probable  that  the  retina  is  altogether  sound. 
The  operation  must  be  proceeded  with  as  gently  and  as  expeditiously  as 
possible. 

2.  In  whatever  mode  an  artificial  pupil  is  formed,  blood  is  apt  to  be  effused  ; 
more  in  separation,  however,  than  in  the  other  operations,  especially  when 
the  iris  is  altered  in  texture  from  inflammation.  In  separation,  the  trunks  of 
the  bloodvessels  which  nourish  the  iris  are  torn  across,  while  after  long  con- 
tinued inflammation,  the  iris  is  thickened  and  loaded  with  blood.  The  bleed- 
ing after  separation,  and  sometimes  after  excision,  is  so  considerable,  that  it 
goes  on  for  a  few  minutes  through  the  wound  of  the  cornea.  Filling  the 
aqueous  chambers,  the  blood  prevents  us  from  making  any  experiments  re- 
garding the  degree  of  vision  likely  to  be  recovered  by  the  operation.  In  24 
hours,  in  general,  the  pupil  becomes  clear.  Indeed,  it  is  remarkable  with 
what  celerity  a  large  quantity  of  blood  is  sometimes  absorbed  from  the  aqueous 
chambers.  (See  p.  66T.) 

3.  In  attempting  incision  in  Cheselden's  method,  the  iris  is  liable  to  be  torn 
away  in  part  from  the  choroid,  instead  of  being  divided,  or  to  be  both  divided 
and  torn  away.  The  accidental  separation  may  take  place  at  any  part  of  the 
circumference  of  the  choroid,  but  I  believe  it  happens,  contrary  to  what  might 
have  been  expected,  oftenest  at  the  nasal  edge.  The  pupil  formed  by  the 
separation  is  likely  to  continue  open,  if  the  substance  of  the  iris  is  pretty 
healthy,  and  thus  the  patient  may  have  two  artificial  pupils.  I  have  seen  the 
one  by  incision  close,  and  the  one  by  separation  remain  open,  and  prove  useful. 
It  will  as  frequently  happen  either  that  no  pupil  is  formed  by  incision  when 
the  iris  separates  in  this  way  from  the  choroid,  or  that  both  pupils  close  from 
inflammation. 

4.  liittle  or  no  pain  attends  incision  or  excision  ;  but  it  is  otherwise  with 
separation,  owing  to  the  tearing  across  of  the  ciliary  nerves.     The  pain  of 


828  ACCIDENTS   IN   FORMING   AN   ARTIFICIAL   PUPIL. 

separation  is  generally  considerable,  and  sometimes  severe,  rendering  necessary 
the  use  of  opium  after  the  patient  is  put  to  bed.  During  the  operation  the 
assistant  requires  to  be  on  his  guard,  lest  the  patient  suddenly  moves  away  his 
head  when  he  feels  the  pain,  an  accident  which  might  lead  to  the  separation 
of  a  much  greater  portion  of  the  iris  than  the  operator  intended,  or  could  be 
consistent  with  useful  vision. 

5.  It  sometimes  happens  in  the  course  of  an  operation,  that  facts  come  to 
light,  or  circumstances  occur,  sufficiently  pressing  to  make  the  operator  change 
his  determination  in  regard  to  the  kind  of  operation  he  should  perform.  For 
instance,  if  he  open  the  cornea  with  the  view  of  forming  an  artificial  pupil  by 
incision  with  Maunoir's  scissors,  and  the  section  of  the  cornea  is  instantly 
followed  by  protrusion  of  the  iris,  which  I  have  seen  happen  even  when  the 
pupil  was  closed  and  its  circumference  adherent  to  the  capsule,  he  should 
abandon  the  idea  of  incision,  and  form  the  new  pupil  by  excision. 

6.  Should  the  operator  find,  that  he  has  formed  too  small  a  pupil  to  be 
very  useful,  he  ought  immediately  to  enlarge  it,  either  by  repeating  the  ope- 
ration which  he  has  been  performing,  or  by  converting  it  into  some  of  the 
compound  operations  described  in  the  preceding  section.  It  must  be 
observed,  however,  that  an  artificial  pupil  will  often  appear  small  immediately 
after  it  is  formed,  and  while  the  eye  is  drained  of  aqueous  humor,  which,  after 
the  eye  becomes  plump,  will  be  found  of  fully  a  medium  size.  A  pupil, 
formed  by  pi'olapsus  with  Tyrrell's  hook,  will  often  present  an  appropriate  size, 
provided  the  iris  remains  prolapsed  ;  but  if  the  prolapsed  part  be  excised, 
and  the  iris  being  set  free  floats  back  into  the  aqueous  humor,  the  pupil  will 
often  assume  a  size  much  too  large. 

T.  When  too  large  an  artificial  pupil  has  been  formed,  so  that  the  eye  is 
dazzled  even  by  moderate  light,  it  is  necessary  that  the  patient  should  shade 
the  eyes,  or  w'ear  before  the  eye,  in  a  spectacle-frame,  a  piece  of  pasteboard, 
light  wood,  or  brass  plate,  concave  within  and  convex  without,  blackened  on 
both  sides,  and  pierced  in  the  centre  with  a  slit,  or  a  round  hole  of  the  size  of 
the  natural  pupil.  This  will  enable  him  to  see  at  least  all  large  objects ;  and 
often,  yvith  the  aid  of  this  contrivance,  he  will  be  able  even  to  read. 

8.  The  treatment  of  patients  who  have  undergone  an  operation  for  artificial 
pupil,  refers  chiefly  to  the  danger  of  inflammation  coming  on  in  the  eye,  and 
especially  internal  inflammation.  The  patient  for  some  days  must  remain  in 
bed,  his  eyes  excluded  from  bright  light,  and  his  diet  strictly  antiphlogistic. 
Belladonna  may  be  applied  when  the  pupil  has  been  formed  by  incision  or  ex- 
cision, but  ought  to  be  avoided  (at  least  immediately)  after  separation.  Should 
pain  in  the  eye,  or  round  the  orbit,  supervene,  venesection  ought  freely  to  be 
employed,  followed  up  by  the  application  of  leeches.  Calomel,  with  opium, 
ought  instantly  to  be  begun,  in  such  doses  as  are  likely  speedily  to  aflPect  the 
mouth,  and  continued  till  all  danger  of  iritis  seems  past.  The  inflammation 
excited  by  an  operation  for  artificial  pupil  often  partakes  of  the  scrofulous 
character,  and  not  unfrequently  is  scrofulo-catarrhal.  Depletion,  in  such  cases, 
does  not  require  to  be  carried  to  the  same  extent  as  when  the  inflammation  is 
internal ;  and  much  benefit  will  be  derived  from  the  administration  of  the  sul- 
phate of  quinia. 

9.  The  degree  of  vision  recovered  by  the  formation  of  an  artificial  pupil 
necessarily  varies  according  to  the  condition  of  the  eye  before  it  was  operated 
on,  the  kind  of  pupil  which  has  been  formed,  and  the  effects  of  the  operation 
on  the  various  textures  of  the  eye.  If  the  lens  has  been  removed,  either  before 
the  formation  of  the  artificial  pupil,  at  the  same  time,  or  afterwards,  cataract- 
glasses  will  be  required.  If  the  patient  is  short-sighted  or  long-sighted,  but 
the  lens  entire,  he  will  still  be  obliged  to  employ  concave  or  convex  spectacles. 


SCLERECTOMIA.  829 

So  far  as  any  other  sort  of  imperfect  sight  is  concerned,  no  glass  will  he  of 
any  use  to  him. 

It  often  happens,  that  those  in  whom  an  artificial  pupil  has  been  formed, 
present,  in  the  first  instance,  but  very  dubious  signs  of  sensibility  of  the  retina; 
so  much  so,  that  the  operator  may  be  led  almost  to  despair  of  a  restoration 
to  sight.  I  have  known  a  fortnight  to  elapse,  after  all  signs  of  inflammation 
bad  subsided,  before  the  patient  could  tell  one  finger  from  another,  and  yet 
very  tolerable  vision  be  recovered. 

10.  A  pupil  behind  the  upper  edge  of  the  cornea  is  apt  to  be  covered  by 
the  upper  eyelid,  and  is  never  so  useful  as  one  placed  behind  any  other  por- 
tion of  the  cornea.  A  pupil  behind  the  temporal  edge  obliges  the  patient  to 
turn  the  side  of  his  head  forward,  or  to  hold  in  a  lateral  direction  the  object 
he  is  looking  at.  In  some  measure  to  remedy  these  disadvantages,  it  might 
perhaps  be  advisable  to  divide  the  upper  rectus  in  the  former  case,  and  the 
external  rectus  in  the  latter,  so  as  to  cause  an  artificial  strabismus.  This  has 
been  recommended,^  indeed,  with  an  exaggerated  estimate  of  its  value,  as  a 
substitute  for  the  formation  of  an  artificial  pupil,  in  cases  of  partial  opacity 
of  the  cornea.  In  such  cases,  when  the  eye  is  turned  much  to  one  side,  either 
by  a  voluntary  effort,  or  by  a  division  of  one  of  the  recti,  an  oblique  passage 
is  afforded  for  the  rays  of  light  to  strike  the  lateral  part  of  the  retina,  and 
thus  to  produce  an  amount  of  indistinct  vision,  greatly  inferior  to  that  which 
is  gained,  under  the  same  circumstances,  by  the  formation  of  an  artificial  pupil. 
Constrained  to  remove  a  portion  of  the  iris  behind  the  upper  or  outer  margin 
of  the  cornea,  instead  of  very  oblique  vision,  we  may  attain  an  approach  to 
direct  vision,  by  dividing  one  of  the  recti,  and  thus  producing  a  permanent 
distortion  of  the  eye. 

11.  The  formation  of  an  artificial  pupil  may  appear  to  have  succeeded  per- 
fectly; for  example,  by  separation  ;  but  the  case  being  complicated  with  cata- 
ract, a  subsequent  operation  is  necessary  for  the  removal  of  the  lens.  This 
may  also  seem  to  have  been  successfully  accomplished  ;  by  division,  we  shall 
say,  through  the  cornea.  Especially  in  scrofulous  constitutions,  the  ultimate 
result  is  not  unfrequently  disastrous ;  the  eye  begins  to  show  signs  of  atrophy, 
and  ends  in  being  soft  and  amaurotic. 


'  Lancet,  June  25,  1853 ;  p.  577.  p.  122 ;  Bruxelles,  1842 :  Bonnet,  Traite  des  Sec- 

*  Cunier,  Annates  d'Oculistique;  Tome  v.  p.     tions  Tendineuses,  pp.  300,  308;  Lj'ons,  1841. 
200;  Bruxelles,  1841:  Serre.Ib.;  1"  Vol.  Suppl. 


SECTION  XI. — SCLERECTOMIA. 
Fig.  Ammon,  Thl.  L  Taf.  IV.  Fig.  11-16.     Taf.  XVL  Fig.  3. 

This  name  is  applied  to  the  attempt  which  has  sometimes  been  made  to 
form  an  artificial  pupil  by  the  removal  of  a  small  portion  of  the  sclerotica  and 
choroid,  in  cases  where  the  whole  cornea  is  opaque,  in  the  hope  that  the  space 
might  I)e  filled  up  by  a  transparent  membrane.  As  all  such  attempts  have 
failed,  I  hold  it  unnecessary  to  do  more  than  refer  the  reader  to  the  works 
where  he  will  find  the  details.^ 


'  Schmid  de  Pupilla  Artificiali  in  Sclerotica  the  cornea ;  on  which  see  Bigger,  Dublin  Jour- 

aperienda;  Tubingas,  1814:  Ammon,  Zeitsohrift  nal  of  Medical  Science;  Vol.  xi.  p.  408:  Stein- 

fiir  die  Ophthaluiologie ;  Vol.  i.  p.  109  ;  Dres-  berg    do    Transplantatione    Corner,    Beroiini, 

den,  1831 ;  Wutzer,  lb.  p.  486:    Ullmann,  lb.;  1840:  Gomptes  rendus  de  I'Academie  des  Sci- 

Vol.  ii.  p.  123;  Dresden,  1832  :  Nimmo,  Glas-  ences,  25  Septeuibre,  1843.  p.  029;  10  Octobre, 

gow  Medical  .Journal,  April,  1833.  p.  817  :  Translation  of  this  Work  into  French, 

Akin  to   sclerectomia,  is  transplantation  of  p.  xxii. ;  Paris,  1844. 


830  MYOSIS. 


CHAPTER  XXII. 

ABNORMAL  STATES  OF  THE  IRIS,  INDEPENDENT  OF 
INFLAMMATION. 


SECTION  T. — MYOSIS. 
From  iaLoi,  I  shut.    Syn. — Phthisis,  Mydriasis,  Aretseus.    Iridoplegia  pupillam  contrahens. 

Symptoms. — The  pupil  is  very  considerably  below  the  medium  size,  per- 
fectly regular,  extremely  limited  and  slow  in  its  motions,  scarcely  dilating  at 
all  when  the  patient  passes  into  a  dark  place,  and  yielding  little  even  to  the 
influence  of  belladonna.  Both  eyes  are  generally  affected.  The  patient's 
vision  is  obscure,  especially  in  weak  light,  in  some  cases  he  sees  only  during 
certain  hours  of  the  day,  and  when  the  myosis  is  complete,  he  is  almost  totally 
blind.  The  complaint  is  attended  by  pains  in  the  head,  especially  in  the  fore- 
head ;  and  the  subjects  of  the  disease  are,  in  general,  debilitated  or  cachectic 
individuals.  In  a  case  of  well-marked  myosis,  I  found,  on  dilating  the  pupils, 
the  margin  of  the  lenses  marked  by  opaque  radii. 

Proximate  cause. — The  proximate  cause  is  in  fact  unknown  ;  but  has  been 
supposed  to  be,  in  some  cases,  of  a  spasmodic  nature,  and  in  others  paralytic. 
Plenck  admits  a,  spasmodic  myosis,  accompanying  hysterical  and  other  nervous 
diseases,  and  attributable  to  spasm  of  the  orbicular  fibres  of  the  iris  ;  and  a 
paralytic  myosis,  arising  from  palsy  of  the  straight  fibres,  and  attendant  on 
other  paralytic  diseases.' 

It  is  worthy  of  observation,  that  contraction  is  the  natural  state  of  the  pupil 
during  sleep. '^  Under  the  influence  of  a  full  dose  of  opium,  also,  the  pupil 
becomes  greatly  contracted.^ 

The  probability  is,  that  myosis  does  not  so  much  depend,  in  general,  on  any 
disease  directly  affecting  the  substance  of  the  iris,  as  on  some  morbid  change 
in  the  nerves  by  which  this  membrane  is  animated  and  excited  to  motion.  In 
certain  cases,  myosis  comes  to  be  conjoined  with  amaurosis. 

Experiments  by  Pourfour  du  Petit,  and  others,  on  the  great  sympathetic 
nerve  and  nervus  vagus  in  the  neck,  showing  that  their  division  caused  per- 
manent contraction  of  the  pupil  of  the  corresponding  eye,  have  brought 
physiologists  to  the  belief,  that  while  the  nerves  derived  from  the  motor  oculi 
give  the  stimulus  for  contraction  of  the  sphincter,  there  are  antagonistic 
nerves,  sent  to  the  radiating  fibres  of  the  iris,  through  the  great  sympathetic 
and  the  lenticular  ganglion,  from  the  cervical  portion  of  the  spinal  cord,  by 
means  of  which  the  pupil  is  excited  to  expansion.*  This  view  of  the  matter 
would  point  to  some  affection  of  the  spinal  nerves,  as  the  source  of  myosis. 
Romberg  mentions,  that  in  tabes  dorsalis  he  had  found  the  pupil  contracted 
to  the  size  of  a  pin's  head.^ 

Exciting  causes. — Frequent  and  long-continued  employment  of  the  eyes  in 
the  examination  of  minute  objects,  especially  of  those  which  reflect  the  light 
strongly,  induces  an  habitual  contraction  of  the  pupil  :  and  this  ends  in  an 
inability  of  this  aperture  to  expand,  even  when  the  eyes  are  exposed  to  feeble 
light.     Those  who  read  or  write  much  by  candlelight,  embroiderers,  watch- 


MYDRIASIS.  831 

makers,  setters  of  jewels,  and  the  like,  are  thus  exposed  more  than  others  to 
myosis. 

Treatment. — The  few  well-marked  cases  of  this  disease  which  have  fallen 
nnder  my  observation,  appeared  to  be  scarcely  at  all  benefited  by  any  mode 
of  treatment.  Temporary  dilatation  of  the  pupil  by  belladonna,  contrary  to 
what  might  have  been  expected,  only  increased  the  weakness  of  sight  by 
which  the  myosis  was  accompanied,  showing  that  the  disordered  condition  of 
the  iris  is  not  the  whole  disease,  but  only  a  part  of  it.  Antispasmodic  and 
antiparalytic  remedies  are  recommended  in  the  treatment  of  this  disease;  but 
probably  more  good  will  be  effected  by  carefully  guarding  against  the  exciting 
causes  of  the  disease,  than  by  medicines  of  any  kind.  The  eyes  should  be 
shaded  ;  reading,  writing,  and  similar  laborious  occupations  of  the  sight, 
should  be  avoided  ;  exercise  in  the  country  should  be  enjoined  ;  and  the 
patient  should  retire  to  rest  at  an  early  hour. 


'  De  Mnrbis  Oculonim,p.l20  ;  Vienute,  1777.  ^  Taylor  on  Poisons,  pp;  581,  582,  584  ;  Lon- 

The   same  notion  was  promulgated  by    Mau-  don,  1848. 

chart,  in  his  dissertation  De  Pupillas  Phthisi.  ■"  Valentin    do    Funetionibus  Nervorum,    p. 

^  Fontana  dci  Moti  dell'  Iride  ;  Lucca,  1705  :  109  ;  Bernae,  1839. 

Janin,  Memoires  et  Observations  sur  rffiil,  p.  *  Manual  of  the  Nervous  Diseases  of  Man  ; 

8;  Lyon,    1773:  Cuvier,    Legons    d'Anatomie  Vol.  ii.  p.299  ;  London,  1853. 
Comparee ;  Tome  ii.  p.  409;  Paris,  1805. 


SECTION   II. MYDRIASIS. 

From  a.fj.[Jio},^^  obscure.     S>jn. — Platycoria,  Aretseus.     Iridoplegia  puplllam  expaudens. 

Abnormal  dilatation  of  the  pupil  is  styled  7nydriasis  ;  the  iris  no  longer  ex- 
panding, even  although  the  eye  be  directed  to  a  near  object,  or  exposed  to  a 
bright  1^'ht.  Yery  frequently,  this  is  merely  one  of  the  symptoms  attending 
certain  kinds  of  amaurosis  ;  such  as  the  hydrocephalic.  In  other  cases,  it 
accompanies  palsy  of  the  muscles  stimulated  by  the  motor  oculi.  (See  p.  355.) 
Slight  divergence  of  the  affected  eye,  and  a  degree  of  diplopia,  when  both 
eyes  are  open,  indicate  that  the  rectus  internus  is  involved,  as  well  as  the  iris. 
Occasionally  mydriasis  occurs  independently  of  any  other  affection,  and  when 
this  is  the  case,  the  dilatation  is  sometimes  to  such  a  degree,  that  only  a  nar- 
row rim  of  iris  remains  in  view.  Of  course,  in  this  state  of  the  pupil,  vision 
is  so  much  dazzled  by  the  uncontrolled  influx  of  light,  that  the  patient  is 
unable,  especially  in  broad  day,  to  turn  the  affected  eye  steadily  towards  any 
object,  or  to  discern  anything  with  it  distinctly.  Near  objects  especially  ap- 
pear dim  and  confused.  By  looking  through  a  hole  in  a  card,  however,  the 
dazzling  effect  of  too  much  light  is  prevented,  spherical  aberration  is  again 
obviated,  and  the  vision  of  the  eye  laboring  under  mydriasis  is  greatly  im- 
proved. In  many  cases,  the  improvement  is  such  that  the  patient  is  able  to 
read  ;  and  this  fact  constitutes  one  of  the  chief  grounds  of  diagnosis  between 
the  sympathetic  dilatation  of  the  pupil  which  attends  amaurosis,  and  idio- 
pathic mydriasis.  A  convex  glass  also  compensates  fer  the  want  of  power  to 
accommodate  the  eye  to  the  sight  of  near  objects,  and  enables  the  patient  to 
read  ;  but  some  to  do  this  require  both  a  convex  glass  and  the  perforated 
card.  Demours  had  never  seen  mydriasis  in  both  eyes.  This  agrees  with 
general  observation,  although  in  some  rare  instances  both  eyes  are  affected. 
Sometimes  the  disease  passes  from  the  one  eye  to  the  other,'  or  shows  itself 
periodically. 

Causes. — Different  species  of  idiopathic  mydriasis  have  been  distinguished 
by  authors ;  such  as,  1\\q  paralytic,  arising  from  palsy  of  the  sphincter  of  the 


832  MYDRIASIS. 

iris,  and  the  spasmodic,  from  spasm  of  the  straight  fibres.  The  mydriasis 
which  follows  the  application  of  belladonna,  and  some  similar  narcotics,  and 
of  which  advantage  is  taken  in  the  treatment  of  inflammation  of  the  iris,  and 
during  the  performance  of  certain  operations  for  cataract,  is  generally  re- 
garded as  a  paralytic  affection  of  the  fibres  of  the  ciliary  nerves,  derived  from 
the  third  nerve  ;  and  that  this,  and  not  stimulation  of  the  great  sympathetic, 
is  the  cause  of  mydriasis,  appears  probable  from  the  fact,  that  this  affection  is 
so  frequently  present  in  palsy  afi"ecting  the  whole  of  the  third  nerve.  An 
occasional  cause  of  mydriasis  is  the  passage  of  a  large  cataract  through  the 
pupil  in  the  operation  of  extraction.  Preternatural  distension  is  supposed  in 
this  instance  to  give  rise  to  atony  of  the  iris,  which,  generally  after  a  few 
days,  wears  off,  so  that  the  pupil  contracts  to  its  former  diameter.  Blows  on 
the  eye,  blows  or  falls  on  the  head,^  and  incised  or  lacerated  wounds  of  the 
brow  or  temple,  sometimes  induce  mydriasis,  without  any  affection  of  the  optic 
nerve.  It  is  rarely  the  case,  that  any  signs  of  cerebral  disorder  attend  simple 
dilatation  of  the  pupil.  "When  it  originates  from  excess  in  venery,  such  signs 
are  present.  Sometimes  mydriasis  is  complicated  with  neuralgia  in  the 
branches  of  the  fifth  nerve,  especially  the  supraorbitary  branch.^  Mr.  Ware 
observes,  that  most  of  the  persons  with  mydriasis  whom  he  had  seen  had  been 
debilitated  by  fatigue  or  anxiety  before  the  disease  of  the  eye  was  discovered  ; 
and  that  in  some  it  had  been  preceded  by  affections  of  the  stomach  and  ali- 
mentary canal,  I  have  known  it  occur  in  a  dyspeptic  subject,  after  exposure, 
in  a  railway  carriage,  to  a  draught  of  cold  air.  Not  unfrequently,  it  appears 
connected  with  a  rheumatic  diathesis,  and  yields  to  anti-rheumatic  treatment. 

To  mydriasis,  amaurosis  is  sometimes  superadded.  In  other  cases,  amau- 
rosis has  been  known  to  attack  an  eye  which  had  been  cured  of  mydriasis. 

Whatever  view  we  ado})t  regarding  myosis,  that  mydriasis  depends  on  some 
peculiar  change  affecting  the  third  nerve,  and  operating  through  the  ophthal- 
mic ganglion,  and  ciliary  nerves,  is  more  than  probable. 

We  are  indebted  to  Dr.  Wells  and  Mr.  Ware  for  two  interesting  cases  of 
mydriasis. 

Case  355. — Dr.  AVells  was  consulted  by  a  gentleman,  about  35  years  of  age,  Tery  tall, 
and  inclining  to  be  corpulent,  who,  about  a  month  before,  had  been  attacked  with  a  catarrh, 
and  as  this  was  leaving  him,  was  seized  with  a  slight  stupor,  and  a  feeling  of  weight  in 
his  forehead.  He  began  at  the  same  time  to  see  less  distinctly  than  formerly  with  his 
right  eye,  and  to  lose  the  power  of  moving  its  upper  lid.  The  pupil  of  the  same  eye  was 
also  observed  to  be  much  dilated.  In  a  few  days,  the  left  eye  became  similarly  affected 
with  the  right,  but  in  a  less  degree.  Previous  to  this  ailment,  the  patient's  sight  had 
always  been  so  good,  that  he  had  never  used  glasses  of  any  kind.  On  examining  the 
eyes.  Dr.  AVells  could  not  discover  in  them  any  other  appearance  of  disease  than  that 
their  pupils,  the  right  particularly,  were  much  too  large,  and  that  their  size  was  little 
affected  by  light.  At  first,  he  thought  that  their  dilatation  was  occasioned  by  a  defect  of 
sensibility  in  the  retinte  ;  but  he  was  quickly  obliged  to  abandon  this  opinion,  as  the 
patient  assured  him  that  his  sensation  of  light  was  as  strong  as  it  had  ever  been  during 
anj'  period  of  his  life.  Dr.  Wells  next  inquired  whether  objects  at  different  distances 
appeared  to  him  equally  distinct.  He  answered,  that  he  saw  distant  objects  accurately, 
and,  in  proof,  told  what  the  hour  was  by  a  remote  public  clock ;  but  he  added,  that  the 
letters  of  a  book  seemed  to  him  so  confused,  that  it  was  with  difficulty  he  could  make  out 
the  words.  He  was  now  desired  to  look  at  a  page  of  a  printed  book,  through  convex 
glasses.  He  did  so,  and  found  that  he  could  read  it  with  ease.  "From  these  circum- 
stances," observes  Dr.  AVells,  "  it  wa.s.  very  plain  that  this  gentleman,  at  the  same  time 
that  his  pupils  had  become  dilated  and  his  upper  eyelids  paralytic,  had  acquired  the  sight 
of  an  old  man,  by  losing  suddenly  the  command  of  the  muscles  by  which  the  eye  is  en- 
abled to  see  near  objects  distinctly  ;  it  being  known  to  those  who  are  conversant  with  the 
facts  relating  to  human  vision,  that  the  eye  in  its  relaxed  state  is  fitted  for  distant  objects, 
and  that  the  seeing  of  near  objects  accurately  is  dependent  upon  muscular  exertion."^ 

Case  35G. — Mr.  Ware  has  recorded  the  case  of  a  lady  between  30  and  40  years  of  age, 
the  pupil  of  whose  right  eye,  when  she  was  not  engaged  in  reading  or  in  working  with 
her  needle,  was  always  dilated  very  nearly  to  the  rim  of  the  cornea ;  but  whenever  she 


MYDRIASIS.  833 

looked  at  a  small  object  nine  inches  from  the  eye,  it  contracted,  within  less  than  a  minute, 
to  a  size  nearly  as  small  as  the  head  of  a  pin.  Her  left  pupil  was  not  atfected  like  the 
right;  but  in  evei-y  degree  of  light  and  distance  was  contracted  rather  more  than  is  usual 
in  other  persons.  The  vision  was  not  precisely  alike  in  the  two  eyes;  the  right  eye  being 
in  a  small  degree  near-sighted,  and  receiving  assistance  from  a  shallow  concave  glass, 
whereas  the  left  eye  derived  no  benefit  from  it.  The  remai-kable  dilatation  of  the  pupil 
of  the  right  eye  had  existed  for  20  years.  A  variety  of  remedies  had  been  employed  at. 
different  times  to  correct  it,  but  none  of  tliem  had  made  any  alteration. 

Mr.  Ware  mentions  particularly,  that,  in  order  to  produce  the  contraction  of  the  dilated 
pupil  in  this  case,  the  object  looked  at  required  to  be  placed  exactly  nine  inches  from  the 
eye.  If  it  were  brought  nearer,  it  had  no  more  power  to  produce  the  contraction  than 
if  it  were  placed  at  a  remoter  distance.  It  was  also  observed,  that  the  continuance  of 
the  contraction  of  the  pupil  depended  in  some  degree  on  the  state  of  the  lady's  health  ; 
since,  although  the  contraction  never  remained  long  after  the  attention  was  withdrawn 
from  a  near  object,  yet  whenever  the  patient  was  debilitated  by  any  temporary  ailment, 
the  contraction  was  of  much  shorter  duration  than  when  her  health  was  entire.^ 

Prognosis. — Deraours,^  who  appears  to  write  on  mydriasis  fully  more  from 
experience  than  most  authors,  pronounces  rather  a  favorable  prognosis  in 
this  disease.  He  says,  that  unless  it  has  been  the  effect  of  a  contusion  or 
serious  wound  of  the  eye,  he  has  generally  seen  it  yield  one-half  in  the  space 
of  the  first  six  months,  even  in  those  who  employed  no  means  of  cure.  What 
remains  of  the  disease  disappears  much  more  slowly.  He  had  witnessed  com- 
plete restoration  of  the  pupil  to  its  natural  size,  even  after  a  contusion  of  the 
eye,  although  in  such  cases  recovery  is  extremely  rare.  The  result  of  his 
observations  was,  that  seven  cases  out  of  nine  proceed  towards  recovery,  even 
without  any  treatment,  a  statement  to  be  regarded,  in  weighing  the  alleged 
influence  of  remedies ;  and  that  little  more  can  be  done  than  to  accelerate 
the  cure,  chiefly  by  external  stimulants. 

Treatment. — "When  the  patient  shows  signs  of  congestion  in  the  head,  and 
is  of  a  robust  frame  of  body,  bloodletting,  general  or  local,  and  a  spare  diet, 
with  alterative  doses  of  mercury,  followed  by  purgatives,  form  the  line  of  treat- 
ment to  be  pursued. 

In  rheumatic  cases,  small  doses  of  calomel  and  Dover's  powder  prove  use- 
ful; also  the  wine  of  colchicum.  Ammoniated  tincture  of  valerian  has  been 
of  service,  from  half  a  drachm  to  a  drachm  being  given  thrice  daily.  In 
weakly  subjects,  bitter  tonics  ought  to  be  prescribed. 

The  brow  and  temple  should  be  rubbed  morning  and  evening  with  a  stimu- 
lating liniment,  or  with  tincture  of  nux  vomica.  Blisters  to  the  forehead  and 
temple  ought  to  be  employed ;  and  it  may  be  proper  to  dust  the  raw  surface 
with  from  ^'g-  to  \  grain  of  stiychnia.  Mr.  Guthrie  recommends  veratria  as 
an  efficient  remedy,  six  to  eight  grains  being  dissolved  in  an  ounce  of  spirit, 
with  which  the  upper  eyelid  and  forehead  are  to  be  painted.'  Small  electric 
sparks  may  be  alternately  drawn  from,  and  directed  against,  the  eye,  and 
the  surrounding  parts,  for  a  few  minutes  daily;  or  one  pole  of  the  electro- 
magnetic machine  may  be  applied  to  the  forehead,  while  the  other  is  made  to  . 
touch  the  eyeball. 

Ergot  of  rye,  taken  in  doses  of  from  three  to  twenty  grains,  three  times  a 
day,  or  the  same  substance  used  as  snuff,  has  been  recommended.  In  some 
cases,  its  effects  appear  to  have  been  remarkably  advantageous ;  in  others 
null.« 

Demours  remarks,  that  if  any  acrid  liquid  is  dropped  upon  an  eye  affected 
with  mydriasis,  even  although  the  dilatation  of  the  pupil  has  been  carried  to 
the  utmost  degree,  that  aperture  instantly  contracts  nearly  one-half,  and  the 
patient  recovers  for  a  minute  or  two  the  power  of  seeing  such  minute  objects 
as  previously  he  had  been  able  to  distinguish  only  by  looking  through  a  hole 
in  a  card.  "We  have  no  specific  for  causing  contraction  of  the  pupil,  possess- 
ing a  property  the  opposite  of  what  exists  in  belladonna.  It  does  not  appear, 
53 


834  TREMULOUS   IRIS. 

then,  to  be  of  mucli  importance,  what  stimulating  fluid  is  chosen  for  the  pur- 
pose of  producing  a  temporary  contraction  of  the  pupil.  Even  water  has  the 
effect  in  some  degree.  Wine  of  opium,  pure  or  diluted,  is  oftenest  used, 
being  dropped  upon  the  eye  once  or  twice  a  day.  A  similar  preparation  of 
aconite  is  likely,  from  what  has  been  observed  in  toxicological  experiments, 
to  have  a  considerable,  yet  by  no  means  specific,  effect.^ 

M.  Serre,  of  Uzes,  has  ventured  to  treat  mydriasis,  by  the  application  of 
nitrate  of  silver  to  the  cornea,  near  its  junction  with  the  sclerotica.  In  a 
memoir  presented  to  the  Royal  Academy  of  Medicine,  he  related  four  cases 
in  illustration  of  the  success  of  his  method,  and  the  committee  of  the  Academy 
to  whom  the  subject  was  referred,  found  the  application  of  the  caustic,  in  the 
manner  directed  by  M.  Serre,  efficacious  in  three  other  instances.  The  caustic 
is  applied  only  for  a  second.  It  produces  redness  of  the  external  vessels  of 
the  eye,  followed  by  a  copious  secretion  of  tears  and  of  the  nasal  mucus,  with 
smart  pain  in  the  forehead  and  cheek.  The  slight  cloud  which  appears  on 
the  cornea,  in  consequence  of  the  application,  rarely  continues,  we  are  told, 
above  a  few  days.  The  cylinder  of  caustic,  filed  down  to  the  form  of  a  pencil, 
is  intended,  I  presume,  to  touch  only  a  single  point  of  the  conjunctiva;  yet 
even  this  limited  application,  although  only  for  an  instant,  may  be  followed 
by  violent  irritation.*" 

A  safer  mode  of  stimulating  the  iris  to  contraction,  is  that  employed  by 
Dr.  Fronmiiller,  and  which  consists  in  making  the  patient  read,  for  a  certain 
period  every  day,  with  the  affected  eye,  through  a  convex  glass,  beginning 
with  one  of  the  longest  focus  which  renders  the  print  distinct,  say  of  12  or  14 
inches,  and  gradually  passing,  as  the  pupil  gains  in  power  of  contraction,  to 
those  of  a  still  longer  focus,  till  the  disease  is  completely  removed.  The 
stimulation,  in  this  mode  of  cure,  is  applied  to  the  retina,  and  being  conveyed 
to  the  brain  is  reflected  from  it  to  the  third  nerve  and  to  the  ciliary  nerves." 


'  Bowman,  Medical  Times  and  Gazette,  June  cine,  Noveinbre,  IS38,  p.  351;  Coraperat,  Lon- 

23,  1853,  p.  91.  don   Medical    Gazette,   September  8,   1848,  p. 

*  Brodie,   Medico-Chirurgical    Transactions,  435;     jMcEvers,  Dublin    Quarterly  Journal  of 
Vol.  xiv.  p.  354;  London,  1828.  Medical  Science,  November,  1848,'p.  484;  Bow- 

'  London  Medical  Gazette;  Vol.  xxii.  p.  68.  man,  Op.  cit.  p.  92. 

*  Philosopbical  Transactions;  Vol. ci. p.  378;  '  Fleming's  Inquiry  into   the  properties  of 
London,  1811.  Aconitum  Napcllus,  pp.  21,  32;  London,  1845. 

'  Ibid.;  Vol.  ciii.  p.  36  ;  London,  1813.  '"  Archives   Gen6rales  de  Medecine;  Tome 

'  Traite  des  Maladies  des  Yeux  ;  Tome  i.  p.  xvii.  p.  307;  Paris,  1828. 

444  ;  Paris,  1818.  "  Annales  d'Oculistique  ;  Tome  xxiv.  p.  197 ; 

'■  Medical  Times,  March  9,  1844,  p.  409.  Bruxelles,  1850. 

*  Kochanowski,  Archives  Gen^rales  dc  Mede- 


SECTION  III. — TREMULOUS  IRIS. 


Srjn. — Iridodonesis.     From  ipif,  iris,  and  hvica,  I  shake. 

The  cases  in  which  the  iris  is  affected,  on  every  movement  of  the  eye,  with 
a  peculiar  tremulous  or  undulatary  motion,  are  various,  and  by  no  means 
unfrequent.  In  some,  the  waving  motion  is  striking ;  in  others,  it  is  seen 
only  when  the  eye  is  considerably  moved,  and  even  then  it  may  be  so  slight, 
that  it  must  be  watched  to  be  detected.  The  texture  of  the  iris,  in  such  cases, 
is  apparently  uninjured,  and  the  pupil  generally  of  its  natural  form  ;  but  the 
membrane  seldom  appears  to  retain  any  power  of  contracting  or  expanding. 
I  have  seen  it,  however,  from  sympathy  with  the  pupil  of  the  other  eye,  which 
was  healthy,  move  briskly  and  extensively. 


GLAUCOMA.  835 

A  tremulous  state  of  the  iris  is  frequently,  but  not  necessarily  connected 
with  amaurosis.  We  meet  with  it  combined  with  cataract,  and  especially 
with  capsulo-lenticular  cataract.  It  is  extremely  apt  to  follow  an  operation 
for  the  removal  of  capsulo-lenticular  cataract.  I  have  seen  it  follow  the  most 
successful  extraction  of  a  common  lenticular  cataract,  without  affecting  vision 
in  the  slightest  degree.  It  often  results  from  a  blow  on  the  eye,  and  in  this 
case  is  generally  attended  by  a  partial  or  complete  insensibility  of  the  retina, 
and  opacity  of  the  lens.  I  have  seen  it  arise  from  a  small  accidental  wound 
of  the  sclerotica  and  choroid,  immediately  behind  the  edge  of  the  cornea ; 
also,  from  the  puncture  made  for  the  extraction  of  a  secondary  capsular 
cataract  through  the  sclerotica,  the  ciliary  muscle  and  processes  being  pro- 
bably wounded,  from  approaching  too  near  to  the  edge  of  the  cornea.  In 
the  last-mentioned  case,  vision  did  not  seem  to  suffer.  In  those  born  amau- 
rotic, or  affected  with  congenital  cataract,  tremulousness  of  the  iris  is  often 
met  with  ;  and  in  such  subjects,  it  is  attended  by  oscillation  of  the  eyeball. 
(See  p.  389.)  When  this  disease  of  the  iris  is  combined  with  cataract,  the 
latter  not  unfrequently  partakes  of  the  tremulous  motion,  and  after  a  time 
is  likely  to  sink,  from  the  vitreous  humor  being  dissolved.  After  operations 
for  cataract  on  eyes,  the  vitreous  humor  of  which  has  been  previously  dis- 
solved, or  from  which  a  considerable  quantity  of  the  vitreous  humor  is  lost 
at  the  operation,  the  iris  frequently  presents  this  undulatory  motion. 

In  almost  all  cases  of  tremulous  iris,  there  appears  to  be  a  larger  quantity 
of  the  aqueous  fluid  in  the  posterior  chamber  than  natural ;  and  in  many  of 
them,  the  whole  cavity  behind  the  iris  is  filled  with  fluid,  in  consequence  of 
destruction  of  the  hyaloid  tissue.  The  iris  hangs  loose,  and  is  unable  to 
resist  those  undulations  of  the  aqueous  humor  which  take  place  whenever  the 
eye  is  turned  from  side  to  side.  It  is  then  only,  in  fact,  that  the  tremulous- 
ness of  the  iris  is  perceptible.  We  do  not  observe  it  so  long  as  the  patient 
fixes  his  attention  on  the  same  object,  nor  does  the  attempt  to  accommodate 
the  eye  to  objects  placed  at  a  variety  of  distances,  but  in  the  same  right  line, 
appear  to  produce  the  motion  in  question. 

This  affection  of  the  iris  has  hitherto  been  regarded  as  incurable,  and  cer- 
tainly it  affords  an  unfavorable  index  of  the  state  of  the  vitreous  humor,  and 
must  make  us  suspicious  also  of  the  retina. 


CHAPTER   XXIII. 
GLAUCOMA  AND  CAT'S-EYE. 


SECTION  I. — GLAUCOMA. 


Syn. — r'Ka.mtufji.a  and  y'Ka.iiKoo^iq,  from  yXauxof,  blue,  green,  or  gray :  because  of  the  bluish, 
greenish,  or  grayish  appearance  of  the  pupil.  Der  griine  Staar,  Gcr.  Diplochromatism 
of  crystalline  lens. 

Fiff.  Beer,  Band  II.  Taf.  IV.  Fig.  2.  Taf.  III.  Fig.  6.  Band  I.  Taf.  III.  Fig.  1.  AVeller,  Tab.  II. 
Ammon,  Thl.  I.  Taf.  X,  Figs.  13,  IS,  19,  24.  Taf.  XV.  Fig.  I.  Dalrymple,  El.  XXIII.  Sichel, 
PL  XXV.  Figs.  3,  4. 

Distinctive  character. — The  distinctive  character  of  glaucoma  is  a  green 
or  greenish  color  of  the  pupil. 

Dejinition. — It  is  not  easy  to  give  a  definition  of  glaucoma;  for  this  reason, 
that  although  the  peculiar  green  appearance  seen  behind  the  pupil,  whence 


836  GLAUCOMA. 

the  disease  is  named,  is  an  invariable  character  in  its  early  stages,  the  symp- 
toms which  follow  embrace  a  great  variety  of  different  phenomena,  or  perhaps, 
more  correctly,  the  collateral  phenomena  are  so  many  different  diseases,  with 
which  glaucoma,  strictly  so  called,  is  combined.  Unfortunately,  the  collateral 
diseases  are  often  of  an  obscure  nature,  whence  arises  the  difficulty  of  mould- 
ing this  subject  into  something  like  consistency. 

Nosological  History. — It  is  evident  that  Hippocrates  comprehended,  under  the  term 
glaucoma,  every  sort  of  opacity  which  appears  behind  the  pupil.  Thus,  in  enumerating 
the  diseases  to  which  man  is  exposed  at  different  periods  of  life,  he  mentions,  along  with 
others  to  which  old  age  is  subject,  o<f>9aX^a}v  xai  ^v£v  lyfOTma;,  a/x^Xvinriai,  yXawdirn;,  xal 
Bapvnxoiat,^  evidently  employing  the  term  yXavKciTii^  to  signify  rather  a  class  of  diseases 
than  any  single  affection  of  the  transparent  parts  of  the  eye.  The  appearances  arising 
from  effusion  of  lymph  into  the  pupil,  or  what  we  now  term  spurious  cataract,  are  no 
doubt  very  different  from  those  presented  by  capsular  or  lenticular  opacity;  and  these, 
in  their  turn,  are,  in  general,  readily  discriminated  from  those  opacities  which  seem  to  be 
situated  still  deeper  in  the  eye.  We,  who  have  the  advantage  of  knowing,  by  dissection, 
the  differences  of  these  three  kinds  of  disease  which  affect  the  transparent  media  of  the 
eye,  need  not  be  surprised  that  they  were  not  accurately'  distinguished  by  the  father  of 
medicine,  who,  though  he  did  not  fail  to  observe  that  the  xo'pai  yXavKov/xevai  presented 
various  colors  and  forms  in  different  cases,  that  this  class  of  diseases  of  the  e3'e  arose 
from  a  variety  of  causes,  and  that  some  of  these  diseases  were  more  destructive  of  vision 
than  others, 2  had  probably  enjoyed  no  opportunity  of  ascertaining,  after  death,  the  nature 
of  those  changes  upon  which  the  yXavudjssi  depend;  nor  had  he  tlie  advantage  of  knowing 
that  some,  at  least,  of  these  diseases  could  be  removed  by  operation,  and  in  this  way 
vision  be  restored. 

It  is  uncertain  by  whom,  or  at  what  period,  the  term  imx_viua  or  I'tto^vo-k;  was  first 
employed  to  signify  a  particular  species  of  opacity  behind  the  pupil.  That  it  had,  in  a 
great  measure,  superseded  the  generic  appellation  employed  by  Hippocrates,  is  evident 
from  the  manner  in  which  Celsus  introduces  this  subject  to  our  notice,  and  from  his  total 
omission  of  yXaixai/xa  or  )/Xa'jxa)s-i?.  "  Suffusio  quoquc,"  says  he,  "  quam  Grteci  iiTrop^urtv 
Dominant,  interdum  oculi  potentia3  qua  cernit,  se  opponit."''  Suffusio,  here,  is  notiiiug 
more  than  a  translation  of  vni-xyyn;,  and  expresses  the  conjectural  and  unfounded  notion 
which  the  Greeks  had  adopted  regarding  the  nature  of  cataract.  They  did  not  know 
that  this  disease  is,  in  general,  nothing  more  than  a  change  in  the  transparency  and  color 
of  a  natural  part  of  the  ej'e,  namely,  the  crystalline  lens.  On  the  contrary,  they  had 
been  taught  (probably  by  Herophilus),  that  the  lens  was  the  immediate  organ  of  vision  ;* 
and,  therefore,  they  were  led  to  ascribe  the  disease,  which  they  found  to  prevent  vision 
till  it  was  removed  by  surgical  operation,  to  the  effusion  of  a  new  substance  between  the 
iris  and  the  lens. 

Although  the  diversity  of  opacities  which  occur  behind  the  pupil  had  either  not  attracted 
the  attention  of  Celsus,  or  was  deemed  by  him  unworthy  of  notice,  or  had  not  been  par- 
ticularly insisted  upon  by  the  Greek  authors  from  whom  he  copied,  the  later  Greeks  were 
well  aware  that  the  opacities  seen  through  the  pupil  were  very  different  in  different  cases, 
and  that  only  some  of  them  were  susceptible  of  cure  by  operation.*  Those  which  were 
generally  incurable  they  distinguished  by  the  name  of  yXavmiixara,  while  on  the  more 
favorable  they  bestowed  that  of  liri'xyfji.ara..  They  also  came  to  the  conclusion,  that  the 
former  set  of  opacities  depended  on  a  change  of  color  and  consistence  in  the  crystalline 
lens,  an  opinion  from  which  the  moderns  have  erroneously  departed  ;  but  that  the  latter 
were  to  be  attributed  to  a  morbid  accumulation  between  the  iris  and  the  crystalline,  a 
notion  which  the  moderns  have  successfullj'  corrected.  Abundant  proof  could  be  brought 
that  these  were  the  doctrines  of  Galen,^  and  even  of  Rufus  ;''  and,  if  it  were  necessary,  we 
might  trace  them  through  the  writings  of  Oribasius,  Aetius,  Paulus,  Actuarius,  and  a  crowd 
of  others,  down  to  the  time  of  Bi'isseau.  Even  Maitre-Jan,  to  whom  we  are  in  a  great  mea- 
sure indebted  for  establishing,  by  dissection,  the  fact  that  the  cataract  is,  in  general,  an 
opacity  of  the  crystalline  lens,  and  not  a  filmy  substance  between  that  body  and  the  iris, 
still  maintained  that  glaucoma  also  was  a  disease  of  the  len.s — "une  alteration  toute  par- 
ticuliere  du  cristallin,  par  laquelle  il  se  desseche,  diminue  en  volume,  change  de  couleur 
et  perd  sa  ti'ansparence,  en  conservant  sa  figure  naturelle,  et  devenant  plus  solide  qu'il 
ne  doit  etre  naturellement."^ 

Preceded  by  Lasnier,  Rolfink,  Borel,  and  others,  in  the  discovery  that  the  most  common 
kind  of  cataract  has  its  seat  in  the  crystalline  lens  (a  discover^',  however,  which  he  con- 
firmed by  many  valuable  observations),  Brisseau^  appears  to  have  been  the  first  to 
announce  to  the  profession  the  opinion,  which  from  that  day  to  this  they  have  almost 
unniversally  adopted,  that,  while  cataract  or  I'no'xyfxa.  was  an  opacity  of  the  lens,  yXauxaiiua 
was  a  similar  affection  of  the  vitreous  humor — an  opacity  deeply  seated  in  the  eye,  fre- 


GLAUCOMA.  83T 

quently  of  a  bluish  or  greenish  color,  and  visible  through  the  transpcarent  lens.  He  had 
been  led  to  this  opinion  partly  from  what  had  been  detected  on  dissecting  the  eyes  of 
Bourdelot,  physician  to  Louis  XIV.,  who,  having  been  the  subject  of  a  disease  pronounced 
to  be  cataract,  left  orders  that  his  eyes  should  be  examined  after  death,  in  order  to  throw 
some  light,  if  possible,  on  the  much  agitated  question,  whether  cataract  was  a  film  occupy- 
ing the  posterior  chamber,  or  an  affection  of  the  crystalline  body.  The  dissection  was 
performed  by  Marechal.  The  lens  in  the  right  eye,  with  which,  for  many  years,  the 
patient  had  been  scarcely  able  to  distinguish  light  from  darkness,  was  found  to  be  totally 
opaque ;  its  exterior  lamellte  were  less  solid  than  the  interior,  forming,  as  it  were,  a 
whitish  membrane  of  about  half  a  line's  thickness,  which  included  a  nucleus  of  more 
solid  consistence,  and  of  a  yellowish  color.  Immediately  behind  the  fossula,  which  con- 
tained the  lens,  the  vitreous  humor  was  also  opaque,  to  the  depth  of  more  than  a  line, 
and  tinged  of  a  yellow  color,  although  not  to  the  same  degree.  The  left  eye,  with  which 
Bourdelot  had  continued  to  see  with  tolerable  distinctness,  had  begun  to  be  affected  in  a 
similar  way ;  for  the  lens  had  already  lost  much  of  its  natural  transparency,  and  the 
vitreous  humor  in  contact  with  it,  was  slightly  yellow.  Brisseau  drew  the  conclusion 
from  this  dissection,  that  in  such  cases  the  complication  of  diseases  would  necessarily 
render  abortive  any  attempt  to  restore  sight  by  operation;  that  although  the  lens  were 
couched,  the  opacity  of  the  vitreous  humor  would  still  continue,  and  be  sufficient  to 
impede  the  passage  of  the  rays  of  light  to  the  retina.  He  considered  himself,  also,  justi- 
fied in  claiming  for  this  opacity  of  the  vitreous  humor  the  name  of  fflaucomaJ" 

Brisseau,  moreover,  having  demonstrated  to  his  full  satisfaction  that  cataract  was  an 
opacity  of  the  lens,  was  naturally  led  to  the  conclusion  that  the  vitreous  humor  was  sub- 
ject to  a  similar  affection,  from  the  well  ascertained  fact,  that  the  loss  of  sight  attendant 
on  the  disease  called  glaucoma  was  incurable  by  operation,  which  he  thought  could  not 
have  been  the  case  had  it  consisted,  as  was  generally  pretended,  in  a  desiccation  and 
change  of  color  of  the  lens.  He  reasoned  that  had  glaucoma  resided  in  the  lens,  it  would 
have  been  cured  by  the  operation  of  depression  ;  but  as  it  was  notorious  that  this  opera- 
tion did  not  cure  the  blindness  which  accompanies  glaucoma,  he  concluded  that  it  was  a 
disease  of  some  other  part  of  the  eye.  He  fixed  upon  the  vitreous  humor  as  its  seat ; 
partly  vindicated,  no  doubt,  in  doing  so,  by  the  above  mentioned  dissection  by  Marechal. 
Brisseau  was  not  aware  that  the  chief  cause  of  the  loss  of  sight  in  glaucoma  resides  neither 
in  the  lens,  nor  in  the  vitreous  liumor,  but  in  the  retina. 

The  generality  of  modern  authors  have  adopted,  without  hesitation,  the  doctrine  that 
glaucoma  is  a  disease  of  the  vitreous  humor.  They  speak  of  it  as  an  opacity  of  the  hya- 
loid membrane,  or  of  the  fluid  therein  contained,  and  some  of  them  as  an  inspissation  of 
the  latter,  as  the  following  extracts  show  : — 

"  Quando  s'intorbida  anche  I'umor  vitreo  nel  glaucoma,  malattia  gravissima  deU'occhio, 
spesso  I'iride  o  non  si  muove  piii,  o  appena  si  muove.  .  .  .  Nel  glaucoma,  se  tutto  Tumor 
vitreo  divenne  opaco,  perche  i  raggi  non  passano  piu,  I'iride  non  si  muove  punto,  o  poco, 
se  pochi  raggi  vi  possano  passare." — Fontana.^^ 

"Stepenumero  nimis  spissum,  tenax  et  obscurum  est  hoc  corpus  vitreum,  et  jam  parit 
glaucoma. —  Voit.^^ 

"  Glaucoma  obscurationem  humoris  vitrei  e  membranoe  hyaloideas  exhibet." — Fabini.^^ 

"In  some  cases  the  vitreous  humor  acquires  a  dull-greenish  color,  accompanied  with 
insensibility  of  the  retina,  a  species  of  amaurosis  which  has  generally  been  called  glau- 
coma."—  Wardrop.  '* 

Professor  Jiingken  states '*  glaucoma  to  be  a  cloudiness  of  the  vitreous  body,  caused  by 
exudation,  the  product  of  chronic  inflammation  of  the  hyaloid  membrane.  He  says  that 
the  retina  always  suffers  along  with  the  vitreous  body,  whence  the  concomitant  appearance 
of  amaurosis  with  glaucoma.  He  tells  us,  that  glaucoma  is  characterized  generally  by  a 
gray-greenish  sea-colored  cloudiness  in  the  bottom  of  the  eye,  remote  from  the  pupil,  and 
appearing  concave.  He  notices  only  one  variety  of  the  disease,  and  never  hints  at  any 
other  seat  of  the  complaint  than  the  vitreous  body. 

Professor  Rosas,  in  his  latest  work  '^  on  diseases  of  the  eye,  distinguishes  three  kinds  of 
glaucoma ;  viz :  one  of  the  hyaloid,  another  of  the  retina,  and  a  third  of  the  choroid. 
He  makes  no  mention  of  the  lens,  which,  however  true  it  is  that  other  textures  are  in- 
volved in  the  disease,  is  always  the  seat  of  that  change,  which  gives  rise  to  the  greenish 
appearance  behind  the  pupil. 

Distinctions. — I  have  already  (pp.  542,  551,  553)  had  occasion  to  mention 
the  occurrence  of  glaucoma  in  cases  of  arthritic  iritis,  and  in  acute  and  chronic 
choroiditis,  in  all  of  which  cases  there  is  reason  to  think  that  the  lens  is 
already  affected  with  the  peculiar  change  which  constitutes  glaucoma,  before 
attention  is  directed  to  the  condition  of  the  humors  of  the  eye,  and  of  vision, 
by  the  supervention  of  one  or  other  of  those  ophthalmise.     The  patient  sud- 


838  GLAUCOMA. 

clenly  becoming  blind  in  acute  choroiditis,  and  tlae  eye  presenting-  a  green 
reflection  behind  the  pupil,  the  name  acute  glaucoma  has  sometimes  been 
employed.  The  disease  we  are  now  about  to  consider  is,  in  contradistinction, 
designated  as  chronic  glaucoma.  It  is  of  frequent  occurrence,  is  in  its  early 
stages  attended  by  no  external  signs  of  inflammation,  and  being  slow  in  the 
progress  which  it  makes  in  changing  the  appearance  of  the  dioptric  media  of 
the  eye,  and  invading  the  perfection  of  vision,  is  apt  to  be  confounded  with 
cataract. 

Subjects. — Glaucoma  is  a  disease  which  does  not  occur  except  after  middle 
age.  Dark-eyed  persons  are  more  liable  to  it  than  those  the  color  of  whose 
iris  is  blue  or  gray.  The  subjects  of  glaucoma  are  often  myopic.  They  often 
labor  under  the  symptoms  of  irregular  gout,  and  not  unfrequently  have  long 
suffered  from  those  pains  in  the  teeth  and  head  which  are  generally  accounted 
rheumatic. 

Stages. — Glaucoma  comprehends  a  series  of  morbid  changes,  which,  in 
genera],  develops  itself  only  in  the  course  of  years,  to  involve  at  last  all  the 
structures  of  the  eye. 

1st  stage.  The  earliest  appearance  of  glaucoma  is  merely  a  greenish  hue, 
reflected  from  behind  the  pupil,  and,  as  is  shown  by  the  liveliness  of  the  iris  and 
the  sensibility  of  the  retina,  not  necessarily  connected  with  any  material  de- 
terioration of  vision.  The  nucleus,  or  central  lamina?,  of  the  lens  have  become 
not  merely  of  the  yellowish  hue  which  pervades  the  whole  substance  of  the 
crystalline  in  advanced  life,  but  of  a  reddish  or  brownish  amber  color. 

2d  stage.  A  muddy  green  color  of  the  crystalline  marks  the  second  stage ; 
and  along  with  this  there  is  a  sluggishness  of  the  pupil,  and  more  or  less 
obscurity  of  vision.  The  pupil  is  not  dilated,  nor  irregular.  If  there  is  any 
change  in  the  consistence  of  the  eyeball,  it  is  rather  firmer  than  natural.  This 
stage  may  last  for  five  or  six  years,  or  more,  vision  declining  by  insensible 
degrees  all  the  time,  but  without  pain  or  external  redness  of  the  eye.  The 
reddish  or  brownish  amber  color,  which  in  the  first  stage  was  confined  to  the 
nucleus,  graduall/pervades  the  whole  lamina3  of  the  lens.  Yision  is  thereby 
impeded  nearly  as  in  cataract ;  but  there  is  little  or  no  coagulation  of  the  len- 
ticular substance,  little  or  no  white  infiltration  between  the  fibres  of  the  lens, 
such  as  exists  in  cataract.  A  most  important  fact  regarding  this  stage  of  glau- 
coma is,  that  it  may  or  may  not  be  attended  by  amaurosis.  If  not  so  attended, 
it  constitutes  the  cataracte  lenticulaire  verte  operable  of  M.  Sichel. 

od  stage.  An  abnormal  hardness  of  the  eye,  with  immobility  and  unequal 
dilatation  of  the  pupil,  a  varicose  state  of  the  external,  and  probably  of  the 
internal,  bloodvessels,  and  a  still  more  marked  loss  of  sight,  are  signs  of  the 
third  stage.  The  patient  now  complains  of  the  frequent  occurrence  of  a  cloud 
over  his  sight,  continuing  for  hours  or  days,  of  sensations  of  fiery  and  pris- 
matic spectra,  alternating  with  fixed  muscoe,  of  intolerance  of  light,  and  of 
pain  in  and  round  the  eye.  In  this  stage  the  choroid  is  inflamed  ;  eff'usion 
taking  place  from  its  internal  surface,  the  retina  is  compressed  ;  the  vitreous 
tissue  is  disorganized,  and  a  superabundant  watery  secretion  comes  to  occupy 
its  place.  For  a  time,  the  eye  may  continue  sensible  to  objects  placed  to  one 
or  other  side  of  the  patient,  while  in  every  other  direction  nothing  is  distin- 
guished.    At  length,  the  retina  becomes  totally  insensible. 

ith  stage.  In  the  fourth  stage,  the  crystalline  becomes  cataractous  as  well 
glaucomatous.  Hitherto  of  a  horny,  muddy  green  hue,  its  surface  slowly  or 
suddenly  becomes  of  an  opaque  white  color.  {Cataracta  viridis,  vel  glauco- 
matosa,  Beer.)  The  lens  also  appears  augmented  in  thickness,  and,  pressing 
forwards  through  the  pupil,  it  at  length  touches  the  cornea.  The  edge  of  the 
pupil  sometimes  appears  rolled  back  into  the  posterior  chamber ;  in  other 
cases  pressed  forwards,  and  fringed  with  the  uvea.     The  iris  is  changed  in 


GLAUCOMA.  839 

color,  its  texture  appears  thinned,  its  fibrous  structure  is  no  longer  discernible, 
and  patches  of  it,  as  Mr.  Wardrop  mentions,'^  seem  eroded.  Varicose  vessels 
are  observed  traversing  its  surface,  and  red  spots,  as  if  from  effused  blood, 
form  between  the  iris  and  the  cornea.  The  sclerotica  becomes  attenuated, 
and  a  choroid  staphyloma  sometimes  rises  abruptly  on  the  surface  of  the  eye. 
Perception  of  external  light  is  totally  lost,  but  the  patient  is  still  affected  with 
sensations  of  flashing  in  the  eye,  from  pressure  on  the  retina. 

bth  stage.  In  the  fifth  stage,  the  cornea,  irritated  by  the  projecting  and 
hypertrophied  lens,  appears  hazy  and  rough,  and  is  partially  infiltrated^^'ith 
blood;  it  inflames,  and  gives  way  by  ulceration  ;  the  lens,  softened  and  opaque, 
escapes  from  the  eye,  and  the  vessels  of  the  iris  and  choroid  bleed  profusely 
through  the  ruptured  cornea. 

Qth.  stage.  The  sixth  stage  presents  the  eye  quiet  and  atrophied.  This 
state  may  ensue  even  without  bursting  of  the  cornea;  the  inflammatory  symp- 
toms subsiding  of  themselves,  and  the  contents  of  the  eyeball  undergoing 
absorption,  so  that  it  shrinks  to  less  than  its  normal  size ;  and,  instead  of  the 
preternatural  hardness  which  it  formerly  presented,  becomes  boggy,  and  sinks 
into  the  orbit. 

These  different  stages  of  glaucoma  run  insensibly  into  each  other.  Al- 
though the  disease  is  scarcely  at  any  period  of  its  course  amenable  to  treat- 
ment, it  is  no  uncommon  thing  for  it  to  be  spontaneously  arrested  in  one  or 
other  of  these  stages,  and  to  make  no  further  progress.  It  often  remains 
stationary  in  the  first  stage  for  a  great  part  of  life;  the  lens  is  glaucomatous 
or  diplochromatic,  but  vision  is  not  materially  impeded.  Under  the  second 
stage,  it  often  happens  that  as  the  amber-colored  degeneration  proceeds  in- 
sensibly towards  the  surface  of  the  lens,  from  year  to  year  the  vision  becomes 
more  and  more  imperfect,  without  the  other  textures  of  the  eye  being  involved. 
The  patient  has  perhaps  been  told  that  cataract  is  forming  in  his  eyes,  and 
that  by  and  by  he  will  be  in  a  condition  for  undergoing  a  cure  by  operation; 
but  both  the  patient  and  the  practitioner  are  apt  to  get  bewildered  in  their 
notions  when  they  find,  that,  instead  of  a  few  months,  as  was  anticipated,  five 
or  six  years,  or  perhaps  twice  that  time,  passes  away,  with  little  apparent  in- 
crease in  the  visible  opacity,  and  a  declension  of  vision,  the  progress  of  which 
is  imperceptible. 

In  the  first  and  second  stages,  glaucoma  is  generally  a  disease  of  the  crys- 
talline alone.  I  say  generally,  for  sometimes  amaurosis  accompanies  glaucoma 
from  the  very  commencement,  or  even  precedes  the  visible  changes  which  after- 
wards take  place  in  the  dioptric  media  of  the  eye.  I  have  known  the  disease 
to  set  in  with  fits  of  iridescent  vision,  followed  by  insensibility  of  the  retina, 
and  after  a  time  by  diplochromatism  of  the  lens.  In  its  advanced  stages, 
glaucoma  presents  symptoms  depending  on  certain  morbid  conditions  of 
almost  every  texture  of  the  eye.  The  elements,  in  which  glaucoma  consists, 
when  far  advanced,  reside  in  the  lens,  the  vitreous  humor,  the  retina,  the  cho- 
roid, the  iris,  the  sclerotica,  the  bloodvessels  of  the  eye,  and  even  in  the  cor- 
nea and  conjunctiva.  The  order  in  which  these  dilferent  parts  become  affected 
is  not  invariably  the  same,  nor  the  proportions  in  which  they  take  part  in  the 
complex  disease. 

The  anomalous  appearances,  too,  which  we  occasionally  meet  with  in  glau- 
coma are  numerous.  One  of  these  implicates  the  epidermis  of  the  cornea. 
The  cornea  having  become  semi-opaque,  its  epithelium  is  separated  from 
it  by  a  fluid,  and  rises  in  the  form  of  an  irregular  vesicle.  The  fluid  may  be 
pushed  from  one  place  to  another  of  the  cornea,  under  the  detached  membrane. 
(See  p.  GGO.)  A  very  curious  appearance,  which  I  saw  in  one  case,  was  that 
of  bloodvessels  proceeding  from  within  the  pupil,  bending  themselves  out- 
wards, and  ramifying  over  the  inner  surface  of  the  cornea. 


840  GLAUCOMA. 

Diagnosis. — The  appearances  presented  by  the  eye  in  the  early  stages  of 
glaucoma  are  calculated  to  lead  the  observer  to  conclude,  that  he  is  looking 
through  a  transparent  lens  at  an  opaque  vitreous  humor.  There  is  a  muddi- 
ness,  or  cloudiness  within  the  eye,  but  he  feels  a  difficulty  in  deciding  what 
part  is  afiTected.  The  opaque  appearance  is  more  distinct  when  the  pupil  is 
regarded  directly:  it  disappears  when  viewed  obliquely,  being  the  opposite 
in  this  respect  to  an  optical  phenomenon,  which  I  have  known  to  puzzle, 
namely,  that  which  arises  when  the  light,  falling  obliquely  on  the  eye,  is  con- 
centrated by  the  cornea,  and  again  reflected  from  the  surface  of  the  lens  be- 
hind one  or  other  edge  of  the  pupil.  The  opacity  in  glaucoma  appears  to 
be  more  deeply  seated  than  the  lens;  more  so,  however,  in  the  commence- 
ment of  the  disease  than  after  it  has  continued  for  some  time.  Indeed,  in 
the  earliest  stage,  the  greenish  reflection  appears  to  come  almost  from  the 
bottom  of  the  eye.  As  the  disease  advances,  the  apparent  opacity,  always 
of  a  greenish  color,  and  often  sea-green,  is  seen  as  if  occupying  the  centre  of 
the  vitreous  humor,  and  at  last  appears  to  be  immediately  behind  or  in  the 
posterior  part  of  the  lens. 

If  the  pupil  of  a  glaucomatous  eye  is  small,  the  appearances  are  particularly 
apt  to  impose  on  the  inexperienced  practitioner  for  those  of  cataract.  The 
color,  however,  of  the  glaucomatous  eye  is  sufficient  to  prove  that  the  case  is 
at  any  rate  not  one  of  simple  lenticular  cataract.  A  green  cataract  is  always 
attended  with  glaucoma.  On  dilating  the  pupil  by  belladonna,  the  green 
appearance  presented  in  simple  glaucoma  seems  to  retire  to  a  greater  depth 
behind  the  iris,  and  to  become  more  circumscribed.  The  other  diagnostic 
symptoms  I  have  fully  considered  at  p.  t05.  I  have  also  explained  there  the 
catoptrical  signs  of  the  early  stages  of  glaucoma. 

There  is  a  traumatic  affection  of  the  eye,  which  bears  a  strong  reseral^lance 
to  glaucoma. ^^  The  injuries  which  cause  the  affection  in  question  are  gene- 
rally severe;  such  as,  a  penetrating  wound  of  the  cornea,  or  a  blow  with  the 
fist.  Iritis  comes  on,  and  in  a  few  days  the  pupil  becomes  of  a  fine  sea-green 
color.  I  suspect  this  state  depends  on  a  lymphatic  or  purulent  deposition  im- 
mediately behind  the  lens. 

Pathological  anatomy. — It  is  remarkable  how  very  few  and  imperfect  are 
the  accounts  of  the  dissections  of  glaucomatous  eyes,  which  have  been  recorded 
either  before  or  after  the  time  of  Brisseau.  The  reader  will  at  once  perceive 
how  little  could  properly  be  concluded  from  the  dissection  of  Bourdelot's  eyes 
by  Marc^chal.  A  single  instance,  however  striking  it  might  be,  and  well  au- 
thenticated, could  not  warrant  a  general  conclusion.  It  is  not  even  stated, 
however,  that  Bourdelot's  eyes  had  ever  presented  at  any  period  of  his  life 
the  symptoms  of  glaucoma;  so  that  had  not  Brisseau  been  led  by  arguments 
of  another  sort,  it  is  very  unlikely  that  he  would  have  drawn  anything  from  a 
fact  so  insulated  and  incomplete. 

I  had  long  felt  anxious  to  ascertain,  by  dissection,  the  changes  which  the 
eye  undergoes  in  glaucoma,  and  being  favored,  some  time  ago,  with  several 
eyes  in  this  state,  I  carefully  examined  them.  The  following  are  the  parti- 
culars which  I  observed  in  the  greater  number  of  cases. 

1.  The  lens  of  an  amber,  or  yellowish-brown  color,  especially  in  and  behind 
its  nucleus ;  its  consistence  firm ;  and  its  transparency  perfect,  or  nearly  so. 
In  some  cases,  however,  the  yellowish-brown  color  of  the  nucleus  and  lamellae 
immediately  posterior  to  it  was  so  deep  as  considerably  to  impair  the  trans- 
parency of  the  lens.     The  part  in  question  was  also  drier  than  natural. 

2.  The  vitreous  humor  in  a  fluid  state;  perfectly  pellucid;  colorless,  or 
slightly  yellow,     No  trace  of  hyaloid  membrane. 

3.  The  choroid  coat,  and  especially  the  portion  of  it  in  contact  with  the 


GLAUCOMA.  841 

retina,  of  a  light  brown  color,  with  little  or  no  appearance  of  pigmentum 
nigrum. 

4.  In  the  retina,  no  trace  of  limbus  luteus,  or  foramen  centrale. 

To  the  first  of  these  changes,  namely,  the  amber  or  yellowish-brown  color 
of  the  lens,  and  especially  of  its  central  lamellte,  I  attribute  the  peculiar  ap- 
pearance of  the  deep-seated  parts  of  the  eye  in  glaucoma.  Indeed,  in  some 
incipient  cases,  an  amber  color  of  the  lens  was  the  only  change  I  could  detect 
on  dissection.  The  glaucomatous  lens,  viewed  in  its  natural  situation,  seems 
of  a  greenish,  sometimes  of  a  deep  sea-green,  color.  Taken  out  of  the  eye, 
all  greenness  is  gone,  both  within  the  eye  deprived  of  its  crystalline,  and  in 
the  lens  under  examination.  On  being  viewed  against  the  light,  the  lens  is 
found  of  a  deep  amber  color.  In  glaucoma,  then,  the  lens  has  become,  in  a 
certain  sense,  diplochromatic.  The  lens,  and  the  vitreous  humor,  which  is 
also  often  yellowish  in  glaucoma,  have  the  power  of  analyzing  the  incident 
light,  absorbing  the  violet,  blue,  and  red  rays,  leaving  the  yellow  and  green 
rays  but  little  affected,  so  that  they  are  dispersed,  whence  results  the  appa- 
rently green  appearance  of  the  humors. 

It  is  well  known  that  various  substances,  natural  as  well  as  artificial,  pre- 
sent a  different  color,  according  as  they  are  seen  by  reflection  or  by  refrac- 
tion. Thus,  a  bit  of  gold  leaf,  viewed  by  reflected  light,  is  yellow,  and  green 
when  viewed  by  transmitted  light.  The  glaucomatous  lens  is  the  reverse  of 
this.  Seen  within  the  eye  by  reflected  light,  it  appears  green ;  seen  out  of 
the  eye  by  transmitted  light,  it  is  of  an  amber,  or  yellowish-brown  color. 
Numerous  other  examples  might  be  mentioned  of  the  same  or  a  similar  pheno- 
menon.^^ 

There  is  no  green  surface  in  the  human  eye  directly  to  reflect  the  green 
rays,  such  as  exist  in  the  tapetum  of  the  eye  of  the  sheep.  It  appears,  then, 
to  be  from  an  absorption  of  the  extreme  prismatic  rays,  as  the  light  passes 
through  the  eye,  that  a  greenish  reflection  is  produced ;  and  the  part  most 
likely  to  affect  the  light  in  this  way  is  the  lens.  In  confirmation  of  this,  if 
the  lens  is  extracted,  or  if  it  sinks  to  the  bottom  of  the  dissolved  vitreous 
humor,  the  glaucomatous  or  green  appearance  in  the  eye  is  lost.  This  I  saw 
very  distinctly  in  a  patient  whose  case  I  have  already  related.  (See  Case 
253,  p.  404.)  Having  extracted  in  this  case  a  glaucomatous  lens,  which  a 
blow  had  brought  into  the  anterior  chamber,  and  the  appearance  of  which, 
viewed  by  transmitted  light,  is  represented  in  Plate  II.,  Fig.  2.,  the  pupil  of 
the  injured  eye  became  perfectly  black,  while  the  opposite  pupil  presented  the 
usual  appearance  of  advanced  glaucoma. 

The  dissolved  state  of  the  vitreous  humor,  which  my  dissections  of  glau- 
comatous eyes  lead  me  to  consider  as  generally  forming  part  of  this  disease, 
is  always  attended,  at  least  in  the  middle  stages  of  glaucoma,  by  an  abnormal 
firmness  of  the  eye  to  the  touch,  evidently  arising  from  an  over-distension  of 
the  tunics. 

In  one  case  of  glaucoma,  I  observed  the  lens  tremulous.  It  was  not 
opaque  or  cataractous.  Its  tremulousness  I  detected  by  the  evident  motion 
of  a  lucid  point  behind  the  pupil,  changing  its  situation  on  every  movement 
of  the  eye. 

The  patient  with  glaucoma,  in  the  second  stage,  and  commencement  of  the 
third,  sees  ill,  partly  from  the  retina  being  unsound,  partly  from  the  pigment 
of  the  choroid  being  unable  to  absorb  the  rays  of  light,  partly  from  the  light 
not  being  freely  transmitted  by  the  central  dark-colored  portion  of  the  lens ; 
but  still  he  sees,  and  often  continues  to  do  so  for  years  after  the  glaucoma 
has  become  observable,  a  sufficient  quantity  of  light  for  the  perception  of 
objects  being  transmitted  through  the  circumferential  portion  of  the  lens. 

If  an  attempt  be  made  to  displace  the  lens  in  the  second,  third,  or  fourth 


842  GLAUCOMA. 

stage  of  glaucoma,  on  touching  it  with  the  needle,  it  is  apt  to  sink  unex- 
pectedly to  the  bottom  of  the  vitreous  humor;  if  extraction  is  attempted,  the 
same  event  sometimes  takes  place,  so  as  to  frustrate  the  object  of  the  opera- 
tion, and  the  eye  is  drained  by  the  loss  of  dissolved  vitreous  humor.  Even 
when  extraction  is  conducted  with  great  caution,  or  performed,  perhaps, 
through  a  small  section  of  the  cornea,  a  large  quantity  of  this  fluid  is  apt  to 
escape. 

The  lens,  simply  glaucomatous,  or  in  the  state  of  glaucomatous  cataract, 
and  left  to  itself,  may  remain  for  many  years  in  situ,  notwithstanding  the  dis- 
solved state  of  the  vitreous  humor,  by  the  zonula  Zinnii,  or  suspensory  liga- 
ment of  the  lens,  still  preserving  its  adhesion  to  the  ciliai'y  processes ;  at 
length,  however,  this  adhesion  may  give  way,  when  the  lens  will  suddenly 
drop  to  the  bottom  of  the  eye,  as  in  the  case  of  cataract  already  quoted  (p. 
188)  from  May  erne. 

Dissections  of  glaucomatous  eyes  in  the  advanced  stages  of  the  disease, 
after  inflammation  of  the  choroid  has  complicated  the  affection  of  the  dioptric 
media,  have  been  recorded  by  Ebie,*"  Rosas,-'  and  Warnatz,-^  and  exhibit 
a  considerable  variety  of  morbid  changes  in  the  different  structures  of  the 
eye. 

The  sclerotic  adhering  to  the  choroid,  and  this  to  the  retina;  the  blood- 
vessels of  the  choroid  enlarged,  and  especially  its  veins  varicose  ;  ossifications 
in  the  choroid ;  adhesions  of  the  iris  to  the  capsule  of  the  lens,  and  to  the 
cornea ;  the  retina  spotted  with  red  punctiform  exudations,  thickened,  softened, 
atrophied;  the  vitreous  body  shrunk;  the  hyaloid  abnormally  firm  in  some 
places ;  fibrinous  effusions,  effusions  of  a  reddish  fluid,  greenish-brown  depo- 
sitions within  it ;  the  crystalline  in  a  softened  and  opaque  state :  these  are 
the  chief  changes  observed  on  dissection. 

I  have  now  before  me  one  of  the  eyes  of  the  patient  whose  case  I  have 
noticed  at  page  105.  The  disease,  which  I  have  stated  was  mistaken  for 
cataract,  ended  in  total  loss  of  vision  from  glaucoma.  On  dissection,  scarcely 
any  trace  of  the  natural  structure  of  the  interior  of  the  eyes  was  to  be  detected. 
The  choroid,  inseparably  adherent  to  the  sclerotica  externally,  was  internally 
so  connected  to  the  contents  of  the  eyeball,  and  these  so  changed  by  fibrin- 
ous exudation,  that  the  retina  could  not  be  distinguished.  In  this,  as  well, 
as  in  another  case  which  I  had  an  opportunity  of  examining  after  death,  the 
optic  nerves  were  flattened  and  atrophic. 

Proximate  cause. — Respecting  the  cause  of  the  alteration  in  the  lens  we 
can  say  nothing  satisfactory.  The  lens  may  be  regarded  so  far  as  a  secretion, 
and  the  alterations  which  it  undergoes  as  dependent  on  the  state  of  the  organ 
by  which  it  is  secreted.  Its  nutrition,  as  well  as  that  of  the  vitreous  humor, 
is  derived  unquestionably  from  the  capillaries  of  the  ciliary  body ;  and  from 
morbid  alterations  in  the  condition  of  these  vessels,  or  of  the  blood  which 
they  convey,  arise  in  all  probability  those  departures  from  the  normal  state, 
to  which  we  give  the  names  of  cataract  and  glaucoma.  Chronic  inflammation  of 
the  choroid  and  retina,  specific  but  obscure  in  its  character,  may,  perhaps,  be 
the  cause  which  leads  to  the  destruction  of  the  hyaloid  membrane,  which,  in 
its  turn,  is  likely  to  pi'oduce  a  series  of  other  local  changes,  even  in  the  very 
organs  which  were  originally  affected.  It  is  probable  that  the  aqueous  fluid, 
which  fills  the  place  of  the  vitreous  humor,  becoming  superabundant,  promotes, 
by  pressure,  the  absorption  of  the  pigmentum  nigrum,  and  completes  the 
insensibility  of  the  already  disordered  retina. 

Although  it  can  scarcely  be  doubted,  that  the  epithelium  of  the  choroid 
fulfils  but  a  subsidiary  part  in  the  exercise  of  vision,  yet  it  is  evident  that 
without  the  aid  of  the  pigmentum  nigrum,  it  is  impossible  for  a  due  impres- 
sion to  be  produced  upon  the  retina.     The  fact  that  the  eye  of  the  albino,  in 


GLAUCOMA.  843 

which  the  cells  of  the  pigment  are  congenitally  destitute  of  coloring  matter, 
is  unable  to  discern  objects  with  distinctness  in  the  ordinary  light  of  day,  is 
sufficient  to  prove  the  necessity  of  a  healthy  condition  of  the  choroidal 
epithelium  for  a  due  performance  of  the  function  of  the  eye. 

Exciting  aiid  predisposing  causes. — The  Germans  appear  to  consider  glau- 
coma as  almost  always  connected  with  arthritis,  or  rather  as  the  result  of  slow 
arthritic  inflammation  of  the  eye,  and  especially  of  the  choroid. 

Similar  causes  to  those  which  lead  to  arthritic  iritis,  and  to  choroiditis  (see 
pp.  543,  553,  554),  appear  to  operate  in  the  production  of  glaucoma,  and 
especially  anxiety,  grief,  and  loss  of  sleep. 

The  cachectic  state  of  the  system  arising  from  the  habitual  use  of  spirits 
and  tobacco  operates  powerfully  in  the  production  of  glaucoma.  This  disease 
also  appears  to  be  more  apt  to  occur  in  those  who  have  been  scrofulous  in 
childhood,  or  who  have  exerted  their  eyes  much  on  minute  objects,  or  such  as 
reflect  the  light  with  intensity. 

It  is  not  easy  satisfactorily  to  explain  the  frequency  of  glaucoma  in  some 
countries,  and  in  certain  classes  of  society,  and  its  rarity  in  others.  Thus, 
Benedict  tells  us,  that  one-half  of  the  glaucomatous  patients  whom  he  had 
seen  during  12  years'  practice  in  Breslaw,  were  Jews,  among  whom  he  states 
glaucoma  to  be  extremely  common."*  Scar}»a,  on  the  other  hand,  has  not 
thought  it  necessary  to  introduce  the  subject  of  glaucoma  into  his  treatise  on 
the  diseases  of  the  eye.  It  is  also  remarkable  that,  in  one  of  his  letters  to 
Maunoir,  he  mentions,  that  during  the  long  series  of  years  in  which  he  filled 
the  anatomical  chair  at  Pavia,  he  had  never,  in  dissection,  met  with  dissolu- 
tion of  the  vitreous  humor,  and  that  after  reading  Sir  William  Adams's  work, 
published  in  1817,  he  made  at  least  40  eyes  be  examined,  of  persons  who  had 
died  between  60  and  80  years  of  age,  without  finding  the  vitreous  humor 
either  wholly  or  partially  dissolved  in  one  of  them. 

Prognosis. — When  glaucoma  has  commenced  in  one  eye,  it  generally 
extends  also  to  the  other.  We  often  see  the  disease  in  different  stages  in 
the  two  eyes. 

Fully  developed  glaucoma  is  absolutely  incurable  ;  but  remedies  may  occa- 
sionally arrest  the  progress  of  the  disease,  and,  under  certain  circumstances, 
even  improve  the  impaired  vision. 

Treatment. — 1.  On  the  presumption  that  glaucoma  originates  in  an  inflam- 
matory affection  of  the  choroid  and  retina,  bleeding  and  purging  have  been 
employed  for  its  cure,  and  occasionally  this  practice  has  been  attended  with 
benefit.  Counter-irritation,  also,  has  been  found  useful,  especially  a  tartar 
emetic  eruption  between  the  shoulders. 

2.  Calomel,  with  opium,  has  been  given,  on  the  principle  that  in  almost 
all  cases  of  deep-seated  inflammation  of  the  eye,  mercury  proves  salutfiry. 
As  is  the  case  in  arthritic  ophthalmia,  with  which  glaucoma  is  certainly  allied, 
an  alterative  course  will  prove  more  beneficial  than  if  the  mercury  were  pushed 
so  as  to  affect  the  mouth.  Indeed,  it  is  evident  that  from  the  age  and  con- 
stitution of  those  who  arc  in  general  the  subjects  of  glaucoma,  neither  deple- 
tion nor  mercurialization  can,  with  propriety,  be  employed,  without  more 
than  ordinary  caution. 

3.  Rest  of  the  eyes,  a  mild  diet,  a  healthy  state  of  the  skin,  and  abstinence 
from  alcoholic  fluids,  and  tobacco  in  every  form,  must  be  enjoined. 

4.  Anti-neuralgic  remedies,  such  as  tinctui'e  of  belladonna  taken  internally 
in  doses  of  from  10  to  15  minims,  or  Fleming's  tincture  of  aconite  in  doses 
of  3  or  4  minims,  thrice  a  day,  are  of  much  use  in  alleviating  the  pain,  which 
often  attends  the  disease. 

5.  Arthritic  inflammation  of  the  eye  is  often  greatly  benefited  by  the  use 


844  GLAUCOMA, 

of  tonics ;  as  precipitated  carbonate  of  iron,  sulphate  of  quina,  and  tbe  like. 
After  depletion,  such  remedies  may  be  also  tried  in  glaucoma. 

6.  Dilatation  of  the  pupil  by  belladonna  improves  the  vision  of  most  glau- 
comatous eyes  in  the  second  stage  of  the  disease,  and  may  be  employed  day 
after  day  as  a  palliative.  The  most  convenient  mode  of  application  is  a  so- 
lution of  atropine  dropped  upon  the  conjunctiva  every  second  evening.  Some, 
however,  find  their  sight  dazzled,  and  a  new  degree  of  mistiness  produced,  by 
dilatation  of  the  pupil,  which,  of  course,  we  must  abandon,  if  followed  by 
such  effects. 

7.  As  a  superabundance  of  dissolved  vitreous  humor  appears  to  form  an 
essential  part  of  the  morbid  changes  observed  in  the  advanced  stages  of  glau- 
coma, it  is  not  unreasonable  to  conclude  that  occasionally  puncturing  the 
sclerotica  and  choroid  might  prove  serviceable,  by  taking  off  the  pressure  of 
the  accumulated  fluid  on  the  retina.  The  puncture  should  be  made  with  a 
broad  iris-knife  at  the  usual  place  of  entering  the  needle  in  the  operation  of 
couching.  Tlie  instrument,  pushed  towards  the  centre  of  the  vitreous  humor, 
is  to  be  turned  a  little  on  its  axis,  and  held  for  a  minute  or  two  in  the  same 
position,  so  that  the  fluid  may  escape.  A  transient  amelioration  of  vision, 
as  well  as  relief  from  pain,  is  sometimes  the  result  of  the  operation,  or  even 
of  that  of  puncturing  the  cornea,  and  evacuating  the  aqueous  humor. 

8.  The  abstraction  of  the  crystalline  lens  from  a  glaucomatous  eye  removes 
the  greenish  appearance  of  the  humors,  and  sometimes  improves  the  vision 
of  the  patient.  At  the  same  time,  although  lam  persuaded  that  the  absence 
of  the  lens  might  be  advantageous  in  the  early  stages,  and  prevent,  in  a 
considerable  measure,  the  progress  of  the  amaurosis  which  comes  to  accom- 
pany glaucoma,  extraction  is  an  operation  which  I  would  by  no  means, 
venture  to  recommend  for  general  adoption.  The  patient,  in  the  second 
stage,  generally  continues  for  a  long  period  to  see  too  much,  to  warrant  our 
exposing  him  to  the  danger  of  arthritic  inflammation  coming  on  after  any 
operation.  I  have  known  glaucoma  operated  on  for  cataract;  that  is  to  say, 
the  amber-colored  lens  removed  by  extraction,  the  operator  apprehending 
that  he  was  removing  an  opaque  or  cataractous  lens  ;  and  I  have  seen  the 
incision,  after  such  an  operation,  heal  without  inflammation,  and  the  patient 
receive  a  considerable  accession  of  vision.  But  I  have  also  known  such 
violent  inflammation  follow  the  removal  of  the  lens  from  a  glaucomatous 
eye,  as  entirely  destroyed  the  natural  structure  of  the  most  important  parts 
of  the  organ.  There  is  reason  to  suspect  that  glaucoma  has  often  been 
operated  on  with  the  needle,  the  disease  being  mistaken  for  cataract ;  and 
that  the  general  result  of  couching  or  of  division  was  fatal  to  vision. 

That  the  early  removal  of  the  lens  might  prove  a  means  of  preventing 
glaucoma,  and  not  merely  the  lenticular,  but  the  retinal  part  of  the  disease, 
is  a  conclusion  to  which  I  was  naturally  led  by  the  following  case  : — 

Case  857. — R.  C,  aged  48  years,  applied  to  me  in  March,  1820,  in  consequence  of  im- 
paired vision  of  the  left  eye,  -which  already  presented  a  glaucomatous  appearance.  In 
his  right  eye,  there  was  a  capsular  cataract,  the  result  of  an  injury  40  years  before, 
■which  had  been  followed  by  absorption  of  the  cryst.alline  lens.  The  vision  of  the  left  eye 
rapidly  declining,  while  evident  perception  of  light  and  shade  was  still  retained  by  the 
right,  I  opened  the  cornea  of  this  eye,  and  drew  the  capsule  out  of  the  pupil  and  partially 
between  the  lips  of  the  incision  of  the  cornea,  leaving  it  to  adhere  there,  and  thus  secur- 
ing a  passage  for  the  rays  of  light  into  the  interior  of  the  eye.  As  good  vision  was  re- 
stored by  this  means  as  generally  follows  an  operation  for  cataract ;  and  the  patient  was 
able,  with  his  right  eye  assisted  by  a  cataract-glass,  to  follow  his  usual  employment  for 
some  years.  The  vision  of  the  left  eye  became  still  more  impaired,  under  signs  which 
appeared  to  me  indubitably  those  of  glaucoma  and  amaurosis.  The  patient,  however, 
was  persuaded  that  he  had  a  cataract  in  this  eye,  and  urged  me  to  operate  on  it.  This  I 
declined  ;  but  I  recommended  the  patient,  since  he  still  had  doubts  about  the  matter,  to 
consult  the  late  Dr.  Monteath.     He  did  so,  and  felt  greatly  dissappointed  when  Dr.  M. 


GLAUCOMA.  845 

only  confirmed  the  opinion  which  I  had  previously  given  him.  Not  yet  satisfied,  he  -went 
to  Edinburgh,  where  he  unfortunately  met  with  encouragement  in  the  notion  of  his  eye 
being  affected  with  cataract,  and  accordingly  underwent  an  operation,  which  was  followed 
only  by  violent  and  destructive  inflammation. 

It  struck  me,  in  reflecting  on  this  case,  that  the  total  absence  not  merely 
of  glaucoma,  but  of  amaurosis  in  the  right  eye,  was  owing  to  the  lens  having 
been  absorbed  at  an  early  period  of  life  ;  for  glaucoma  is  a  disease,  which, 
under  ordinary  circumstances,  rarely  attacks  the  one  eye  without  speedily 
affecting  the  other  also.  The  absence  of  the  lens  may  have  operated  also  in 
preventing  the  disease  of  the  hyaloid  membrane,  which  ends  in  its  destruc- 
tion, and  to  which  I  feel  inclined,  so  far  as  our  present  evidence  goes,  to 
attribute  in  a  considerable  measure,  the  origin  of  the  affection  of  the  retina 
which  attends  glaucoma. 

The  second  stage  of  glaucoma  is  the  only  one  in  which  the  removal  of  the 
lens  can  be  defended.  The  pale  muddy  green  opacity  behind  the  pupil,  more 
deeply  seated  than  the  opacity  in  ordinary  cataract,  so  that,  owing  to  the 
transparency  of  the  superficial  laminse  of  the  lens,  the  iris  throws  a  broader 
shadow  on  the  opacity  than  when  the  surface  of  the  lens  is  affected ;  the  con- 
sistence of  the  eyeball  natural;  the  iris  healthy  in  texture;  the  pupil  not 
abnormally  dilated ;  no  inverted  image  visible,  while  the  deep  erect  image 
forms  a  large  yellow  blaze;  vision  such  as  attends  lenticular  cataract;  the 
progress  of  the  disease  much  slower  than  that  of  lenticular  cataract,  occu- 
pying as  many  years,  generally,  as  a  common  cataract  does  months,  to  be- 
come ripe  for  operation ;  these  are  circumstances  which  enable  us  to  pronounce 
the  disease  to  be  glaucoma  in  the  second  stage,  and  vision  likely  to  be 
restored  by  the  removal  of  the  lens.  This  last  is  an  important  fact,  because 
practitioners  are  apt  to  conclude,  when  they  see  a  green  opacity  behind  the 
pupil,  that  the  case  is  one  of  amaurosis,  as  well  as  change  in  the  refracting 
media  of  the  eye.  Hence  patients  are  left  as  incurable,  to  whom  the  removal 
of  the  glaucomatous  lens  might  restore  vision.  In  the  cases  in  question,  a 
careful  examination  shows  that  vision  is  not  extinguished,  but  that  the  eye 
retains  nearly  the  same  degree  of  sight  as  does  a  cataractous  eye;  the  eyeball 
is  not  hard  and  stony  to  the  feeling,  as  it  is  in  the  third  stage,  when,  to  a 
glaucomatous  state  of  the  lens,  there  is  added  a  dissolution  and  accumulation 
of  vitreous  humor ;  the  sclerotica  is  not  thinned,  so  as  to  allow  the  choroid 
to  shine  through ;  nor  are  the  bloodvessels  of  the  eye  enlarged  and  varicose, 
as  in  the  advanced  and  hopeless  stages  of  the  disease. 

It  sometimes  happens,  however,  that  incomplete  amaurosis  attends  the 
second  stage  of  glaucoma,  as  was  the  case  in  the  right  eye  of  the  patient 
whose  case  I  am  about  to  relate,  and  then  the  operation  proves  fruitless. 

Case  358. — Robert  Shaw,  a  weaver,  aged  56,  was  admitted  at  the  Glasgow  Eye  Infir- 
mary, January  14th,  1841,  with  lenticular  opacity  in  each  eye,  of  a  pale  muddy  greenish 
hue,  confined  apparently  to  the  central  and  posterior  portions  of  the  lenses.  Vision  of 
right  eye,  in  which  the  opaque  appearance  is  the  more  advanced,  so  much  impaired  that 
he  cannot  distinguish  objects  with  it.  Vision  of  left  eye  also  imperfect,  but  with  it  can 
still  distinguish  the  fingers.  Pupils  of  natural  size ;  their  motions  limited  and  sluggish. 
Eyeballs  of  normal  consistence  ;  deep  set  in  orbits.  Sight  began  to  fail  four  or  five  years 
ago,  after  having  had  typhus  fever  followed  by  erysipelas.  Has  never  been  myopic  nor 
presbyopic,  as  far  as  he  knows. 

15th.  Extract  of  belladonna  was  applied  yesterday,  since  which  he  thinks  his  vision  less 
distinct. 

Feb.  1st.  With  left  eye  can  discern  characters  an  inch  in  height.  Right  eye  almost 
insensible,  except  to  light  and  shade.  Opacity  of  lenses  so  far  advanced  that  no  inverted 
image  is  visible  on  examining  eyes  catoptrically. 

Sept.  12th.  Opacity,  still  of  the  same  muddy  green  color,  has  slowly  advanced  towards 
the  iris.  Has  been  till  lately  employed  as  a  house-factor,  but  cannot  see  to  continue  this 
employment. 

28th.  Right  pupil  being  dilated  by  belladonna,  curved  needle  introduced  through  scle- 
rotica, and  anterior  capsule  divided. 


846  GLAUCOMA. 

29th.  An  attack  of  pain  last  night,  for  which  he  was  bled,  and  had  a  calomel  and 
opium  pill.  Belladonna  continued  to  right  eyelids.  Pill  to  be  continued  morning  and 
evening. 

Oct.  1st.  Pills  to  be  omitted. 

Nov.  Gth.  Curved  needle  again  introduced  through  right  sclerotica,  and  capsule  and 
lens  divided. 

7th.  Was  bled  this  morning  on  account  of  pain  in  right  eye,  and  had  four  grains  of 
calomel  and  one  grain  of  opium. 

17th.  A  very  fine  straight  needle  introduced  through  left  sclerotica,  with  the  view  of 
displacing  the  lens,  in  the  manner  recommended  by  Mr.  Morgan,  in  Gm/s  Hospital  Re- 
ports, Vol.  vii.  p.  461.  This  not  being  effected,  the  anterior  capsule  was  divided,  and  the 
needle  withdrawn.     Belladonna  to  be  applied  to  left  eyelids. 

Dec.  10th.  Division  of  left  capsule  repeated  with  curved  needle  passed  through  sclerotica, 
and  the  comminution  extended  partly  to  the  lens. 

Feb.  2d,  1843.  Left  pupil  being  dilated  by  belladonna,  capsule  and  lens  again  divided 
with  curved  needle  passed  through  sclerotica. 
14th.  Vision  does  not  improve. 
May  16th.  Vision  much  improved  since  last  report. 

Aug.  1st.  Left  pupil  perfectly  clear,  and  vision  of  this  eye  good  ;  lower-outer  part  of 
right  pupil  clear;  its  upper-inner  part  occupied  by  an  opaque  capsular  shred.  With  a  2.V 
inch  convex  glass,  reads  a  school  Testament  with  left  eye.  AVith  right  eye  sees  a  little 
Avhen  he  looks  dextrad. 

In  the  third  stage  of  glaucoma,  the  hope  of  doing  any  good  by  an  ope- 
ration is  gone ;  and  from  the  dissolved  state  of  the  vitreous  humor  and  vari- 
cose condition  of  the  vessels,  there  is  much  risk  in  attempting  such  a  thing. 

I  have  already  hinted  that  the  different  elements  of  glaucoma  do  not  present 
themselves  in  the  same  invariable  order.  The  retinal,  or  amaurotic  element, 
for  example,  is  often  the  first  to  attract  notice.  Weller  thinks  that  it  is  always 
the  first  in  the  series  of  morbid  changes,  for  he  says,  "  Primum  hujus  morbi 
syraptoma  visiis  defcctio  est,  pupillse  color  subviridis  multo  serius  demum  ani- 
madvertitur."^  But  I  believe  it  were  more  conformable  to  the  fact  to  say, 
that  in  such  instances  as  Weller  has  taken  for  the  ground  of  this  remark,  an 
amaurotic  eye  has  become  glaucomatous,  than  that  the  group  of  symptoms 
which  constitute  glaucoma  has  originated  in  the  retina. 

Amaurosis  so  generally  attends  the  advanced  stages  of  glaucoma,  that  it 
has  been  presumed  always,  and  in  all  stages,  to  do  so.  Mr.  Wardrop,  as  we 
have  already  seen,  even  goes  the  length  of  calling  glaucoma  a  species  of  amau- 
rosis. Shaw's  case  shows  the  erroneousness  of  this  view ;  his  left  eye  was 
affected  with  distinct  glaucoma,  advanced  into  the  second  stage,  yet  the  retina 
proved  perfectly  sensible. 

It  is  necessary  to  be  aware  that  a  glaucomatous  eye  is  always  very  suscepti- 
ble of  suffering  infiammation  and  disorganization,  even  from  the  slightest 
operation  which  may  be  practised  upon  it.  Arthritic  inflammation,  with 
severe  and  long-continued  pain,  closure  of  the  pupil,  and  total  insensibility 
of  the  retina,  is  exceedingly  apt  to  be  the  result  of  displacing  a  glaucomatous 
lens  ;  while  the  operation  of  extraction  exposes  the  eye  almost  as  much  to 
the  danger  of  complete  suppuration.  Hence  the  propriety  of  having  recourse 
rather  to  the  operation  of  comminuting  the  centre  of  the  anterior  capsule  by 
means  of  a  fine  needle  passed  through  the  sclerotica  or  cornea,  and  afterwards 
repeating  a  cautious  division  of  the  lens  every  six  weeks,  till  it  is  entirely 
absorbed.  A  cataractous  eye  is  generally  perfectly  healthy,  except  that  the 
lens,  and  especially  its  surface,  has  become  opaque,  but  in  every  texture  of  a 
glaucomatous  eye  there  is  a  lurking  tendency  to  disease  against  which  we 
cannot  be  too  much  on  our  guard. 


'  Aphorisinorum.  Sec.  iii.  31.  ivfiTiixt,  «  ^aviac  s^cuira/,  s/t'  w  ti pottLTice-i  -rai- 

*"Ai    Xs    k;c*(    yK-tuKoufxivxt,    »  afi-yvpoc^iu  it-jTuiytvoioLTc,  ut' a.i'rifAttTSLi." — Prffidictionum, 

ytvi/xtvrti,  M    Kuavati,    c'jiS'h  y(j,n<r-!OV.  TsuTaJv  S'i  Lib.  ii.  28. 

i\iyu.i  aiJ-ii'Jw;,  oxitra./  »  cr[Aix.p-nipni  fxivovTM,  H         ^  Be  Pve  Medica;  Lib.  vi.  cap.  iii.  sec.  ii. 


cat's-eye. 


847 


*  "Sul>  his  giitta  humoris  est,  ovi  albo  similis, 
a  qnS  videndi  fucultas  proficiscitur :  Kfjo-TOX- 
AOiiS'nc  a  Grfecis  nominatur." — lb.,  Lib.  vii.  pars 
ii.  cap.  i.  sec.  ii. 

'  Pliny  mentions  botti  glaitcomata  and  siiffu- 
sloncs  ;  but  makes  no  accurate  distinction  be- 
tween tliem. — Historia  Naturalis,  Lib.  x.xviii. 
g29;  xxi.\-.  ^38  ;  x.x.xy.^?  51. 

^  "  Ka«  yu.0  KSLi  toZt'  (loyiTAt  Trpi^Biv,  kh)  ic  avTo 
TO  xpvTjeiK'AOcS'H  uyfjcv-^TO  TrpSiTtjv  is'Tiv  i:pya.vov  T»c 

O-^iOIC.  TS)tf/»p/Oi  ITS  iVADyH;  to.  KOLhOV^iVlt,  TTpCi  tSiv 
i*Tp£v  CTroX^/UitTA,  (AiaH.  fyliV  l7Ta./^iVt  TOO  Kp\j~ 
ffTO.KKOiii'O'JC  CyfOll  Kltl  TOV  KipO.TCiiS'oijC  ^ItaVO^. 

Kai  cue  TO  TTa^yifxa.,  to  5T^cc  tSiV  IttTpSjV  oi'O- 

fJCet^-jUiVOV  yKtinaiC-tC,    ?)ipOT>IC    /MSf    SO'T/,    HAl    "TTtiyK 

afjt-iTfOQ  To-j  ^u^ToiAXciiJ'oZ^  vypov." — Galenus  De 
IJsu  Partium ;  Lib.  ix.  Opera,  Vol.  i.  p.  473  ; 
Basileae,  1538. 

^  Quoting  from  Rufus,  Oribasius  observes, 
"  Glaucoma  et  suffusionem  veteres  unum  eun- 
demque  morbum  esse  existimarunt:  posteriores 
ver6  glaucomata  humoris  glacialis,  qui  ex  pro- 
prio  colore  in  glaucum  convertatur  et  mutetur, 
morbum  esse  putaverunt :  suffusionem  vero  esse 
effusiunera  humorum  inter  uveam  et  crystalloi- 
dem  tunicam  concrescenlium :  eajter&m  glauco- 
mata omnia  curationem  non  recipiunt;  suffu- 
siones  ver6  recipiunt,  sed  non  omnes." — Ori- 
bassi  Synopseos,  Lib.  viii. ;  Cap.  47;  Rasario 
intcrprete  ;  Basileaj,  1557. 

*  Traite  des  Maladies  de  I'CEil,  p.  223; 
Troyes,  1711. 

'  Traite  do  la  Cataracte  et  du  Glaucoma; 
Paris,  1709. 

'"  Ileister  de  Cataracta,  Glaucomate,  et 
Amaurosi,  p.  46  ;  Altorfi,  1713. 

"  Dei  Moti  dell'  Iride,  pp.  15,  16;  Lucca, 
1765. 

'*  Commentatioexhibens  Oculi  Humani  Ana- 
tomiam  et  Pathologiam,  p.  40  ;  Norimberga3, 
1810. 

'^  Doctrinade  Morbis  Oculorum,  §460;  Pes- 
thini,  1831. 

'■"  Essaj's  on  the  Morbid  Anatomy  of  the 
Human  Eye  :  Vol.  ii.  p.  127;  London,  1818. 

''  Lehre  von  den  Augenkrankheiten,  p.  565  ; 
Berlin,  1836. 

'*  Lehre  von  den  Augenkrankheiten,  p.  326; 
Wien,  1834. 

"  Op.  cit.  Vol.  ii.  p.  264  ;  London,  1818. 

'^  Aramon's  Zeitschrift  flir  die  Ophthalmo- 
logie;  Vol.  v.  p.  62;  Heidelberg,  1835. 


"  The  infusion  of  lignum  nrpliriticvm,  if  held 
between  the  light  and  the  eye,  appears  of  a 
golden  or  reddish  color  ;  but  if  held  from  the 
light,  so  that  the  eye  is  between  the  light  and 
the  phial,  it  appears  of  a  blue  color.  (Boyle's 
Experiments  and  Considerations  touching 
Colors,  pp.  199,  216  ;  London,  1670.)  The  pur- 
purate  of  ammonia,  viewed  by  transmitted  light, 
is  of  a  deep-red  color  ;  while,  by  reflected  light, 
the  two  broadest  opposite  faces  of  the  crystals 
of  that  salt  appear  of  a  brilliant  green.  (Philo- 
sophical Transactions  for  1818,  p.  423.)  If  a 
current  of  hydro-sulphuric  acid  gas  is  trans- 
mitted through  ox's  blood,  whipped  and  de- 
prived of  its  fibrine,  a  large  quantity  of  the  gas 
is  absorbed,  and  the  blood  becomes  of  a  dingy 
olive-green  color  by  reflection,  of  a  dingy  m/id- 
dy  red  by  transmission.  A  solution  of  bile  in 
alcohol  presents  also  these  two  kinds  of  color. 
(Tiedemann  et  Gmelin,  Recherches  sur  la  Di- 
gestion, p.  xix;  Paris,1827.)  Asolution  of  sul- 
phate of  quina  in  tartaric'aoid,  largely  diluted, 
although  perfectly  transparent  and  colorless 
when  held  between  the  eye  and  the  light  or  a 
white  object,  exhibits  in  certain  aspects,  and 
under  certain  incidences  of  the  light,  an  ex- 
tremely vivid  and  beautiful  celestial  blue  color. 
(Ilerschel,  Philosophical  Magazine,  March, 
1845,  p.  256.) 

The  last-mentioned  phenomenon  is  an  exam- 
ple of  what  istermodby  Professor  Stokes  (Phi- 
losophical Transactions  for  1852,  p.  463),  fluo- 
rescence, and  it  may  turn  out  on  further  exami- 
nation that  the  diplochromatic  appearance  of  the 
glaucomatous  lens  may  belong  to  the  same  cate- 
gory. DijjJochromatism  may  be  used  to  signify 
such  change  of  color  as  we  observe  in  the  glau- 
comatous lens,  and  in  various  other  substances, 
according  as  they  are  viewed  by  reflected  or  by 
transmitted  light ;  the  terms  dichmmatism  and 
dicroiam  being  already  appropriated  to  other 
optical  phenomena. 

^°  Ammon's  Zeitschrift  fiir  die  Ophthalmo- 
logic; Vol.  i.  p.  310  ;  Dresden,  1831. 

*'  Handbuch  der  Augenheilkunde;  Vol.  ii. 
p.  726;  Wien,  1830. 

*^  Ueber  das  Glaukora,pp.  92,  150;  Leipzig, 
1844. 

^^  Handbuch  der  praktisehen  Augenheil- 
kunde; Vol.  V.  p.  146;  Leipzig,  1825. 

^^  Icones  Ophthalmologicai,  p.  22;  Lipsiaj, 
1824. 


SECTION  II. — CAT'S-EYE. 


There  can  be  little  doubt  that  under  the  appellation  of  caVs-eye,  several 
diseased  states  have  been  confounded,  differing  entirely  in  their  nature  and 
seat,  and  agreeing  only  in  an  opalescent  appearance  of  the  pupil,  or  of  the 
bottom  of  the  eye,  these  parts  reflecting  the  light  in  various  colors,  or  at  least 
with  various  degrees  of  intensity,  according  to  the  direction  in  which  the  eye 
is  turned.  This  appearance  Beer*  compared  to  the  reflection  from  the  tape- 
tum  of  the  eye  of  a  cat. 

1.  What  Beer  calls  amaurotic  cat's-eye,  occurring  in  children,  after  injuries 
of  the  eye,  is  nothing  else  than  what  has  been  already  described  (page  075) 
as  a  non-malignant  deposition  occupying  the  place  of  the  vitreous  humor. 


848  MYOPIA. 

This  occurs  in  adults  as  well  as  children,  and  ought  from  the  occasion  which 
gives  rise  to  it,  to  be  called  traumatic  cat's-eye. 

Case  359. — Iq  a  man  who  came  under  my  care,  a  wound  of  the  cornea  by  a  chip  of  iron 
caused  considerable  inflammation  of  the  external  tunics,  great  muddiness  of  the  anterior 
chamber  from  eflTused  lymph,  and  a  gold-green  color  of  the  iris.  As  the  anterior  chamber 
cleared,  lymph  was  seen  lying  on  the  capsule;  this,  under  the  usual  treatment,  was 
absorbed,  and  the  lens  was  now  seen  transparent;  but  behind  it,  an  opaque  concave 
appearance  of  a  yellowish-green  color  was  observed,  as  if  from  lymph  covering  the 
retina.     The  eye,  in  this  state,  retained  a  mere  perception  of  light  and  shade. 

2.  The  afiection  in  old  people,  which  Beer  includes  in  the  description 
already  referred  to,  and  which  presents  a  peculiar  reflection,  often  of  a  silvery 
or  nacreous  appearance,  from  the  bottom  of  the  eye,  is  different.'^  I  have 
seen  this  sort  of  cat's-eye  both  in  eyes  which  retained  vision,  and  in  amaurotic 
eyes.  The  reflection  generally  came  from  one  side  of  the  eye,  and  seemed  to 
be  as  deep  as  the  retina.  The  patients,  in  all  the  cases  I  have  seen,  were  far 
advanced  in  life.  The  cause  of  the  reflection  is  unknown,  but  it  cannot  be  a 
mere  deficiency  pf  pigmentura  nigrum. 

3.  There  is  another  state  of  the  eye,  in  which  the  reflected  and  varying 
light  seems  to  come  from  the  front  of  the  crystalline  capsule,  and  presents  a 
close  resemblance  to  the  reflection  from  a  piece  of  opal,  a  mineral  popularly 
called  cat's-eye.  In  the  cases  in  question,  when  we  view  the  eye  directly  in 
front,  the  appearance  is  merely  that  of  a  brownish  opacity ;  but  whenever  the 
patient  looks  upwards,  the  opalescence  becomes  very  striking,  presenting 
almost  a  glittering  or  silvery  reflection. 

The  nature  of  this  disease,  which  is  plainly  quite  different  from  those  already 
noticed,  has  never  been  determined  by  dissection. 

In  one  ease,  in  which  both  eyes  were  affected,  and  a  mere  perception  of 
light  and  shade  was  retained,  I  ventured,  at  the  patient's  request,  to  open 
one  of  the  cornea;,  and  introduced  a  cataract  needle  through  the  pupil.  I 
felt  nothing  like  the  resistance  of  the  lens,  a  profuse  discharge  of  aqueous 
fluid  took  place,  the  cornea  healed,  and  the  opalescent  appearance  continued 
almost  exactly  the  same  as  before  the  operation. 

In  another  instance,  in  which  this  kind  of  cat's-eye  was  very  distinct,  the 
patient  read  with  facility  by  the  help  of  glasses,  and  presented  no  signs  of 
amaurosis. 


'  Lclire    von    den    Augcnkrankheitcn ;   Vol.     Aminon,  in  his   Darstellungen ;    Theil  i.  Taf. 
ii.  p.  495  ;  Wien,  1817.  15.  Fig.  10,  11. 

"^  This  variety  of  cat's-eye  is  represented  by 


CHAPTER   XXIV. 

VARIOUS  STATES  OF  ABNORMAL  VISION. 


SECTION  I. — MYOPIA. 


Syn. — Mj'opia,  from  /uusb,  /  shut,  and  a>\,  the  eye ;  the  MiJa;^,  or  short-sighted  person,  being 
in  the  habit  of  half-shutting  his  eyes  when  he  endeavors  to  see  distant  objects.  Short- 
sightedness.    Near-sightefJness.     Vue  basse,  Fr.     Over-refraction. 

There  is  a  certain  distance  from  the  eye,  called  the  point  of  distinct  vision, 
at  which  objects  are  perceived  better  than  at  any  other  distance.  This  point, 
however,  varies  in  different  individuals,  or  even  in  the  two  eyes  of  the  same 


MYOPIA.  849 

person.  It  averages  from  about  fifteen  to  twenty  inches.  The  shortest  dis- 
tance at  which  objects  can  be  seen  with  any  ordinary  degree  of  distinctness  by 
common  eyes,  is  about  seven  or  eight  inches.  But  some  eyes  can  discern  no 
object  distinctly  unless  it  be  brought  nearer  than  the  ordinary  distance  for 
distinct  vision,  or  even  within  seven  inches,  while  others  require  the  object  to 
be  removed  further  than  the  average  point  of  distinct  vision.  Eyes  affected 
in  the  former  way,  are  said  to  be  myopic  ;  in  the  latter,  irreshyopic.  In  both 
cases,  they  may  be  said  to  be  out  of  focus. 

These  two  classes  of  defective  eyes  are  generally  regarded  as  dependent 
upon  some  peculiarity  in  the  transparent  media  of  the  organ.  In  the  myopic 
eye  it  is  supposed  that  the  rays  of  light  must  either  be  refracted  too  much, 
so  that  they  converge  into  foci  anteriorly  to  the  retina,  or  that  the  axis  of 
the  eye  must  be  longer  than  natural,  so  that  the  retina  is  too  far  back,  and 
does  not  receive  that  perfect  impression  which  is  necessary  for  distinct  vision. 
The  reverse  of  this  is  supposed  to  have  place  in  the  presbyopic  eye.  Either 
its  axis  is  too  short,  or  its  refractive  powers  too  feeble,  so  that  the  rays  of 
light  proceeding  from  objects  and  entering  the  eye,  tend  to  collect  into  foci, 
not  upon  the  retina  as  they  ought  to  do,  but  behind  it.  It  is  only,  however, 
by  that  degree  of  refraction,  or  with  that  form  of  the  eye,  which  permits  the 
rays  of  light  proceeding  from  the  luminous  points  of  objects  placed  at  an 
ordinary  distance  from  the  observer,  to  be  brought  into  corresponding  or 
nearly  corresponding  focal  points  upon  the  retina,  that  perfect  vision  can  be 
produced.  Falling  either  before  the  retina,  or  tending  to  fall  behind  it,  the 
image  will  necessarily  be  diluted,  and  the  impression  obtuse.  To  remedy 
these  defects,  the  person  affected  with  myopia  brings  the  object  within  that 
distance  which  will  insure  the  image  being  thrown  so  far  back  as  to  fall 
upon  the  retina,  while  the  presbyopic  person,  by  removing  the  object  to  a 
certain  distance  from  his  eye,  brings  the  image  forwards  to  the  retina. 

Fig.  146. 


Lot  r  in  the  annexed  diagram  (Fig:.  146)  represent  a  radiant  point :  if  the  rays  proceeding  from  it  fall  upon 
a  normal  eye,  their  focus  ■svill  be  at  f  o\\  the  retina :  if  upon  a  myopic  eye,  their  focus  will  be  at/'  in  front  of 
the  retina;  if  on  a  presbyopic  eye,  their  focus  will  be  at /"behind  the  retina;  and  in  these  two  cases,  the 
image  of  r  on  the  retina  will  occupy  the  space  ss',  so  as  to  be  greatly  diluted. 

Symptoms. — 1.  Objective  symptoms. — The  eyes  of  the  short  sighted  are 
frequently  prominent,  and  the  cornea  preternaturally  convex;  there  is  an  ap- 
proach to  the  state  of  hydrophthalraia,  the  anterior  chamber  being  more  than 
commonly  deep ;  the  pupil  is  generally  large  and  not  very  lively,  the  eyeball 
firm,  the  eyelids  often  tender. 

2.  Subjective  symjJtoms. — As  the  myopic  eye  has  its  point  of  distinct  vision 
as  well  as  the  perfect  eye,  those  affected  with  the  greatest  degree  of  near- 
sightedness bring  every  object  which  they  wish  to  see  clearly,  to  the  distance 
of  two  or  three  inches,  or  even  as  close  as  one  inch  from  the  eye,  while  other 
myopic  persons  are  able  to  enjoy  as  good  vision,  although  the  object  is  at  six 
or  nine  inches  distance.  The  eye  which  perceives  nothing  distinctly  beyond 
ten  inches,  may  be  considered  myopic.  The  imperfection,  then,  cannot  be 
concealed,  if  the  individual  affected  with  it  attempts  to  read,  or  to  examine 
any  small  object  minutely.  If  we  direct  his  attention  to  objects  at  a  consider- 
54 


850  MYOPIA. 

able  distance,  it  is  evident  that  they  either  make  no  impression  on  his  retina, 
or  one  which  is  exceedingly  indefinite  and  obscure.  He  cannot  distinguish 
the  countenances  of  the  performers  on  the  stage,  nor  the  subject  of  pictures 
placed  a  few  feet  above  his  head;  he  cannot  read  the  inscriptions  on  doors 
and  houses,  nor  recognize  persons  across  the  street ;  if  he  go  into  a  large 
room,  in  which  there  are  many  persons,  he  cannot  readily  distinguish  those 
he  knows. 

It  is  remarked  of  those  who  are  short-sighted  that  they  do  not  look  at  the 
person  with  whom  they  converse,  because  they  cannot  see  the  motion  of  his 
eyes  and  features,  and  therefore  they  are  attentive  to  his  words  only;  that  in 
reading  they  hold  the  book  obliquely  towards  their  eyes,  this  helping  them  to 
see  it  distinctly,  perhaps  by  allowing  the  light  to  illuminate  it  better;  that 
they  see  more  distinctly  and  somewhat  further  off  by  a  strong  light  than  a 
weak  one,  on  account  of  the  contractoin  of  the  pupil  which  is  thereby  pro- 
duced, and  which  serves  to  exclude  all  but  the  more  direct  rays  of  light,  and 
consequently  to  lessen  the  apparent  confusion;  that  on  the  same  principle, 
when  they  endeavor  to  see  any  distant  object  distinctly,  they  almost  close  their 
eyelids,  and  that  through  a  pinhole  in  a  card,  objects  appear  to  them  clearer 
and  better  defined  than  with  the  naked  eye. 

Short-sighted  persons  write  a  small  cramp  hand,  and  prefer  to  read  a  small 
type,  the  enlargement  of  the  visual  angles  by  the  proximity  of  the  object 
enabling  them  to  do  so. 

In  an  obscure  light  they  commonly  see  better  than  those  whose  sight  is 
good,  on  account  of  the  largeness  of  the  pupil.  The  short-sighted  person 
sees  near  objects  without  effort;  whereas  those  who  have  ordinary  sight,  con- 
tract the  eyelids  and  the  pupil,  to  obtain  the  same  effect,  and  consequently 
receive  less  light  in  a  medium  degree  of  illumination,  and  when  the  eye  is 
directed  to  near  objects,  than  do  those  w^ho  are  myopic. 

Short-sighted  persons  generally  attribute  to  distant  objects  a  greater  mag- 
nitude than  do  those  who  have  a  good  common  sight.  The  reason  is  that, 
while  distinct  images  are  formed  in  the  perfect  eye  only  at  the  intersection 
of  the  rays  of  light  issuing  from  the  object,  the  short-sighted  eye  receives  on 
the  retina  all  those  rays  beyond  their  intersection,  and  consequently  at  a  point 
where  they  are  more  extended. 

The  sight  of  one  who  is  myopic  is  much  improved  by  his  looking  through 
a  small  hole,  such  as  that  made  by  a  pin  in  a  card.  A  myopic  eye  sees  near 
objects  distinctly,  because  the  foci  of  the  refracted  rays  are  at  the  retina. 
Distant  objects  are  seen  indistinctly,  because  the  retini  being  behind  the  foci, 
the  image  of  each  point  is  expanded  on  the  retina,  in  the  form  of  a  circular 
halo;  and  as  the  images  of  adjacent  points  overlap,  indistinct  vision  is  a 
necessary  consequence.  The  area  of  the  halo  formed  by  each  point  depends 
on  the  diameter  of  the  pupil ;  being  greater,  the  greater  that  diameter.  Hence 
it  obviously  follows  that  by  diminishing  the  aperture  through  which  the  light 
is  admitted,  the  halo  will  be  less  extensive,  and  the  images,  of  the  adjacent 
points  more  distinct,  or,  in  other  words,  vision  will  be  clearer.^ 

If  a  short-sighted  person  looks  at  a  candle  placed  a  yard  or  two  off,  it 
appears  dim  and  enlarged,  and  seems  doubled,  tripled,  or  quadrupled.  This 
multiplication  by  the  myopic  eye  in  viewing  distant  objects,  must  arise  from 
each  surface  of  the  dioptric  media  forming  an  image  in  succession.  Similar 
multiplied  images  are  seen  by  ordinary  eyes,  when  the  eye,  in  viewing  a  dis- 
tant object,  is  by  a  voluntary  eSbrt  adapted  for  vision  at  a  short  distance. 
Thus,  when  a  person  with  ordinary  sight  adapts  his  eyes  for  vision  at  10 
inches,  and  looks  at  a  candle  at  the  distance  of  six  feet,  the  appearance  pre- 
sented is  that  of  several  images  partially  overlapping  each  other.  This  seems 
to  indicate  that  in  the  adjusting  of  the  eye  to  distances  a  change  takes  place 


MYOPIA.  851 

in  the  relative  curvatures  of  the  dioptric  media.  On  the  theory  of  there  being 
no  accommodating  power  in  the  eye,  only  one  image,  ill-defined  and  slightly 
enlarged,  would  be  expected  in  such  a  case. 

It  is  a  question  which  naturally  occurs  to  one  who  first  turns  his  attention 
to  the  nature  of  myopia,  whether  this  disease  consists  merely  in  over-refrac- 
tion, or  involves  also  a  deficiency  in  the  accommodating  power  of  the  eye 
to  different  distances.  Dr.  Smith  is  of  opinion,  that  the  power  of  varying 
the  quantity  of  refraction  is  still  retained  by  the  myopic  eye.  "If  short- 
sighted persons,"  says  he,  "can  read  a  small  print  distinctly  at  two  different 
distances,  whereof  the  larger  is  but  double  the  lesser,  which  I  believe  most  of 
them  can  do  ;  it  follows  that  as  great  alternations  of  figures  are  made  in  their 
eyes  as  must  be  made  in  perfect  eyes,  in  order  to  see  distinctly  at  all  inter- 
mediate distances  between  infinity  and  the  larger  of  those  two.  And  this  is 
the  reason  that  a  short-sighted  person  can  see  distinctly  at  all  distances  with 
one  single  concave  of  a  proper  figure,  which  otherwise  must  have  been  differ- 
ently figured  for  different  distances.  It  follows,  then,  that  the  cause  of  short- 
sightedness is  not  a  want  of  power  to  vary  the  figure  of  the  eye  and  the 
quantity  of  refractions,  but  that  this  whole  quantity  is  always  too  great  for 
the  distance  of  the  retina  from  the  cornea."* 

It  is  rarely  the  case  that  the  two  eyes,  even  of  the  same  person,  correspond 
in  refractive  power.  The  left,  partaking  perhaps  in  the  tendency  to  weakness 
and  disease,  which  so  frequently  attaches  itself  to  the  left  side  of  the  body, 
is  often  found  to  be  somewhat  short-sighted.  Few  are  aware  of  the  disparity 
which  often  exists  between  their  eyes,  until  some  accidental  circumstance 
leads  them  to  make  a  comparative  trial  of  the  two  ;  and  it  is  by  no  means 
uncommon  to  meet  with  individuals  who,  on  making  the  experiment,  have 
discovered  that  one  eye  was  greatly  defective,  or  even  entirely  blind.  Mr. 
Wardrop  remarks,^  that  it  will  generally  be  found  that  not  only  the  right  is 
more  perfect  than  the  left  eye,  but  that  when  a  person  is  apparently  looking 
at  an  object  with  both  eyes,  genei'ally  only  one  of  them,  and  that  the  right 
one,  is  actually  directed  to  the  object.  But  this  will  depend  entirely  on 
whether  the  right  or  the  left  is  the  better  of  the  two.  To  ascertain  the  fact, 
let  a  spot,  at  the  distance  of  a  few  yards  from  the  observer,  be  covered  with 
the  point  of  one  of  his  fingers,  while  he  endeavors  to  look  at  it  with  both  eyes. 
If  the  short-sighted  eye,  which  we  may  suppose  to  be  the  left,  be  now  closed, 
the  point  of  the  finger  will  continue  to  appear  to  cover  the  spot,  and  preserve 
the  same  relative  situation  to  it  as  when  both  eyes  were  open  ;  but  if  the  right 
eye  be  closed  and  the  left  opened,  then  the  relative  situation  of  the  point  of 
the  finger  and  spot  will  appear  altered,  the  spot  being  uncovered  ;  proving 
that  in  directing  the  finger  to  cover  the  spot,  the  right  eye  alone  had  been 
employed.  Mr.  Wardrop  has  met  with  myopia  more  frequently  in  the  left 
eye  than  the  right;  Mr.  Ware,  on  the  other  hand,  observes  that  most  of  the 
near-sighted  persons  with  whom  he  has  conversed,  had  the  right  more  affected 
than  the  left,  and  he  thinks  it  not  improbable  that  the  difference  had  arisen 
from  the  habit  of  using  a  single  concave  hand-glass,  which,  being  commonly 
applied  to  the  right  eye,  contributes  to  render  it  more  short-sighted  than  the 
other.* 

Efficient  causes. — Myopia  has  been  attributed  to  a  variety  of  eCQcient  causes, 
several  of  which  may  coexist. 

1.  Too  (/reat  convexity  of  the  cornea. — As  it  is  before  the  rays  of  light  reach 
the  crystalline  lens  that  they  undergo  their  greatest  refraction,  it  is  evident 
that  a  cornea,  abnormally  convex,  will  produce  a  convergence  so  rapid  that 
the  foci  will  fall  considerably  short  of  the  retina.  While  it  is  undeniable, 
however,  that  in  aggravated  instances  of  myopia,  the  cornea,  natural  in 
diameter,  may  be  observed  to  project  considerably  above  its  average  altitude, 


852 


MYOPIA. 


it  is  also  certaiu  that  this  coiiforiuatiou  is  by  no  means  a  constant,  nor  even 
a  very  frequent  attendant  on  this  disease.  When  it  does  occnr,  it  is  gene- 
rally accompanied  by  an  evident  superabundance  of  aqueous  humor,  and  occa- 
sionally by  a  degree  of  pressure  backwards  on  the  iris,  so  that  this  membrane, 
instead  of  being  plane,  becomes  concave  anteriorly. 

2.  Too  great  thichiess  of  the  cornea  will  undoubtedly  tend  to  bring  the 
rays  of  light  to  a  focus  sooner  than  they  ought  to  be  brought ;  but  it  is  not  at 
all  likely  that  the  cornea  is  ever  of  such  extraordinary  thickness  in  the  adult  eye, 
as  of  itself  to  be  the  cause  of  myopia.  At  birth,  indeed,  the  cornea  is  very 
thick  in  proportion  to  the  size  of  the  eye ;  and  to  this  Petit  has  ascribed,  in 
part,  the  indistinctness  of  vision  in  very  young  children.^ 

3.  Too  great  convexity  of  the  crystalline  lens  will  assuredly  produce  short- 
sightedness, whether  the  over-convexity  be  on  one  only,  or  on  both  sides  of 
that  body.  Such  conformation  has  been  regarded  as  probably  one  of  the 
most  frequent  causes  of  myopia;  and  notwithstanding  the  testi)nony  of  Percy 
and  Reveille-Parise,"  that  on  examining  the  lenses  taken  from  the  eyes  of  a 
number  of  persons  who  during  life  had  been  short-sighted,  they  were  unable 
to  detect  any  excessive  convexity,  we  must  still  admit  not  merely  the  possi- 
bility of  this  cause,  but  the  likelihood  of  its  frequent  existence. 

I  have  already  mentioned  the  disparity  of  the  eyes  of  most  individuals,  I 
cannot  but  think  that  this  often  depends  on  diiferent  degrees  of  refractive 
power  in  the  crystalline  lenses,  and  the  opinion  is  corroborated  by  what  is 
stated  by  Meckel,  that  the  crystalline  lenses  of  the  two  eyes  of  the  same 
person  have  sometimes  a  very  diQercnt  forni.^ 

4.  Preternatural  density  of  any  or  all  of  the  transparent  media  of  the  eye 
is  also  a  cause,  which  will  infallibly  produce  myopia,  and  which  is  not  un- 
likely sometimes  to  occur.  I  have  generally  observed  that  myopic  eyes  are 
considerably  firmer  to  the  touch  than  natural,  even  at  an  early  period  of  life. 

Those  who  suppose  the  adjustment  of  the  eye  to  near  objects  to  be  accom- 
plished by  pressure  on  the  lens,  by  which  means  its  surfaces  are  made  more 
convex,  incline  to  think  that  this  pressure,  frequently  exercised  in  consequence 
of  intense  and  continued  api)lication  to  near  objects,  renders  the  lens  denser 
than  ordinary  towards  its  centre,  and  that  the  result  is  myopia.  This  is  the 
opinion  of  Mr.  Smith, ^  who  believes  the  capsule  to  be  muscular ;  a  notion 
which  is  no  doubt  incorrect.  The  same  result,  however,  might  follow,  were 
the  change  of  figure  in  the  lens  atfected,  as  Professor  Forbes  thinks  it 
probably  may  be,  by  the  action  of  the  external  muscles  communicated  to 
the  entire  eyeball,  and  propagated  by  hydrostatic  pressure  through  the 
liumors." 

5.  Abnormal  elongation  of  the  eyeball,  so  that  the  distance  between  the 
cornea  and  retina  is  increased,  will  necessarily  occasion  myopia,  and  has  even 
been  regarded  by  some  as  the  only  admissible  cause  of  the  disease.  Such 
coufornaation  of  the  eye  has  been  supposed  to  be  sometimes  congenital,  and 
in  other  cases  to  be  acquired  from  frequent  exercise  of  the  sight  upon  minute 
objects.  When  congenital,  it  has  been  ascribed  to  unnatural  shortness  of  the 
recti ;  when  acquired,  to  abnormal  contraction  of  these  muscles,  and  of  the 
obliqui. 

6.  Over-activity  of  tlte  power  inherent  in  the  eye,  of  accommodating  itself 
to  the  vision  of  near  objects,  may  be  regarded  as  a  probable  cause  of  myopia. 
Of  the  existence  of  this  faculty  in  the  eye  there  can  be  no  doubt,  but  by  what 
particular  means  the  adjustment  is  accomplished,  is  a  question  upon  which  a 
great  diversity  of  opinion  prevails.*"  According  to  the  calculation  of  Olbers, 
if  the  distance  of  the  crystalline  lens  from  the  retina  could  be  varied  to  the 
extent  of  a  line,  we  should  be  enabled  to  see  objects  with  equal  distinctness 
from  a  distance  of  four  inches  to  the  utmost  extent  of  human  vision.     The 


I 


MYOPIA,  853 

same  effect  would  result  from  a  change  of  place  in  tlie  lens  to  the  amount  of 
half  a  line  only,  provided  the  radius  of  the  cornea  admitted  of  being  varied 
to  about  two-fifths  of  a  line.  If  we  suppose,  then,  that  there  is  an  over- 
activity in  the  organs  by  which  these  or  other  adjusting  changes  in  the  diop- 
tric media  of  the  eye  are  produced,  an  over-activity  excited  by  too  frequent 
application  of  the  eye  to  near  objects,  and  degenerating  into  a  habit,  we 
assign  as  a  possible  cause  of  myopia,  and  one  which  is  rendered  probable  by 
the  success  which  sometimes  attends  methodical  and  continued  attempts  to 
correct  and  overcome  the  habit.  " 

T.  The  large  pvpil,  which  almost  always  accompanies  myopia,  has  been 
generally  set  down  amongst  the  causes  of  the  disease,  whereas  it  is  more  pro-' 
bably  an  effect.  When  the  sight  is  perfect,  and  still  more  when  it  is  presby- 
opic, the  pupil  will  have  frequent  occasion  to  contract,  in  aiding  the  person 
to  see  near  objects  more  distinctly,  and  thus  an  habitual  degree  of  myopsis 
may  be  produced  ;  but  in  those  who  are  short-sighted  this  will  not  happen, 
for  to  them  near  objects  appear  distinct,  and  therefore  not  having  occasion  to 
contract  the  pupil  for  seeing  such  objects  more  distinctly,  this  aperture  pro- 
bably maintains  a  habitual  state  of  dilatation. 

By  contracting  the  pencils  of  light  which  are  allowed  to  reach  the  retina, 
as  in  looking  through  a  pinhole,  the  vision  of  the  myopic  eye  for  distant 
objects  is  rendered  more  distinct,  an  effect  equivalent  to  an  elongation  of  its 
focus ;  and  the  same  result  will  be  produced  by  anything  causing  contraction 
of  the  pupil  of  the  myopic  eye,  such  as  dropping  wine  of  opium  on  the  eye, 
or  rubbing  the  brow  with  concentrated  tincture  of  ginger  or  pepper,  a  fact 
taken  advantage  of  by  impostors  in  their  pretensions  to  cure  myopia. 

Subjects. — 1.  Age.  Young  people  seldom  discover  that  they  are  remarkably 
near-sighted,  until  about  the  age  of  puberty,  or  when  they  begin  to  use  their 
eyes  in  earnest.  If  it  occurs  rather  suddenly,  myopia  is  apt  to  be  mistaken 
for  some  more  serious  affection. 

Case  360. — A  young  lady,  aged  16,  became  suddenly  short-sighted,  after  having  been 
engaged  in  flower-painting  and  worsted  work,  at  a  boarding-school  in  Edinburgh.  The 
effort  to  see  at  the  usual  distance,  and  even  to  read,  caused  pain  in  the  eyes.  The  pupils 
presented  the  sluggishness  which  often  attends  myopia.  A  physician  of  eminence  was 
consulted,  and  pronounced  the  disease  to  be  amaurosis.  He  had  the  patient  leeched, 
gave  her  mercury,  and  advised  a  vomit  and  blisters.  When  the  patient  was  brought  to 
ine,  I  found  she  saw  perfectly  through  a  double  concave  glass  of  48  inches  focus,  and 
learned  that  several  of  her  near  relations  labored  under  myopia. 

Many  persons  reach  the  age  of  30  or  40  years,  who  have  no  notion  that 
they  are  near-sighted,  until  they  happen  accidentally  to  look  through  the 
concave  glasses  of  some  other  individual,  when  they  are  surprised  and 
delighted  to  find  that  they  perceive  remote  objects  with  a  clearness  and  sharp- 
ness of  outline,  to  which  they  had  formerly  been  altogether  strangers.  They 
may  have  suspected  that  they  did  not  see  across  the  street  or  at  the  theatre, 
quite  so  plainly  as  other  people  ;  but  as  they  could  read  a  small  print  as  well 
as  any  body,  they  had  no  idea  that  they  were  the  subjects  of  any  defect  in 
their  eyes,  or  that  they  could  improve  their  vision  by  any  kind  of  glass. 

Although  near-sightedness  is  in  general  gradual  in  its  progress,  manifest- 
ing itself  about  the  period  of  puberty,  and  increasing  from  that  period  up  to 
20  or  25  years  of  age,  yet  instances  occasionally  occur  of  its  existence  even 
in  children,  or  of  its  suddenly  affecting  the  eye  of  a  grown-up  person  who 
had  previously  seen  distinctly  at  the  ordinary  distance. ^^  When  children, 
about  the  period  of  being  sent  to  school,  are  supposed  to  be  myopic,  we 
should  carefully  examine  the  appearances  presented  through  the  pupil,  for 
very  often  a  central  cataract  (see  p.  789)  will  be  found  to  exist  under  such 
circumstances ;  while  the  sudden  accession  of  shortness  of  sight  in  adults 
who  had  previously  seen  well,  should  lead  us  to  suspect   conical  cornea, 


854  MYOPIA. 

dropsy  of  the  aqueous  humor,  or  even  some  affection  of  the  retina  or  of  the 
brain. 

It  is  a  vulgar  error,  that  near-sighted  eyes  are  by  age  rendered  fitter  for 
perceiving  distant  objects  than  they  were  in  youth.  This  opinion  appears  to 
have  been  built  on  the  following  false  analogy  ;  viz  :  that  if  those  who  pos- 
sess ordinary  vision  when  young,  become,  from  the  flatness  of  the  cornea  or 
other  changes  in  the  structure  of  the  eye,  far-sighted  as  they  approach  to 
old  age,  which  is  a  well-established  fact,  then,  the  short-sighted  must,  from 
similar  changes,  become  better  fitted  to  see  distant  objects.  Short-sighted- 
ness tends  generally  to  increase  rather  than  to  diminish,  as  age  advances ; 
and  should  it  come  to  be  combined  with  a  glaucomatous  state  of  the  lens, 
the  person  is  obliged  to  bring  any  object,  which  he  wishes  to  see  distinctly, 
within  a  very  short  distance  of  the  eye. 

2.  Rank  and  occupation.  Myopia  is  much  more  common  in  the  higher 
than  in  the  lower  ranks  of  life,  and  among  those  who  occupy  themselves 
with  the  close  examination  of  minute  objects  than  in  those  who  scarcely  ever 
attempt  to  read,  write,  or  apply  themselves  to  any  similar  pursuit.  Mr.  Ware 
remarks,  that  among  persons  in  the  inferior  stations  of  society,  artificial 
means  are  rarely  resorted  to  for  correcting  slight  defects  of  this  nature ;  and 
that  there  is  even  reason  to  believe  that,  in  such  people,  near-sightedness  is 
not  unfreqnently  overcome  by  the  increased  exertions  that  are  made  by  the 
eye  to  distinguish  distant  objects.  When  persons  in  the  higher  ranks,  on 
the  other  hand,  discover  that  their  discernment  of  distant  objects  is  less  quick 
or  correct  than  that  of  others,  though  the  dilference  may  be  very  slight,  in- 
fluenced perhaps  by  fashion  more  than  by  necessity,  they  immediately  have 
resource  to  a  concave  glass  ;  the  natural  consequence  of  which  is,  that  their 
myopia  in  a  short  time  becomes  so  confirmed  that  the  recovery  of  distant 
vision  is  difficult,  if  not  impossible. 

With  regard  to  the  proportion  of  near-sighted  persons  in  the  different  ranks 
of  society,  Mr.  Ware  endeavored  to  obtain  satisfactory  inforraatio'n,  by  mak- 
ing inquiry  in  those  places  where  a  large  number  of  individuals  of  nearly  the 
same  station  are  associated  together.  He  inquired,  for  instance,  of  the  sur- 
geons of  the  three  regiments  of  foot-guards,  consisting  of  nearly  10,000  men  ; 
and  he  was  informed  that  near-sightedness  was  almost  unknown  amongst 
them,  not  six  individuals  having  l)een  discharged,  nor  six  recruits  rejected, 
on  account  of  this  imperfection,  in  the  space  of  nearly  20  years.  At  the 
Military  School  at  Chelsea,  where  there  were  1300  children,  the  complaint 
of  near-sightedness  had  never  been  made  among  them,  until  Mr.  Ware  men- 
tioned it,  and  then  only  three  were  found  who  experienced  the  least  incon- 
venience from  it.  He  pursued  his  inquiries  at  several  of  the  colleges  in  Ox- 
ford and  Cambridge,  and  found  near-sightedness  very  prevalent  in  these 
institutions.  In  one  college  in  Oxford,  where  the  society  consisted  of  121 
members,  32  either  wore  spectacles  or  used  hand-glasses.  It  is  not  impro- 
bable, that  some  of  these  were  induced  to  do  so,  solely  because  the  practice 
was  fashionable  ;  but  Mr.  Ware  believes  the  number  of  such  to  have  been 
inconsiderable,  compared  with  that  of  those  whose  sight  received  some  small 
assistance  from  glasses,  although  this  assistance  could  have  been  dispensed 
with  without  incon»'enience,  if  the  practice  had  not  been  introduced." 

Predisposing  and  exciting  causes. — 1.  Karely  congenital,  but  often  con- 
nected with  a  hereditary  tendency,  myopia  owns,  as  a  chief  predisposing  or 
exciting  cause,  the  using  of  the  eyes  too  much  in  early  youth,  on  small  and 
near  objects.  Henke  refers  short-sightedness  to  the  narrow  circle  of  vision 
rendered  customary  in  confined  nurseries."  2.  The  use  of  concave  glasses 
so  notoriously  produces  or  increases  myopia,  that  in  France  they  were  often 
employed  for  the  purpose  of  thereby  rendering  the  wearers  unfit  for  military 


MYOPIA.  855 

service,  and  thus  enabling  them  to  escape  the  conscription.  The  plan  seems 
to  have  been  to  commence  with  pretty  deep  concaves,  and  gradually  employ 
deeper  and  deeper,  till  the  sight  became  so  short  that  distant  objects  could 
not  be  discerned." 

General  treatment. — It  is  but  rarely  the  case  that  the  medical  practitioner 
has  an  opportunity  of  advising  those  in  whom  myopia  is  not  yet  confirmed, 
to  that  course  of  treatment  which  might  remove  the  incipient  symptoms  of 
this  very  serious  imperfection  of  sight.  If  it  be  correct  that  this  disease,  in 
by  far  the  greater  number  of  instances,  is  induced  by  too  much  exercise  of 
the  eyes  upon  minute  objects,  as  in  reading,  writing,  sewing,  miniature  paint- 
ing, engraving,  and  the  like,  the  cure  would  probably  be  found  in  abstaining 
entirely  for  a  time  from  such  occupations,  refraining  also  from  the  use  of 
concave  glasses,  and  employing  the  eyes  chiefly  upon  large  and  distant  ob- 
jects. It  is  probable,  that  the  plan  of  gradually  removing  the  book  from 
the  eye  till  it  can  be  read  at  the  ordinary  distance,  reading  through  convex 
glasses,  and  other  attempts  of  a  similar  sort,  will  prove  of  little  use,  in  com- 
parison of  the  good  effects  to  be  derived  from  frequent  exercise  out  of  doors, 
walking  and  riding  into  the  country,  and  travelling  through  new  and  interest- 
ing scenes. 

If,  instead  of  such  a  plan  of  conduct,  recourse  be  had  to  the  employment 
of  concave  glasses,  and  frequent  and  long-continued  observation  of  near  ob- 
jects be  persisted  in,  the  disease  becomes  not  only  confirmed,  but  sometimes 
greatly  aggravated. 

"  Children,"  says  Sir  Charles  Blagden,  "born  witli  eyes  which  are  capable  of  adjusting 
themselves  to  the  most  distant  objects,  gradually  lose  that  power  soon  after  they  begin 
to  read  and  write ;  those  who  are  most  addicted  to  study  become  near-sighted  more 
rapidly  ;  and  if  no  means  are  used  to  counteract  the  habit,  their  eyes  at  length  lose  irre- 
coverably this  faculty  of  being  brought  to  the  adjustment  for  parallel  rays.  Of  this  I  am 
myself  an  example 

"When  1  first  learned  to  read,  at  the  usual  age  of  four  or  five  years,  I  could  see  most 
distinctly,  acfoss  a  wide  church,  the  contents  of  a  table  on  which  the  Lord's  Prayer  and 
the  Belief  were  painted  in  suitable  large  letters.  In  a  few  years,  that  is,  about  the  ninth  or 
tenth  or  my  age,  being  much  addicted  to  books,  I  could  no  longer  read  what  was  jjainted 
on  this  table  ;  but  the  degree  of  near-sightedness  was  then  so  small,  that  I  found  a  watch- 
glass,  though  as  a  meniscus  it  made  the  rays  diverge  very  little,  sufficient  to  enable  me  to 
read  the  table  as  before.  In  a  year  or  two  more,  the  watch-glass  would  no  longer  serve 
my  purpose  ;  but  being  dissuaded  from  the  use  of  a  common  concave  glass,  as  likely  to 
injure  my  sight,  I  suffered  the  inconvenience  of  a  small  degree  of  myopia,  till  I  was  more 
than  thirty  years  of  age.  That  inconvenience,  however,  gradually  though  slowly  increas- 
ing all  the  time,  at  length  became  so  grievous,  that,  at  two  or  three  and  thirty,  I  deter- 
mined to  try  a  concave  glass ;  and  then  found  that  the  numbers  two  and  three  were  to  me 
in  the  relation  so  well  described  by  Mr.  Ware  ;  that  is,  I  could  see  distant  objects  tole- 
rably well  with  the  former  number,  but  still  more  accurately  with  the  latter.  After 
contenting  myself  a  little  time  with  No.  2,  1  laid  it  wholly  aside  fur  No.  3  ;  and,  in  the 
course  of  a  few  more  years,  came  to  No.  5,  at  which  point  my  eye  has  now  been  stationary 
between  fifteen  and  twenty  years.  An  earlier  use  of  concave  glasses  would  probably  have 
made  me  more  near-sighted,  or  would  have  brought  on  my  present  degree  of  moypia  at 
an  earlier  period  of  life.  If  my  friends  had  persuaded  me  to  read  and  write  with  the 
book  or  paper  always  as  far  from  mj^  eyes  as  I  could  sec,  or  if  I  had  occasionally  inter- 
mitted study,  and  taken  to  field  sports  or  any  employment  which  would  have  obliged 
me  to  look  much  at  distant  objects,  it  is  very  probable  that  I  might  not  have  been  near- 
sighted at  all.  "5 

3fetkodical  exercise  of  the  eyes, — As  myopia  may,  to  a  certain  extent,  be 
regarded  as  a  halnt,  arising  from  too  frequent,  and  at  last  continued  adjust- 
ment to  near  objects,  and  as  any  one  by  too  much  exercise  of  the  sight  on 
such  objects  can  make  himself  short-sighted,  it  is  reasonable  to  suppose  that 
much  may  be  done  in  correcting  this  failing,  by  an  opposite  exercise  of  the 
sight,  gone  about  in  a  methodical  and  persevering  manner.  For  this  purpose. 
Professor  Bcrthold  recommends  the  use  of  a  corrective  desk,  or  myoiJodior- 


856  MYOPIA. 

tlioticon,  upon  which  all  the  reading  and  writing  of  the  patient  should  be 
carried  on.  From  the  back  of  the  desk  two  screws  rise  vertically',  one  at 
either  side.  These  screws  pass  through  and  support  a  crossbar,  which  is 
moved  upwards  by  means  of  two  nuts  situated  below  it,  and  moved  down- 
wards or  retained  in  position  by  two  other  nuts  situated  above  it.  Through 
the  middle  of  the  crossbar  a  graduated  rest  passes  for  the  support  of  the 
forehead,  which  rest,  being  movable  to  and  fro  horizontally,  is  also  held  in 
position  by  a  screw.  By  the  motion  of  the  crossbar  on  the  vertical  screws, 
and  of  the  rest  in  the  crossbar,  the  apparatus  is  so  regulated,  that  the  head, 
in  relation  to  the  book  to  be  read  or  paper  to  be  written  on,  is  placed  in  the 
position  best  adapted  to  the  power  of  sight.  Parallel  to  the  vertical  screws, 
two  scales,  graduated  like  the  horizontal  rest,  to  tenths  of  an  inch,  pass  up- 
wards through  the  crossbar.  By  these  scales,  the  apparatus  is  adjusted  to 
the  differently  sized  print  of  the  books  to  be  read,  and  to  the  gradual  exten- 
sion of  vision  as  the  cure  proceeds. 

In  employing  the  apparatus,  it  must  be  so  regulated  that  the  person  using 
it  can  read  large  print  with  ease,  whilst  leaning  with  the  upper  part  of  the  root 
of  the  nose  against  the  horizontal  rest.  Moving  the  crossbar  upwards,  by 
turning  the  nuts  on  the  vertical  screws,  the  distance  between  the  free  extremity 
of  the  rest,  ou  which  the  forehead  leans,  and  the  book,  or  the  distance  of  dis- 
tinct vision,  is  to  be  increased  every  second,  third,  or  fourth  day,  from  jV  to 
jg-  inch,  measured  on  the  scales,  but  never  to  a  point  where  the  print  cannot 
be  read  with  facility.  A  rapid  increase  of  distance  must  be  especially  avoided, 
as  the  power  of  adjusting  the  eye  to  remote  objects  is  but  slowly  attained. 
For  reading  with  the  apparatus,  a  book  must  be  chosen  of  a  clear  and  large 
print,  and,  if  possible,  of  the  same-sized  type  throughout.  As  the  same  print 
should  be  read  as  long  as  possible,  a  work  consisting  of  a  large  number  of 
volumes  is  preferable.  For  writing,  the  distance  of  the  eye  from  the  paper 
may  be  somewhat  more  ample  than  for  reading,  if  the  patient  observes  the 
rule,  to  write  a  large  hand. 

The  principle  of  Professor  Berthold's  apparatus  is  simple  and  correct,  the 
application  of  it  requiring  only  patience  on  the  part  of  the  person  employing 
it,  and  a  devotedness  to  the  object  to  be  gained.  The  duration  of  the  treat- 
ment with  the  apparatus  will  be  proportioned  to  the  degree  of  the  myopia, 
and  in  early  life  a  more  rapid  cure  may  ])e  expected  than  in  mature  age.  The 
chief  condition  of  success,  is  the  slow  but  steadily  progressive  increase  of  the 
distance  at  which  vision  is  exercised,  especially  in  the  beginning  of  the  treat- 
ment.*^ 

Concave  glasses. — If  convex  spectacles  were  not  invented  by  Roger  Bacon, 
they  were  well  known  about  the  time  of  his  death,  in  1294  ;  although  not  long 
before  that  period.  It  is  probable,  that  the  use  of  concave  glasses,  to  help 
the  vision  of  those  who  are  short-sighted,  followed  soon  after  that  of  convex 
ones,  though  no  trace  of  their  introduction  is  mentioned  in  the  history  of 
optical  science.  Maurolicus,  in  his  treatise  De  Lumine  et  Umbra,  written  in 
1554,  considers  the  crystalline  as  the  principal  instrument  of  vision,  and  as 
transmitting  to  the  optic  nerve  the  images  of  objects  ;  and  he  explains  why 
some  persons  are  long-sighted  and  others  short-sighted,  according  to  the  less 
or  greater  convexity  of  the  surfaces  of  the  crystalline,  showing  that  in  the 
former  case  the  rays  have  not  been  converged  to  a  focus  when  they  reach  the 
retina,  while  in  the  latter  they  have  been  converged  before  they  reach  it. 
He  explains,  also,  how  the  convergency  may  be  hastened  in  the  long-sighted 
eye  by  the  use  of  a  convex  glass,  and  delayed  in  the  short-sighted  by  a  con- 
cave one.  These  observations  of  Maurolicus  were  not  known  to  Kepler, 
when  it  was  proposed  to  him,  as  a  question  by  his  patron,  Dietrichstein,  in 
what  manner  spectacles  assisted  sight.     The  first  answer  he  gave,  as  he  tells 


MYOPIA.  85t 

ns  in  his  Ad  VitelUonem  ParaUpomena,  published  in  1G04,  was,  that  convex 
glasses  were  of  use,  by  making  objects  appear  larger.  But  his  patron  ob- 
served, that  if  objects  were  by  them  rendered  more  distinct,  because  larger, 
no  person  Avould  be  benefited  by  concave  glasses,  since  these  diminished  ob- 
jects. The  striking  resemblance  between  experiments  with  the  camera  obscura 
and  the  manner  in  which  vision  is  performed  in  the  eye,  had  been  pointed  out 
byBaptista  Porta,  in  his  Marjia  Naturalis,  published  in  15G0,  where  he  com- 
pares the  pupil  to  the  hole  in  the  window-shutter,  but  falls  into  the  mistake 
of  assigning  to  the  crystalline  the  office  of  receiving  the  images,  like  the  walls 
or  screen  in  the  camera  obscura.  Kepler,  in  his  work  above  referred  to,  was 
the  first  to  show  that  the  office  of  receiving  the  images  of  external  objects  is 
performed  by  the  retina.  He  now  gave  a  clear  account  of  the  effects  of  the 
lenses,  whether  within  or  without  the  eye,  in  making  the  rays  of  a  pencil  of 
light  converge  or  diverge  ;  and  explained,  that  convex  glasses  assist  the  sight 
of  presbyopic  persons,  by  so  altering  the  directions  of  rays  diverging  from  a 
near  object,  that  they  fall  upon  the  eye,  as  if  they  had  proceeded  from  a  more 
remote  one,  and  that  concave  glasses  benefit  the  myopic,  by  producing  a  con- 
trary effect  upon  rays  which  diverge  from  a  distant  object,  making  them  fall 
upon  the  eye  as  if  they  proceeded  from  a  near  one. 

The  glasses  commonly  employed  for  the  assistance  of  myopic  eyes  are 
double-concaves,  of  equal  concavity  on  each  side.  Occasionally,  however,  the 
two  sides  are  made  of  unequal  depth.  A  plano-concave  or  concavo-convex 
glass  might  answer.  Dr.  Wollaston  introduced  a  kind  of  spectacles,  which, 
from  their  affording  an  opportunity  of  looking  round  at  various  objects  without 
moving  the  head,  he  called  jjeriscopic.  Tlicy  owe  this  property  to  always 
having  the  surface  next  the  eye  concave,  whether  the  glasses  are  intended  for 
short  or  long-sighted  persons,  the  convex  outer  surface  being  a  segment  of  a 
larger  sphere  than  the  concave  inner  surface  for  short-sighted  persons,  and  of 
a  smaller  one  for  long-sighted  persons.  A  wider  field  is  gained  in  proportion 
as  the  second  surface  approaches  to  the  curvature  of  the  cornea  ;  at  the  ex- 
pense, however,  of  distinctness  of  vision,  as  such  lenses  increase  the  aberration 
both  of  color  and  of  figure. ^^ 

"When  we  look  at  any  object,"  says  the  author  of  the  article  "  Optics," 
in  the  Edinburgh  Encijclopmdia,  "so  as  to  see  it  distinctly,  we  have  distinct 
vision  only  over  the  small  portion  of  it  to  which  the  axis  of  the  eye  is  directed, 
all  the  rest  of  it  being  seen  in  a  confused  manner  by  oblique  or  indirect  jjcu- 
cils.  In  reading,  therefore,  or  in  the  examination  of  minute  objects,  we  cannot 
see  any  advantage  in  the  use  of  periscopic  spectacles  ;  but,  on  the  other  hand, 
when  used  out  of  doors,  eitlier  in  viewing  a  landscape,  where  the  oblique  por- 
tion of  the  image  forms  part  of  the  picture,  or  in  giving  us  warning  of  the 
oblique  approach  of  objects,  they  are  of  essential  use." 

Myopic  persons  are  extremely  apt  to  adopt  the  use  of  a  single  e3'e-glass, 
against  which  we  ought  to  put  them  on  their  guard.  Spectacles  are  always 
preferable,  because  by  keeping  both  eyes  in  action,  not  only  is  vision  ren- 
dered brighter  and  easier,  but  the  labor  of  each  eye  is  considerably  lessened. 

Double-concave  glasses  are  numbered  1,  2,  3,  &c.,  beginning  with  the 
longest  focus,  or  shallowest  concavity. ^^  We  must  recommend  to  the  near- 
sighted person  to  be  content  with  the  shallowest  glass,  or  lowest  number, 
which  answers  his  purpose.  If  No.  1  enables  him  to  discern  distinctly  the 
names  on  the  corners  of  the  streets,  and  gives  a  decided  outline  to  objects 
whose  distance  does  not  exceed  about  forty  feet,  he  ought  not  to  have  recourse 
to  No.  2.  Objects  should  appear  clear  through  the  glass  which  is  chosen  ; 
but  if  it  makes  them  less  than  natural,  or  gives  them  a  dazzling  or  glaring 
appearance,  or  if  the  eye  feels  strained  or  fatigued  after  looking  through  it 
for  a  short  time,  it  is  too  deep,  and  a  lower  number  should  be  selected. 


858  MYOPIA. 

When  a  near-sigbted  person  wishes  to  be  fitted  with  concave  glasses,  the 
simplest  and  surest  plan  is  to  try  a  series  of  them,  at  an  optician's  shop.  It 
may  happen,  however,  that  an  individual  in  the  country  is  desirous  of  writing 
to  town  for  concave  glasses,  and  wishes  to  mention  the  focus  which  will  be 
likely  to  suit  his  eye.  This  may  be  ascertained  by  means  of  the  optometer, 
as  improved  by  Dr.  Young  ;  but  as  this  instrument  is  not  always  at  hand,  the 
following  rules  may  be  adopted. 

1.  If  the  near-sighted  person  is  desirous  of  assistance  in  seeing  remote 
objects,  ^.  e.  beyond  200  or  300  yards,  the  focal  distance  of  the  glasses  which 
he  will  require  for  that  purpose  should  be  the  distance  at  which  a  small 
object  appears  distinct  to  his  naked  eye.  For  example,  if  he  read  this  type 
at  12  inches  distance,  12  inches  will  be  the  focus  of  the  concave  glasses  which 
he  will  require  for  seeing  distant  ol^jects  distinctly. 

2.  If  the  glasses  wanted  are  intended  for  reading  with,  or  seeing  near 
objects,  let  the  near-sighted  person  multiply  the  distance  at  which  he  is  able 
to  read  with  ease  with  the  naked  eye,  say  4  inches,  by  the  distance  at  which 
he  wishes  to  read,  say  12  inches;  divide  the  product  48  by  the  difference 
between  the  two,  which  in  this  instance  is  8 ;  the  quotient,  6,  is  the  focal 
length  in  inches  of  the  glass  which  is  required. 

It  is  a  common  error  with  those  persons  who  begin  to  use  concave  glasses, 
to  tire  of  those  which  they  first  employ,  and  have  recourse  to  deeper  ones. 
To  these  the  eyes  do  not  fail  (at  least  for  a  time)  to  accommodate  themselves  ; 
but,  in  the  end,  the  patient,  who  thus  proceeds  from  one  degree  of  concavity 
to  a  greater,  will  find  it  difficult  to  obtain  glasses  sufficiently  deep  to  afford 
him  much  assistance,  or  he  may  produce  such  a  condition  of  the  organs  of 
visions  as  shall  render  him  unfit  to  engage  in  any  ordinary  pursuit.  Near- 
sightedness generally  continues,  as  has  been  already  stated,  in  nearly  the 
same  degree  during  the  greater  part  of  life.  Therefore,  the  same  glass  will 
continue,  for  many  years,  to  afford  precisely  the  same  assistance,  and  ought 
not  to  be  heedlessly  changed  for  one  of  deeper  concavity. 

Dr.  Kitchener  tells  us  that  he  was  about  fifteen  years  old  when  he  first 
discovered  that  he  could  not  discern  distant  objects  so  distinctly  as  people 
who  have  common  eyes  usually  do. 

"Seeing,"  says  be,  "  that  I  could  not  sec  wliat  persons  ■with  common  eyes  frequently 
pointed  out  to  me  as  well  deserving  my  attention,  I  paid  a  visit  to  an  optician,  and  pur- 
chased a  concave  eye-glass  "So.  2.  Alter  using  this  some  little  time,  I  accidentally  looked 
through  a  concave  No.  3,  and  finding  my  sight  much  sharper  with  this  than  with  No.  2, 
had  my  spectacles  glassed  with  No.  o,  which  appeared  to  afford  my  eye  as  much  assistance 
as  it  could  receive.  After  using  No  3  for  a  few  montlis,  I  chanced  too  look  through  No. 
4,  and  again  found  the  same  increase  of  sharpness,  «S:c,  which  I  perceived  before  when  I 
had  been  using  No.  2  and  first  saw  through  No.  3,  therefore  concluded  that  I  had  not  j'et 
got  glasses  sufficiently  concave,  and  accordingly  procured  No.  4;  however,  this  soon  be- 
came no  more  stimulus  to  the  optic  nerve  than  its  predecessors  Nos.  2  and  3  had  been.  I 
then  began  to  think  that  the  sight  was  subject  to  the  same  laws  which  govern  the  other 
parts  of  our  system,  i.  e.  an  increased  stimulus  by  repetition  soon  loses  its  power  to 
produce  an  increased  effect.  Therefore,  I  refused  my  eye  any  further  assistance  than  it 
received  from  spectacles  glassed  with  No.  2,  which  I  have  worn  for  upwards  of  thirty-one 
years,  and  it  is  very  nearly,  if  not  quite,  as  sufficient  help  to  me  now  as  it  was  when  I 
first  employed  it.''^ 

The  same  author  recommends  persons  who  are  extremely  short-sighted, 
in  order  to  prevent  their  being  obliged  to  stoop,  in  writing,  reading  music, 
and  the  like,  to  wear  spectacles  with  very  shallow  concaves,  just  enough  to 
enable  them  to  see  the  ofjjects  required  in  such  cases,  at  the  same  distance 
with  other  persons ;  but  for  distant  objects,  to  use  a  small  opera-glass,  which 
having  an  adjustable  focus,  if  it  magnifies  only  twice,  will  be  infinitely  better 
than  any  single  concave,  because  it  can  be  exactly  adapted  to  the  various 
distances. 


MYOPIA.  859 

When  once  a  near-sighted  person  has  experienced  the  pleasure  of  seeing 
remote  objects  with  that  distinctness  and  comparative  brilliancy  which  the 
aid  of  concave  glasses  affords,  it  is  not  easy  to  persuade  him  to  renounce  their 
use.  It  is  advisable  that  near-sighted  persons  should  not  wear  spectacles 
QODStantly,  but  only  on  occasions  when  they  more  particularly  require  such 
assistance.  When  they  have  been  worn  for  a  considerable  time,  the  person 
does  not  at  first  see  so  well  on  leaving  them  off  as  he  did  before  ;  but  this  is 
only  temporary. 

It  is  not  uncommon  for  myopic  persons,  and  especially  those  in  whom  my- 
opia is  combined  with  nebula?  of  the  cornea  from  corneitis,  to  use  convex 
glasses  for  near  objects.  With  such  glasses,  they  bring  the  object  nearer 
than  they  would  do  were  they  viewing  it  with  the  naked  eye,  and  they  see  it 
magnified. 

Myotomy. — The  operation  for  strabismus  having  been  found,  in  some 
instances,  to  remove  the  myopia  by  which  the  strabismus  had  been  attended, 
has  led  to  the  proposal  of  dividing  certain  muscles  of  the  eye,  in  cases  where 
myopia  exists  alone. 

Mr.  Phillips,  having  remarked  that  the  amelioration  of  myopia  had  taken 
place  in  cases  where  he  had  cut  the  superior  oblique,  proposes  that  a  division 
of  this  muscle  should  be  tried.  M.  Guerin,  in  what  he  calls  mechanical  or 
muscular  myopia,  in  contradistinction  to  that  which  is  optical  or  ocular,  and 
which  he  attributes  to  an  original  shortness  or  to  an  active  retraction  of  the 
recti,  recommends  two  of  the  muscles,  the  internal  and  external,  or  the  supe- 
rior and  inferior  recti,  to  be  divided.  M.  Bonnet  comes  to  the  conclusion 
that  myopia  depends  on  an  elongation  of  the  globe  of  the  eye,  from  its  being 
compressed  between  the  two  oblique,  which  he  remedies  bydividing  the  inferior 
oblique.  The  success  attending  this  operation  in  the  hands  of  M.  Bonnet, 
he  states  as  very  remarkable,  as  may  be  seen  by  consulting  his  Traiti  des 
Sections  Tendineuses  et  Musculaires.  At  the  same  time,  the  circumstance  of 
his  having  found  the  same  operation  available  in  a  disease  of  a  very  different 
character  from  myopia,  namely,  asthenopia,  which  is  attended,  in  fact,  by  an 
incapability  of  maintaining  the  eyes  in  a  state  of  adjustment  to  near  objects, 
must  make  us  pause  in  receiving  his  conclusions,  and  lead  us  to  suspect  that 
the  benefit  ascribed  to  the  division  of  the  inferior  oblique  in  myopia,  if  not 
altogether  an  illusion,  may  be  attributable  merely  to  the  temporary  excite- 
ment, both  of  the  organ  operated  on  and  of  the  mind  of  the  patient,  arising 
from  an  operation  having  been  performed  on  the  eye. 


*  On  vision  through  a  pinhole,  see  the  author's  '^  See  Henry,  Memoirs  of  the  Literary  and 
Physiology  of  Vision,  p.  153:  London,  1841.  Philosophical  Society  of   Manchester;  Vol.  iii. 

"  Complete  System  of  Optics;  Vol.  ii.  p.  2;  p.  182:  Warrington,  1790. 

Cambridge,  1738.  '■'  Philosophical    Transactions;  Vol.  ciii.  p. 

"  Morbid  Anatomy  of  the  Human  Eye;  Vol.  31:  London,  1813. 

ii.  p.  229;  London,  1818.  '"  Ilandbuch  der  Kinderkrankheiten,  quoted 

*  Philosophical   Transactions;    Vol.    ciii.  p.  in  Evanson  and  Maunsell  on  the  Management 
34;  London,  1813.  and  Diseases  of  Children,  p.  62;  Dublin,  1842. 

'  Moinoires  de  I'Academie  Royale  des  Sci-  '*  Duval,  Traite  de  I'Amaurose,  p.  117  ;  Paris, 

ences,  pour  1727,  p.  346;  Amsterdam,  1732.  1851. 

^  HygieneOculaire, par J.H. Reveille-Parise,  '"  Philosophical  Transactions;    Vol.  ciii.  p. 

p.  32;  Paris,   1816.  110. 

''  Manuel  d'Anatomie  Geuer.ale,  Descriptive  '^  Berthold,    Das    Myopodiorthoticon,    oder 

et  Pathologique,  traduit  par  Jourdan  et  Bros-  der  Apparat,   die    Kurzsiehtigkeit    zu   heilen  ; 

chet  ;  Tome  iii.  p. 244;  Paris,  1825.  Gottingen,  1840;  Franz,  London  Medical  Ga- 

'  Philosophical  Magazine,  .July,  1833;  p.  12.  zette.  August,  28,  1840,  p.  866;  December  11, 

»  Transactions  of  the  Koy.al  Society  of  Edin-  1840.  p.  442. 

burgh.  Vol.  xvi.  p.  6;   Edinburgh,  1849.  "  Nicholson'sJournal  of  NaturalPhilosophy ; 

"■  On  the  adjustment  of  the  eye  to  distances.  Vol.  vii.  p]).  143    192,  242,  291,  Vol.  viii.  p.  38; 

see  the  author's  Physiology  of  Vision,  Chap.  xi.  London,  1 804. 

"  Berthold,  London  Medical  Gazette,  Aug.  '"  Cimcave  glasses  ought  always  to  be  dis- 

28,  1840,  p.  867.  tinguished  by  their  focal  lengths,  and  never  by 


860 


PRESBYOPIA. 


numbers;  bceniise  the  grarlations  of  concavity 
are  not  always  worked  to  a  certain  standard,  so 
that  what  one  optician  calls  No.  1,  another  rates 
as  No.  2,  and  so  on.  Mr.  Rauisden  made  the 
first  number  of  his  concave  glasses  equivalent 
to  a  convex  of  24  inches  focus,  i.  e.  if  a  convex 
of  that  focal  length  were  united  to  a  concave 
No.  1,  the  combination  «ould  bo  equivalent  to 
a  plane,  and  objects  would  appear  through  the 
two  glasses  neither  larger  nor  smaller  than  they 
really  are.  No.  2  he  made  to  correspond  to  a 
21-inch  convex;  No.  3  to  an  18:  and  so  on. 

The  following  are  the  foci  in  inches  of  a  set 

of  concave  glasses  which  I  keep  by  me,  with 

which  to  try  myopic  eyes:- 

No. 


1    - 

-     4S 

No.  7    - 

-     9 

2     - 

-     36 

8     - 

-    7 

3     - 

-     24 

9     - 

-     5 

4     - 

-     18 

10     - 

-    4 

5     - 

-     14 

11     - 

-     3 

6    - 

-     12 

12     - 

-     2 

In  Germany,  what  is  called  No.  1  is  com- 
monly of  the  focal  length  of  2^  or  3  inches, 
and  each  following  number  has  an  inch,  or  a 
certain  number  of  lines,  of  additional  focal 
length. 

The  focus  of  a  concave  lens  may  be  ascer- 
tained by  reflecting  from  its  surface,  upon  an 
opaque  body,  the  image  of  any  very  distant  lu- 
minous object,  such  as  the  sun,  observing  when 
the  image  becomes  smallest,  and  measuring  the 
distance  between  the  centre  of  the  reflecting 
surface  and  the  body  upon  which  the  imago  is 
received ;  double  this  distance  is  the  focal 
length  of  the  lens,  and  is  equal  to  the  radius  of 
curvature  of  its  surfaces,  these  being  ground  on 
the  same  tool.  The  two  surfaces,  however,  are 
not  alwa3's  ground  on  a  tool  of  the  same  radius; 
so  that  the  one  side  is  sometimes  deeper  than 
the  other. 

-°  Economy  of  the  Eyes,  Part  i.  p.  Ill  ;  Lon- 
don, 1826. 


SECTION  II. — PRESBYOPIA. 

Si/n. — Presbyopia,  from  Trfis-Cv;,  old,  and  m-^,  the  eye ;  this  being  a  state  of  vision  to 
which  advanced  age  is  almost  invariably  subject.  Long-sightedness.  Far-sightedness. 
Vue  longue,  Fr.     Diminished  refraction. 

Although  this  state  of  defective  vision,  the  general  nature  of  which  has 
been  explained  at  the  beginning  of  the  last  section,  occasionally  occurs,  like 
myopia,  suddenly  and  at  any  period  of  life,  yet,  in  by  far  the  greater  number 
of  instances,  it  is  merely  part  of  the  changes  which  the  human  system  under- 
goes from  advancing  years.  The  refractive  powers  of  the  eye  becoming  too 
feeble,  or  its  axis  shorter  than  natural,  the  rays  of  light  are  not  converged 
sufficiently  soon  to  be  brought  to  focal  points  upon  the  retina.  The  image, 
therefore,  is  diffused,  and  the  perception  indistinct ;  to  remedy  which,  the 
individual  moves  the  object  of  examination  forwards  from  his  eye,  to  a  greater 
distance  than  his  previous  point  of  distinct  vision,  by  this  means  counteracting 
the  tendency  of  the  rays  of  light,  proceeding  from  the  object  when  at  the 
usual  distance,  to  collect  into  foci,  not  upon  the  retina,  but  behind  it.  (Fig. 
146,  p.  849.) 

Symj^toms. — 1.  Objective  symptoms.  The  objective  symptoms  which  gene- 
rally attend  presbyopia,  are  an  apparent  diminution  in  the  size  of  the  eye- 
ball, which  is  also  more  sunk  in  the  orbit,  flatness  of  the  cornea,  shortening 
of  the  axis  of  the  anterior  chamber,  and  smallness  of  the  pupil, 

2.  Subjective  symptoms.  It  is,  in  general,  about  the  age  of  45  years  that 
we  discover  we  see  near  objects  less  perfectly,  especially  by  candlelight,  and 
that  we  are  obliged  at  once  to  illuminate  them  more,  and  remove  them  further 
from  the  eye  than  formerly.  The  discovery  that  the  eye  is  thus  beginning  to 
be  impaired  by  age,  is  gradually  made,  in  consequence  of  the  difficulty  which 
the  individual  experiences  in  reading  small  print,  nibbing  a  pen,j threading  a 
needle,  and  the  like.  On  attempting  to  examine  any  small  object  close  at 
hand,  its  outline  becomes  obscure,  as  if  it  were  seen  through  a  mist ;  very 
minute  objects,  such  as  the  characters  of  a  small  printed  book,  are  either  not 
discerned  at  all,  or  they  appear  obscure,  running  into  one  another,  or  double; 
and  if  the  attempt  to  see  such  objects  is  persevered  in,  the  eyes  soon  feel 
fatigued,  and  the  head  begins  to  ache.  Distant  objects  continue  to  be  seen  as 
before.     The  person  can  read  a  distant  inscription,  or  tell  the  hour  by  a 


PRESBYOPIA.  861 

cliurcli  clock,- when  he  cannot  read  a  common  printed  book,  or  see  the  figures 
and  hands  of  a  watch,  held  in  his  hand. 

As  years  continue  to  advance,  the  presbyopic  defect  generally  becomes 
more  decided,  the  eye  appears  to  lose  more  and  more  the  power  of  discerning 
near  objects  with  distinctness,  so  that  the  individual,  unless  he  has  recourse 
to  the  aid  of  glasses,  is  forced  to  renounce  all  employments  which  require 
minute  inspection ;  or,  if  he  has  begun  the  use  of  glasses,  he  is  obliged  to 
change  them  from  time  to  time,  in  proportion  as  the  refractive  power  of  his 
eyes  decreases.  There  are,  however,  great  differences  in  the  progress  of  far- 
sightedness in  different  individuals.  Some  eyes  at  30  years  of  age  require 
the  aid  of  convex  glasses  as  much  as  others  do  at  50,  while  the  sight  of  cer- 
tain individuals  continues  almost  as  perfect  at  50  as  it  was  at  30.  Young 
men  of  20  sometimes  cannot  see  to  read  or  write  without  convex  glasses  of 
six  or  eight  inches  focus,  while  persons  of  80  years,  and  upwards,  are  occa- 
sionally met  with,  who  are  able  to  read  even  a  small  print,  at  the  ordinary 
distance,  without  assistance.  Some,  after  commencing  the  use  of  spectacles, 
are  obliged  every  few  years  to  change  them  for  others  of  shorter  focus  ;  others 
change  them  only  once  or  twice  in  the  course  of  a  prolonged  old  age,  or 
continue  perhaps  for  40  years  together  to  see  satisfactorily  with  the  aid  of 
the  same  glasses.  These  and  similar  differences  depend  upon  the  original 
formation  of  the  eyes,  how  they  have  been  used,  and  the  general  health  and 
constitution  of  the  individual. 

The  few  who  can  see  to  read  by  candlelight  quite  as  well  after  the  age  of 
40  as  they  could  before  that  age,  will  generally  find  that  there  is  a  small 
degree  of  shortness  in  the  sight  of  one  or  both  of  their  eyes,  which  is  the 
cause  of  their  possessing  that  advantage  longer  than  persons  in  general  do. 
If  they  try  a  very  shallow  concave  glass,  first  to  the  one  eye  and  then  to  the 
other,  they  will  find  it  give  a  decided  outline  to  distant  objects,  which  perhaps 
they  never  saw  so  sharply  defined  before.  It  is  a  circumstance  often  over- 
looked, that  the  one  eye  may  be  presbyopic  while  the  other  is  myopic.  As 
age  has  advanced,  the  person  furnishes  himself  with  convex  glasses,  being 
perhaps  obliged  to  do  so,  in  order  to  read  at  eighteen  or  twenty  inches,  as 
are  preachers,  lecturers,  &c.  But  after  using  them  for  years,  he  tries  acci- 
dentally to  read  without  them,  and  finds  he  can  do  so  at  six  or  eight  inches. 
He  throws  the  glasses  aside,  and  continues  to  read  without  them  ;  but,  he 
can  also  read  with  them,  showing  that  one  eye  at  least  is  still  presbyopic. 

Instances  occasionally  occur  of  old  persons,  long  accustomed  to  use  convex 
glasses  of  considerable  power,  recovering  their  former  sight  at  the  advanced 
age  of  eighty  or  ninety  years,  so  that  they  no  longer  require  any  artificial 
assistance  even  in  reading.  Dr.  Porterfield  was  led  to  attribute  this  remark- 
able amendment  to  a  decay  of  the  adipose  substance  at  the  bottom  of  the 
orbit,  in  consequence  of  which,  he  supposes  that  the  eye,  from  a  want  of  its 
usual  support,  will  be  brought  by  the  pressure  of  the  muscles  on  its  sides 
into  a  kind  of  oval  figure,  in  which  state  the  retina  will  be  removed  to  a  due 
distance  from  the  flattened  cornea.^  Mr.  Ware  objects  to  this  explanation, 
that  we  never  see  a  morbid  accumulation  of  adipose  substance  in  the  orbit 
produce  presbyopia,  but  that,  on  the  contrary,  myopia  is  sometimes  induced 
by  that  cause ;  and  thinks  it  more  probable  that  the  remarkable  revolution 
in  question  is  occasioned  by  an  absorption  of  part  of  the  vitreous  humor,  in 
consequence  of  which  the  sides  of  the  sclerotica  are  pressed  inward,  and  the 
axis  of  the  eye  proportionably  lengthened.-  Mr.  White  Cooper  regards  such 
a  change  of  sight  as  premonitory  of  hard  cataract.^ 

Although  the  eye,  after  middle  life,  loses  the  power  of  distinguishing  near 
objects  with  correctness,  it  generally  retains  the  sight  of  those  that  are  dis- 
tant.    To  see  distant  objects  with  distinctness,  therefore,  glasses  are  in  gene- 


862  PRESBYOPIA. 

ral  not  required  by  the  presbyopic  eye  ;  on  the  contrary,  parallel  rays  being 
sufficiently  converged  by  the  refractive  media  of  the  eye  itself,  to  be  brought 
to  their  respective  foci  on  the  retina,  the  convex  glasses  must  he  laid  aside 
when  objects  at  a  distance  are  to  be  examined.  Instances,  however,  are  not 
wanting  of  persons  of  advanced  age,  requiring  the  aid  of  convex  glasses  to 
enable  them  to  see  distant,  as  well  as  near  objects  ;  the  surface  of  their  eye 
having  become  so  flat,  or  its  refraction  so  diminished,  that  it  cannot  converge 
even  parallel  rays  to  the  retina  without  convex  glasses,  which  is  equivalent 
to  a  power  of  bringing  convergent  rays  to  a  focus.  Thus,  Dr.  Wells  informs 
us,  that  when  twenty  years  younger,  he  was  able,  with  his  left  eye,  to  bring 
to  a  focus  on  the  retina,  pencils  of  rays  which  flowed  from  every  distance 
greater  than  seven  inches  from  the  cornea ;  but  by  the  time  he  reached  the 
age  of  fifty-five,  his  eyes  had  altered  considerably,  with  respect  to  their  seeing 
near  objects  distinctly,  and  he  had,  in  consequence,  been  obliged,  not  only  to 
use  convex  glasses,  but  to  change  them  several  times  for  others  of  higher 
power.  On  carefully  examining  the  state  of  his  sight,  previously  to  the 
repetition  of  some  optical  experiments,  he  found,  to  his  great  surprise,  that 
the  power  of  adapting  his  eyes  to  different  distances  was  completely  gone ; 
in  other  words,  that  he  was  obliged  to  regard  all  objects,  whether  near  or 
remote,  in  the  same  refractive  state  of  those  organs.  He  found  that  he 
required  not  only  a  convex  glass  of  six  inches  focus,  to  enable  him  to  bring 
to  a  point  on  the  retina  rays  proceeding  from  an  object  seven  inches  from 
the  eye,  but  likewise  a  convex  glass  of  thirty-six  inches  focus,  to  enable  him 
to  bring  to  a  point  parallel  rays.* 

Causes. — There  can  be  no  doubt  that  deficient  refraction  is  the  proximate 
cause  of  presbyopia,  and  that  it  is  intimately  connected  with  the  decline  of 
life.  It  is  also  said  that  it  is  more  apt  to  occur  in  those  who  have  used  their 
eyes  much  upon  remote  objects. 

With  regard  to  the  efficient  causes,  flatness  of  the  cornea  from  diminution 
in  the  quantity  of  the  aqueous  and  vitreous  humors  is  the  one  most  frequently 
mentioned,  this  diminution  being  supposed  to  depend  on  the  impeded  manner 
in  which  the  function  of  secretion  is  performed  in  advanced  life. 

Diminished  density  of  any  of  the  refractive  media  of  the  eye,  or  diminished 
convexity,  will  prove  a  sufficient  cause  of  presbyopia.  So  far  as  the  crystal- 
line lens  is  concerned,  it  is  generally  admitted  that  its  density  increases  as 
age  advances,  which  should  tend  to  counteract  any  presbyopic  tendency, 
arising  from  flattening  of  the  cornea  or  deficiency  of  the  aqueous  or  vitreous 
humors.  At  the  same  time,  the  increase  of  density  of  the  lens  may  possibly 
be  attended  by  a  degree  of  shrinking,  by  which  its  form  may  be  rendered  less 
convex,  and  its  refractive  power  diminished.  I  believe  flattening  of  the  lens, 
much  more  than  of  the  cornea,  to  be  the  cause  of  presbyopia. 

It  appears  to  be  the  general  opinion,  that  along  with  diminished  refraction, 
there  attends  upon  presbyopia  a  loss  of  that  power  of  accommodation  to  the 
perception  of  near  objects,  which  is  possessed  by  the  healthy  eye.  Whether 
this  power  depends  on  a  change  of  form  or  of  place  in  the  crystalline  lens,  or 
or  on  both  of  these,  or  on  some  change  different  from  either,  it  is  easily  con- 
ceivable that  a  partial  or  total  loss  of  this  power  would  be  quite  analogous  to 
the  diminished  activity  which  takes  place  in  all  the  functions  of  the  body  on 
the  approach  of  old  age.  That  the  cornea  loses  its  elasticity  as  we  advance 
in  life,  as  well  as  that  the  crystalline  becomes  dense  amd  unyielding,  are  facts 
well  ascertained. 

Prevention  and  treatment. — Although  it  would  be  in  vain  to  expect  any 
plan  of  treatment  to  have  the  effect  of  removing,  or  perhaps  even  lessening  a 
degree  of  presbyopia  already  produced  in  consequence  of  advanced  age,  it  is 
but  reasonable  to  suppose  that  by  avoiding,  whatever  over-fatigues  the  sight, 


I 


PRESBYOPIA.  863 

and  by  following  whatever  tends  to  delay  the  progress  of  decrepitude,  this 
defect  may  in  a  consideraljle  measure  be  warded  off.  It  is  only  to  such  influ- 
ences, added  to  an  original  soundness  of  constitution,  that  we  can  attribute 
the  exemption  from  presbyopia,  which  is  occasionally  possessed  by  men  far 
advanced  in  life,  and  who  have  never  been  myopic. 

.The  assistance  which  the  presbyopic  eye  derives  from  a  double-convex 
glass,  ought  neither  to  be  too  soon  had  recourse  to,  nor  too  long  delayed. 
Many  injure  their  sight  by  adopting  the  use  of  magnifiers  suddenly,  and  before 
they  have  any  need  of  them ;  while  others,  actuated  perhaps  by  a  desire  of 
concealing  their  age,  refrain  from  employing  them  long  after  the  period  when 
glasses  would  not  merely  have  afforded  valuable  assistance,  but  have  proved 
a  means  of  saving  their  sight.  I  have  seen  a  public  lecturer  rejecting,  from 
some  silly  motive,  the  aid  of  convex  glasses  at  seventy  years  of  age,  assemble 
on  and  at  the  side  of  his  desk  six  glaring  wax  candles,  in  order  to  illuminate 
his  manuscript,  and  while  he  kept  one  of  the  candles  shorter  than  the  rest, 
dancing  over  the  apper,  he  yet  stopped  ever  and  anon  from  a  difficulty  in  decy- 
phering  it.  Such  conduct  is  as  dangerous  to  sight,  as  it  is  ridiculous.  The 
presbyopic  eye,  if  refused  assistance,  is  necessarily  strained  by  every  attempt 
to  perceive  near  objects,  and  suffers  more  in  a  few  months,  by  forced  exertion, 
that  it  would  do  in  as  many  years,  if  assisted  by  such  glasses  as  would  render 
vision  easy  and  agreeable. 

It  would  evidently  be  absurd  to  fix  upon  any  period  of  life  at  which  glasses 
should  be  first  employed,  or  at  which  the  presbyopic  eye  should  be  assisted 
by  stronger  magnifiers  than  those  made  choice  of  in  the  first  instance ;  but 
it  may  be  laid  down  as  a  general  rule,  that  whenever  a  person  of  forty-five 
years  of  age,  or  upwards,  finds  that,  in  order  to  see  small  objects  distinctly, 
he  is  obliged  to  carry  them  far  from  his  eye  ;  that  he  moves,  as  it  were  in- 
stinctively, nearer  to  the  light,  when  he  wishes  to  read  or  work,  or  holds  the 
book  or  other  object  close  to  the  light,  in  order  to  see  with  facility  ;  that  very 
small  objects,  after  he  has  looked  at  them  earnestly  for  some  time,  appear>con- 
fused  ;  that  his  eyes,  after  slight  exertion,  become  so  much  fatigued  that  he  is 
obliged  to  turn  them  to  other  objects,  in  order  to  give  them  some  relaxation ; 
and  that  the  sight,  on  awakening  in  the  morning,  is  very  weak,  and  does  not 
recover  its  customary  degree  of  force  for  some  hours  ;  then,  he  may,  if  he  has 
not  hitherto  used  convex  glasses,  begin  to  use  them,  or  if  he  has  already  had 
recourse  to  those  of  a  very  long  focus,  he  may  change  them  for  a  pair  of 
shorter  focus,  or,  in  other  words,  of  greater  refractive  power. 

A  double-convex  glass  improves  the  vision  of  a  presbyopic  eye,  simply  by 
lessening  the  divergence  of  the  rays  of  light  proceeding  from  near  objects, 
and  thus  insuring  their  being  brought  into  foci  upon  the  retina.  Presbyopic 
persons  sometime  use  what  is  termed  a  reading  glass,  which  is  a  double-con- 
vex lens,  broad  enough  to  permit  both  eyes  to  see  through  it.  By  spectacles 
it  is  proposed  only  to  render  objects  distinct  at  a  given  distance,  but  the 
reading  glass  is  used  to  magnify  the  object. 

As  a  meniscus  will  produce  the  same  effect  as  a  double-convex  glass,  in 
enabling  the  presbyopic  eye  to  perceive  near  objects  with  distinctness,  while 
it  will  allow  the  eye  greater  latitude  without  fatigue.  Dr.  Wollaston  has 
recommended  the  former  as  a  periscojnc  glass  for  far-sighted  persons.  Jt  is 
liable,  however,  to  the  same  objection  as  the  concavo-convex  glass  recom- 
mended for  the  myopic  eye,  namely,  increased  aberration  of  color  and  figure. 
(See  p.  857.) 

Similar  directions  must  be  followed  in  choosing  convex  glasses  as  in  select- 
ing concave  ones;  viz :  that  the  lowest  power,  or  longest  focus,  which  answers 
the  pupose,  is  to  be  chosen ;  and  that  as  the  concave  glasses  made  use  of  by 
the  near-sighted  should  not  make  objects  appear  smaller,  neither  should  the 


864  PRESBYOPIA. 

convex  glasses  employed  by  the  far-sighted  make  them  appear  larger  than 
natural.'  Convex  spectacles  should  be  chosen  with  candlelight,  as  those 
which  suffice  in  daylight  will  not  prove  strong  enough  when  used  in  the 
evening. 

Persons  at  a  distance  from  an  optician  may  determine  the  focal  length  of 
the  convex  glasses,  which  they  will  require,  by  means  of  the  following  rules. 

1.  If  they  have  a  distinct  vision  of  objects  vioderatety  remote,  let  them  mul- 
tiply the  distance  at  which  they  see  minute  objects  most  distinctly,  say  20 
inches,  by  the  distance  at  which  they  wish  to  read  by  the  aid  of  glasses,  say 
12  inches,  and  divide  the  product,  240,  by  the  difference  between  the  two,  8 ; 
the  quotient,  30,  will  be  the  focal  length  of  the  glasses  required. 

2.  If  the  distance  at  which  the  person  sees  most  distinctly  be  very  great, 
then  the  focal  length  of  the  glasses  required  will  be  equal  to  the  distance  at 
which  he  wishes  to  see  the  objects  most  distinctly. 

Convex  glasses  of  about  36  inches  focus  are  often  used  by  ignorant  people, 
under  the  name  of  preservers,  before  their  sight  has  attained  that  degree  of 
presbyopia  which  renders  the  use  of  glasses  necessary.  They  seem  to  think 
that  preservers  have  some  specific  power  of  arresting  the  progress  of  that 
failure  of  the  sight,  which  is  the  natural  consequence  of  age. 

As  it  is  chiefly  by  candlelight  that  the  presbyopic  patient  complains  of  his 
deficient  sight,  even  after  he  has  supplied  himself  with  proper  glasses,  it  is 
advisable  that  he  should  refrain  as  much  as  possible  from  employing  himself 
at  night  in  occupations  which  require  intense  use  of  the  organs  of  vision. 
The  moment  that  the  eyes  begin  to  feel  hot  and  fatigued,  while  the  individual 
is  occupied  in  reading,  writing,  or  the  like,  especially  by  candlelight,  he  should 
take  the  hint,  and  allow  them  a  period  of  repose. 

A  loss  of  the  power  to  adjust  the  eyes  to  the  vision  of  near  objects,  which 
is  equivalent  to  presbyopia,  sometimes  suddenly  occurs  in  subjects  much  under 
the  age  of  40,  or  even  in  children.  I  have  seen  this  affection,  in  children, 
follow  influenza  in  some  cases,  and  in  others  inflammation  of  the  tonsils,  with 
considerable  febrile  excitement.  The  patients  could  not  read  at  all  at  the 
usual  distance,  but  held  the  book  18  inches  or  more  from  the  eyes,  and  saw 
better  with  convex  glasses.  In  some  instances,  there  was  a  dimness  even 
over  remote  objects.  A  complete  cure  was  effected  by  leeches  to  the  temples, 
blisters  behind  the  ears,  and  small  doses  of  calomel  followed  by  quinine.  Dr. 
James  Hunter  relates  a  case,  in  which  a  cure  was  effected  by  purgatives." 

That  this  affection  in  children  was  the  result  of  the  feverish  complaint  by 
which  it  was  preceded,  could  scarcely  be  doubted ;  and  it  seemed  more  likely 
to  be  the  result  of  disturbance  in  the  nervous  power  upon  which  the 
adjusting  apparatus  of  the  eye  depends  for  its  activity,  than  of  any  immediate 
change  in  the  eyeball  such  as  might  cause  a  shortening  of  its  axis,  or  of  any 
derangement  in  the  curvatures  or  densities  of  its  dioptric  media. 

This  variety  of  presbyopia,  if  we  may  be  allowed  to  call  it  so,  is  easily  dis- 
tinguished from  asthenopia,  by  the  deficiency  being  constantly  experienced 
till  it  yields  to  medical  treatment ;  whereas  the  fits  of  long-sightedness  in 
asthenopia,  occur  only  after  the  eyes  have  been  exercised  for  an  apj)reci- 
able  time,  perhaps  for  half  an  hour  or  longer,  upon  near  objects,  and  during 
a  short  period  of  rest  subside  of  themselves.  The  cases  related  by  Mr.  Ware,'' 
as  occurring  in  young  persons,  seem  to  partake  more  of  the  character  of 
asthenopia  than  of  presbyopia. 


'  Treatise  on  the  Eye;  Vol.  iii.  p.  70  ;  EJin-  "  Association    Medical    Journal,    November 

burgh,  17j9.  11,  1853,  p.  996. 

^  Philosnpliical  Transactions  :  Vol.  eiii.  p.  42  ;  *  Pliiloso]jliical  Transactions  ;  Vol.  ci.  p.  380; 

London,  IS13.  London, 1811. 


IRREGULAR   REFRACTION,  865 

'  Convex    glasses  are  kept  in   the  shops  of  The  focus  of  a  convex  glass  may  be  measured 

every  focal  length,  from  48  inches  to  6.     It  is  by  holding  it  near  the  side  of  a  room  facing  a 

evident  that  no  certain  estimate  can  be  formed  window,  or  opposite  to  the  sun,  and  moving  it 

from  a  person's  age  of  the  focal  length  of  the  slowl}' backwards  and  forwards,  until  the  image 

glass  which  he  will  require  ;  although  perhaps  of   the   window-frame,  or  of  the  sun,  upon  tho 

the  following  may   be  received  as  a  tolerable  wall,  becomes  smallest  and  most  distinct:  the 

approximation  to  an  average  upon  this  head  : —  distance  between  the  glass  and  the  wall  at  that 

Years  of  age 40  46  60  55  58  60  65  moment  is  the  focal  length. 

Focal  lengths,]                   „„  „„  „,  „„  ,o  ,«  ,,  "   Edinburgh  Medical  and  Surgical  Journal, 

in  inches...]  January,  1840,  p.  124. 

Years  of  age 70  75  80  85  90  100  ■"  Philosophical  Transactions;  Vol.  ciii.p.  48; 

Focal   lengths,)                       I9in    Q    8    7       6  I^ondon,  1813. 

in  inches. . . J 


SECTION  III. — IRREGULAR   REFRACTION. 

To  insure  perfection  in  vision,  the  dioptric  media  of  the  eye  would  require 
to  be  normal  in  curvature,  density  and  position.  It  is  probable,  however, 
that  the  lenses  of  the  eye,  and  especially  the  cornea  and  the  crystalline,  are 
affected  with  irregularities  in  these  respects  more  frequently  than  is  generally 
supposed,  and  that  few  eyes,  in  fact,  are  perfectly  free  from  them.  When 
such  an  irregularity  is  slight,  the  eft'ect  is  that  an  object,  seen  generally  out 
of  focus,  but  in  some  instances  when  placed  at  the  distance  of  greatest  dis- 
tinctness, appears  multiplied  to  the  eye  affected,  a  symptom  which  is  called 
tmiocular  diplopia ;  while  in  aggravated  cases,  vision  is  exceedingly  disturbed, 
and  as  the  rays  of  light  coming  from  a  luminous  point,  and  falling  upon  the 
whole  surface  of  the  pupil  cannot  be  brought  to  a  corresponding  point  within 
the  eye,  but  at  diflerent  distances  converge  in  such  a  manner  as  to  form  two 
linear  images  at  right  angles  to  each  other,  the  imperfection  has  received  the 
name  of  astigmatism.  If  very  considerable,  such  irregularities,  especially 
when  they  affect  the  curvatures  of  the  cornea,  may  perhaps  be  detected  by 
the  observer's  watching  the  progress  of  a  candle  in  front  of  the  patient's  eye, 
and  noticing  the  appearances  of  the  three  reflected  images.  The  patient  may 
detect  the  existence  of  such  irregularities  by  closing  one  eye,  and  directing 
the  other  to  a  very  narrow  well-defined  luminous  object,  not  too  bright  (the 
horns  of  the  moon,  when  a  slender  crescent,  only  two  or  three  days  old,  are 
very  proper  for  the  purpose),  and  turning  the  head  in  various  directions. 
The  line  will  be  multiplied,  or  variously  distorted:  and  careful  observation 
of  its  appearance,  under  different  circumstances,  may  sometimes  lead  the 
patient  to  a  knowledge  of  the  peculiar  conformation  of  the  refracting  surfaces 
causing  those  appearances,  and  may  suggest  the  proper  remedy. 

§  1.    Uniocidar  Diplopia. , 

A  layer  of  mucus,  lying,  as  a  soft  solid,  on  the  surface  of  the  cornea,  and 
not  being  parallel  to  it,  is  apt  to  cause  a  multiplied  image,  exactly  as  if  the 
eye  were  directed  through  a  plano-convex  lens,  the  convex  surface  of  which 
being  ground  into  facets,  it  became  a  multiplying  glass.  Nictitation,  in  this 
instance,  clears  away  the  mucus,  and  the  diplopia  disappears. 

A  similar  result  will  follow,  if  the  surfaces  of  the  cornea,  or  the  crystalline, 
are  not  perfectly  regular.  If  any  malposition  exists  in  regard  to  the  succes- 
sive surfaces  of  the  dioptric  media,  from  the  cornea  inwards ;  or  if  the  pupil 
is  filled  with  a  net  of  threads,  the  result  of  fibrinous  effusion  ;  instead  of  the 
luminous  rays  which  enter  converging  to  a  single  focus,  they  will  converge 
to  two  or  more  foci  on  the  retina.  A  myopic  eye  always  sees  several  super- 
imposed images  of  the  flame  of  a  candle,  when  the  object  is  placed  consider- 
ably beyond  the  point  of  its  distinct  vision  ;  and  the  presbyopic  eye  is  apt  to 
55 


866  IRREGULAR   REFRACTION. 

see  the  same  thing,  when  the  candle  is  placed  near  it.  By  moving  towards 
the  object  in  the  one  case,  and  from  it  in  the  other,  the  false  images  are  made 
to  disappear ;  and  the  same  effect  is  produced  by  looking  through  a  concave 
lens  if  the  eye  is  myopic,  through  a  convex  one  if  presbyopic,  and  in  either 
case  by  looking  through  a  pin-hole,  or  through  the  meshes  of  fine  wire 
gauze.* 

It  is  rarely,  if  ever,  the  case  that  a  patient  complains  of  uniocular  diplopia, 
unless  the  opposite  eye  from  the  one  affected  is  so  much  impaired  as  to  be 
useless.  Then  it  is,  that  the  double  vision  of  the  remaining  eye  proves  annoy- 
ing. The  two  centres  of  refraction  are  generally  more  or  less  oblique  in 
respect  to  one  another.  Whether  the  eye  is  myopic  or  presbyopic,  as  the 
patient  withdraws  himself  from  the  object  regarded,  the  false  image,  which  is 
paler  and  less  sharply  defined  than  the  true,  separates  more  and  more  in  a 
direction  obliquely  upwards  or  downwards,  till  at  last,  in  some  cases,  it  fades 
and  disappears.  When  the  false  image  appears  in  a  direction  outwards  and 
downwards,  we  may  conclude  that  the  cause  of  the  diplopia  resides  in  the 
inner  and  upper  part  of  the  eye. 

Uniocular  diplopia  is  sometimes  a  precursor  of  cataract. 

Nothing  positive  is  known  as  to  the  cause  of  uniocular  diplopia.  That,  from 
malformation  or  disease,  the  vertices  of  the  cornea  and  crystalline  are  out  of 
their  normal  relation,  or  that  the  poles  of  the  crystalline  are  not  in  the  same 
straight  line,  are  mere  conjectures. 

M.  Prevost,  at  the  age  of  eighty-one  years,  published''  an  account  of  his 
own  case  of  double  vision  with  a  single  eye,  which  he  thought  might  perhaps 
arise  from  a  fracture,  bruise,  or  partial  flattening  of  the  lens,  or  separation 
of  its  lamiufe.  M.  Prevost  also  communicated  with  Mr.  Babbage,  who  is 
affected  in  either  eye  singly  with  double  vision,  a  defect,  however,  which  he 
finds  himself  able  to  remedy,  by  looking  through  a  small  hole  in  a  card,  or 
through  a  concave  lens. 

All  that  can  be  done  for  uniocular  diplopia,  is  to  use  the  palliative  remedy 
afforded  by  a  concave  or  convex  lens,  according  as  the  eye  is  myopic  or 
presbyopic.^ 

§  2.  Astigmatism. 
From  a.  privative,  and  g-riyfAa,  point. 

Numerous  instances  have  been  recorded,  in  which,  from  some  defect  in  its 
refraction,  the  rays  of  light  falling  upon  the  eye  are  brought  to  a  nearer  focus 
in  a  vertical  than  in  a  horizontal  plane,  so  that  the  eye,  regarded  as  an  optical 
instrument,  is  not  symmetrical  about  its  axis.  We  meet  with  many  eyes  in 
this  condition,  that  if  a  straight  black  line,  drawn  on  a  sheet  of  paper,  is  pre- 
sented in  a  vertical  direction,  it  appears  double,  but  the  instant  it  is  turned 
in  a  horizontal  direction  it  is  seen  single. 

Dr.  Young  tells  us,*  that  his  "  eye,  in  a  state  of  relaxation,  collects,  to  a 
focus  on  the  retina,  those  rays  which  diverge  vertically  from  an  object  at 
the  distance  of  ten  inches  from  the  cornea,  and  the  rays  which  diverge  hori- 
zontally from  an  object  at  seven  inches  distance."  This  would  take  place  if 
the  cornea,  instead  of  being  a  surface  of  revolution,  in  which  the  curvature 
of  all  its  sections  through  the  axis  must  be  equal,  were  of  some  other  form, 
in  which  the  curvature  in  a  vertical  plane  was  greater  than  in  a  horizontal. 
Dr.  Young,  however,  considered  the  cause  in  his  case  to  be  an  obliquity  of 
the  cornea  and  crystalline  lens,  with  respect  to  the  visual  axis.  The  same 
effect  might  arise  from  the  lens  having  one  or  both  of  its  surfaces  cylindrical, 
or  from  a  want  of  symmetry  in  the  variation  of  its  density. 

Professor  Fischer,  of  Berlin,  observed,  that  if  he  placed  a  number  of  fine 


IRREGULAR  REFRACTION.  86T 

parallel  lines  before  him  in  a  horizontal  direction,  he  could  count  them  when 
at  the  distance  of  from  fifteen  to  twenty  inches,  but  the  instant  he  placed 
them  in  a  vertical  position  they  were  undistinguishable,  till  he  brought  them 
to  within  six  or  eight  inches  of  his  eye.  Looking  at  the  bars  of  a  window, 
with  his  head  in  the  vertical  position,  the  cross-bar  appeared  longer  than  it 
should  have  done  ;  but  with  his  head  bent  towards  the  shoulder,  the  vertical 
bar  appeared  elongated.^ 

A  similar  instance  of  irregular  refraction  has  been  adduced  by  Mr.  Airy, 
Astronomer  Royal,  as  existing  in  one  of  his  own  eyes. 

Case  361. — Mr.  Airy  discovered  tliat,  in  reading,  he  did  not  usually  employ  his  left  eye, 
and  that  in  looking  at  any  near  object  it  was  totally  useless;  in  fact,  the  image  formed 
in  that  eye  was  not  perceived,  unless  attention  was  particularly  directed  to  it.  Supposing 
this  to  be  entirely  owing  to  habit,  and  that  it  might  be  corrected  by  using  the  left  eye  as 
much  as  possible,  he  endeavored  to  read  with  the  right  eye  closed,  or  shaded;  but  found 
that  he  could  not  distinguish  a  letter,  at  least  in  small  print,  at  whatever  distance  from 
his  eye  the  characters  were  placed.  Some  time  afterwards,  he  observed  that  the  image 
formed  by  a  bright  point,  such  as  a  distant  lamp  or  a  star,  in  his  left  eye,  was  not  circular, 
as  it  is  in  the  eye  which  has  no  other  defect  than  that  of  being  near-sighted,  but  elliptical, 
the  major  axis  making  an  angle  of  about  35°  with  the  vertical,  and  its  higher  extremity 
being  inclined  to  the  right.  Upon  putting  on  concave  spectacles,  by  the  assistance  of 
which  he  saw  distant  objects  distinctly  with  his  right  eye,  he  found  that  to  his  left  eye  a 
distant  lucid  point  had  the  appearance  of  a  well-defined  line,  corresponding  exactly  in 
direction,  and  nearly  in  length,  to  the  major  axis  of  the  ellipse  above  mentioned.  He 
found  also,  that  if  he  drew  upon  paper  two  black  lines  crossing  each  other  at  right  angles, 
and  jilaced  the  paper  in  a  proper  position,  and  at  a  certain  distance  from  the  eye,  one 
line  was  seen  pei'fectly  distinct,  while  the  other  was  barely  visible  ;  while  upon  bringing 
the  paper  nearer  to  the  eye,  the  line  which  was  distinct  disappeared,  and  the  other  was 
seen  well  defined.  All  these  appearances  indicated  tliat  the  refraction  of  the  eye  was 
greater  in  the  plane  nearly  vertical  than  in  that  at  right  angles  to  it;  and  that  conse- 
quently it  would  not  be  possible  to  see  distinctly  by  the  aid  of  lenses  with  spherical 
surfaces.  Mr.  A.  found,  indeed,  that  by  turning  a  concave  lens  obliquely,  or  on  looking 
directly  through  a  part  near  the  edge,  he  could  see  objects  without  confusion;  but  in 
both  cases  the  distortion  produced  was  such,  that  he  could  not  hope  to  make  any  use  of 
the  eye  without  some  more  effectual  assistance. 

Mr.  Airy's  object  now  was  to  form  a  lens  which  should  refract  more  powerfully  the 
rays  in  one  certain  plane,  than  those  in  the  plane  at  right  angles  to  it ;  and  his  first  idea 
was  to  employ  one  whose  surfaces  should  be  cylindrical  and  concave,  the  axes  of  the 
cylinders  crossing  each  other  at  right  angles,  and  their  radii  different.  To  show  that  this 
construction  would  eifect  the  purpose,  it  is  only  necessary  to  imagine  such  a  lens  divided 
into  two  lenses  by  a  plane  perpendicular  to  its  axis ;  thus  it  is  easily  seen  that  the  refrac- 
tion of  one  will  not  be  perceptibly  altered  by  that  of  the  other,  and  that  the  whole  refrac- 
tion will  be  the  combination  of  the  two  separate  refractions.  The  rays  in  one  plane  will 
be  made  to  diverge  entirely  by  the  refraction  of  one  lens,  and  those  in  the  other  plane 
by  that  of  the  other  lens.  This  construction  then  was  sufficient ;  but,  for  the  facility  of 
grinding,  and  for  the  diminution  of  the  curvatures,  it  appeared  preferable  to  make  one 
surface  cylindrical,  the  other  spherical,  both  concave. 

To  discover  the  necessary  data  for  the  formation  of  the  lens,  Mr.  A.  made  a  very  fine 
Jiole  with  the  point  of  a  needle  in  a  blackened  card,  which  he  caused  to  slide  on  a  gradu- 
ated scale ;  then  strongly  illuminating  a  sheet  of  jsaper,  and  holding  the  card  between  it 
and  the  eye,  he  had  a  lucid  point  upon  which  he  could  make  observations  with  ease  and 
exactness.  Resting  the  end  of  the  scale  upon  the  cheek-bone,  and  sliding  the  card  on  this 
scale,  he  found  that  what  was  seen  as  a  point  when  close  to  the  eye,  at  the  distance  of  6 
inches  appeared  a  well-defined  line,  inclined  to  the  vertical  about  35°,  and  subtending  an 
angle  of  (b}' estimation)  2°:  at  the  distance  of  3.}  inches  it  appeared  a  well-defined  line  at 
right  angles  to  the  former,  and  of  the  same  apparent  length.  It  was  necessary,  therefore, 
to  make  a  lens,  which,  when  parallel  rays  were  incident,  should  cause  those  in  one  plane 
to  diverge  from  the  distance  3}  inches,  and  those  in  the  other  plane  from  the  distance  6 
inches. 

Having  procured  a  spherico-cylindricallens,  of  which  the  radius  of  the  spherical  surface 
measured  8i  inches,  and  that  of  the  cylindrical  surface  4i  inches,  iNIr.  A.  found  that  he 
could  read  the  smallest  print  at  a  considerable  distance,  with  the  left  eye  as  well  as  with 
the  right.  He  found  that  vision  was  most  distinct  when  the  cylindrical  surface  was  turned 
from  the  eye ;  and  as,  when  distant  from  the  eye,  the  lens  altered  the  apparent  figure  of 
objects,  by  refracting  differently  the  rays  in  different  planes,  he  had  the  frame  of  his  spec- 


868  IRREGULAR   REFRACTION. 

tacles  made  so  as  to  bring  tbe  glass  pretty  close  to  the  eye.  With  these  precautions,  he 
found  that  the  eye  which  he  had  once  feared  would  become  quite  useless,  could  be  used  in 
almost  every  respect  as  well  as  the  other. 

"  I  believe  it  has  generally  been  found,"  says  Mr.  Airy,  "  th.at  where  the  direction  of 
the  axis  is  distorted,  the  sight  of  the  c^'e  is  defective,  but  not  lost :  and  the  distortion  is 
by  many  ascribed  to  the  disuse  of  the  eye  which  is  occasioned  by  this  defect.  If  it  .should 
be  found  that  the  defect  is  at  all  similar  to  that  which  I  have  described,  it  can  be  perfectly 
corrected.  The  examination  of  the  defect,  in  the  manner  which  I  have  detailed,  is  very 
easy ;  and  it  is  merely  necessary  to  write  dowu  fully  the  appearance  of  the  brilliant  point 
at  diiferent  distances,  in  order  to  enable  the  theoretical  optician  to  invent  a  glass  which 
shall  make  the  vision  of  the  eye  distinct.  If  the  defects  arise  from  insensibility  of  the 
nerve  or  opacity  of  the  humors,  they  are  beyond  his  power  ;  but  any  fault  in  the  refracting 
surfaces  it  is  possible  to  correct."  ® 

Having  occasion,  twenty  years  after  the  first  account  of  the  malformation  of  his  left  eye 
was  submitted  to  the  Cambridge  Philosophical  Society,  to  explain  that  a  change  had  hap- 
pened in  the  state  of  the  eye,  .Mr.  Airy  took  an  opportunity  of  mentioning  that  as  the 
nature  of  the  effect  of  that  malformation  was,  that  the  rays  of  light  coming  from  a  lumi- 
nous point,  and  falling  upon  the  whole  surface  of  the  pupil,  did  not  converge  to  a  point  at 
any  position  within  the  eye,  but  converged  in  such  a  manner  as  to  pass  through  two  lines 
at  right  angles,  the  Rev.  Dr.  Whewell  had  affixed  to  this  phenomenon  the  term '/«^V/wiff/i47«. 
Mr.  A.  further  stated,  that  in  the  interval  between  1825  and  184G,  while  the  short-sighted- 
ness of  his  left  eye  had  materially  diminished,  the  fault  which  had  produced  the  astigma- 
tism had  undergone  very  little  or  no  alteration. 

"Upon  examining  the  right  eye  in  tlie  same  manner,"  says  Mr.  A.,  "I  find  no  per- 
ceptible fault.  The  image  of  a  fine  hole  is  a  luminous  point  very  sharply  defined.  The 
distance  of  accurate  definition  is  as  nearly  as  possible  4.7  inches  ;  tbe  same  as  the  nearest 
distance  at  which  the  left  eye  forms  a  well-defined  line  for  the  image  of  a  point.  It  would 
seem,  therefore,  that  tbe  normal  formation  of  the  two  eyes  is  the  same,  and  that  the 
abnormal  alteration  in  the  left  eye  is  of  tbe  nature  of  a  refraction  through  a  dense  medium 
cylindrically  concave,  or  through  a  rare  medium  cyliudrically  convex,  superadded  to  nor- 
mal refraction."' 

Tlie  publication  of  Mr.  Airy's  case  having  directed  attention  to  defects  of 
vision  from  malconforraations  of  the  lenses  of  the  eye,  several  other  remarka- 
ble instances  of  the  same  sort  have  been  recorded.  One  of  these  occurred  in 
the  right  eye  of  Dr.  Goode  f  a  second,  in  both  eyes  of  a  patient  of  Dr. 
Hamilton  ;''  and  a  third,  in  both  eyes  of  a  clergyman  in  Philadelphia,  whose 
case,  related  by  himself,  is  published  by  Dr.  Hays.*"  [Dr.  Hays  also  re- 
ports the  histories  of  two  other  cases  of  Irregular  Refraction  which  have 
come  under  his  notice. — H.]  In  Dr.  Goode,  the  affection  appeared  to  be 
hereditary,  his  mother  having  a  defect  of  a  similar  nature  in  both  eyes.  Dr. 
Hamilton's  patient,  besides  being  astigmatic  and  myopic,  labored  under  night- 
blindness.  On  looking  at  a  clock,  he  could  not  distinguish  the  hour,  if  the 
hands  pointed  vertically ;  but  if  horizontally,  he  found  no  difficulty.  In  all 
the  three  cases,  a  remedy  was  found  in  the  use  of  lenses,  plane  on  one  surface, 
and  concavo-cylindrical  on  the  other.  When  a  lens  of  the  proper  strength  is 
procured,  it  is  found  to  correct  the  error  in  all  states  of  adaptation  of  the 
eye.  Hence  the  error  is  independent  of  the  state  of  adaptation.  If  a  per- 
son affected  with  astigmatism  be  obliged  to  employ  also  convex  or  concave 
glasses,  the  curvature  necessary  to  correct  the  astigmatism  may  be  combined 
with  the  curvature  necessary  on  account  of  the  presbyopic  or  myopic  state  of 
the  eye.  A  cylindrical  lens  produces  no  convergency  or  divergency  in  parallel 
rays,  incidental  in  the  plane  of  its  axis  ;  whilst  it  converges  or  diverges  rays 
in  a  plane  at  right  angles  to  the  axis,  as  a  spherical  surface  of  equal  curvature 
would  do.  If,  then,  such  a  cylindrical  surface  be  conjoined  with  a  sjjherical 
one,  the  focus  of  the  spherical  surface  will  remain  unaltered  in  one  plane,  but 
in  the  other  will  be  changed  to  that  of  a  lens  formed  by  it,  and  a  spherical 
surface  of  ecpial  curvature  with  the  cylinder." 

The  required  curvature  of  the  cylindrical  surface  is  directed  to  be  calculated 
by  means  of  the  distances  of  the  card  from  the  eye,  when  the  two  focal  lines 
are  formed  ;  but  it  is  sometimes  found  difficult  to  prevent  the  eye  from  alter- 


PHOTOPSIA.  869 

ing  its  state  of  adaptation  during  the  measurement  of  the  distances.  To  meet 
this  difficulty,  Professor  Stokes,  of  Cambridge,  has  constructed  an  instrument 
for  determining  the  nature  of  the  required  lens,  an  account  of  which  he  com- 
municated to  the  British  Association  for  the  Advancement  of  Science,  at  their 
meeting  in  1849.'^ 


'  Cranniore,  Philosophical  Magazine,  June,  phioal   Society;    Vol.  ii.    p.   267;    Cambridge, 

1850,  p.  485.  1827. 

"  Annates  de  Chiinie  et  de  Physique;  Tome  "  IliiJ.  ;  Vol.  viii.  p.  361  :  Cambridge,   1849. 

li.  p.  210  :  Paris,  1832.  *  Ibid.  p.  493  :  and  Monthly  Journal  of  Me- 

^  On  Uniocular  Diplopia,  consult  Heyfelder,  dical  Science,  April,  1848,  p.  711. 

Animon's  Zeitschrift  fiir  die   Ophthahnologie ;  '  Ibid.,  June,  1847,  p.  S'jl. 

Vol.   iv.    p.    189;  Leipzig,    1834:  Steifensand,  '°  Lawrence  on  Diseases  of  the  Eye,  edited 

Grafe  und  Walther's  Journal  der  Chirurgie  und  by  Hays,  p.  669;  Philadelphia,  1854. 

Augenheilkunde ;    Vol.   xxiii.   p.    80;    Berlin,  "'  Hersehel,    Encyclopedia    Metropolitana, 

1835:  Szokalski,  De  la  Diplopio  Uni-oculaire;  article  Light,  p.  398,  ^359:  Airy  and   Goode, 

Paris,  1839.  Op.  cit.:  Brewster,  Edinburgh  Journal  of  Sci- 

*  On  the  Mechanism  of  the  Eye;  Philosophi-  ence,  October,  ] 827,  p.  325. 

cal  Transactions,  for  1801.  '^  Notices  of  Communications  to  the  British 

'  Gerson,  De  Forma  Cornea;,  p.  17;  Gottingte,  Association,  1849,  p.   10;  London,  1850  :  Coo- 

1810.  per  on  Near-Sight,  &c.,  p.  219;  London,  1853. 

°  Transactions   of   the  Cambridge    Philoso- 


SECTION  IV. PHOTOPSIA. 


Syn. — Photopsia,  from  ^aif,  ^2^^^  and  ov^j;,  I'iswn.     Mapfxafuyh;   Hippocrates.    Visus lucidus. 

It  is  evident,  that  in  health  we  should  suffer  no  imitations  of  visual  sensa- 
tions, no  flashes  of  light  from  internal  changes  in  the  eye,  no  false  perceptions 
of  any  kind ;  that  we  should  see  objects  of  their  natural  colors,  not  tinged 
with  hues  entirely  foreign  to  them,  or  of  which  they  in  general  appear  to  be 
free;  and  that  we  should  have  the  consciousness  of  being  impressed  by  the 
view  of  external  objects,  only  when  such  objects  are  present,  and  actually 
affecting  our  organs  of  vision.  Yet  such  is  the  constitution  of  the  optic 
apparatus;  that  by  various  derangements  to  which  it  is  liable,  we  become  the 
subjects  of  many  sensations,  which  have  actually  no  prototype.  Even  a 
mere  defect  of  power  in  this  apparatus,  frequently  gives  rise  to  such  phe- 
nomena. 

In  this,  and  some  of  the  following  sections,  we  shall  notice  the  most  remark- 
able false  visual  sensations.     The  first  is  what  is  called  jjhotopsia. 

That  sensations  of  light  may  be  excited  independently  of  the  ordinary  im- 
I^ressions  from  external  objects,  is  familiarly  known.  The  flash,  produced 
upon  sneezing,  or  by  gentle  pressure,  or  a  sudden  blow  on  the  eye,  or  by  the 
passage  of  the  Galvanic  influence  through  different  parts  of  the  face,  as  in  the 
simple  experiment  of  applying  a  piece  of  zinc  and  a  piece  of  silver  to  the 
tongue  and  then  bringing  them  into  contact,  affords  sufficient  proof,  that  the 
retina  may  be  so  affected,  as  to  produce  the  sensation  of  light  altogether  in- 
dependently of  the  actual  presence  of  light.  In  the  last  three  cases,  the  effect 
is  produced  whether  the  eyes  be  open  or  closed,  and  in  all  of  them  whether 
the  experiment  be  made  in  daylight  or  in  the  dark. 

The  simplest  illustration  of  photopsia,  as  well  as  of  another  pseudo-sensa- 
tion called  chrupsia,  or  colored  vision,  is  thus  noticed  by  Newton  in  Query 
16,  at  the  end  of  his  Optics:  "When  a  man  in  the  dark  presses  either 
corner  of  his  eye  with  his  finger,  and  turns  his  eye  away  from  his  finger,  he 
will  see  a  circle  of  colors  like  those  in  the  feathers  of  a  peacock's  tail.  If  the 
eye  and  the  finger  I'emain  quiet,  these  colors  vanish  in  a  second  minute  of 
time ;  but  if  the  finger  be  removed  with  a  quivering  motion,  they  appear 


8T0  PHOTOPSIA. 

again."  This  experiment  affords  an  example  at  once  of  photopsia  and  of 
chrupsia,  produced  by  artificial  pressure  on  the  convex  surface  of  the  retina.^ 

In  like  manner,  there  are  sensations  of  light,  which  are  altogether  the  re- 
sult of  disease  in  the  optic  apparatus.  Flashes  of  light,  the  appearance  of 
shining  stars,  a  glittering  as  if  from  the  points  of  innumerable  needles,  or  the 
sides  of  innumerable  prisms,  and  a  variety  of  other  lucid  spectra,  attend  cho- 
roiditis, and  occur  in  the  commencement  of  the  congestive  varieties  of  amau- 
rosis. In  some  peculiar  and  distressing  cases  of  ocular  hyperaesthesia,  the 
patient  is  annoyed  by  the  sensation  as  if  his  eyes  were  directed  towards 
globes  of  light  swimming  or  revolving  before  him,  or  as  if  he  were  looking 
at  a  sea  of  molten  gold. 

The  distress  which  patients  affected  with  such  false  sensations  experience, 
varies  greatly  in  degree;  but,  on  the  whole,  these  lucid  spectra  are  much  less 
supportable  by  those  who  experience  them,  than  the  dark  or  serai-transparent 
appearances,  fixed  or  floating,  which  so  frequently  occur,  and  which  are  called 
muscce. 

Photopsia  may  result  from  irritation  of  any  portion  of  the  nervous  optic 
apparatus,  from  its  peripheral  termination  in  the  retina  to  its  central  origin 
in  the  corpora  quadrigemina:  exactly  as  disease  of  the  pons  Varolii  or  of  the 
Gasserian  ganglion  will  cause  neuralgia  of  the  fifth  nerve,  so  may  the  patient 
be  troubled  with  flashings  and  coruscations,  if  the  optic  nerve,  or  its  origin  in 
the  brain,  be  affected  with  disease. 

Any  cause  operating  on  either  surface  of  the  retina,  so  as  to  produce  gentle 
pressure  of  its  nervous  substance,  excites  a  luminous  sensation,  whereas  if  the 
pressure  is  much  increased,  the  membrane  becomes  for  the  time  totally  insen- 
sible. 

When  one  looks  fixedly  for  a  few  minutes  at  the  clear  sky,  a  multitude  of 
minute  lucid  points  begins  to  be  visible,  darting  in  every  direction  through 
the  field  of  vision.  The  motion  of  the  points  is  real,  and  altogether  independ- 
ent of  any  movement  of  the  eyeball;  and  is  so  exactly  like  that  of  ,the  circu- 
lation in  the  web  of  a  frog's  foot  as  seen  in  the  microscope,  that  it  cannot  be 
doubted  that  this  spectrum  is  owing  to  the  blood  passing  through  the  vessels 
either  of  the  retina  or  of  the  choroid.  •• 

A  perception  of  this  circulatory  spectriim,  in  the  ordinary  use  of  sight,  and 
not  searched  for  by  gazing  steadily  at  the  sky,  is,  in  some  cases,  one  of  the 
earliest  symptoms  of  amaurosis,  degenerating  gradually  into  the  sensation  of 
gleams  of  light,  fiery  sparks,  and  colored  coruscations.  After  a  time,  the 
pressure  on  the  retina  still  continuing  and  increasing,  these  luminous  appear- 
ances are  changed  for  others  of  a  totally  opposite  character,  namely,  such  as 
are  known  as  fixed  muscce. 

Those  who  have  suffered  from  internal  ophthalmia  are  often  troubled  with 
such  sensations  as  that  of  a  luminous  ring  whirling  before  them ;  subjects 
inclined  to  apoplexy,  on  raising  their  heads  after  stooping,  see  showers  of 
shining  spectra;  and  flashes  of  light  are  often  the  precursors  of  convulsive 
attacks,  such  as  epilepsy.  Similar  feelings  occur,  as  insensibility  approaches 
in  those  who  have  inhaled  ether  or  chloroform.  The  inhalation  of  nitrous 
oxide  also  produces  trains  of  vivid  spectra.  Phrenitis  is  attended  by  false 
impressions  of  the  same  sort,  which  often  continue  long  after  all  the  other 
symptoms  have  ceased.  In  cases  of  hypertrophy  and  dilatation  of  the  heart 
the  patient  frequently  suffers  from  dazzling  of  the  sight,  as  well  as  from  obsti- 
nate pain  in  the  head,  and  othef  cerebral  symptoms.  In  some  instances,  pho- 
topsia is  merely  a  sympathetic  effect  produced  from  disordered  stomach,  or 
the  ingestion  of  some  poisonous  substance.  Digitalis  is  well  known  to  have 
this  effect.  I  have  known  tea,  taken  to  breakfast,  and  suspected  to  contain 
a  mixture  of  the  leaves  of  some  poisonous  plant,  blamed  for  producing  pho- 


PHOTOPSIA.  811 

opsia,  the  patient  having  a  sensation  of  silvery  zigzag  lines  vibrating  before 
him,  with  dimness  of  sight,  and  visiis  mterruptus,  so  that  the  word  or  letter 
looked  at  could  not  be  seen,  symptoms  which  subsided  in  an  hour  or  two. 
After  fever,  or  any  disease  in  which  the  patient  lies  long  in  the  horizontal 
position,  photopsia  is  liable  to  occur,  but  is  generally  got  quit  of  as  the  pa- 
tient becomes  able  to  sit  up. 

It  is  of  great  importance,  in  every  case,  to  trace  photopsia  to  its  proper 
cause,  and  to  distinguish  it  accurately  from  photophobia.  The  latter  often 
simulates  the  former,  especially  in  scrofulous,  hypochondriacal,  and  hysterical 
patients.  The  cause  of  photopsia  being  discovered,  the  line  of  treatment 
can  scarcely  be  mistaken.  Sir  David  Brewster  tells  ns^  of  a  case,  in  which 
the  patient  had  constantly  the  sensation  of  a  luminous  circle  before  him,  in 
consequence  of  an  excrescence  on  the  inside  of  the  eyelid,  which  produced  a 
continued  pressure  on  the  eyeball.  The  removal  of  the  excrescence  would 
afford  a  cure  in  this  case.  When  photopsia  is  owing  to  cerebral  congestion, 
depletion  will  be  necessary;  when  dyspepsia  is  the  cause,  emetics  and  purga- 
tives, followed  by  tonics,  will  be  proper. 

The  following  interesting  case  of  photopsia  has  been  recorded  by  Mr.  Ware, 
in  the  words  of  the  patient  himself,  a  medical  practitioner  : — 

Case  3G2. — "  About  ten  years  ago,  ■when  about  48  years  of  age,  I  experienced  the  first 
attack  of  the  maladj'  which  I  mean  to  describe  ;  and  it  has  repeatedly  returned,  at  irregu- 
lar periods,  from  that  to  the  present  time.  The  first  notice  that  I  have  of  the  attack  is  a 
peculiar  indescribable  sensation  at  the  bottom  of  the  eye,  wliich  docs  not  amount  to  pain, 
and  is  so  slight  that  its  reality  is  not  to  be  determined  unless  I  direct  my  attention  very 
particularly  to  it.  After  a  few  seconds,  the  objects  in  a  small  point  nearly  in  the  centre 
of  the  field  of  vision  become  indistinct,  and  shortly  afterwards  invisible.  *  *  * 
In  a  few  seconds  more,  that  is,  in  about  half  a  minute  from  the  commencement  of  the 
attaclc,  the  point  that  was  invisible  becomes  lucid,  appearing  to  be  a  circular  spot,  about 
the  eighth  of  an  inch  in  diameter,  in  which  a  yellow  flame  seems  to  undulate  from  the 
centre  to  the  circumference  with  almost  coruscating  quickness  and  splendor.  This  spot 
increases  by  the  extension  of  the  undulating  flame  until  it  acquires  an  apparent  diameter 
of  about  three-quarters  of  an  inch,  which  takes  place  generally  in  about  six  or  eight 
minutes.  The  fiery  veil  which  conceals  objects  becomes  then  thinner  in  the  centre,  and 
objects  are  there  seen  through  it.  The  vision  increases,  until  at  length  a  ring  of  light  only 
remains,  which  continues  to  enlarge  until  it  is  lost  by  seeming  to  extend  beyond  the  field 
of  vision. 

"  The  returns  of  the  attack  have  been  very  irregular.  Sometimes  they  have  occurred 
daily  for  a  week  or  ten  days  together ;  at  other  times,  more  than  a  month  has  elapsed 
between  their  appearance.  During  one  forenoon  they  returned  almost  every  hour;  but  of 
late  the  intervals  are  much  lengthened,  and  I  have  been  now  exempted  from  the  malady 
more  than  three  months. 

"At  first  no  pain  was  felt;  but  during  the  last  12  months,  a  slight  uneasiness  under 
the  forehead,  on  the  opposite  side  to  that  of  the  alfected  eye,  has  generally  accompanied 
and  succeeded  the  attack. 

"The  disease  is  common  to  both  eyes,  though  it  has  never  yet  occurred  in  both  at  the 
same  time.  My  sight  is  not  injured,  though  the  sensibility  of  the  retina  appears  to  be 
morbidly  increased ;  a  strongly  illuminated  object  producing  a  more  brilliant  spectrum 
than  it  used  to  do. 

"About  six  weeks  ago,  I  first  saw  the  unpleasing  appearance  of  a  small  dark  circular 
spot,  which,  varying  its  situation  with  every  motion  of  the  eye,  showed  how  appropriately 
the  term  'musca  volitans'  had  been  applied  to  it.  The  possibility  of  its  being  a  partial 
paralytic  affection,  resulting  from  the  frequent  morbidly  increased  action  of  the  retina, 
naturally  alarmed  me  ;  but  six  weeks  having  elapsed  without  any  return,  I  am  become  easy 
concerning  it.  In  this  instance,  the  immediate  cause  of  the  afi^ection  appears  to  have  been 
an  irregularly  increased  action  of  the  retina  ;  and  the  remote  causes  were  an  over  eager 
exercise  of  the  mind,  joined  with  too  long  continued  employment  of  the  eyes,  and  a  dis- 
ordered state  of  the  stomach  and  bowels. 

"With  regard  to  the  means  of  cure,  reprehensible  as  it  may  appear,  I  for  a  long  time 
employed  none.  About  three  years  ago,  however,  having  been  harassed  repeatedly  at 
short  intervals,  and  sometimes  two  or  three  times  in  the  day.  by  the  above-mentioned 
appearances,  I  called  on  you,  and,  by  your  advice,  took  a  dose  of  five  grains  of  calomel. 
After  this,  the  spectrum  did  not  appear  for  several  months  ;  and  when  I  again  saw  it,  it 


872  CHETJPSIA. 

yielded  to  a  repetition  of  the  same  remedy.  In  the  following  year,  having  travelled  two 
days  together,  and  taken  food  of  an  improper  kind  and  in  an  irregular  manner,  the  attacks 
on  the  third  morning  were  so  frequently  repeated,  that  I  was  unable  to  see  my  way  without 
difficulty  and  danger.  I  therefore  stopped,  and  took  my  dose  of  calomel ;  after  which  the 
spectrum  immediately  disappeared,  and  it  did  not  return  for  many  mouths.  That  which 
was  black,  as  well  as  those  which  were  lucid,  were  equally  removed  by  the  use  of  this 
medicine  ;  and  I  have  not  now  perceived  either  of  them  for  a  considerable  length  of 
time."* 


^  The  production  of  a  lucid  and  colored  spec-  numerous  affections  of  the  eye  where  the  rays 

trum,  referred   to   in  the  text,  has  been  styled  of  light  can  no  longer  form  images  on  the  retin.i, 

phnsphene  (from  ?ic,  lii/ht,  and  ifihw,  I  ma/ie  on  account  of  the  opacity  of  the  parts  which 

appear),  by  M.  Serres,  of  Uzes,  by  whom  (An-  they  have   to  traverse,  the  ocular  spectra  are 

nales  d'Oculistique,  Tomexix.  p  76  ;  Tome  xxiv.  found    to    be   unimpaired  in  their    brightness, 

pp.  31,  160,  247  ;  Tome  xxv.  p.  126  ;  Bruxelles,  This  refers  only  to  spectra  produced  by  pressure 

1848,  1850,  1851:   Bulletin   General  de  Thera-  on  the  eyeball;  for  (as  is  stated  by  Mliller,  Ele- 

peutique,  Tome    xlvi.  p.  490,  Paris,  1854),  the  ments  of  Physiology,  translated  by  Baly,  Vol. 

experiment  of  making  pressure  on  the  eyeball  ii.p.  1072,  London,  1842)  luminous  spectra  may 

has  been  recommended  as  a  means  of  discrirai-  be   produced  by    internal   causes  affecting  the 

nating  the  diseases  of  the  retina  and  optic  nerve  brain,  in  complete  amaurosis,  or  even  after  ex- 

from  those  which  affect  the  crystalline,  the  iris,  tirpation  of  the  eyeltall. 

and  the  other  parts  in  front  of  the  retina.     In  ^  Philosophical  Magazine,  August,1832,p. 90. 

amaurosis,  glaucoma,  and  other  affections  of  the  '  Medico-Chirurgical  Transactions;  Vol.  v.  p. 

nervous  parts,  the  spectra  are  found  to  become  274;  London,  1814:  Seethe  case  of  M.  Savigny, 

faint  in  proportion  as  the  nervous  powers  are  im-  Archives  Generales  de  Medecine,  Aout,  1838, 

paired;  and  are  entirely  absent  when  the  visual  p.  495. 
sensibility  is  lost.     On  the  other  hand,  in  those 


SECTION   V. — CHRUPSIA. 
Si/n. — Chrupsia,  from  ^poa,  color,  and  o%^if,  vision.    Visus  coloratus.     Iridescent  vision. 

Patients,  who  are  incompletely  amaurotic,  complain  not  unfrequently  of 
luminous  objects,  as,  a  lighted  candle,  appearing  to  be  surrounded  by  the 
colors  of  the  rainbow.  This  symptom,  which  is  called  chrupsia,  may  depend 
either  on  some  derangement  of  the  lenses  of  the  eye,  by  which  its  achromatic 
power  is  disturbed,  or  on  some  irritation,  from  pressure  or  otherwise,  of  the 
convex  surface  of  the  retina,  or  of  some  portion  of  the  optic  nerve.  "We  have 
thus  two  varieties  of  chrupsia,  the  dioptric  and  the  nervous. 

Any  one  may  produce  dioptric  ch-upsia,  by  causing  the  image  of  an  external 
object  to  fall  upon  the  retina,  out  of  its  focal  distance.  If  a  white  object 
upon  a  black  ground,  or  a  black  object  upon  a  white  ground,  is  held  before 
the  eyes  nearer  or  more  distant  than  the  distance  to  which  the  eyes  are  at  the 
time  adjusted,  the  object  will  appear  double,  indistinct,  and  surrounded  with 
fringes  of  color.  Such  fringes  may  occur  as  a  symptom  of  an  affection  of  the 
adjusting  apparatus,  without  any  change  in  the  retina.  Midler  notices^  as  an 
instance  of  this  phenomenon,  the  red  border  which  surrounds  the  letters  of  a 
book,  when  the  adjusting  power  is  paralyzed  by  passion,  mental  exertion,  or 
inclination  to  sleep.  Dioptric  chrupsia  occurs,  also,  when  we  suspend  the 
adjusting  power,  and  dilate  the  pupil,  by  belladonna. 

As  a  variety  of  dioptric  chrupsia,  may  be  mentioned  the  yellow  hue  which 
objects  assume  in  certain  cases  of  jaundice.  In  common,  patients  with  this 
disease  do  not  perceive  any  change  of  color  in  the  objects  around  them  ;  but 
when  the  humors  of  the  eye  and  the  cornea  become  deeply  tinged  with  the 
bile,  then  all  objects  appear  arrayed  in  yellow.  Dr.  Mason  Good  experienced 
this  in  his  own  case.^ 

A  patient  under  my  care  with  prolapsus  of  the  nasal  portion  of  the  iris 
through  an  accidental  wound  of  the  cornea,  saw  all  objects  of  a  greenish  hue. 

Nervous  chrupsia  also  presents  its  varieties ;  according  as  it  arises  from  an 


CHRUPSIA.  873 

affection  of  the  retina  or  of  the  brain,  and  according  as  it  tinges  objects 
with  some  uniform  but  unnatural  hue,  or  fringes  them  with  the  prismatic  colors. 

A  young  lady,  whom  I  attended  for  scrofulous  sclerotitis,  saw  brilliant  blue, 
green,  and  red  colors  playing  over  the  objects  she  regarded,  such  as  the  face 
of  a  person  sitting  before  her,  or  a  white  handkerchief  held  in  her  hand.  I 
judged  this  to  arise  from  pressure  on  the  retina. 

Boyle'  mentions  iridescent  vision  as  the  earliest  symptom  complained  of  by 
those  infected  with  the  plague.  This  symptom  continued  for  about  a  day, 
and  was  generally  removed  by  the  operation  of  a  vomit.  He  records  also  a 
case  of  iridescent  vision  arising  from  a  fall  on  the  head  near  the  eye,  in  which 
this  symptom  continued  for  five  or  six  weeks.* 

Patouillat  records'  the  case  of  nine  persons  being  poisoned  by  roots  of 
henbane,  which  were  mistaken  for  parsnips.  Being  treated,  some  by  tartar 
emetic,  and  others  by  theriaca,  they  recovered  ;  but  during  the  first  day  after 
being  poisoned,  they  saw  double,  and  during  the  second  day  after,  all  ob- 
jects appeared  to  them  as  red  as  scarlet. 

A  patient  told  Dr.  Conolly,  that  for  a  time,  after  an  attack  of  paralysis, 
everything  appeared  to  be  green. ^ 

Dr.  Parry  relates'  four  cases,  in  which  the  patients  saw  objects  of  a  dif- 
ferent color  from  what  was  natural  to  them.  In  one  of  these,  an  old  gene- 
ral, just  before  the  lighting  of  the  candles  in  the  evening,  and  for  an  hour  on 
first  waking  in  the  morning,  saw  all  white  objects  of  a  deep  orange  color, 
approaching  to  scarlet.  In  another,  a  lady  often  saw  white  objects  of  a  very 
bright  blue  color. 

Case  363. — Iq  the  month  of  July,  a  lady  of  advanced  age  went  from  Londoii  to  the 
eastern  coast  of  Kent,  where  she  lodged  in  a  house  looking  immediately  upon  the  sea,  and 
of  course  very  much  exposed  to  the  glare  of  the  moi'ning  sun.  The  curtains  of  the  bed 
in  which  she  slept,  and  also  of  the  windows,  were  of  white  linen,  which  made  her  apart- 
ment very  light.  When  she  had  been  there  about  ten  days,  she  observed  one  evening,  at 
the  time  of  sunset,  that  first  the  fringes  of  the  clouds  appeared  red,  and  soon  after,  the  same 
color  was  diffused  over  all  the  objects  around  her.  It  was  particularly  conspicuous  when 
she  regarded  anything  white,  ^.s  a  sheet  of  paper,  a  pack  of  cards,  or  a  lady's  gown. 
This  lasted  the  whole  night.  The  next  morning  her  sight  was  perfectly  restored.  But 
as  the  evening  advanced,  the  same  appearances  came  on  again ;  and  they  continued  to  do 
so  regularly  every  evening,  as  long  as  she  remained  at  that  place,  which  was  thi-ee  weeks 
from  the  commencement  of  her  complaint ;  the  natural  vision  always  returning  in  the 
morning.  Six  days  after  she  had  left  the  coast,  Dr.  Heberden  saw  her  in  London,  still 
subject  to  the  same  affection.  It  persevered  a  fortnight  longer,  and  then,  of  its  own  ac- 
cord, ceased  suddenly  and  entirely.  While  it  was  upon  her,  the  sight  seemed  to  be  no 
otherwise  impaired  than  by  the  degree  of  indistinctness  necessarily  produced  by  this 
unnatural  color,  which  overspread  all  her  view.* 

There  seems  every  reason  to  suppose  that  this  lady's  complaint  was  brought  on  by  her 
being  exposed  to  an  unusual  glare  of  light;  and  it  may  be  doubted  whether  it  did  not 
partake  as  much  of  the  nature  of  an  ocular  spectrum  as  of  those  affections  which  are 
classed  under  the  head  of  chinipsia. 

In  supposed  cases  of  chrnpsia,  whether  dioptric  or  nervous,  it  will  be  pro- 
per to  guard  against  our  being  deceived,  on  the  one  hand,  by  those  causes 
which  might  induce  a  decomposition  of  the  rays  of  light  by  inflection  merely, 
such  as  the  bringing  of  the  eyelids  pretty  close  together,  and  on  the  other, 
by  such  as  might  give  rise  to  ocular  spectra. 


'  Elements    of    Physiology,    translated    by  ^  Inquiry  concerning  the  Indications  of  In- 

Baly;  Vol.  ii.  p.  1161;  London,  1842.  sanity,  p.  238  ;  London,  1830. 

^  Study   of  Medicine;  Vol.  i.  p.  420;    Lon-  ''  Collections  from  the  unpublished  Medical 

don,  1829.  Writings   of  C.   II.  Parry,   M.  D.;  VoL  i.  pp. 

"  Experiments  and  Considerations  touching  560,  5G8,  and  569;   London,  1825. 

Colors,  p.  14;  Loudon,  1670.  *  Medical    Transactions    of   the    College    of 

*  Ibid.  p.  17.  Physicians;  Vol.  iv.  p.  56;  London,  1813. 

'  Philosophical    Transactions;    Vol.    xl.   p. 
446;  London,  1741. 


814  OCULAR   HYPERiESTHESIA. 


SECTION  VI. — OCULAR  HYPERESTHESIA. 


The  very  remarkable  state  of  disease,  which  I  purpose  to  designate  by  the 
name  ocular  hypercesthesia,  appears  to  consist  chiefly  in  a  greatly  increased 
sensitiveness  both  of  the  optic  nerve,  and  of  the  ophthalmic  division  of  the 
fifth.  The  chief  characteristic  of  the  affection  is  great  intolerance  of  light, 
with  which  are  combined,  in  a  greater  or  less  degree,  photopsia,  chrupsia, 
pain  in  the  eye  and  head,  augmented  tactual  sensibility  of  the  eyeball  and 
eyelids,  and  spasmodic  contraction  of  the  orbicularis  palpebrarum.  So  far 
as  the  disease  implicates  the  fifth  nerve  and  the  portio  dura  of  the  seventh, 
it  appears  to  be  the  effect  of  a  reflex  action  communicated  to  them,  in  conse- 
quence of  the  excited  state  of  the  retina  and  optic  nerve. 

The  disease  occurs  both  in  an  acute  and  in  a  chronic  form ;  the  former 
generally  arising  suddenly  from  some  evident  external  cause,  reaching  its 
greatest  degree  of  severity  in  a  few  hours,  and,  after  some  days,  either  yield- 
ing speedily  to  treatment,  or  rapidly  subsiding  of  itself;  the  latter  rarely 
traceable  to  any  particular  excitement  of  the  orgau  of  vision,  but  seeming  to 
depend  rather  on  the  state  of  the  constitution,  gradually  increasing  in  vio- 
lence during  a  number  of  days  or  weeks,  often  continuing  severe  during  many 
months,  proving  scarcely  amenable  to  treatment,  apt  by  its  long  continuance 
materially  to  compromise  the  general  health  of  the  patient,  merging  some- 
times into  a  state  which  we  might  be  tempted  to  call  ocular  hypochondriasis , 
but  ultimately  undergoing  a  perfect  and  almost  spontaneous  cure. 

In  the  acute  variety,  one  eye  is  generally  first  alfected,  but  by  and  by  both 
become  implicated.  I  have,  however,  seen  the  reverse  of  this,  both  eyes  suf- 
fering at  the  commencement,  while  the  disease  concentrated  itself  speedily  in 
one  eye  only.  The  attack  commences  with  such  excruciating  pain  in  the  eye, 
as  causes  the  patient  to  shriek  aloud,  and  sometimes  to  fall  suddenly  to  the 
ground.  He  is  rendered  totally  incapable  of  exposing  the  eye  to  the  light, 
and  he  immediately  seeks  to  relieve  this  symptom-,  by  remaining  in  the  dark- 
est place  to  which  he  has  access,  pressing  his  eyes  with  his  hands,  or  lying  on 
his  face  in  bed,  and  pressing  his  eyes  against  the  pillow.  The  spasm  of  the 
orbicularis  palpebrarum  is  such,  that  it  is  almost  impossible  to  obtain  a 
glimpse  of  the  eye.  The  pulse  is  full  and  quick,  and  the  head  hot.  The 
symptoms  are  so  severe  that  the  patient  concludes  his  sight  to  be  lost,  and 
the  practitioner,  if  unacquainted  with  the  true  nature  of  such  cases,  perhaps 
adopts  the  same  idea,  and  pronounces  the  disease  to  be  acute  retinitis. 

The  following  cases  illustrate  the  causes,  as  well  as  the  course,  of  acute 
ocular  hyperesthesia. 

Case  3G-t. — A  soldier,  of  sanguine  temperament,  exposed  during  military  exercise  to 
tbe  heat  of  a  July  sun,  fell  suddenly,  and  then  ran  screaming  to  his  tent,  where  he  sought 
to  exclude  himself  entirely  from  the  light.  As  he  was  known  to  be  one  who  endeavored 
to  evade  duty,  the  drill-sergeant  thought  he  was  playing  off  a  trick,  and  sent  him  off  to 
the  guard-house.  He  continued  to  seek  the  darkest  corner  of  the  place  where  he  was 
confined,  and  uttered  the  most  piercing  cries  if  an  attempt  was  made  to  take  his  hands 
from  his  eyes.  He  was  immediately  sent  to  the  camp-hospital  at  Beverloo,  and  placed 
under  the  care  of  M.  Cuuier,  1st  July,  1838.  In  the  darkest  part  of  the  ophthalmic  ward, 
he  lay  on  his  belly,  with  his  head  between  his  hands,  groaning  loudly.  M.  Cunier  sought 
to  open  his  eyelids ;  but  their  spasm  was  so  violent  that  he  could  not  accomplish  it. 
Once  he  succeeded  in  separating  a  little  way  the  left  eyelids,  when  the  patient  threw  him- 
self back,  and  a  profuse  flow  of  tears  took  place  from  both  eyes.  He  was  bled  to  20 
ounces  ;  mercurial  ointment,  with  belladonna,  was  used  in  friction ;  a  pediluvium,  with 
mustard,  was  employed  ;  and  the  room  kept  dark.  At  the  evening  visit,  there  was  a 
slight  amelioration.     The  pediluvium  was  repeated. 

2d  July. — Patient  in  the  same  state  as  yesterday  evening.  Four  drachms  of  mercu- 
rial ointment,  with  extract  of  belladonna,  to  be  used  in  the  day.  Thirty  grains  of  tartar 
emetic  to  be  divided  into  six  doseSj  one  of  which  is  to  be  taken  every  two  hours.     Pedilu- 


OCULAR   HYPERESTHESIA.  875 

vium  with  mustard.  In  the  evening,  a  diminution  of  the  palpebral  spasm.  M.  Cunier 
could  half  open  the  eyelids.  The  eye  was  but  slightly  intlamed ;  the  pupil  was  much 
contracted. 

3d  July. — The  same  remedies  were  continued,  and  blisters  applied  to  the  temples. 

The  disease  continued  to  abate  till  the  Gth,  when  the  patient  desired  to  be  led  out  of 
doors.  The  photophobia  returned,  and  with  it  there  was  constant  photopsia.  Five  grains  of 
tartar  emetic  were  given  in  four  doses,  a  dose  every  two  hours ;  six  drachms  of  mercurial 
ointment,  with  extract  of  belladonna,  were  ordered;  pediluvium,  with  mustard;  an  irri- 
tating application  to  the  blisters. 

7th  July. — Scarcely  any  photophobia;  no  photopsia;  the  revulsives  continued. 

9th  July. — Began  to  use  the  eyes,  the  retina  becoming  less  and  less  irritable. 

15th  July. — Completely  cured- ^ 

Case  365. — Mr.  G.,  a  gentleman  of  remarkable  skill  in  minute  and  microscopical  dissec- 
tion, was  engaged,  on  Friday,  29th  March,  1844,  in  dissecting  the  nerves  of  the  human 
tongue,  under  a  powerful  microscope,  and  in  a  situation  exposed  to  the  full  influence  of 
the  sun,  which,  although  occasionally  obscured,  burst  forth  at  times  with  great  power. 
The  nerves,  having  been  cleanly  dissected,  were  of  a  dazzling  whiteness;  and  whilst  he 
was  intently  regai-Lling  them  through  the  microscope,  the  sun  suddenly  shone  forth  with 
all  its  brilliancy  upon  them.  Acute  pain  was  instantly  felt  in  the  eye,  pervading  the 
whole  globe,  so  severe  as  to  cause  Mr.  G.  to  start  back  and  utter  an  exclamation.  He 
paused  from  work ;  but  for  some  time  was  unable  to  see  anything  with  that  eye,  the 
spectrum  of  the  sun  continuing  before  it,  whether  closed  or  open.  In  about  twenty 
minutes,  however,  this,  as  well  as  the  pain,  had  sufficiently  subsided  to  enable  him  to  re- 
sume work  with  the  other  eye  ;  but  the  injured  organ  was  not  free  from  uneasiness  until 
the  evening. 

The  following  day,  the  eye  was  not  painful,  and  he  incautiously  used  it  in  completing 
his  dissection;  when  the  very  same  occurrence  took  place  as  on  the  previous  day,  the 
reflected  rays  of  the  sun  being  thrown  powerfully  upon  the  retina.  The  shock  was  exces- 
sive ;  deeply-seated  pain,  pervading  the  whole  globe,  with  much  intolerance  of  light, 
immediately  set  in,  and  the  spectrum  of  the  sun  was  most  distressing.  He  remained  in 
this  state  all  the  evening  and  the  following  night. 

Next  day,  his  sufferings  continued  to  increase,  with  a  sensation  of  fulness  and  tender- 
ness of  the  globe,  and  extreme  intolerance  of  light.     Fomentations  failed  to  aff"ord  relief. 

On  Monday,  when  the  patient  consulted  Mr.  White  Cooper,  the  following  were  the 
symptoms :  Acute,  deep-seated  pain  in  the  eye ;  exquisite  tenderness,  especially  at  the 
upper  half  of  the  globe  ;  great  intolerance  of  light ;  profuse  lachrymation ;  any  attempt  at 
vision  produced  luminous  spectra;  pupil  contracted;  iris  natural;  conjunctiva  but 
slightly  injected  ;  pulse  feeble  and  irritable  ;  he  complained  of  weakness  and  mental  de- 
pression. He  was  sent  to  bed  in  a  darkened  room,  and  ordered  to  apply  twelve  leeches 
around  the  eye,  to  foment,  and  to  take  a  purge.  Mercury,  he  stated,  always  disagreed 
with  him,  and  was  therefore  used  with  great  caution. 

Next  day  he  was  rather  easier  ;  friction  of  the  brow  and  temple  with  mercurial  oint- 
ment and  opium  was  directed  ;  blue  pill,  with  conium,  was  ordered  at  night,  with  saline 
draughts  and  antimony  at  intervals. 

The  following  day,  all  the  symptoms  were  alleviated.  The  antimony  was  omitted,  but 
the  mercurials  continued.  On  Thursday,  a  still  greater  improvement  was  manifest,  the 
eye  being  perfectly  free  from  pain,  except  when  exposed  to  the  light ;  there  was,  how- 
ever, great  debility  and  general  exhaustion.  Half  a  grain  of  quinine,  twice  a  day,  with 
a  moderate  meat  diet,  was  ordered,  the  mercurial  friction  being  continued.  This  treat- 
ment, with  counter-irritation  behind  the  ear,  and  the  use  of  a  mild  astringent  collyrium, 
was  steadily  pursued  for  a  week,  with  advantage ;  although  the  least  exertion  of  the  eye 
immediately  produced  luminous  spectra.  The  further  treatment  presented  nothing  re- 
markable ;  the  eye  steadily  and  perfectly  recovering."^ 

Called  to  visit  a  patient  with  chronic  ocular  hypersesthesia,  we  are  proba- 
bly ushered  into  a  room  as  absolutely  dark  as  it  is  possible  to  make  it,  every 
chink  by  which  light  might  enter  being  closed,  and  a  large  screen  so  placed 
as  to  impede  any  gleam  which  might  intrude  on  the  door  being  opened. 
There  we  find  the  patient,  in  some  cases  sitting  up,  in  others  lying  in  bed, 
with  his  eyes  shaded,  and  his  head  covered  with  a  thick  veil  or  shawl.  In 
this  state,  we  are  perhaps  informed,  he  has  been  for  months.  In  such  a  case, 
no  persuasion  will  convince  the  patient  that  he  might  bear,  for  a  few  moments, 
sufficient  light  to  enable  us  to  see  his  eyes  ;  or  if  he  yields  so  much  as  to 
remove  the  coverings  from  them,  his  terror  of  their  being  touched  with  the 


876  OCULAR   HYPERESTHESIA. 

finger  prevents  us  from  making  any  satisfactory  examination  of  their  state. 
The  increased  sensibility  of  the  fifth  nerve  is  a  symptom  scarcely  less  promi- 
nent in  such  cases  than  the  excessive  intolerance  of  light.  The  least  touch 
about  the  eye  is  painful,  and  continues  to  be  felt  for  a  long  time. 

There  is,  in  general,  both  in  the  acute  and  in  the  chronic  variety  of  ocu- 
lar hyperesthesia,  a  combination  of  blepharospasm,  of  photopsia,  and  often 
also  of  chrupsia,  such  as  I  have  already  (pp.  20T,  869,  872)  described  them. 
Yet  it  is  remarkable,  that  there  may  be  neither  photopsia,  chrupsia,  nor 
spasm  of  the  eyelids.  I  have  met  with  cases  in  which,  though  the  smallest 
degree  of  light  was  insufferable,  so  that  the  patient  remained  in  complete 
darkness,  and  his  eyes  shaded  lest  any  accidental  ray  might  reach  them,  yet 
his  eyes  were  open  and  affected  neither  with  spasm  of  the  orbicularis  palpe- 
brarum, nor  with  any  subjective  sensations  of  light. 

Although  severe  pain  always  attends  the  acute  variety  of  the  disease,  the 
feelings  of  this  kind  which  are  present  in  chronic  cases  vary  greatly.  In 
some,  they  are  pretty  acute,  being  concentrated  in  the  eyeball,  or  extending 
to  the  forehead  and  temples.  In  others,  scarcely  any  complaint  is  made  of 
pain. 

I  have  known  patients  for  many  months  affected  with  chronic  ocular  hyper- 
esthesia, their  power  of  vision  remaining  acute,  and  not  at  all  impaired  from 
their  continuing  so  long  in  the  dark.  Indeed,  the  acuteness  of  their  sight 
has  sometimes  appeared  to  be  increased  beyond  what  is  ordinary,  so  that,  in 
a  state  of  almost  complete  darkness,  they  managed  to  see  sufficiently  to  take 
their  food,  and  to  distinguish  readily  the  furniture  in  their  room  and  the  per- 
sons about  them.  Dilatation  of  the  pupil  may  be  partly  the  cause  of  this 
approach  to  oxyopia,  partly  it  may  be  attributed  to  the  forced  tranquillity  of 
the  retina  rendering  it  fit,  after  a  time,  to  receive  impressions  such  as  other- 
wise would  be  too  faint  to  be  perceived. 

Diagnosis. — From  the  photophobia  of  scrofulous  or  any  other  ophthalmia, 
we  distinguish  ocular  hypera?sthesia  by  the  age  of  the  patients,  and  by  the 
absence  of  redness  of  the  eyes.  From  retinitis  it  is  distinguished  by  the 
excessive  pain  and  intolerance  of  light,  symptoms  which  do  not  attend  inflam- 
mation of  the  retina ;  and  by  the  complete  and  generally  sudden  restoration 
to  the  exercise  of  vision  which  happens  in  hyperesthesia,  whereas  the  recovery 
from  retinitis  is  slow  and  uncertain.  After  recovery  from  hyperesthesia, 
there  is  no  evidence  that  the  nutrition  of  the  retina,  nor  of  the  other  structures 
of  the  eye,  had  been  at  all  interfered  with  ;  retinitis  generally  leaves  both  the 
nerve  of  vision,  and  other  parts  of  the  eye,  seriously  compromised  in  texture 
and  function. 

Subjects. — The  subjects  of  ocular  hyperesthesia  are  qftenest  young  adults. 
I  have  met  with  it,  however,  in  persons  far  advanced  in  life.  It  is  more  apt 
to  affect  females  than  males.  It  does  not  seem  connected  necessarily  either 
with  a  plethoric  or  with  an  anemic  state  of  the  circulation.  The  eyes  of  those 
affected  are  generally  normal  in  construction,  although  I  have  met  with  the 
disease  in  eyes  that  were  myopic  and  affected  with  oscillation. 

Causes. — As  causes  of  the  acute  variety  may  be  mentioned,  1.  Exposure 
to  intense  light  and  heat.  2.  Over-use  of  the  eyes,  as  in  microscopic  obser- 
vations. 3.  The  influence  of  lightning.  4.  Febrile  affections,  in  which  the 
brain  suffers  much.  Such  causes  are  often  awanting  in  the  chronic  variety, 
and  then  its  origin  is  obscure.  In  females,  it  sometimes  appears  to  be  an 
hysterical  affection,  or  to  depend  on  irregularity  of  the  catamenia. 

Prognosis. — However  severe  the  symptoms,  we  may,  both  in  the  acute 
and  in  the  chronic  variety,  promise  a  perfect  recovery.  In  the  acute,  the 
recovery  is  generally  sudden  ;  in  the  chronic,  gradual,  but  sometimes  sudden 
and  complete.     The  long  duration  of  the  chronic  affection  sometimes  operates 


OCULAR   SPECTRA.  87Y 

unfavorably  on  the  nutrition  and  general  strength  of  the  patient,  so  that  he 
continues  feeble  and  reduced  in  body  after  his  ocular  symptoms  are  entirely 
subdued. 

J'reatment. — Acute  cases,  from  the  violence  of  the  pain  by  which  they  are 
attended,  have  generally  been  treated  by  depletory  measures,  such  as  venesec- 
tion and  the  application  of  leeches,  followed  by  calomel,  with  opium,  and,  after 
a  time,  by  sulphate  of  quina.  I  have  known  a  complete  cure  effected  by  this 
plan  of  treatment.  In  a  severe  case,  to  which  I  was  called,  in  which  leeches 
and  counter-irritation  had  been  employed,  neither  the  internal  use  of  tincture 
of  belladonna,  nor  fomentations  with  opium  and  belladonna,  were  of  any 
avail ;  but  as  soon  as  the  mouth  became  sore  from  the  administration  of  calomel 
and  opium,  the  symptoms  w^ere  overcome,  and  the  cure  was  completed  under 
the  use  of  the  citrate  of  iron  and  quina. 

The  intolerance  of  light,  in  both  the  acute  and  the  chronic  variety,  yields 
for  a  time  to  the  antesthetic  effect  of  inhaling  the  vapor  of  sulphuric  ether  or 
chloroform  ;  and  I  have  known  the  repeated  use  of  this  means  produce  perma- 
nent relief. 

The  vapor-bath  is  a  means  which  proves  very  beneficial  in  chronic  cases. 

The  re-establishment  of  the  general  health,  after  the  more  distressing  symp- 
toms have  yielded,  may  be  greatly  promoted  by  change  of  climate,  and  espe- 
cially by  passing  the  winter  in  the  southern  parts  of  Europe. 

When  the  eyes  are  extremely  intolerant  of  light,  the  best  sort  of  shade  is 
one  formed  of  several  layers  of  black  crape,  or  black  silk,  mounted  on  a  light 
frame  of  silver  or  brass  wire,  embracing  the  upper  half  of  the  face  like  a  mask, 
but  sufficiently  hollow  not  to  come  into  contact  with  the  eyes. 

In  cases  of  less  severity,  shaded  glasses  may  be  employed,  those  for  day-use 
being  neutral  tinted,  those  for  night-use  blue. 


'  Annales  d'Oculistique;  l^""  Vol.,  Supp.  p.  Times  and  Gazette,  June  5, 1852,  p.  559;  Cases 

48;  Bruxelles,  1842.  from    lightning,  by    Mayo,  Medical     Gazette; 

'  Lancet,  July   6,  1844,  p.  487.     See  case  of  Vol.  ii.  p.  58:  by  Lawrence,  Treatise  on  Dis- 

acute  ocular  hypersesthesia,  by  Taylor,  Medical  eases  of  the  Eye,  p.  481 ;  London,  1841. 


SECTION   VII. — OCULAR   SPECTRA. 
Syn. — Adventitious  colors,  Boyle.     Couleurs  accidentelles,  Biiffon. 

A  short  notice  of  this  class  of  phenomena  will  not,  I  think,  appear  out  of 
place,  if  we  consider  that  they  are  the  result  of  fatigue  of  the  eye,  or,  to  use  the 
ex]»ression  of  Portertield,  of  a  "too  violent  agitation  excited  in  the  retina," 
and  that  fatigue  or  agitation  of  this  kind  may  not  only  be  regarded  as  in  itself 
a  disease,  but  is  the  prelude  often  to  other  diseases  of  more  permanent  cha- 
racter. As  we  proceed,  we  shall  find  that  the  phenomena  of  ocular  spectra 
connect  themselves,  also,  with  various  other  parts  of  our  subject. 

As  long  as  the  condition  into  which  the  stimulus  of  light  has  thrown  the 
retina  endures,  the  sensation  also  remains,  though  the  exciting  cause  or  visual 
object  should  have  ceased  to  act.  The  interval  in  which  the  sensation  con- 
tinues is  extremely  short,  not  exceeding  in  ordinary  cases  from  3  to  4  tenths 
of  a  second  ;  yet  upon  this  persistence  of  sensation  depends  the  fact,  that  in 
the  act  of  winking,  we  never  lose  sight  of  the  objects  at  which  we  are  look- 
ing. Even  after  this  interval,  the  retina  does  not  suddenly  and  completely 
return  to  the  state  in  which  it  was  before  being  submitted  to  the  excitement 
of  impression.     To  the  actual  sensation,  there  follows  what  is  called  the  after- 


8t8  OCULAR   SPECTRA. 

sensation  or  spectrum,  the  duration  of  which  is  proportionate  to  the  intensity 
and  duration  of  the  impression  which  caused  it. 

If  we  look  for  a  short  time  at  a  window  from  the  end  of  a  long  apartment, 
and  promptly  closing  the  eyes,  turn  them  from  the  window  and  cover  them 
with  the  hand,  we  perceive  an  accurate  representation  of  the  window,  with 
the  bars  dark  and  the  panes  bright.  This  appearance,  called  a  direct  ocular 
spectrum,  is  instantly  succeeded,  if  we  turn  the  closed  eyes  towards  the  light 
and  remove  the  hand,  by  a  reverse  ocular  spectrum,  or  complementary  picture, 
in  which  the  bars  appear  bright,  and  the  panes  dark.  This  spectrum  con- 
tinues for  a  considerable  space  of  time ;  its  duration  may  be  prolonged,  by 
passing  the  hand  up  and  down  before  the  closed  eyes,  so  as  to  permit  the 
light  to  fall  upon  them  only  at  intervals ;  and  it  is  lost  at  length,  only  after 
a  series  of  oscillations,  in  which  it  appears  and  disappears  alternately. 

If  we  look  steadily  for  a  considerable  time  upon  a  spot  of  any  given  color, 
placed  on  a  white  or  black  ground,  it  will  appear  surrounded  with  a  border 
of  another  color;  for  instance,  if  the  spot  be  red,  a  green  border  will  appear, 
and  if  we  direct  our  eyes  to  another  part  of  the  white  or  black  ground,  we 
shall  perceive  a  spot  of  green  of  the  size  and  form  of  the  red  spot.  By  simi- 
lar experiments  the  ojjposite  or  accidental  color,  as  it  is  termed,  of  every  tint 
may  be  found.  Thus,  the  spectrum  which  is  seen  by  fatiguing  the  eye  with 
looking  at  a  green  object,  is  red ;  that  of  a  violet  object  is  yellow :  that  of 
yellow,  violet.     These  are  therefore  called  opposite  colors. 

If  the  impression  of  a  luminous  object  on  the  retina  be  very  intense,  as 
when  we  look  steadily  at  the  setting  sun,  the  spectrum  assumes  a  variety  of 
different  colors  in  succession. 

From  the  ocular  spectrum  of  an  object  being  often  of  a  color  different 
from  that  of  the  object  which  has  produced  it,  Boyle'  gave  to  the  colors  which 
arise  in  this  way  the  name  of  adventitious  colors,  while  Buffon^  called  them 
accidental  colors,  in  order  to  distinguish  them  from  those  produced  by  the 
elements  of  white  light  naturally  reflected  from  external  bodies. 

To  understand  the  meaning  of  the  term  complementary,  as  applied  to  such 
colors,  it  is  necessary  to  observe,  that  the  color  of  the  spectrum  is  always 
such  as  being  added  to  the  color  of  the  object  with  which  the  retina  has  been 
fatigued,  makes  up  the  sum  of  the  three  primary  colors,  red,  yellow,  and  blue, 
which  by  their  combination  form  white  light ;  hence  the  name  complementary, 
which  has  been  given  to  the  colors  of  ocular  spectra.  Green,  then,  which  is 
composed  of  yellow  and  blue,  is  the  complementary  color  to  red ;  violet,  a 
compound  of  red  and  blue,  to  yellow ;  and  orange,  a  mixture  of  red  and 
yellow,  to  blue.  Two  colors,  which  together  yield  a  gray  color,  such  as  black 
and  white,  are  also  complementary. 

From  what  has  already  been  stated,  the  reader  will  see  the  propriety  of 
arranging  ocular  spectra,  with  Midler,^  into  three  classes. 

The  explanation  given  by  that  physiologist  of  the  j^rs^  class,  namely,  color- 
less spectra  after  colorless  images,  such  as  the  reverse  spectrum  of  the  Ijars 
and  ]3anes  of  the  window,  is  this :  The  part  of  the  retina  which  has  received 
the  luminous  image  remains  for  a  time  in  an  excited  state,  while  that  which 
has  received  a  dark  image  is  in  an  unexcited,  and  therefore  much  more  excit- 
able condition.  The  eye  in  this  condition  being  directed  towards  a  white 
surface,  the  luminous  rays  from  this  sm-face  produce  upon  the  excited  pai"ts 
of  the  retina  a  much  more  feeble  impression  than  upon  the  other  parts  which 
are  as  yet  unexcited,  and  therefore  more  susceptible  of  their  action.  Hence, 
the  parts  of  the  retina  upon  which  the  dark  portions  of  the  previous  image 
had  fallen  receive  a  more  intense  impression  from  the  white  surface  than 
those  upon  which  the  luminous  portions  of  the  image  were  directed,  and 
thence  the  inversion  of  the  light  and  dark  parts  of  the  image  in  the  spectrum. 


OCULAR   SPECTRA.  819 

A  succession  of  colored  spectra  from  the  impression  of  colorless  objects, 
as  is  the  case  after  looking  at  the  sun,  constituting  the  second  class,  cannot 
be  explained  by  any  external  conditions  acting  on  the  eye,  and  thus  afford 
proof  that  colors  have  their  immediate  cause  in  the  conditions  of  the  retina 
itself. 

Colored  spectra  from  colored  images,  which  form  the  third  class,  have 
generally  been  explained  on  physical  principles  as  follows  :  "White  light 
contains  all  the  colors  as  its  elements.  The  retina,  when  long  fixed  on  a  red 
object,  is  rendered  insensible  to  the  red  light,  but  is  still  susceptible  of  the 
impression  of  the  other  colored  rays ;  if  it  be  now  directed  towards  a  white 
surface,  being  no  longer  sensible  to  the  red  rays  contained  in  the  white  light, 
it  perceives  only  the  remaining  component  rays  of  white  light — those  which 
produce  the  color  complementary  of  red,  namely,  green. 

At  variance  with  this  explanation  is  the  fact,  that  colored  spectra  from 
colored  objects  appear,  although  the  eyes  are  in  total  darkness  ;  so  that  there 
remains  only  the  physiological  explanation,  which  is  this  :  The  perception 
of  any  of  the  three  simple  colors  consists  merely  in  the  retina  being  in  one 
of  those  conditions  to  which  it  has  a  tendency  when  in  a  state  of  excitement; 
if  this  condition  be  artificially  excited  in  an  intense  degree,  the  retina  acquires 
an  extreme  tendency  to  that  of  the  complementary  color  which,  consequently, 
is  perceived  as  the  ocular  spectrum. 

The  following  miscellaneous  facts  regarding  ocular  spectra  appear  worthy 
of  notice.  For  the  full  illustration  of  them,  the  reader  may  consult  the 
works  mentioned  in  the  note.* 

1.  Though  a  certain  quantity  of  light  facilitates  the  formation  of  reverse 
spectra,  a  greater  quantity  prevents  their  formation,  as  the  more  powerful 
stimulus  excites  even  the  fatigued  parts  of  the  eye  into  action  ;  otherwise  we 
should  see  the  spectrum  of  the  last  viewed  object  as  often  as  we  turn  our 
eyes. 

2.  All  experiments  upon  ocular  spectra  are  apt  to  be  confounded,  if  they 
are  made  too  soon  after  each  other,  as  the  remaining  spectrum  will  mix  up 
with  the  new  ones.  This  is  a  very  troublesome  circumstance  to  painters,  who 
are  obliged  to  look  long  upon  the  same  color  ;  and  in  particular  to  those 
whose  eyes,  from  natural  debility,  cannot  long  continue  the  same  kind  of 
exertion.  One  accidental  color,  however,  cannot  be  added  to,  or  combined 
with,  another.  When  the  eye  sees  an  accidental  color,  suppose  red,  the  ex- 
cited part  of  the  retina  is  insensible  to  all  other  rays  but  those  of  the  acci- 
dental color.  If  the  same  portion  of  the  retina  is  instantly  excited  by  another 
object,  productive  of  an  accidental  green,  and  is  thus  rendered  insensible  to 
red,  then  the  eye  perceives  blackness,  not  because  the  accidental  red  and 
the  accidental  green  compose  blackness,  but  because  the  eye  has  been  in  suc- 
cession rendered  insensible  to  two  colors  which  compose  white  light  itself.^ 

3.  From  experiments  on  ocular  spectra,  it  would  appear  that  an  impres- 
sion oh  the  one  retina  can  be  conveyed  to  the  other.  Sir  Isaac  Newton, 
having  been  asked  by  Locke  his  opinion  respecting  a  fact  relating  to  this 
subject  stated  in  Boyle's  experiments,  communicated  to  his  friend  the  follow- 
ing observations  made  by  himself: — 

"  The  observation  j'ou  mention  in  Mr.  Boyle's  boolv  of  Colors,  I  once  made  upon  myself, 
with  the  hazard  of  my  eyes.  The  manner  was  this:  I  looked  a  very  little  while  npon 
the  sun  in  the  looking-glass  with  my  right  eye,  and  then  turned  my  eyes  into  a  dark 
corner  of  my  chamber,  and  winked,  to  observe  the  impression  made,  and  the  circles  of 
colors  which  encompassed  it,  and  how  they  decayed  by  degi-ees,  and  at  last  vanished. 
This  I  repeated  a  second  and  a  third  time.  At  the  third  time,  when  the  phantasm  of 
light  and  colors  about  it  were  almost  vanished,  intending  my  fancy  upon  them  to  see  their 
last  appearance,  I  found  to  my  amazement,  that  they  began  to  return,  and,  by  little  and 
little,  to  become  as  lively  and  vivid  as  when  I  had  newly  looked  upon  the  sun.    But  when 


880  OCULAR   SPECTRA. 

I  ceased  to  intend  ray  fancy  upon  them,  they  vanished  again.  After  this,  I  found  that, 
as  often  as  I  went  into  the  dark,  and  intended  my  mind  upon  them,  as  when  a  man  looks 
earnestly  to  see  anj'ihing  which  is  difficult  to  be  seen,  I  could  make  the  phantasm  return 
without  looking  more  upon  the  sun  ;  and  the  oftener  I  made  it  return,  the  more  easily  I 
could  make  it  return  again.  And  at  length,  by  repeating  this  without  looking  any  more 
upon  the  sun,  I  made  such  an  impression  on  my  eye,  that  if  I  looked  upon  the  clouds,  or 
a  book,  or  any  bright  object,  I  saw  upon  it  a  round  bright  spot  of  light,  like  the  sun;  and, 
which  is  still  stranger,  though  I  looked  upon  the  sun  with  my  right  eye  only,  and  not 
with  my  left,  yet  my  fancy  began  to  make  an  impression  upon  my  left  eye  as  well  as  upon 
my  right.  For  if  I  shut  my  right  eye,  or  looked  upon  a  book  or  the  clouds  with  my  left 
eye,  I  could  see  the  spectrum  of  the  sun  almost  as  plain  as  with  my  right  eye,  if  1  did  but 
intend  my  fancy  a  little  while  upon  it ;  but  by  repeating,  this  appeared  every  time  more 
easily.  And  now,  in  a  few  hours'  time,  I  had  brought  my  eyes  to  such  a  pass,  that  I 
could  look  upon  no  bright  object,  with  either  eye,  but  I  saw  the  sun  before  me,  so  that  I 
durst  neither  write  nor  read  ;  but,  to  recover  the  use  of  my  eyes,  shut  myself  up  in  my 
chamber,  made  dark,  for  three  days  together,  and  used  all  means  to  divert  my  imagina- 
tion from  the  sun.  For  if  1  thouglit  upon  him,  I  presently  saw  his  picture,  though  1  was 
in  the  dark.  But,  by  keeping  in  the  dark,  and  employing  my  mind  about  other  things, 
I  began,  in  three  or  four  days,  to  have  some  use  of  my  eyes  again  ;  and,  by  forbearing  to 
look  upon  bright  objects,  recovered  them  pretty  well ;  though  not  so  well  but  that,  for 
some  months  after,  the  spectrum  of  the  sun  began  to  return  as  often  as  I  began  to  meditate 
upon  the  phenomena,  even  though  I  lay  in  bed  at  midnight  with  my  curtains  down.  But 
now  I  have  been  very  well  for  many  years ;  though  I  am  apt  to  think,  if  I  durst  venture 
my  eyes,  I  could  still  make  the  phantasm  return  by  the  power  of  my  fancy. "^ 

It  deserves  to  be  remarked,  that  the  fact  of  the  transmission  of  the  ocular 
spectrum  of  the  sun  from  the  retina  of  tlie  one  eye  to  that  of  the  other,  was 
observed  and  described  by  Sir  David  Brewster,"  long  before  the  letter  of 
Newton,  of  which  the  above  is  an  extract,  was  given  to  the  world. 

4.  The  ocular  spectra  which  are  produced  by  looking  at  the  sun  are  not 
only  apt  to  continue  for  hours,  days,  or  weeks,  but  are  often  followed  by 
serious  affections  of  the  retina. 

Buffon  tells*  us,  that  one  of  his  friends  having  one  day  looked  at  an  eclipse 
of  the  sun  through  a  small  hole,  observed  for  more  than  three  weeks  a  colored 
image  of  that  body  upon  all  objects.  When  he  fixed  his  eyes  upon  a  bril- 
liant yellow,  as  that  of  a  gilt  frame,  he  saw  a  purple  spot ;  when  on  blue,  as 
that  of  a  slated  roof,  a  green  spot. 

Sir  David  Brewster  found,  after  his  experiments,  that  his  eyes  were  re- 
duced to  such  a  state  of  extreme  debility,  that  they  were  unfit  for  any  farther 
trials.  A  spectrum  of  a  darkish  hue  floated  before  his  left  eye  for  many 
hours,  succeeded  by  the  most  excruciating  pains,  shooting  through  every 
part  of  the  head.  These  pains,  accompanied  with  a  slight  inflammation  in 
both  eyes,  lasted  for  several  days.  Two  years  after,  the  debility  of  the  eyes 
still  continued,  and  several  parts  of  the  retina  in  both  eyes  had  completely 
lost  their  sensibility. ^ 

The  case  recorded  by  Boyle,  w^hich  gave  rise  to  Newton's  letter  to  Locke, 
was  that  of  an  eminent  scholar,  who  from  looking  at  the  sun  through  a  tele- 
scope, without  any  colored  glass  to  take  off  the  splendor  of  the  object, 
brought  on  such  an  ocular  spectrum,  that  nine  or  ten  years  afterwatds  he 
still  saw,  on  turning  towards  a  window,  or  any  white  object,  a  globe  of 
light,  of  about  the  bigness  with  which  the  sun  originally  appeared  to  hijry 

5.  There  must  at  all  times,  and  from  every  object,  be  a  tendency  .t^'  the 
production  of  ocular  spectra  ;  but  partly  from  habitual  inattention  to  them, 
partly  from  their  being  lost  in  the  overwhelming  effect  of  direct  impressions, 
and  effaced  from  the  retina  in  the  intervals  of  repose,  they  are  seldom  made 
the  subject  of  complaint,  exce])t  by  those  whose  eyes  are  peculiarly  sensible,  or 
have  become  greatly  weakened  by  over-fatigue  and  other  causes. '°  In  such 
persons  a  combination  of  photopsia,  muscie  volitantes,  and  ocular  spectra  is 
not  uncommon.  I  knew  a  person,  who  had  by  night-study  induced  muscse 
volitantes,  and  who  was  considerably  troubled  during  the  early  hours  of  rest 


INSENSIBILITY  TO  CERTAIN  COLORS.  881 

with  photopsia,  and  in  the  morning  with  reverse  spectra  of  the  objects  in  his 
dressing-room,  such  as  a  black  chair,  which  appeared  in  white  whenever  he 
turned  his  eyes  to  the  walls  of  the  room,  or  a  framed  print,  the  spectrum 
of  which  appeared  black  with  a  white  edge,  the  result  of  a  dark  frame  and 
whitish  print. 

"All  persons,"  says  Midler,  "are  not  equally  susceptible  of  the  phenomena 
of  the  colored  spectra.  Some  individuals  perceive  them  with  difficulty, 
others  without  any  trouble.  When  once  seen,  the  observation  is  repeated 
with  extreme  ease.  Most  persons  are  little  acquainted  with  the  ocular 
spectra,  owing  to  their  attention  not  having  been  directed  to  them.  When, 
however,  they,  and  the  laws  of  their  production,  are  known,  their  constant 
presence  frequently  becomes  tormenting." 

Looking  through  blue  or  green  glasses  is  necessarily  productive  of  ocular 
spectra.  The  moment  blue  glasses  are  laid  aside,  all  light-colored  objects 
appear  of  an  orange  hue  ;  if  the  glasses  are  green,  on  removing  them,  every- 
thing is  seen  of  a  red  color,  the  complementary  color  of  green.  When  the 
eyes  are  so  weak  as  to  require  to  be  shaded  by  colored  glasses,  Ihose  of  a 
neutral  or  smoky  tint,  are  generally  to  be  preferred.  The  Chinese,  Mr.  White 
Cooper  informs  us,^'  have  shown  wisdom,  in  using  from  time  immemorial,  for 
checking  the  glare  of  the  sun,  a  transparent  substance,  which,  from  the  resem- 
blance of  its  hue  to  that  of  a  weak  infusion  of  black  tea,  is  called  tea-stone. 


'  Boyle's    Experiments    and    Considerations  lore,  in  the  Edinburjrh  Encyclopedia  :  Plateau, 

touching  Colors,  p.  16;  London,  1670.  Menioires  de  I'Acadeniie  Royale  des  Sciences 

"  BuiiFon  snr  les  Couleurs  Accidentelles,  Me-  de  Bruxelles:  Tomeviii.;  Bruxelles,1834:  Ibid., 

moires  de  I'Acndeuiie  Royale  des  Sciences,  an-  Philosophical   Maj^azine,  May,  1839,   pp.  330, 

nee  1743,  p.  147  ;  Paris,  1746.  439  :  Brewster,  Ibid.,  Dec.  1839,  p.  435  :  Fech- 

'  Elements  of  Pbysiologv,  translatedby  Baly ;  ner,  PoggendorfF's  Annalen  ;  Band  xliv.  pp.  221, 

Vol.  ii.  p.  1180;  London,  1842.  513  :  Band  1.  pp.  193,427;  Leipzig,  1838,  1840. 

*  De  la  Hire  sur  les  differens  Accidens  de  la  '   Brewster,  Edinburgh  Review,  April,  1834, 

Vue,  Memoires  de  I'Academie  Royale  des  Sci-  p.  161. 

ences,  annee    1694;   Tome   ix.  p.  614;  Paris,  ^  Locke's  Life,  by  Lord  King;  Vol.  i.  p.  405; 

1730  :  Jurin's  Essay  on  Distinct  and  Indistinct  London,  1830. 

Vision,  at  the  end  of  Smith's  Optics  :  Porterfield  ■"  Article,  Accidental  Colors,  in  the  Edinburgh 

on  the  Eye  ;  Vol.  i.  p.  343  :  J^pinus,  Novi  Com-  Encyclopaedia. 

mentariiPetropolitani;  Tome  x.  p.  283  ;  Petro-  '  Op   cit.  p.  155. 

poli,  1766:  Scherffer  sur  les  Couleurs  Acciden-  'Article,    Accidental    Colors,    in    the  Edin- 

telles,  Rozier's  Observations  sur  la  Physique  ;  burgh  Encyclopsedia. 

Tome    xxvi.  pp.   175,  273,   291;  Paris,    1785:  '"  Galenus  de  Symptomatum  Causis  ;  Lib.  i. 

Darwin,  Philosophical  Transactions;  Vol.  Ixxvi.  cap.  2. 

p.  313  ;  London,  1786  :  Article,  Accidental  Co-  ^i  On  Near  Sight,  <fec.,  p.  190  ;  London,  1853. 


SECTION   VIII. — INSENSIBILITY   TO   CERTAIN   COLORS. 

Syn. — Dyschromatopsia,  from  Ju?,  with  difficulty,  xpa'^wa,  color,  and  v-\>a-iq,  vision.  Color- 
blindness, Brewster.     Mangel  an  f  arbensiun,  Ger. 

Numerous  instances  are  recorded  of  persons,  who  were  liable  to  strange 
mistakes  regarding  the  colors  of  objects,  or  were  even  totally  unable  to  per- 
ceive certain  colors.  Some  of  the  individuals  in  question  appear  to  have  been 
myopic,  but  the  eyes  of  most  of  those  who  presented  this  defect  are  described 
as  appearing  in  no  way  diseased  or  abnormal,  and  to  have  fulfilled  their  func- 
tions perfectly,  so  far  as  communicating  ideas  of  the  form,  size,  and  distance  of 
objects,  from  a  cognizance  of  light  and  shade,  was  concerned. 

Mr.  Huddart  mentions  the  case  of  one  Harris,  a  shoemaker  atMaryport,  in 

Cumberland,  who  could  distinguish  only  black  and  white,  and  who  had  two 

brothers  almost  equally  defective,  one  of  whom  always  mistook  orange  for 

green.     Harris  observed  this  defect  when  he  was  four  years  old.     Having  by 

56 


882  INSENSIBILITY  TO  CERTAIN  COLORS. 

accident  found  in  the  street  a  child's  stocking,  he  carried  it  to  a  neighboring 
house  to  inquire  for  the  owner  :  he  observed  the  people  call  it  a  red  stocking, 
though  he  did  not  understand  why  they  gave  it  that  denomination,  as  he  him- 
self thought  it  completely  described  by  being  called  a  stocking.  The  circum- 
stance, however,  remained  in  his  memory,  and,  together  with  subsequent 
observations,  led  him  to  the  knowledge  of  his  defect.  He  observed,  for 
instance,  that  other  children  could  discern  cherries  on  a  tree  by  some  pre- 
tended difference  of  color,  though  he  could  distinguish  them  from  the  leaves 
by  their  difference  only  in  size  and  shape.* 

Another  case  of  a  Mr.  Scott  is  recorded,  to  whom  full  reds  and  full  greens 
appeared  alike,  while  yellows  and  dark  blues  were  very  easily  distinguished. 
Mr.  Scott's  father,  his  maternal  uncle,  one  of  his  sisters,  and  her  two  sons, 
had  all  the  same  imperfection.^ 

Dalton,  the  celebrated  chemist,  could  not  distinguish  pink  from  blue,  by 
daylight ;  and  in  the  solar  spectrum,  the  red  was  scarcely  visible  to  him,  the 
rest  of  it  appearing  to  consist  of  two  colors,  yellow  and  blue.  He  appears  to 
have  remmned  long  unconscious  of  his  defect ;  and  was  led,  rather  to  suppose 
that  there  existed  some  perplexity  in  the  nomenclature  of  colors,  than  any 
incapability  in  his  own  power  of  distinguishing  them."' 

Those  who  feel  inclined  to  examine  the  particulars  of  other  instances  of  this 
sort,  may  consult  the  works  referred  to  in  the  note.*  They  will  find,  on  doing 
so,  that  the  chief  peculiarities  of  these  cases  are,  the  confounding  of  red  with 
green,  and  pink  with  blue;  in  other  words,  that  red  light,  colors  in  which  red 
forms  an  ingredient,  and  its  accidental  color,  green,  are  not  distinguishable 
by  those  who  labor  under  the  defect  in  question,  lied  appears  to  them  merely 
a  dark  color,  and  green  a  shade  of  drab.  They  judge  of  orange,  purple,  and 
brown,  with  great  difficulty.  The  only  colors  they  can  truly  distinguish  are 
yellow  and  blue,  which  appear  to  them  entire  opposites,  as  much  so  as  black 
and  white.  Blue  is  by  many  imperfectly  distinguished  from  red.  In  all,  the 
perception  of  yellow  is  the  most  perfect.  By  gas-light  or  candle-light,  the  dis- 
tinction between  red  and  green,  which  is  so  slight  by  daylight,  becomes  in 
many  cases  quite  apparent.  Examined  very  carefully  by  Sir  John  Herschel, 
Mr.  Troughton  was  found  capable  of  fully  appreciating  only  blue  and  yellow 
tints,  and  these  names  uniformly  corresponded  in  his  nomenclature  to  the  more 
or  less  refrangible  rays  generally ;  all  belonging  to  the  former  indifferently 
exciting  a  sense  of  blueness,  and  the  latter  of  yellowness.^  Mention  has  been 
made  of  individuals  seeing  well  in  other  respects,  but  devoid  altogether  of  the 
sense  of  color,  distinguishing  different  tints  only  as  brighter  or  darker  than 
another ;  but  such  a  case  is,  probably,  one  of  extremely  rare  occurrence. 

At  Dr.  Nicholl's  suggestion,  one  patient  made  the  curious  observation,  that 
on  fatiguing  his  sight,  at  different  times,  with  gazing  upon  spots  of  red  and 
green,  laid  on  a  white  ground,  the  eyes  became  painfully  affected,  but  no  acci- 
dental color  made  its  appearance. 

We  should  scarcely  suppose,  that  a  deficiency  in  the  perception  of  colors 
could  be'  attended  with  any  advantage  ;  yet  in  one  respect,  this  appears  to  be 
the  case.  In  a  case  recorded  by  Turberville,  the  patient  could  read  in  a  very 
obscure  light. ^  "I  see  objects,"  says  one  of  the  subjects  of  this  defect,  "at 
a  greater  distance  and  more  distinctly  in  the  dark  than  any  one  I  recollect  to 
have  met  with ;  this  I  discovered  many  years  before  I  was  aware  of  my  defective 
error  in  colors."^  Another  makes  the  following  observation  on  the  same 
point:  "All  objects  whatever,  when  viewed  at  a  distance,  lose  their  local 
coloring,  and  assume  more  or  less  of  a  pale  or  azure  blue  tinge,  which  painters 
term  the  color  of  the  air,  which  is  interposed  between  the  spectator  and  the 
distant  object.  No  color  contrasts  to  me  so  forcibly  with  black  as  this  azure 
blue,  and  as  you  know  that  the  shadows  of  all  objects  are  composed  of  black, 


INSENSIBILITY  TO   CERTAIN   COLORS.  883 

the  forms  of  objects  which  have  acquired  more  or  less  of  this  blue  hue,  from 
being  distant,  become  defined,  and  marked  by  the  possession  of  shadows, 
which  are  invisible  to  me  in  the  high-colored  objects  in  a  foreground,  and 
which  are  thus  left  comparatively  confused  and  shapeless  masses  of  color.  So 
much  is  this  the  case  with  me,  when  viewing  a  distant  object,  as  to  overcome 
the  effect  of  perspective,  and  the  shading  in  the  form,  and  the  garments  of 
human  beings  at  some  distance  from  my  eye,  is  often  so  predominant,  and 
marks  them  so  distinctly,  as  to  overcome  the  effect  of  diminution  of  size  ;  and 
although  I  see  the  object  most  distinctly,  I  am  unable  to  tell  whether  it  be  a 
child  near  me,  or  a  grown-up  person  at  a  considerable  distance."^  A  color- 
blind engraver,  who  reports  his  case  to  Dr.  Wilson,  states  that  his  defective 
vision  is,  to  a  certain  extent,  useful  and  valuable.  "When  I  look  at  a 
picture,"  says  he,  "I  see  it  only  in  white  and  black,  or  light  and  shade  ;  and 
any  want  of  harmony  in  the  coloring  of  a  picture  is  immediately  made  mani- 
fest by  a  corresponding  discord  in  the  arrangement  of  its  light  and  shade,  or, 
as  artists  term  it,  the  effect.  I  find,  at  times,  many  of  my  brother  engravers 
in  doubt  how  to  translate  certain  colors  of  pictures,  which  to  me  are  matters 
of  decided  certainty  and  ease."^ 

A  counter-view  of  color-blindness  of  great  importance,  pointed  out  by 
Dr.  Wilson,  refers  to  the  use  of  colored  signals  on  railways,  or  at  sea.  As 
a  separation  of  a  few  yards,  or  even  a  few  feet,  abolishes  their  sense  of  dis- 
tinction between  red  and  green,  danger-signals  of  these  colors  must  prove 
useless  to  the  color-blind, *°  the  number  of  whom  is  much  greater  than  is 
generally  supposed.  Dalton  had  been  informed  of  nearly  twenty  persons 
with  vision  like  his  own ;  and  out  of  twenty-five  pupils  he  once  had,  to  whom 
he  explained  the  subject,  two  were  found  color-blind,  and  on  another  similar 
occasion,  one.  Among  every  twenty  men,  assembled  by  chance,  Prevost 
reckoned  upon  one  being  color-blind." 

That  portion  of  Dr.  Wilson's  paper,  which  takes  up  the  extent  to  which 
color-blindness  prevails,  has  not  appeared  when  I  am  obliged  to  send  this 
section  to  press ;  but  I  have  been  favored  by  that  gentleman  with  the  follow- 
ing statement : — 

"As  foi-  color-blind  statistics,  I  certainly  disbelieve  Prevost's  numbers,  if  intended  to 
apply  to  cases  such  as  Dalton's.  If,  on  the  other  hand,  he  included,  every  degree  of  con- 
fusion or  uncertainty  about  colors,  and  in  particular  that  regarding  blue  and  green,  his 
numbers  may  be  just;  but  it  would  be  easy  to  show  that  blindness,  deafness  and  lame- 
ness are  as  common. 

"  My  own  conclusions,  as  gathered  from  the  examination  of  1154  persons  in  Edinburgh, 
are,  in  reference  to  the  three  kinds  of  confusion,  as  follows  : — 

Confounded  red  with  green  .  .  .  1  in  55. 

Confounded  brown  with  green     .  .  .  1  in  60. 

Confounded  blue  with  green         .  .  .  1  jn  46. 

"  The  first  two  are  degrees  of  the  same  affection ;  all  in  the  first  category  must  be 
added  to  those  in  the  second,  and  many  of  those  in  the  second  might  appear  in  the  first ; 
but  no  one  was  counted  more  than  once.  The  blue  and  green  forced  themselves  upon 
notice,  and  were  not  specially  looked  for." 

Color-blindness  has  been  detected  much  oftener  in  males  than  in  females. 
It  runs  in  families ;  but  when  thus  entailed,  it  sometimes  overleaps  one  gene- 
ration or  more.  It  is  propagated  more  frequently  by  female  than  by  male 
descendants.  Amongst  the  many  cases  now  recorded,  I  do  not  recollect  that 
it  has  ever  been  found  to  affect  only  one  eye. 

There  are  no  objective  signs  of  color-blindness,  sufficiently  constant  to  be 
relied  upon.  The  iris  is  frequently  light-blue,  interspersed  with  yellow  spots 
near  the  edge  of  the  pupil ;  and  a  depression  above  the  middle  of  the  eye- 
brow, indicating,  according  to  the  phrenologists,  a  defective  organ  of  color, 
is  observed  in  many,  although  not  in  all  instances. 


884  INSENSIBILITY   TO   CERTAIN   COLORS. 

I  considered  tbis  affection  as  always  a  congenital  one,  till  I  was  consulted 
by  a  man  who  had  gradually  become  subject  to  it.  He  was  by  trade  an 
ornamental  painter,  and  could  judge  at  one  time  perfectly  of  colors.  His 
right  eye  was  affected  with  mydriasis  when  he  called  upon  me,  and  there  was 
incomplete  amaurosis  of  both  eyes,  so  that  he  could  no  longer  read  a  com- 
mon type.  On  trying  him,  I  found  he  mistook  red  and  green.  The  use  of 
spirits  and  tobacco  was  probably  the  exciting  cause  of  the  affection  of  sight 
in  this  individual.  Concussion  of  the  brain, ^^  and  other  causes  of  cerebral 
disease,  have  been  known  to  give  rise  to  color-blindness,  temporarily  or 
permanently."  Congenital  cases  appear  to  undergo  no  change,  either  for 
the  better  or  worse,  in  the  course  of  life.  Originating  from  diseased  braiu, 
a  cure  has  been  effected.  Esquirol  mentions  the  case  of  a  lady,  aged  sixty- 
eiglit,  to  whom,  under  an  attack  of  cerebral  congestion,  which  lasted  about 
one  hour,  everything  appeared  to  be  black,  even  the  persons  who  addressed 
her,  and  whose  voices  she  recognized.  The  attack  was  immediately  removed 
by  applying  leeches  to  the  neck.**  In  Mary  Bishop,  whose  case  is  recorded 
by  Dr.  Hays,  bloodletting  and  purging  relieved  the  symptoms  of  cerebral 
congestion,  and  restored  the  power  of  distinguishing  colors." 

Causes. — The  following  are  some  of  the  notions  which  have  been  formed 
regarding  the  efficient  cause  of  insensibility  to  colors. 

1.  Dalton  thought  it  probable  that  the  red  light  is,  in  these  cases,  absorbed 
by  the  vitreous  humor,  which  he  supposed  might  have  a  blue  color ;  a  very 
unlikely  conjecture  at  the  best,  but  which  appears  to  be  refuted  by  the  simple 
experiment  of  looking  through  a  pair  of  green  or  blue  glasses.  When  we 
do  so,  we  still  recognize  every  primitive  color  in  bodies,  with  a  shade  merely 
of  green  or  blue  over  it.  Therefore,  supposing  the  rays  of  light  to  pass 
through  a  blue  vitreous  humor,  it  does  not  follow  that  objects  should  appear 
blue,  or  that  we  should  be  prevented  from  discerning  red  light,  or  any  other 
color.  In  old  age,  we  view  all  objects  through  an  amber-colored  crystalline, 
and  yet  see  everything  of  its  natural  hue. 

2.  On  the  supposition  that  the  choroid  coat  is  essential  to  vision,  it  has 
been  hinted,  that  the  loss  of  red  light  in  the  subjects  of  this  defect,  might 
arise  from  the  retina  itself  having  a  blue  tint,  so  that  the  light,  falling  upon 
the  choroid  coat,  being  deprived  of  its  red  rays  by  the  absorptive  power  of 
the  blue  retina,  the  impression  conveyed  back  to  the  retina  by  the  choroid, 
would  not  contain  that  of  red  light.'"  In  obedience  to  the  directions  of  Dal- 
ton, an  examination  of  his  eyes  were  made,  after  death,  by  Mr.  Ransorae. 
The  crystalline  lens  was  amber-colored,  as  usual  in  old  persons;  but  no  blue 
vitreous  humor  nor  blue  retina  was  there,  thus  affording  a  refutation  of  both 
these  conjectures.*^ 

3.  Dr.  Young,  adopting  apparently  the  notion  of  Darwin,  that  the  retina 
is  active,  not  passive  in  vision,  regards  it  as  the  simplest  explanation  of  this 
defect,  to  suppose  that  those  fibres  of  the  retina,  which  are  calculated  to  per- 
ceive red,  are  absent  or  paralyzed.*"* 

4.  Sir  David  Brewster  conceives  that  the  eye,  in  these  cases,  is  insensible 
to  the  colors  at  one  end  of  the  spectrum,  just  as  the  ear  of  certain  persons 
has  been  proved,  by  Dr  Wollaston,  to  be  insensible  to  sounds  at  one  ex- 
tremity of  the  scale  of  musical  notes,  while  it  is  perfectly  sensible  to  all 
other  sounds.*"  Dr.  Wilson  observes,  however,  that  blindness  to  red  is  the 
obverse  of  deafness  to  shrill  sounds.  "  According  to  the  undulatory  theory," 
says  he,  "the  wave  of  red  light  is  slower  in  its  vibrations  than  the  other 
colored  waves.  It  thus  corresponds  to  the  slower  undulations  of  sound,  which 
produce  low  tones.  Blindness  to  red  is,  therefore,  analogous  to  deafness  to 
grave,  not  acute  sounds."* 

5.  The  followers  of  Gall  and  Spurzheim  maintain,  that  the  faculty  of  dis- 


INSENSIBILITY  TO   CERTAIN  COLORS.  885 

tinguishing  colors  does  not  depend  on  the  eye,  but  on  a  particular  part  of 
the  brain,  to  which  they  give  the  name  of  the  organ  of  color;  and  that  in 
those  who  are  deficient  in  judging  of  colors,  the  defect  lies  in  this  organ,  and 
not  in  the  eyes,  the  mechanical  construction  and  optical  effects  of  which  ap- 
pear to  be  perfect  in  the  individuals  in  question.  This  view  of  the  matter 
appears  also  to  be  adopted  by  Sir  John  Herschel.  "We  have  examined, 
with  some  attention,"  says  he,  "  a  very  eminent  optician,  whose  eyes  (or 
rather  eye,  having  lost  the  sight  of  one  by  an  accident)  have  this  curious 
peculiarity,  and  have  satisfied  ourselves,  contrary  to  the  received  opinion, 
that  all  the  prismatic  rays  have  the  power  of  exciting  and  affecting  them 
with  the  sensation  of  light,  and  producing  distinct  vision,  so  that  the  defect 
arises  from  no  insensibility  of  the  retina  to  rays  of  any  particular  refi'angi- 
bility,  nor  to  any  coloring  matter  in  the  humors  of  the  eye  preventing  certain 
rays  from  reaching  the  retina  (as  has  been  ingeniously  supposed),  but  from  a 
defect  in  the  sensorium,  by  which  it  is  rendered  incapable  of  appreciating  ex- 
actly those  differences  between  rays  on  which  their  color  depends.  "^^ 

In  those  affected  with  color-blindness,  as  well  as  in  those  defective  in  per- 
ceiving the  harmony  of  colors,  the  phrenologists  find  a  depression  immedi- 
ately above  the  middle  of  the  eyebrow,  indicative,  they  suppose,  of  want  of 
development  in  a  particular  convolution  of  the  cerebrum,  in  which  they  place 
the  organ  of  color.  They  tell  us,  that  the  smallness  of  this  organ  is  remark- 
able in  the  bust  of  Dalton,  modelled  by  Cardwell ;  and  Mr.  Ransome,  who 
is  no  phrenologist,  states,  as  a  fact  noticed  in  the  dissection  of  Dalton,  "  that 
there  was  a  marked  deficiency  in  the  convolutions  of  the  brain  over  the  orbitar 
plates,  which  are  assigned  to  the  organ  of  color. '"^'^ 

On  whatever  cause  an  insensibility  (partial  or  complete)  to  color  depends, 
it  is  a  state  of  vision  for  which  there  appears  to  be  no  means  of  cure.  Two 
facts,  however,  noticed  by  the  elder  Seebeck,^^  have  led  to  the  suggestion  of 
a  palliative  remedy.  The  facts  in  question  were  that  color-blind  persons  were 
able  with  artificial  light,  to  pronounce  certain  colors  to  be  unlike,  which  they 
confounded  when  regarded  with  the  naked  eye  in  daylight ;  and  that  the  same 
happened  when  they  looked  through  certain  colored  glasses.  It  does  not 
appear  what  were  the  colors  of  the  glasses  used  by  Seebeck  ;  but  Wartmann 
speaks  of  the  surprising  effect  produced  by  making  a  color-blind  person  look 
through  a  red  medium  in  order  to  distinguish  red  and  green.  I  had  con- 
siderable doubts  as  to  this  point ;  and  on  applying  to  Dr.  Wilson,  I  was  in- 
formed by  him,  that  he  had  found  red  and  green  glasses  give  no  help  to  the 
color-blind,  in  distinguishing  between  the  red  and  green  objects  which  with 
unassisted  vision  they  were  liable  to  confound.  It  was  otherwise  with  yellow 
glasses,  which  Dr.  W.  found  markedly  to  assist  a  certain  class  of  color-blind 
persons.  As  artificial  light  differs  from  daylight,  mainly,  as  is  believed,  by 
an  excess  of  yellow  rays,  it  struck  him  that  if  parties  who  were  able  to  dis- 
tinguish red  and  green  by  yellow  candle  or  gas-light,  were  to  use  yellow 
glasses  in  daylight,  they  might  thereby  reduce  the  light  of  the  sun  to  the 
quality  of  candle-light,  and  see  by  the  former,  as  they  did  by  the  latter.  Ac- 
cordingly, Dr.  W.  distributed,  among  his  more  accessible  color-blind  friends, 
yellow  or  rather  pale  orange  glasses.  Several  got  no  good  from  them,  and 
all  complained  of  the  loss  of  light ;  but  two  parties  found  themselves  able  to 
make  the  same  distinction  between  red  and  gi'een  by  daylight,  as,  without 
such  glasses,  they  made  by  gas  or  candle-light.  Some  time  after  making 
these  trials,  and  publicly  advising  the  use  of  yellow  glasses,  as  a  palliative 
for  color-blindness.  Dr.  W.  found,  that  Sir  David  Brewster'--*  had  previously 
recommended  them  as  best  fitted,  in  many  cases  of  imperfect  vision,  to  excite 
a  torpid  retina,  on  the  ground  that  this  membrane  receives  a  more  powerful 
luminous  impression  from  yellow  light  than  from  the  pure  white   light,  of 


886 


MYODESOPIA. 


which  the  yellow  forms  a  part.  It  seems  probable,  however,  that  yellow 
glasses  will  prove  of  use  to  color-blind  persons,  not  so  much  because  yellow 
light  has  the  power  of  exciting  the  retina  to  a  general  increased  sensitiveness, 
as  because,  acting  chromatically,  it  reduces  the  quality  of  daylight  to  that 
of  artificial  light,  and  communicates  to  bodies  those  tints  to  which  color- 
blind eyes  respond  the  best. 


'  Philosophical  Transactions ;  Vol.  Ixvii.  p. 
260  ;  London,  1777. 

*  Ihiil. ;  Vol.  Ixviii.  p.  Cll;  London,  1779. 

^  Memoirs  of  the  Literary  and  Philosophical 
Society  of  Manchester  ;  1st  Series,  Vol.  v.  p. 
28:  Manchester,  1798. 

*  Nicholl,  Medico-Chirurgical  Transactions; 
Vol.  vii.  p.  477;  Vol.  ix.  p.  359;  and  Annals 
of  Philosophy  ;  New  Series,  Vol.  iii.  p.  128  ; 
Butter,  Transactions  of  the  Phrenological  So- 
ciety, p.  209;  Combe,  Ibid.,  p.  222:  Harvey, 
Transactions  of  the  Royal  Society  of  Edin- 
burgh, Vol.  X.  p.  553  ;  and  Edinburgh  Journal 
of  Science,  Vol.  v.  p.  114;  Brewster,  Edin- 
burgh Journal  of  Science,  Vol.  iv.  p.  85 ; 
Phrenological  Journal,  Vol.  iii.  p.  265  :  and 
Vol.  vii.  p.  152  ;  Colquhoun,  Glasgow  Medi- 
cal Journal ;  Vol.  ii.  p.  12  ;  Griife  und  Walther's 
Journal  der  Chirurgie  und  Augenheilkunde ; 
Band  v.  p.  19;  Berlin,  1825;  Earle,  Ameri- 
can Journal  of  the  Medical  Sciences,  April, 
1845,  p.  346:  D'Hombres-Firmas,  Comptes 
Rendus  des  Seances  de  I'Academie  des  Sci- 
ences, 13  Aoat,  1849,  p.  175. 

'  Article  Lff^ht,  in  Encyclopaedia  Metropoli- 
tana,  p.  435,  ^  507. 

'  Philosophical  Transactions,  No.  164;  or 
Lowthorp's  Abridgment;  Vol.  iii.  Part  1.  p.  40. 

'  Modico-Chirurgical  Transactions;  Vol.  ix. 
p.  361;  London,  1818. 

'  Glasgow  Medical  Journal;  Vol.  ii.  p.  14; 
Glasgow,  1829. 


'  Monthly  Journal  of  Medical  Science,  De- 
cember, 1853,  p.  494. 

'"  Ibid.,  November,  1853,  p.  392. 

"  Wartmann,  Memoires  de  la  Societe  de 
Physique  et  d'Histoire  Naturelle  de  Geneve; 
Tome  xii.  p.  196;  Geneve,  1849. 

'^  Taylor's  Scientific  Memoirs;  Vol.  iv.  p. 
185  ;  London,  1846. 

'"  Wilson,  Op.  cit,  December,  p.  506. 

"  Des  Maladies  Mentales;  Tome  ii.  p.  26; 
Paris,  1838. 

"  American  Journal  of  the  Medical  Sci- 
ences, August,  1840,  p.  277. 

'^  Edinburgh  Journal  of  Science  ;  Vol.  iv.  p. 
86. 

'^  London  Medical  Gazette,  March  21,  1845, 
p.  810. 

'*  Lectures  on  Natural  Philosophy;  Vol.  ii. 
315;  London,  1807. 

'"  Edinburgh  Journal  of  Science;  Vol.  iv.  p. 
86:  Philosophical  Magazine,  August,  1844,  p. 
134. 

"  Op.  cit.,  April,  1854,  p.  315. 

"'   Op.  cit.,  p.  434.  §  507. 

"^^  Phrenological  Journal ;  Vol.  xix.  p.  252  ; 
Edinburgh,  1846. 

'^^  Poggendorif 's  Annalen;  Band  xlii.  pp. 
216,,218;  Leipzig,  1837. 

^*  Philosophical  Magazine,  August,  1844,  p. 
139. 


SECTION  IX. MYODESOPIA. 

Syn. — Myodesopia,  from  /uuik,  a  fly,  eI^oj,  form,  and  £>/,,  appearance,  or  siffht.  Visus  mus- 
carum.  Visio  phantasmatum.  Muscas  volitantes.  Mouches  volantes ;  Imagiuations 
perp^tuelles,  Fr.     Die  Flecken  vor  den  Augeu ;  Das  Flockensehen ;  Das  Miickensehen,  Ger. 

Fig.  Demours,  PI.  65.     Weller,  Tab.  V. 

The  vision  of  objects  on  the  surface  or  in  the  interior  of  the  eye  has  attracted 
attention,  chiefly  in  relation  to  a  symptom,  to  which  the  name  of  muscce  voli- 
tantes has  been  given.  Any  spectrum,  or  visual  appearance,  which  is  apt  to 
impose  on  the  patient,  and  lead  him  to  think  that  flies  are  moving  before  him, 
is  called  a  musca  volitans ;  and  that  whether  it  results  from  an  impres- 
sion on  the  retina  produced  by  an  object  on  or  in  the  eye,  or  from  a  loss  of 
sensibility  in  that  membrane.  The  seeing  of  muscse  volitantes  has  received 
the  name  of  myodesopia;  an  affection  which,  although  in  some  instances  the 
result  of  a  mere  want  of  sensibility  in  certain  parts  of  the  retina,  arises  oftener 
from  the  actual  perception  of  objects  on  or  in  the  eye.  Hence  the  distinc- 
tion of  myodesopia  sensitiva  and  insensitiva. 

In  general,  it  is  only  when  the  perception  of  the  different  kinds  of  spectra 
of  which  the  eye  is  susceptible  becomes  exaggerated,  that  the  disease  called 
myodesopia  can  be  said  to  exist.  By  simple  methods,  which  I  have  else- 
where* fully  described,  the  various  spectra,  which  produce  sensitive  myodes- 


MYODESOPIA.  88t 

opia,  may  all  of  them  be  perceived  and  examined  by  the  normal  eye,  as  well 
as  certain  spectra,  which  are  at  least  analogous  to  the  imitations  of  sensations 
constituting  the  insensitive  variety  of  the  disease. 

Myodesopia  sensitiva  comprehends  those  sensations  which  arise  from,  1. 
The  layer  of  mucus  and  tears  on  the  surface  of  the  cornea.  2.  Corpuscles 
between  the  external  surface  of  the  cornea  and  the  focal  centre  of  the  eye. 
3.  Corpuscles  between  the  focal  centre  of  the  eye  and  the  sensitive  layer  of 
the  retina. 

Myodesopia  insensitiva  arises  from  certain  diseased  conditions  of  1.  The 
retina.     2.  The  choroid. 

I.    MYODESOPIA  SENSITIVA. 

§  1.   Muco-lachrymal  Muscce    Volitantes. 

Vision  of  the  layer  of  mucus  and  tears  on  the  surface  of  the  cornea. — If  a  normal  or  a  pres- 
byopic eye  be  directed  through  a  pretty  deep  concave  lens,  as  one  of  2J  inches  focus,  or 
"what  is  called  No.  12,  toward  the  flame  of  a  candle  placed  at  the  distance  of  about  20  feet, 
a  circular  luminous  figure  appears,  dotted  all  over  with  minute  round  spots,  and  bounded 
by  a  finely  indented  edge.  The  edge  is  that  of  the  pupil  greatly  magnified  ;  and  the  spots 
are  images  of  the  candle  multiplied  by  the  layer  of  fluid  lying  on  the  surface  of  the  cornea, 
and  which  consists  of  globules.  The  spectrum  is  inverted  in  this  way  of  viewing  it;  the 
globules  at  the  upper  part  of  the  cornea  being  seen  below,  and  vice  versd.  They  are  seen 
to  run  together  occasionally,  so  as  to  form  larger  spots ;  and  then  to  sepai'ate,  as  we  wink, 
into  smaller  ones.  On  closing  the  eye,  the  upper  eyelid,  with  its  cilia,  is  seen  as  if  rising 
from  the  lower  part  of  the  field  of  view  ;  and  the  globules,  after  each  act  of  nictitation, 
appear  as  if  they  floated  down  over  the  cornea.  The  fluid  which  gives  rise  to  this  appeai'- 
ance  is  a  mixture  of  tears  with  the  mucous  secretion  of  the  conjunctiva,  lying  on  the  sur- 
face of  the  cornea  in  the  form  of  minute  drops,  and  exercising  the  function  of  preserving 
that  surface  in  a  moist  and  transparent  state,  fit  for  the  easy  transmission  of  the  rays  of 
light.  Invisible,  in  general,  to  the  naked  eye  it  is,  in  this  simple  experiment,  rendered 
visible,  by  directing  through  it  a  small  pencil  of  divergent  light,  each  globule  acting  on 
the  light  which  falls  upon  it,  so  as  to  converge  it  sufiiciently,  along  with  the  refraction  of 
the  transparent  media  of  the  eye,  to  bring  it  to  a  focus  on  the  retina. 

3fuco-lachrymal  spectrum  seen  in  the  field  of  the  microscope  and  telescope. — 
In  hanging  the  head  over  the  microscope,  especially  if  one  is  affected  with 
catarrh  at  the  time,  the  globules,  by  gravitating  to  the  centre  of  the  cornea, 
not  unfrequently  appear  to  the  observer  so  as  to  impede  his  view  of  the  ob- 
ject, till  by  the  act  of  nictitation  he  clears  them  away.  In  telescopic  obser- 
vations, also,  the  muco-lachrymal  spectrum  is  apt  to  prove  a  source  of  annoy- 
ance. Thus,  in  looking  at  the  sun  through  a  tinted  glass,  the  observer  may 
be  unable  to  distinguish  the  spots  on  that  body,  being  perplexed  by  what 
seems  the  reflection  of  some  part  of  his  own  eye  interspersed  between  it  and 
the  sun.  This  is  caused  by  the  layer  of  mucus  and  tears  on  the  surface  of 
the  cornea. 

Muco-lachrymal  miiscce  volitantes. — As  a  very  rare  occurrence,  I  may  state 
the  following  instance  of  the  muco-lachrymal  spectrum  giving  rise  to  the 
sensation  of  muscse  volitantes. 

Case  366. — I  was  consulted  by  a  very  short-sighted  person,  occasionally  troubled  with 
the  appearance  of  numerous  opaque  round  spots  before  one  of  his  eyes;  each  spot 
being  surrounded  by  a  halo.  Sometimes  several  of  them  appeared  to  run  together  into 
dots,  which  again  divided  and  disappeared.  He  noticed  that  they  ascended  after  every 
act  of  nictitation.  From  the  patient's  description,  and  the  figure  he  sent  me  of  what  he 
saw,  I  had  no  doubt  that  the  sensation  of  which  he  complained  arose  merely  from  the 
globules  on  the  surface  of  the  cornea. 

I  2.  Muscce  volitantes  depending  on  corpuscles  between  the  external  surface  of 
the  cornea  and  the  focal  centre  of  the  eye. 

Want  of  accurate  observations  of  the  spectra  produced  by  corpuscles  in  this  situation — Methods 
of  detecting  and  distinguishing  such  spectra. — I  know  of  no  accurate  observations  of  spectra 


888  MYODESOPIA. 

depeading  on  corpuscles  floating  in  the  aqueous  humor.  Depositions  in  the  cornea,  or  in  the 
crystalline,  are  readily  perceived  on  looking  through  a  hole  in  a  blackened  card  made 
with  the  point  of  a  needle.  Even  a  fissure  in  the  crystalline,  running  in  the  direction  of 
the  radii  formed  by  its  fibres,  may,  if  I  mistake  not,  be  discerned  in  this  way.  Opacities 
of  the  cornea,  or  the  crystalline,  may  also  be  seen  by  the  same  means  which  enable  us  to 
see  the  globules  of  mucus  on  the  cornea.  They  are  to  be  distinguished  from  these  by 
their  occupying  an  immediately  posterior  plane  in  the  field  of  view  ;  by  the  double  images 
formed  of  them  by  exposing  the  eye  to  two  divergent  beams  of  light,  being  less  separated 
from  one  another  than  the  double  images  of  the  muco-lachrymal  spectrum;  and  by  their 
not  suffering  the  same  changes  from  the  act  of  nictitation.  From  corpuscles  residing  in 
the  vitreous  humor  they  will  be  distinguished  by  their  occupying  an  anterior  plane  in  the 
field  of  view ;  by  their  double  images  being  more  widely  separated  ;  and  by  the  possibility  of 
readily  inverting  their  spectrum  by  the  same  means  by  which  we  invert  that  of  the  glo- 
bules on  the  cornea.  All  objects  anterior  to  the  focal  centre  of  the  eye  are  seen  inverted 
on  looking  through  a  double  concave  lens,  as  above  directed.  To  see  them  in  their  natural 
position,  it  is  sufficient  to  view  a  candle  at  20  feet  distance,  or  a  street  lamp  at  60  feet 
distance,  through  a  double  convex  lens  of  li  inch  focus  placed  close  before  the  eye.  If  we 
carry  such  a  lens  forward  from  the  eye,  so  that  the  cornea  is  no  longer  within  the  focal 
distance  of  the  lens,  all  objects  on  or  in  the  cornea,  in  the  aqueous  humor  or  in  the  crys- 
talline, are  instantly  inverted. 

Depositions  in  the  cornea,  aqueous  humor,  or  crystalline,  never  produce,  as  far  as  I 
know,  the  sensation  of  muscce  volitantes.  The  effect  of  specks  of  the  cornea  and  partial 
opacities  of  the  crystalline  or  its  capsule,  is  merely  to  produce  indistinctness  of  vision  ; 
exactly  as  when  we  place  a  pin  close  in  front  of  the  cornea.  Closing  one  eye,  and  hold- 
ing a  pin  at  such  a  distance  before  the  other  eye  as  to  see  it  most  distinctly,  if  we  gradu- 
ally bring  the  pin  towards  the  eye,  it  becomes  less  and  less  distinct,  and,  at  last,  when 
so  close  as  to  touch  the  eyelashes,  it  disappears  ;  the  whole  effect  of  its  presence  being  to 
throw  a  shadow  over  the  entire  retina,  and  thus  cause  a  mistiness  in  our  pei'ception  of 
surrounding  objects,  so  slight,  however,  as  not  even  to  prevent  our  reading  a  printed  book 
placed  at  the  ordinary  distance.  If  we  now  take  a  card  perforated  with  a  pin-hole,  and 
bring  it  between  the  eye  and  the  pin,  we  find  that  through  the  pin-hole  we  see  the  pin 
distinctly.  By  the  same  contrivance,  which  is  equivalent  simply  to  limiting  the  breadth 
of  the  luminous  pencil  admitted  to  the  [retina,  any  corpuscle  or  deposition  on  or  within 
the  eye  becomes  visible  ;  although  in  naked  vision  its  impression  may  be  imperceptible. 

Under  ordinary  circumstances,  then,  corpuscles  or  depositions  anterior  to 
the  focal  centre  of  the  eye,  which  is  generally  regarded  as  close  behind  the 
crystalline,  will  not  be  visible  to  the  person  in  whose  eye  they  exist ;  and,  if 
few  and  minute,  will  have  little  effect  on  the  distinctness  of  vision.  They 
may  perhaps  be  visible  to  an  eye  exceedingly  myopic,  and,  to  the  scientific 
observer  may  sometimes  prove  a  still  more  serious  evil  than  the  globules  on 
the  cornea,  as  their  shadow,  perceptible  on  looking  through  a  microscope 
or  telescope  of  high  power,  cannot  be  got  quit  of,  like  the  muco-lachrymal 
spectrum,  by  mere  nictitation. 

§  3.  Muscm  volitantes  depending  on  corpuscles  hettveen  tlic  focal  centre  of  the 
eye  and  the  sensitive  layer  of  the  retina — Entohyaloid  muscce — Floating 
micscce. 

Four  different  entohyaloid  spectra — Methods  of  viewing  them — Relative  position  of  the  cor- 
puscles which  produce  them. — If  one  looks  at  the  flame  of  a  candle  two  or  three  feet  dis- 
tant, or  at  the  sky,  through  a  hole  made  in  a  blackened  card  with  the  point  of  a  fine 
needle,  or  through  a  convergent  lens  of  short  focus,  such  as  the  eye-glass  of  a  compound 
microscope,  on  steadily  regarding  the  luminous  field  presented  to  view,  four  sets  of  spec- 
tra will  be  seen  (Plate  II.  Fig.  3),  independent  of  the  muco-lachrymal  spectrum.  The 
most  remarkable  appears  nearest  to  the  eye,  and  consists  of  twisted  strings  of  minute 
pearly  globules,  hung  across  the  field  of  view  (Plate  II.  Fig.  3  a).  The  second  in  point 
of  remarkableness,  and  the  farthest  of  the  four  from  the  eye,  consists  of  watery-like 
threads,  destitute  of  any  globular  appearance,  and  depending  chiefly  from  the  upper  part 
of  the  field  (Plate  II.  Fig.  .3  6).  I  call  the  former  the  pearly  spectrum,  and  the  latter  the 
tvatery  spectrum.  In  two  distinct  planes,  between  those  occupied  by  these  two  spectra, 
float  two  sets  of  globules,  not  aggregated  into  threads,  but  insulated.  These  constitute 
what  I  call  the  insulo-globiilar  spectra.  The  individual  globules  of  the  set  further  from 
the  eye,  being  hazy  and  ill-defined,  may  be  compared  in  appearance  to  small  gi-ains  of 
sago  (Plate  II.  Fig.  3  c).     The  globules  of  the  set  nearer  to  the  eye  are  clear  in  their 


MYODESOPIA.  889 

centre,  exteriorly  to  whicli  they  present  a  sharp  black  ring,  and  still  more  exteriorly 
a  lucid  circumference  (Plate  II.  Fig.  3  d).  These  four  sets  of  spectra  never  mingle  with 
one  another,  so  as  to  change  the  order  in  which  they  stand  before  the  eye  ;  but  the 
pearly  spectrum  always  appears  the  nearest ;  then  the  sharply  defined  insulo-globular ; 
then  the  obscurely  defined  globules ;  and  farthest  away  the  watery  threads. 

Method  of  procuring  double  images  of  corpuscles  situated  in  front  of  the  retina. — The  fol- 
lowing experiment  we  owe  to  Sir  David  Brewster,^  who  has  by  its  means  thrown  more 
light  on  the  subject  of  musca3  volitantes  than  all  preceding  writers. 

Place  two  candles  before  the  eye,  at  the  distance  of  a  few  inches  from  each  other.  Look 
at  them  through  a  pin-hole,  or  through  a  double  convex  lens,  so  as  to  make  the  two 
luminous  fields  to  overlap.  In  the  middle  space  formed  by  the  overlapping  of  the  two 
fields,  double  images  will  be  seen  of  all  the  perceptible  objects  on  the  eye,  or  within  it, 
and  in  front  of  the  sentient  layer  of  the  retina  ;  and  amongst  these,  double  images  of  the 
muco-lachrymal  globules,  the  watery  spectrum,  the  insulo-globular  spectra,  and  the 
pearly  spectrum.  If  the  candles  are  placed  about  ten  feet  from  the  eye,  and  viewed 
through  a  convergent  lens  of  IJ  inch  focus,  the  double  images  of  the  muco-lachrymal 
globules  will  be  seen  widely  apart  from  one  another :  those  of  the  threads  of  the  watery 
spectrum  less  widely  ;  less  widely  still  those  of  the  obscure  insulo-globular  spectrum,  and 
of  the  sharply  defined  one ;  while  the  double  images  of  the  pearly  spectrum  are  quite 
close  to  one  another,  showing  the  relative  position  of  the  causes  of  these  spectra  in  the 
eye,  viz :  the  muco-lachrymal  substance  on  the  surface  of  the  cornea,  and  the  corpuscles 
causing  the  pearly  spectrum  close  to  the  sentient  layer  of  the  retina ;  while  the  causes  of 
the  watery  and  insulo-globular  spectra  occupy  the  middle  space. 

Appearances  of  the  watery  spectrum. — The  depending  threads  of  which  the  watery 
spectrum  consists  have  somewhat  of  a  rounded  appearance,  difiFering  in  this  respect  from 
the  pearly,  the  threads  of  which  seem  flat.  Each  of  the  watery  threads  is  bounded  by 
two  dark  lines,  within  which  there  is  a  broad  space,  which  is  cleai',  and  destitute  of  any- 
thing like  globules.  These  watery  threads  measure  fully  twice  the  diameter  of  the 
threads  of  the  pearly  spectrum.  They  are  not  all  in  one  plane.  Their  general  course  is 
vertical  and  gently  flexuous.  They  often  divide  at  their  lower  extremity  into  two  or 
more  branches,  wliich  seem  to  melt  away  insensibly.  They  have  so  much  the  appearance 
which  we  might  suppose  streams  of  tears  to  have,  as  they  descend  from  the  lachrymal 
ducts  and  flow  over  the  cornea,  that  I  at  one  time  thought  this  was  their  real  nature,  till  , 
I  discovered  that  they  exist  in  a  plane  or  planes  posterior  to  the  muco-lachrymal  spec- 
trum, and  posterior  to  any  deposition  on  the  anterior  surface  of  the  crystalline.  At  first 
view  they  seem  to  slide  down  slowly  from  the  upper  to  the  middle  part  of  the  field  of 
view ;  but  they  possess  neither  the  extent  nor  the  quickness  of  motion  of  the  pearly  spec- 
trum. They  are  rarely  observed  at  the  lower  part  of  the  field  of  view,  and  must  exist, 
therefore,  being  seen  inverted,  chiefly  in  the  lower  portion  of  the  entohyaloid  space.  Any 
bending  or  extending  which  they  undergo  in  the  movements  of  tlie  eye  are  slight ;  and 
their  seeming  to  be  displaced  and  broken  into  fragments  by  nictitation  is  a  deception. 

I  have  called  this  spectrum  the  watery,  merely  from  its  appearance  ;  for  I  have  ascer- 
tained neither  its  exact  seat  nor  its  nature.  It  seems  probable  that  the  cause  upon  which 
it  depends  is  not  far  behind  the  crystalline,  if  not  actually  in  contact  with  the  posterior 
capsule. 

Muscce  volitantes  produced  hy  the  watery  spectrum. — The  watery  spectrum 
becomes,  in  some  cases,  so  much  exaggerated  as  to  give  rise  to  the  sensation 
of  musca3  volitantes,  most  apt  to  be  perceived  on  first  going  out  in  the  morn- 
ing. It  is  compared  by  some  patients  to  the  appearance  of  threads  of  spun 
glass,  laid  across  each  other,  or  to  that  of  a  fine  lock  of  wool.  It  appears  a 
little  above  the  centre  of  the  field  of  vision,  and  of  course  seems  greatly  mag- 
nified by  the  distance  of  the  surface  against  which  it  is  viewed.  Although  it 
still  retains  the  form  of  numerous  watery  threads,  and  these  never  appearing 
to  contain  globules,  the  threads  are  more  irregularly  heaped  together,  and 
often  assume  a  zigzag  figure.  They  are  also  either  readily  dispersed  by  one 
or  two  forcible  acts  of  nictitation  (differing  in  this  respect  from  the  spectrum, 
as  viewed  through  a  pin-hole  or  the  eye-glass  of  a  compound  microscope),  or 
by  such  acts  the  eye  falls  into  a  state  in  which  they  are  no  longer  perceptible. 
The  circumstances  now  noticed  are  very  apt  to  mislead  the  patient  as  to  the 
seat  of  what  he  sees,  which  he  probably  refers  to  the  surface,  and  not  to  the 
interior  of  his  eye,  where  the  cause  actually  resides. 

Muscce  volitantes  produced  hy  the  insido-globular  spectra. — The  ill-defined 


890  MYODESOPIA. 

globules,  wliicli  lie  immediately  behind  the  watery  spectrum,  rarely  give  rise 
to  the  sensation  of  muscle  volitantes  ;  but  the  globules  which  occupy  the  next 
plane,  and  whose  edges  are  sharp  and  dark,  frequently  appear  to  the  naked 
eye,  either  as  simple  black  points  or  as  black  rings.  Viewed  carelessl^r,  or 
without  the  aid  of  any  optical  contrivance,  they  often  seem  to  be  connected  to 
the  outside  of  the  threads  constituting  the  pearly  muscie  volitantes. 

Appearances  of  the  pearly  spectrum. — Almost  every  eye,  even  the  most  healthy,  and  ■which 
has  never  attracted  the  possessor's  attention  b}'  muscre  volitantes,  exhibits  the  pearly 
spectrum,  on  being  directed  towards  aluminous  field,  through  a  fine  pin-hole,  the  eye-glass 
of  a  compound  microscope,  or  a  convex  or  concave  lens  of  short  focus.  I  have  given  it 
the  name  of  the  pearly  spectrum,  from  its  resemblance  to  a  String  of  pearls.  Prevost^  had 
already  called  it  apparence  perlee,  or  simi>\j  perles. 

The  lines  of  the  pearly  spectrum  are  hung  across  the  field  of  vision  as  often  transversely 
as  vertically.  On  first  directing  the  eye  towards  the  luminous  field,  in  one  or  other  of  the 
methods  just  mentioned,  perhaps  only  a  very  few  small  pearly  globules  are  perceived  ;  but 
after  steadily  regarding  it  for  a  short  time,  numerous  strings  of  them  are  discovered, 
generally  twisted  in  different  forms,  and  presenting  a  variety  of  knots,  loops,  and  agglo- 
merations. Sometimes  they  are  so  numerous  as  to  form  an  extensive  shower  or  cloud. 
The  pearly  threads  are  of  different  lengths  ;  some  of  them  very  short,  others  stretching 
across  the  whole  field.  Not  unfrcqueutly  some  of  them  end  abruptly  in  a  sort  of  bulb. 
The  globules  or  pearls  forming  the  threads  or  rosaries,  seem  joined  together  merelj'  by 
apposition,  without  being  contained  in  any  tube.  Sometimes,  however,  the  globules  are 
rather  indistinct,  and  then  the  threads  approach  to  a  tubular  appearance.  The  globules 
are  always  in  single  rows.  They  appear  destitute  of  any  nucleus.  They  are  not  all  of 
one  diameter,  but  are  all  smaller  than  the  globules  of  the  insulo-globular  spectra.  I  have 
not  satisfied  myself  that  all  the  pearly  threads  occupy  the  same  plane,  although  it  is  very 
evident  that  they  are  behind  the  insulo-globular  spectra. 

Apparent  and  real  motions  of  the  pearly  spectrum. — That  portion  of  the  pearly  spectrum 
which  appears  in  the  centre  of  the  field  of  view  has  but  little  real  motion,  less  perhaps 
than  the  watery  spectrum  which  is  seen  beyond  it.  Both  partake,  of  course,  in  the  motion 
of  the  eyeball ;  and  this  gives  to  both  a  wide  apparent  motion.  But  if  the  field  be  ex- 
amined towards  its  circumference,  or  if  the  eye.be  suddenly  rotated  upwards,  other  pearly 
spectra  appear,  which  it  is  difficult  or  impossible  for  the  observer  to  bring  directly  before 
him;  and  which,  when  he  succeeds  in  some  measure  in  doing  so,  quickly  subside  again 
out  of  view,  partly  by  a  real  motion  of  their  own,  partly  by  a  wide  apparent  motion, 
owing  to  their  obliquity  in  respect  to  the  axis  of  vision.  It  is  these  last  spectra,  chiefly, 
■which  produce  the  pearly  muscse  volitantes. 

Appeai-ances  of  the  pearly  muscce  volitantes. — Those  who  begin  to  be 
troubled  with  by  far  the  most  common  kind  of  muscoe  volitantes  find  their 
attention  attracted  by  the  appeai-ance  of  one  or  more  dark  bodies  dancing 
before  them  in  the  air,  and  leading  them  to  suppose  that  perhaps  a  bit  of  soot 
is  sticking  to  the  eyelashes,  or  a  minute  spider  suspending  itself  from  the  brim 
of  the  hat.  On  trying  to  brush  away  the  supposed  object,  they  find  out  the 
mistake,  and  that  the  spectrum  which  they  see  depends  on  something  more 
immediately  affecting  the  organ  of  vision  than  they  at  first  imagined. 

In  other  cases  the  earliest  appearance  is  that  of  a  thin  cloud,  somewhat  like 
the  wing  of  a  fly,  or  that  of  serai-opaque  threads,  like  a  spider's  web.  Some- 
times the  spectrum  is  so  dark  as  to  be  compared  to  a  bit  of  black  lace. 

On  directing  the  eyes  from  side  to  side,  the  spectrum  moves  also,  and  with 
such  seeming  swiftness  as  often  to  lead  the  patient  to  suppose  that  a  gnat  or 
small  fly  is  crossing  the  field  of  vision. 

In  this  state  the  patient  often  continues  for  months  or  years,  without  taking 
the  trouble  to  examine  the  appearance  with  any  degree  of  attention.  Some- 
times, indeed,  the  annular  figure  of  the  darkest  portion  of  the  muscse  is  too 
striking  to  escape  notice,  and  patients  often  designate  such  by  the  appellation 
of  black  stars.  If  the  patient  happens  to  turn  his  eyes  steadily  to  the  clear 
sky  for  a  minute  or  two,  he  often  sees  what  had  hitherto  appeared  like  a  thin 
cloud,  bit  of  cobweb,  or  wing  of  an  insect,  resolve  itself  into  a  great  number 
of  globules,  or  minute  rings,  moving  as  the  eye  moves,  and  connected  together 


MYODESOPIA.  891 

as  if  by  some  invisible  film,  so  that,  altliougli  they  may  change  in  some 
measure  their  relative  positions,  they  never  separate  entirely  from  one  another. 

A  more  careful  examination  of  his  muscle  volitantes  against  the  sky,  or 
against  the  ground  covered  with  snow,  probably  discloses  to  the  patient  a 
twisted  tubular  appearance,  the  tube  being  bounded  by  two  lines,  while  the  cen- 
tral space  is  occupied  by  a  chain  of  obscure  spots  or  globules,  not  sufficiently 
large  in  general  to  fill  the  diameter  of  the  tube,  so  that  while  he  compares  the 
whole  spectrum  to  a  twisted  snake,  he  tells  us  perhaps  that  the  interior  of  it 
resembles  the  withered  substance  within  the  cavity  of  a  quill.  The  globules, 
however,  are  not  all  of  one  size,  for  here  and  there  one  larger  than  the  rest, 
and  with  more  of  the  appearance  of  being  nucleated,  fills  the  tube's  diameter, 
while  not  unfrequently  one  or  two  of  the  rings  of  the  insulo-globular  spectrum 
is  seen  as  if  attached  to  the  outside  of  the  tube.  The  observer  also  remarks  in 
some  cases,  that  the  tubes  seem  to  end  in  dark  bulbous  extremities,  as  if 
formed  by  agglomerations  of  globules.  The  dark  spots,  or  Mack  stars,  which 
he  first  saw  when  he  began  to  be  troubled  with  such  sensations,  he  finds  to  be 
caused  either  by  such  agglomerations,  or  by  an  appearance  at  certain  points, 
as  if  the  tubes  were  coiled  up  or  doubled  upon  themselves.  Such  dark  spots 
are  often  so  dense,  that  in  a  good  light  they  are  visible  even  through  the  closed 
eyelids. 

If  the  patient  views  the  muscse  volitantes  through  the  eye-glass  of  a  com- 
pound microscope  against  the  flame  of  a  candle,  the  appearance  of  a  tube  con- 
taining globules  is  by  no  means  so  striking  as  when  he  views  them  with  the 
naked  eye  against  the  sky,  so  that  he  sees  merely  rosaries  and  showers  of 
globules,  and  these  destitute  of  nuclei.  The  appearance  of  a  tube  is  pro- 
duced, in  fact,  by  those  portions  of  the  rings  or  globules  which  touch  each 
other  becoming  obscure,  while  the  portions  by  which  they  do  not  touch  con- 
tinue more  or  less  distinct.  Hence  the  edges  of  the  tubes  do  not  appear  as 
straight  lines,  but  undulated.  Pearly  muscje  appear  chiefly  when  the  patient 
looks  at  the  clear  sky,  a  thin  light  cloud,  the  ground  covered  with  snow,  a 
white  wall,  and  the  like.  By  twilight,  or  candle-light,  he  seldom  notices  them  ; 
nor  do  they  appear  when  he  regards  a  dark  object,  or  is  in  a  place  where  there 
is  but  little  light.  They  annoy  him  less  in  dark  wintry  weather  than  during 
summer.  He  seldom  remarks  them  when  he  looks  at  near  objects,  or  when  he 
keeps  his  eye  still. 

Position  of  the  pearly  muscce  volitantes — Their  apparent  motion. — The 
pearly  muscae  are  rarely,  if  ever,  in  the  axis  of  vision,  but  generally  a  con- 
sidoi'able  number  of  degrees  from  it,  outwards  or  inwards,  upwards  or  down- 
wards, but  most  frequently  outwards,  or  in  the  direction  of  the  temple,  as  if 
their  cause  lay  near  the  entrance  of  the  optic  nerve.  The  consequence  is, 
that  the  patient  finds  it  difficult,  in  proportion  to  the  obliquity  of  their  position, 
to  examine  their  configuration  and  apparent  structure  ;  for  whenever  he  ti-ies 
to  bring  them  directly  before  him,  they  flit  away,  so  that  he  sees  them  only  by 
a  side  glance.  They  partake  also  in  the  movements  of  the  eye,  darting 
upwards  or  downwards,  or  from  side  to  side,  as  the  eye  is  moved,  and  justifying 
by  their  apparent  motions  the  comparison  indicated  by  the  name  of  muscce 
volitantes. 

Real  motion  of  the  pearly  muscce  volitantes. — If  a  musca  volitans  is  not 
very  remote  from  the  axis  of  vision,  it  is  easy  for  the  patient  to  keep  it  fixed 
for  a  length  of  time  over  any  particular  spot  in  the  prospect  before  him,  or  in 
the  centre  of  the  luminous  field  presented  by  a  candle,  viewed  through  a  convex 
or  concave  lens.  The  pearly  muscse,  however,  have  a  motion  of  their  own, 
excited  no  doubt  by  the  motion  of  the  eyeball,  but  still  more  extensive  than 
their  apparent  motion,  and  partly  exhibited  after  the  eyeball  is  at  rest.  Thus, 
if  from  looking  before  him  in  a  horizontal  direction,  the  patient  suddenly 


892  MYODESOPIA. 

raises  his  eyes  towards  a  point  about  30°  above  the  horizon,  and  fixes  them 
on  some  object  at  that  height,  he  observes  that  the  muscEe  fly  upwards  con- 
siderably beyond  that  degree  of  elevation,  and  even  beyond  the  field  of  view, 
and  then  come  sailing  down  before  him  till  they  disappear  below,  evidently 
showing  that  whatever  be  the  nature  or  seat  of  the  corpuscles  by  which  such 
spectra  are  produced,  they  are  not  entirely  fixed,  but  enjoy  a  certain  degree 
of  freedom. 

Muscse  volitantes  are  described  by  some  authors*  as  suddenly  darting 
upwards,  and  then  as  suddenly  sinking;  but  they  never  move,  unless  set  in 
motion  by  movement  of  the  eyeball  ;  and  although  the  motion  which  they 
perform  in  consequence  of  the  impetus  given  them  by  the  movement  of  the 
eyeball  is  rapid,  that  by  which  they  return  to  their  former  place  is  compara- 
tively slow. 

Were  the  corpuscles  which  cause  the  pearly  muscre  situated  anterior  to  the  focal  centre 
of  the  eye,  their  real  motion  would  correspond  with  the  apparent  motion  of  the  spectrum 
or  niuscEe,  that  is  to  say,  they  would  descend  within  the  eye  when  the  muscse  appeared  to 
descend  ;  but  if  the  corpuscles  be  situated  behind  the  focal  centre,  the  apparent  descent  of 
the  muscae  must  depend  on  an  actual  ascent  of  the  corpuscles.  Wherever  a  corpuscle  is 
situated,  whether  at  a,  or  at  a^  (Fig.  147),  its  spectrum  will  appear  as  if  projected  out  of 

Fig.  147. 


the  eye  in  the  continued  course  of  a  straight  line,  passing  through  the  corpuscle,  and  falling 
perpendicularly  on  the  retina  at  A.  A  corpuscle  at  b,  anterior  to  the  focal  centre  of  the 
eye,  C,  or  at  b',  posterior  to  that  centre,  will  form  its  image  at  B,  and  produce  the  sensa- 
tion of  a  spectrum  out  of  the  eye,  in  the  direction  of  the  line  B  b^  b.  If  the  corpuscle 
is  situated  at  a,  and  sinks  in  the  eye  to  b,  its  image  will  move  over  the  retina  from  A  to  B, 
and  its  spectrum  will  appear  to  the  patient  to  descend  from  A''  to  B''.  But  if  the  corpuscle 
is  situated  at  a',  it  will  only  be  by  floating  upwards  from  a^  to  b^  in  the  vitreous  humor 
that  its  image  will  move  over  the  retina  from  A  to  B,  and  its  spectrum  appear  to  the 
patient  to  descend  from  A**  to  B''. 

If  the  cause,  then,  of  the  pearly  muscse,  which  always  appear  to  descend  when  the  eye 
is  fixed  on  any  elevated  object,  resided  anj'where  anterior  to  the  focal  centre  of  the  eye, 
C,  this  apparent  descent  of  the  musca3  would  depend  on  a  real  descent  of  the  corpuscles 
by  which  they  are  produced ;  but  if  the  cause  resides  posterior  to  the  focal  centre,  C,  the 
apparent  descent  of  the  musca3  must  depend  on  a  real  ascent  of  the  corpuscles. 

Besides  the  motions  of  ascent  and  descent,  the  pearly  muscse  present  lateral 
movements,  although  less  marked,  as  well  as  changes  in  the  relative  positions 
of  their  several  parts.  If  three  or  four  black  stars,  as  they  are  termed,  exist 
in  the  mesh-like  texture  which  floats  before  the  eye,  they  will  perhaps  be 
observed  to  lie  sometimes  in  a  straight  line,  and  at  other  times  to  form  an  angle 
with  one  another,  being  thrown  into  different  positions  in  the  various  move- 
ments of  the  eye.  The  upper  part  of  the  rosariform  spectrum  will  sometimes 
seem  to  bend  in  one  direction,  and  the  lower  part  in  the  opposite.  The 
threads  will  appear  to  uncoil  themselves,  and  then  twist  themselves  into  their 
former  shape.  A  vacillating  motion  is  sometimes  observed,  as  if  the  web 
waved  backward  and  forward.  All  these  movements  are  excited  by  the 
motion  of  the  eyeball ;  but  it  is  easily  observed  that  their  extent  is  greater 
than  that  of  the  motion  of  the  eyeball. 


MYODESOPIA.  893 

Seat  of  the  efficient  causes  of  the  pearly  nmscce  volitantes. — Many  conjectures 
have  been  offered  regarding  the  seat  of  the  corpuscles  or  filaments,  which 
give  rise  to  the  pearly  muscce.  The  surface  of  the  cornea,  the  aqueous  humor, 
the  humor  of  Morgagni,  the  vitreous  humor,  the  interval  between  the  hyaloid 
membrane  and  the  retina,  the  retina,  and  the  choroid,  have  each  been  supposed 
to  be  occupied  by  the  efficient  cause  of  this  symptom.  That  the  pearly  muscte 
do  not  arise  from  corpuscles,  situated  on  the  cornea  or  in  the  aqueous  humor, 
is  evident  from  their  existing  in  a  plane  far  behind  the  corpuscles  which  pro- 
duce the  muco-lachrymal  and  watery  spectra,  from  their  never  mingling  with 
these  spectra,  from  their  not  being  inverted  in  the  exi)eriment  which  inverts 
the  muco-lachrymal  spectrum,  and  from  the  closeness  of  their  double  images  to 
one  another  when  viewed  by  means  of  two  divergent  beams  of  light.  The  fact 
that  double  images  of  the  pearly  spectrum  are  always  produced  in  this  mode 
of  examining  it  shows  that  the  cause  does  not  reside  in  the  sentient  layer  of 
the  retina,  or  in  the  choroid. 

I  shall  not  pretend  to  decide  that  absolutely  in  no  case  can  floating  muscae 
depend  on  the  structures  of  the  retina  anterior  to  its  sentient  layer,  and  in 
particular  on  the  ramifications  of  its  bloodvessels,  especially  since  the  cause 
of  the  pearly  spectrum  is  ascertained  to  be  sometimes  no  farther  from  the 
sentient  layer  than  l-85th  of  an  inch,  which  is  one  of  the  measurements  of 
Sir  David  Brewster.  That  the  sentieut  structure  itself  is  not  the  part  afl'ected 
is  shown  by  the  fact  that  between  the  several  portions  of  the  muscae,  and  by 
the  side  of  them,  the  eye  sees  everything  with  perfect  distinctness  ;  and  that 
even  the  portions  of  the  retina,  over  which  the  shadows  which  cause  the  ap- 
pearances of  the  muscae  fall,  are  found  by  the  patient,  Avhen  the  corpuscles 
ascend  out  of  the  field  of  vision,  to  be  perfectly  sensible. 

Size  of  the  elementary  filament  of  the  pearly  spectrum. — lis  distance  from  the  retina. — 
Every  spectrum  appears  larger  in  proportion  as  the  ground  upon  whicli  it  is  viewed  is 
more  remote  from  the  eye ;  vphile  its  angular  magnitude,  of  course,  continues  the  same. 
The  size  of  the  convoluted  or  agglomerated  muscse  is  quite  indefinite.  Sir  David  Brews- 
ter informs  me,  that  a  musca  which  he  sees  "would  cover  the  moon :  for  it  consists  of  a 
knot  of  filaments."  But  it  is  an  interesting  question — What  is  the  size  of  the  elementary 
or  single  filament  of  the  pearly  spectrum,  or  of  the  globules  by  the  concatenation  of 
which  the  pearly  thread  is  formed?  Sir  David,  by  looking  through  a  very  minute  aper- 
ture at  two  bright  sources  of  light,  obtains,  by  two  divergent  beams,  double  images  on 
the  retina  of  all  objects  placed  within  the  eyeball;  and  by  this  means  determines  the 
diameter  of  the  musca  or  its  filaments,  and  its  distance  from  the  retina.  "  The  filaments 
or  ftiuscas  in  the  anterior  part  of  the  vitreous  humor,"  he  says,  "will  have  their  double 
images  very  distinct:  those  in  the  middle  of  it  will  have  their  double  images  much 
nearer;  those  near  the  retina  will  have  their  two  images  close,  or  perhaps  overlapping 
each  other;  while  any  object  on  the  retiSa  itself,  any  black  spot  arising  from  defective 
sensibility,  will  have  only  one  image,  as  it  were.  Now,  if  we  measure  the  distance  of 
the  two  sources  of  light  from  each  other,  and  also  their  distance  from  the  centre  of  visible 
direction,  when  the  two  images  of  the  filaments,  &c.,  are  just  in  contact,  we  may  de- 
termine the  size  of  the  filament  and  its  exact  position,  as  well  as  its  distance  from  the 
retina.  In  making  this  experiment,  I  first  found  that  the  angle  of  apparent  magnitude 
of  the  shadow  of  the  filament.  A,  B,  C  [referring  to  an  elementary  filament],  was  eight 
minutes,  and,  consequently,  that  it  subtended  this  angle  at  the  centre  of  visible  direction. 
Now,  if  we  take  the  radius  of  the  retina  as  0.524  of  an  inch,  the  diameter  of  the  shadow 
of  the  filament  will  be  0.00122,  or  u4jjth  of  an  inch,  and  its  distance  from  the  retina, 
0.0118,  or  gVtli  Pfirt  of  an  inch."5 

On  projecting  the  spectrum  of  an  elementary  filament,  which  I  see  with  my  right  eye, 
upon  a  micrometer,  and  marking  its  apparent  size,  the  shadow  measured  ^^^j  inch;  which 
is  not  very  far  from  Sir  David  Brewster's  calculation. 

What  are  the  filaments  and  corpuscles  in  the  vitreous  humor  which  cause  the  watery,  insulo- 
ylohular,  and  pearly  muscx? — As  by  means  of  proper  experiments  the  pearly  spectrum  is 
rendered  visible  to  all  eyes,  whether  young  or  old  (and  the  same  holds,  I  believe,  with 
respect  to  the  watery  and  the  insulo-globular),  the  efficient  cause,  or  object  seen,  can 
scarcely  be  the  result  of  disease,  however  much  the  being  sensible  of  these  spectra,  to 
the  extent  of  what  is  termed  muscae  volitantes,  must  be  admitted  as  the  result  of  some 


894  MYODESOPTA. 

abnormal  condition  of  the  eye.  As  to  the  question,  What  are  the  filaments  and  corpus- 
cles which  are  seen  ?  we  are  left  entirely  to  conjecture  ;  no  decisive  observations,  either 
in  the  living  or  the  dead  subject,  bearing  upon  it. 

Were  the  whole  of  the  corpuscles  or  filaments  situated  close  to  the  retina,  as  those 
which  cause  the  pearly  spectrum  are,  we  might  be  inclined  perhaps  to  suppose  that  they 
consisted  of  minute  portions  of  the  capillary  system  of  the  retina,  elevated  and  disen- 
gaged by  some  chance  from  their  natural  situation  in  the  layer  of  gray  fibres,  and  vacil- 
lating between  that  and  the  hyaloid.  But  the  succession  of  planes  occupied  by  the 
corpuscles  and  filaments  obliges  us  to  renounce  the  idea  of  so  limited  a  space  for  their 
existence,  and  to  refer  them  to  the  interior  of  the  vitreous  humor. 

"Were  they  fixed,  or  regularly  distributed,"  says  Sir  David  Brewster,  "we  might 
regard  them  as  transparent  vessels  which  supply  the  vitreous  humor ;  but,  existing  as 
they  do  in  detached  and  floating  portions,  they  resemble  more  the  remains  of  some  organic 
structure  whose  functions  are  no  longer  necessary."^ 

This  observation  tallies  remarkably  with  the  fact,  that  the  arteries,  generally  two  in 
number,  springing  from  the  central  artery  of  the  retina,  and  passing  through  the  vitreous 
body  to  the  posterior  capsule  of  the  crystalline,  although  conveying  blood  in  the  foetus, 
exist  in  the  adult  only  in  an  obliterated  or  ligamentous  state.  In  the  vitreous  humor, 
then,  there  lie  the  exuviie  of  an  orqanic  structure  u-hose  functions  have  ceased,  consisting  of 
filaments,  or  contracted  bloodvessels,  none  of  them  likely  to  exceed  -j^^  inch  in  diameter, 
and  most  of  them  probably  much  smaller.  In  the  foetus,  the  exterior  surface  of  the  hya- 
loid membrane  is  also  covered  with  bloodvessels  derived  from  the  central  artery  of  the 
retina,  the  persistence  of  which  in  the  adult  otherwise  than  obliterated  must  be  regarded, 
I  presume,  as  rare  and  exceptional. 

On  the  supposition  of  the  slightest  mobility  of  the  hyaloid  membrane,  the  diffracted 
shadow  of  the  last-mentioned  obliterated  vessels  on  the  retina  might  afford  a  plausible 
explanation  of  the  pearly  muscas;  while  the  insulo-globular  and  watery  might  be  ascribed 
to  the  remains  of  the  capsular  arteries. 

Microscopic  corpuscles  exist,  as  Donn6  has  shown,''  both  in  the  aqueous  and  vitreous 
humors  in  large  quantity,  measuring  between  ^^g'jjj  and  -fj'y 5  inch  in  diameter,  and  of 
less  specific  gravity  than  the  fluid  in  which  they  are  contained.  As  the  appearance  of  a 
tube  containing  globules,  in  the  pearly  muscre,  may  be  entirely  the  result  of  difl'raction, 
the  whole  phenomena  of  the  insulo-globular  and  pearly  spectra  may  be  referred,  with 
considerable  probability,  to  a  concatenation  of  transparent  globules  attached  to  the  fine 
lamime,  or  filaments,  which  pervade  and  give  consistence  to  the  vitreous  body.  As  the 
watery  spectrum,  viewed  either  with  the  naked  eye  or  through  a  minute  aperture,  ex- 
hibits no  appearance  of  globules,  it  may  be  regarded  as  depending  simply  on  fine  trans- 
parent filaments. 

Action  of  the  filaments  and  corpiiscles  which  cause  miiscx  on  light. — On  account  of  their 
perfect  identity  with  the  phenomena  of  the  diffraction  of  light  produced  by  transparent 
fibres,  Sir  David  Brewster  ascribes  the  appearances  of  the  muscae  volitantes  we  are  now 
considering  to  shadows  formed  on  the  retina  by  divergent  light  passing  by  and  through 
transparent  filaments  and  particles ;  a  view  of  the  matter  which  had  also  occurred  to 
Prevost.  AVhen  Sir  David  says  "  divergent  light,"  he  refers  to  those  experiments  by 
which  the  light  faling  on  the  retina  is  made  to  diverge  from  a  point  within  the  eyeball. 
The  muscfe  are,  no  doubt,  seen  very  distinctly  when  we  look  through  a  fine  aperture,  or 
through  a  lens,  so  as  to  produce  divergent  light  within  the  eye  ;  but  the  phenomena  of 
diti'ractiou  are  visible  when  the  rays  of  light  are  convergent,  or  parallel,  as  well  as  di- 
vergent ;  and  so  are  also  the  pearly  muscce.  Indeed,  the  identity  of  the  phenomena  of 
the  pearly  muscte  with  those  of  diffraction  by  fibres  is  more  strikingly  displayed  when 
the  muscte  are  regarded  with  the  naked  eye  against  the  sky  than  in  any  other  way  of 
viewing  them.  What  appears,  when  seen  through  a  pin-hole,  as  a  string  of  globules, 
assumes,  when  viewed  against  the  sky  with  the  naked  eye,  the  semblance  of  a  tube  with 
a  central  dark  line  running  down  the  middle  of  it ;  the  result,  no  doubt,  of  the  two  streams 
of  light  which  flow  round  the  filament  interfering  with  each  other.  Sir  David  Brewster 
states,  that  the  two  lines  bounding  the  filaments  which  he  sees,  are  colored,  and  have,  on 
the  outside,  one  or  more  colored  fringes ;  another  circumstance  referable  to  the  inter- 
ference of  light. 

The  sharply  defined  insulo-globular  spectrum  is  also  plainly  to  be  attributed  to  the  dif- 
fraction of  light  by  minute  spherules ;  but  the  obscurely  defined  insulo-globular  and  the 
■watery  spectra  betray  much  less  distinctly  alternate  rings  or  stripes,  owing,  no  doubt,  to 
the  greater  distance  at  which  they  are  placed  from  the  retina,  or  screen  on  which  the 
diffracted  shadows  are  thrown,  and  which,  to  display  distinctly  the  phenomena  resulting 
from  interference,  requires  to  be  at  a  certain  distance  from  the  body  Avhose  shadow  it 
receives. 


#  MYODESOPIA.  895 

Subjects  of  the  pearly  muscce  volitantes. — Speaking  of  the  filaments  by 
which  muscfe  volitantes  are  produced,  Sir  David  Brewster  observes,  that 
"as  they  exist  in  all  ages,  whether  young  or  old,  they  are  neither  the  result 
of  disease,  nor  do  they  indicate  its  approach."  Certain  it  is,  that  the  pearly 
spectrum  is  recognizable  by  all  eyes,  when  sought  for  through  a  pin-hole,  or 
through  the  eye-glass  of  a  compound  microscope. 

It  is  also  true,  that  the  same  objects  which  produce  pearly  spectra  are  seen 
by  many  individuals,  who  do  not  make  any  formal  complaint  of  musciB  voli- 
tantes, or  ever  fancy  that  they  are  affected  with  any  disease  of  their  eyes. 
"I  was  consulted,"  says  Demours,  "not  long  ago,  by  a  lady,  who  was  firmly 
persuaded  that  these  floating  phantoms,  which  she  had  begun  to  perceive, 
would  lead  to  blindness.  I  found  in  her  house  twenty  persons,  whom  I 
begged  leave  to  question:  out  of  the  twenty,  seven  had  seen  them  for  a  great 
number  of  years,  without  having  ever  spoken  of  them:  one  young  person 
added  that  she  amused  herself  greatly  in  seeing  them  descend  in  the  air."^ 
"These  muse®,"  says  Weller,  "are  evidently  not  observed,  or  are  entirely 
neglected  by  those  who,  taken  up  by  business,  want  leisure  to  think  of  their 
disease."^  On  the  other  hand,  they  are  never  so  troublesome  as  when  they 
coexist,  either  with  some  other  affection  of  the  eyes,  such  as  asthenopia,  or 
with  disease  of  some  other  organ,  such  as  dyspepsia.  Any  disorder  which  un- 
fits one  for  exertion,  and  leads  to  brooding  over  one's  complaints,  such  as 
hypochondriasis,  is  extremely  apt  both  to  lead  to  the  detection  of  muscae 
volitantes,  and  to  fill  the  mind  with  apprehensions  regarding  their  result. 

Condition  of  the  eyes  of  those  affected  with  entohyaloid  muscce. — The  eyes 
of  those  troubled  with  floating  muscae  present  no  objective  symptoms,  by 
which  the  existence  of  such  an  affection  can  be  detected.  Yet  eyes  of  normal 
conformation  are  seldom  subject  to  muscae  volitantes.  On  the  contrary,  when 
a  person  complains  much  of  this  symptom,  we  always  find  him  myopic  or 
presbyopic;  or  perhaps  myopic  with  the  one  eye,  and  presbyopic  with  the 
other.  This  shows  that  the  interception  of  the  rays,  proceeding  from  exter- 
nal objects,  by  filaments  in  front  of  the  retina  or  even  the  formation  of  mag- 
nified shadows  by  diffraction,  produces  comparatively  little  effect  when  the 
remainder  of  those  rays  are  brought  accurately  to  focal  points  upon  that  mem- 
brane. Dilution  of  the  images  of  external  objects  favors  the  perception  of 
the  muscte,  which,  in  their  turn,  are,  to  a  certain  extent,  extinguished  in  per- 
fect vision. 

Exciting  causes  of  entohyaloid  muscce. — Most  of  the  patients  who  complain 
of  pearly  muscae  ascribe  the  origin  of  the  affection  to  some  exciting  cause.  It 
is  extremely  probable,  however,  that  in  many  instances,  there  is  merely  a  coin- 
cidence in  point  of  time  between  the  circumstances  blamed  by  the  patients 
and  their  first  remarking  the  existence  of  the  muscae,  and  no  such  relation  as 
that  of  cause  and  effect. 

The  following  are  among  the  exciting  causes  most  frequently  mentioned : — 

1.  Over-use  of  the  eyes  upon  minute  objects,  as  in  reading,  writing,  paint- 
ing, and  the  like.  As  often  connected  with  this  cause,  may  be  mentioned 
intense  application  of  the  mind.  Nor  are  the  want  of  proper  exercise  and  the 
bent  posture  of  the  body  to  be  omitted  as  concurrents. 

A  gentleman  who  had  been  a  few  years  in  practice  as  a  surgeon,  and  who 
had  attended  my  lectures  on  the  eye,  came  to  me,  complaining  of  musca?.  On 
inquiring  whether  he  could  trace  them  to  any  cause,  he  told  me  that  he  as- 
cribed them  to  his  having  positively  read  through  Cooper's  Surgical  Dic- 
tionary, a  large  book  printed  in  a  small  type.  He  died  not  long  after  of 
apoplexy. 

Charles  Bonnet  consulted  Yan  Swieten  about  pearly  muscat  which  he  saw, 
and  which  he  attributed  to  too  much  use  of  the  microscope.     Yan  Swieteu 


896  MYODESOPIA.  % 

replied,  that  having  employed  the  microscope  himself  too  frequently,  when  a 
young  man,  in  the  examination  of  anatomical  injections,  he  had  brought  on 
the  very  same  appearances  as  his  correspondent.^" 

Hanmann  says,'' he  brought  on  myodesopia  by  straining  his  eyes  in  the 
study  of  Greek,  at  a  period  when  they  were  already  weakened  by  previous 
disease. 

Nothing  serves  so  much  to  increase  the  perception  of  muscre  volitantes,  as 
often  searching  for  them  through  pin-holes,  lenses,  &c.  Such  experiments 
seem  to  rouse  them  into  existence,  and  he  who  has  thus  brought  himself  to 
discover  them,  continues  to  see  them,  and  cannot  get  quit  of  them.  "Almost 
all  the  mathematicians  and  all  the  microscopical  observers  that  I  know,"  says 
Walther,'^  "have  muscag  volitantes,  which  is,  therefore,  an  appearance  refer- 
able to  the  strained  state  of  the  eye,  and  the  too  great  use  of  sight." 

2.  It  is  a  common  opinion  that  muscae  are  a  sign  of  congestion  in  the  head 
and  eyes,  and  often  the  precursors  of  apoplexy.  Over-use  of  the  eyes  pro- 
bably acts  detrimentally,  by  producing  congestion.  Other  influences  likely 
to  cause  a  determination  of  blood  to  the  brain,  are  sometimes  referred  to  by 
patients,  as  having  brought  on  muscie.  Thus,  the  excitement  attendant  on 
sexual  connection,  while  under  the  influence  of  wine,  was  mentioned  to  me 
by  a  patient  as  the  cause  which  suddenly  gave  rise  in  him  to  muscoe  volitantes. 

3.  Febrile  diseases  are  very  apt  to  bring  on  muscae,  and  none  more  so  than 
the  epidemic  catarrhal  fever,  called  influenza. 

Dr.  Stark  attributes  the  origin  of  the  complaint  in  himself  to  a  severe  course 
of  study  while  laboring  under  influenza,  and  at  the  same  time  straining  his 
eyes  in  microscopic  pursuits.'^ 

4.  Inflammatory  diseases  of  the  eyes  are  frequently  followed  by  the  pearly 
muscat  and  their  congeners.  I  have  known  not  only  retinitis,  iritis,  and  post- 
febrile ophthalmitis  to  produce  them,  but  even  catarrhal  conjunctivitis. 

5.  Want  of  the  due  quantity  of  sleep,  the  being  roused  from  rest  night 
after  night,  and  above  all  watching  during  a  number  of  successive  nights, 
with  little  sleep  even  during  the  day,  appear  in  many  instances  to  bring  on 
myodesopia. 

6.  Disordered  digestion  is  often  accused  as  a  cause  of  musca?.  Nothing  is 
more  common,  when  such  an  aff'ection  of  the  eyes  is  spoken  of,  than  for  both 
patient  and  practitioner  to  exclaim,  It  is  the  stomach!  Certain  it  is,  that  the 
disease  is  often  met  with  in  patients  who  are  laboring  under  disorder  of  the 
stomach  and  bowels,  being  troubled  with  want  of  appetite,  indigestion,  acidity, 
flatulence,  and  costiveness. 

7.  Mr.  Wardrop  has  pointed  out  a  disturbed  action  of  the  heart  as  a  cause 
of  muscae."  In  consequence  of  some  change  in  the  action  of  the  heart,  or 
of  its  actual  hypertrophy,  the  blood  is  distributed,  he  thinks  unequally  to  the 
brain  and  nerves,  and  amongst  other  eff'ects,  muscae,  which  he  terms  "  ocular 
spectra,"  are  produced.  Agitation  of  the  circulation,  a  peculiar  thrill  in  the 
pulse,  swimming  in  the  head,  whizzing  noise  in  the  ears,  and  increased  impulse 
of  the  heart,  are  amongst  the  attendant  symptoms. 

8.  Another  cause  to  which  the  origin  of  muscae  is  often  attributed,  is  what 
is  styled  nervousness,  weakness  of  the  nerves,  an  impaired  state  of  the  nervous 
system,  or  a  morbidly  sensitive  state  of  it.  Thus,  Mr.  Lawrence  speaks  of 
the  disease  occurring  "when  the  energy  of  the  nervous  system  is  impaired 
by  pressure  of  business,  by  anxiety  and  distress,  by  severe  and  continued 
affliction,  or  overwhelming  grief."'* 

Mr.  Ware  tells  us,  that  when  "a  morbid  sensibility  is  excited,  like  that  which 
general  debility  or  much  anxiety  is  apt  to  occasion,  the  retina  (which  has  a 
larger  quantity  of  nervous  medulla  spread  over  it,  in  proportion  to  its  dimen- 
sions, than  any  other  part  of  the  body)  becomes  morbidly  impressed  by  any 


MYODESOPIA,  89T 

little  points  or  projections  that  happen  to  be  in  contact  with  it."  Pressure, 
then,  on  one  or  more  minute  points  of  the  retina,  and  a  morbid  sensibility  of 
the  membrane,  are  regarded  by  Mr.  Ware  as  the  conditions  on  which  muscse 
depend.  "The  more  common  exciting  cause  of  these  motes,"  he  adds, 
"  appears  to  me  to  be  too  close  application  of  the  mind  to  objects  that  occa- 
sion anxiety  or  distress.  "^^ 

Before  making  a  few  remarks  on  the  exciting  causes  above  enumerated,  it 
may  be  proper  to  mention,  that  the  entohyaloid  muscce,  independently 
altogether  of  the  degree  of  light  to  which  the  eyes  are  exposed,  or  the  gene- 
ral state  of  body  and  mind  of  the  person  affected,  are  liable  to  vary  from 
time  to  time  in  number  and  intensity,  although  much  less  considerably  and 
less  suddenly  than  some  authors  have  represented.  Hence  the  question, 
whether,  invisible  under  ordinary  circumstances,  they  become  visible  in  con- 
sequence of  an  increased  sensibility  of  the  retina. 

"This  supposition,"  observes  Sir  David  Brewster,  "is  by  no  means  pro- 
bable, because  the  muscte  are  not  visible  by  any  light  of  their  own,  and  an 
increase  of  sensibility  in  the  retina  would  affect  equally  the  luminous  field  on 
which  they  are  seen.  But  as  this  point  is  of  some  importance  both  in  a 
physiological  and  a  medical  aspect,  I  have  submitted  it,"  he  goes  on  to  say, 
"  to  direct  experiment.  With  this  view,  I  examined  the  muscEC  in  the  morn- 
ing before  the  sensibility  of  the  retina  had  been  diminished  by  exposure  to 
daylight,  and  found  that  they  were  neither  increased  in  number  nor  intensity. 
I  varied  this  experiment  by  diminishing  the  sensibility  of  the  retina.  This 
was  done  by  holding  a  bright  gas  flame  close  to  the  eye,  and  near  the  axis  of 
vision,  till  the  retina  lost  its  sensibility  to  all  the  rays  of  the  spectrum,  except 
a  few  of  the  more  I'efrangible  ones.  In  this  case,  too,  the  muscjB  were  as 
numerous  and  distinct  as  before,  and  we  may  therefore  consider  it  as  certain, 
that  the  muscse  described  by  Mr.  Ware,  in  so  far  as  they  were  of  the  same 
character  as  those  in  the  healthy  eye,  are  not  affected  by  any  variation  in  the 
sensibility  of  the  retina."''' 

If  we  examine  into  the  probable  mode  of  action  of  the  several  exciting 
causes  of  muscge,  we  shall  find  that  all  of  them  have  a  tendency  to  produce 
a  determination  of  blood  to  the  vessels  of  the  head  and  eyes.  Over-use  of 
the  eyes  upon  minute  objects,  intemperance,  the  venereal  orgasm,  a  union  of 
these,  febrile  diseases,  extraordinary  excitement  or  actual  disease  of  the  heart, 
it  will  readily  be  granted  have  this  tendency.  As  for  disordered  digestion, 
which  is  often  blamed  for  producing  myodesopia,  I  suspect  that  in  most  cases 
the  disorder  of  the  stomach  and  the  affection  of  the  eyes  are  merely  coincident 
effects,  arising  fi'om  one  and  the  same  cause ;  such  as  improper  diet,  neglect 
of  the  bowels,  a  torpid  condition  of  the  liver,  and  very  frequently,  even  when 
it  is  least  suspected,  the  use  of  alcohol,  especially  in  the  shape  of  drams  and 
cordials.  Pressure  of  business,  anxiety,  distress  of  mind,  and  grief,  which 
form  another  set  of  exciting  causes,  operate  in  all  likelihood  exactly  in  the 
same  way,  producing  (it  may  be  in  persons  of  feeble  health)  congestion  of 
the  head  and  eyes. 

Nor  is  want  of  sleep  an  exception  to  the  general  principle,  that  all  the 
exciting  causes  of  myodesopia  act  by  producing  congestion.  Whether  watch- 
fulness arises  from  disease,  artificial  means  employed  to  produce  it,  as  the 
use  of  coffee,  which  Bereis'^  particularizes  as  a  cause  of  muscce,  the  urgent 
calls  of  professional  occupation,  or  prolonged  study,  it  always  leads  to  an 
irregular  action  of  the  circulating  system,  and  an  unnatural  determination  of 
blood  to  the  organs  of  vision. 

Prognosis  in  cases  of  entohyaloid  muscce. — As  the    muscffi  of  this  class 
often  occur  suddenly,  the  patient  is  apt  to  be  alarmed  by  their  appearance, 
and  to  suppose  that  he  is  about  to  lose  his  sight  by  cataract  or  by  amaurosis. 
57 


898  MYODESOPIA. 

We  may  calm  his  fears  on  these  heads,  for  with  neither  cataract  nor  amauro- 
sis have  these  spectra  any  connection.  Even  on  the  supposition  that  a  gradual 
increase  of  the  muscifi  is  to  take  place,  not  even  the  greatest  possible  accumu- 
lation of  them  can  ever  end  in  the  production  of  an  amaurosis,  and  much 
less  of  cataract.  It  will  be  well,  however,  in  any  case  in  which  the  practi- 
tioner is  consulted,  to  ascertain  whether,  independently  of  the  muscce,  there 
be  any  symptoms  of  either  of  these  two  diseases  present.  The  presence  or 
absence  of  cataract  we  ascertain  by  the  use  of  the  catoptrical  test.  (See  p. 
105.)  We  have  no  such  simple  or  certain  test  of  amaurosis.  But  if  the 
pupil  moves  with  its  natural  vivacity,  and  the  patient  is  able  to  read  a  small 
type  with  the  suspected  eye,  we  may  assure  him  it  is  not  affected  with  amau- 
rosis. 

A  question  which  the  patient  is  very  likely  to  put  to  us  is,  whether  the 
floating  motes  and  threads  which  he  sees  are  not  liable  to  increase,  and  that 
to  such  a  degree  as  at  length  to  deprive  him  of  sight.  That  they  increase  is 
true,  although  only  very  slowly,  and  never  to  such  an  extent  as  materially  to 
intei'fere  with  vision.  Even  when  the  whole  field  of  view  presents  entohya- 
loid  spectra,  the  patient  is  still  able  to  read,  although,  as  he  continues  to  do 
so,  the  muscaa  sometimes  gather  together,  so  as  to  render  portions  of  the  page 
before  him  temporarily  obscure.  Very  often  they  remain  stationary  for  ten 
or  twenty  years,  or  increase  by  almost  insensible  degrees ;  and  although 
alarming  at  first,  the  patient  gets  habituated  to  them,  and  troubles  himself  no 
more  about  them.  1  believe  the  increase  of  myodesopia  arises  more  from  the 
eye  becoming  in  a  greater  degree  susceptible  to  the  impressions  of  the  bodies 
which  cause  this  disease,  than  from  any  increase  of  the  bodies  themselves. 
This  increasing  susceptibility  arises  from  over-use  of  the  eyes,  and  from  search- 
ing for  and  examining  the  muscae  too  much. 

Many  authorities  might  be  quoted  to  prove,  that  entohyaloid  muscse 
increase  only  with  extreme  slowness,  or  remain  entirely  stationary,  and  some- 
times become  even  less  perceptible. 

"I  know  many  people  who  have  complained  to  me  of  such  things  fifteen  and  twenty 
years  ago,  and  who  are  still  at  this  moment  in  the  same  state. "'^ — MaUre-Jan. 

"These  kinds  of  phantoms^  which  increase  sometimes  very  slowly  during  the  first  five 
or  six  3'ears,  continue  during  the  whole  remainder  of  life  without  any  kind  of  incon- 
venience. *  *  *  I  know  a  great  number  of  persons  who  have  seen  them  thirty,  forty 
years,  and  more,  without  their  number  or  their  figure  having  undergone  the  slightest 
change."* — Demours. 

"  Twenty-five  years  after  I  had  been  first  consulted  in  this  case  I  again  saw  the  patient. 
She  then  enjoyed  good  health  and  spirits.  The  motes  were  still  occasionally  perceived ; 
but  they  had  become  so  faint  that  she  could  only  see  them  in  a  strong  light,  and  when 
she  took  pains  to  look  for  them.  It  ought,  however,  to  be  mentioned,  that  at  this  time 
her  daughter  was  just  married,  whereas,  when  she  first  consulted  me,  she  had  lately  lost 
her  husband."^' — Ware. 

"  Twelve  years  afterwards,  I  had  occasion  to  see  this  gentleman  again :  when  he  informed 
me  that  he  retained  the  perfect  sight  of  both  ej'es,  and  could  distinguish  the  most  minute 
objects  with  either  of  tliem.  In  a  bright  light,  however,  he  still  perceived  the  motes  as 
before,  if  he  took  pains  to  look  for  them ;  but  he  was  now  so  much  accustomed  to  their 
appearance  that  they  did  not  occasion  any  uneasiness. "^^ — Ibid. 

"It  is  certainly  for  from  twenty  to  thirty  years  that  I  have  seen  these  same  appearances," 
says  Prevost,  at  the  age  of  50;  and,  at  the  age  of  79,  he  adds:  "Since,  up  to  a  very 
advanced  age,  I  have  enjoyed  very  good  sight,  I  may  support,  by  my  case,  the  opinion  of 
the  oculists  who  reckon  these  appearances  of  small  importance."^' 

"  They  are  quite  innocent  in  their  nature,  and  exist  in  persons  whose  powers  of  vision 
are  most  acute.     I  have  been  subject  to  them  from  childhood."^* — M'dller. 

Treatment  of  entohyaloid  muscce. — Entohyaloid  or  floating  musciB  are 
not  much  under  control,  and  are  very  seldom  removed  by  medical  applica- 
tions. If  of  old  standing,  and  not  increasing,  it  is  needless  to  interfere. 
When  of  recent  origin,  and  the  exciting  cause  evident,  they  are  sometimes 
cured. 


MYODESOPIA.  899 

The  treatment  most  likely  to  be  useful  is  as  follows  : — 

1.  The  patient  must  be  put  on  his  guard  against  the  exciting  causes,  and 
carefully  avoid  them  ;  such  as  too  much  straining  of  the  sight,  excess  of  every 
sort,  night-watching,  and  the  use  of  alcohol  in  any  form  or  quantity.  "  The 
only  means  which  often  does  good  in  this  disease,"  says  Walther,  "is  rest  of  the 
eyes,  and  abstaining  from  every  employment  which  strains  the  sight.  I  know 
patients  who  have  got  completely  free  of  muscfe  volitantes  which  they  had 
seen  for  several  years,  by  giving  their  eyes  long-continued  rest,  which,  how- 
ever, again  appeared,  as  soon  as  they  wrought  for  some  days,  so  as  to  strain 
their  sight.^^ 

2.  If  the  stomach  is  weak,  and  the  bowels  costive,  a  course  of  laxatives, 
followed  by  tonics,  should  be  prescribed.  To  strengthen  the  constitution, 
and  especially  the  nervous  system,  should  by  every  likely  means  be  attempted. 
This  indication  will  best  be  answered  by  cinchona,  steel,  and  the  cold  bath. 
Richter  mentions  the  case  of  a  lady,  who  was  troubled  with  this  disease  after 
a  difficult  labor,  and  who  was  completely  freed  of  it  by  the  continued  use  of  sul- 
phuric ether.  In  another  case,  in  which  the  digestion  was  much  impaired,  and 
the  patient  troubled  with  acid  eructations,  a  mixture  of  ox-gall  and  assafoetida 
was  of  great  use.^*^  The  patient  must  carefully  avoid  such  articles  of  food  or 
drink  as  induce  acidity,  flatulence,  and  the  other  signs  of  indigestion.  Dr. 
Cheyne  mentions'^''  a  case  in  which  the  patient  was  cured  by  giving  up  the 
use  of  sugar. 

3.  A  torpid  state  of  the  liver  requires  small  doses  of  the  blue  pill,  either 
by  itself  or  combined  with  purgatives.  I  have  known  a  gentle  course  of 
mercury  successful  in  curing  the  disease,  probably  by  its  sorbefacient  powers. 
Iodide  of  potassium,  I  have  also  found  completely  successful  in  removing 
muscEe  volitantes  of  recent  standing. 

4.  Where  the  symptoms  of  determination  of  blood  to  the  head  are  well 
marked,  venesection  or  arteriotomy,  leeches  to  the  head  or  cupping,  and 
counter-irritation  are  indicated.  Of  twelve  cases  treated  by  Dr.  Schlagint- 
weit,  eight,  we  are  told,  were  cured  by  solvent  and  derivative  medicines,  and 
by  bleeding  at  the  foot.^^ 

5.  When  muscae  appear  to  depend  on  disease  of  the  heart,  leeches  are 
recommended  by  Mr.  Wardrop  to  be  applied  over  this  organ  till  its  impulse 
is  diminished.  The  fulfilment  of  this  indication  may  be  promoted  by  small 
doses  of  antimony  and  the  use  of  laxatives.  If  the  patient  complains  of  cold 
feet,  the  warm  pediluvium  is  to  be  used  at  bedtime ;  and  it  may  be  remarked 
that  this  simple  remedy  is  of  great  importance,  where  the  disease  is  connected 
with  a  difficulty  of  obtaining  sleep.  An  irritable  state  of  the  heart,  remain- 
ing after  its  impulse  is  subdued,  Mr.  Wardrop  endeavors  to  remove  by  the 
exhibition  of  sulphate  of  iron. 

6.  Antispasmodics  appear  to  have  been  chiefly  confided  in  by  Ware  in  the 
treatment  of  muscas  ;  such  as,  two  or  three  times  in  the  day  a  small  dose  of 
the  volatile  tincture  of  valerian,  mixed  with  an  equal  quantity  of  tincture  of 
castor,  and  joined  occasionally  with  the  camphor  mixture,  or  with  infusion  of 
cascarilla. 

t.  Exercise  in  the  open  air,  and  a  change  of  residence,  with  such  occupa- 
tions and  amusements  as  are  likely  to  withdraw  the  mind  from  any  source  of 
anxiety  or  distress,  are  found  to  be  beneficial.  A  course  of  mineral  waters 
has  sometimes  been  successful,  probably  more  from  the  change  of  scene, 
hilarity  of  mind,  exercise  of  body,  and  regularity  of  habits,  by  which  such  a 
course  is  accompanied,  than  from  the  effects  of  the  waters  themselves. 

8.  If  the  eyes  feel  hot,  heavy,  or  uncomfortable,  they  should  be  bathed 
with  either  some  cold  or  some  warm  application,  according  as  the  patient  feels 
the  one  or  the  other  the  more  agreeable.    Cold  water,  or  a  cold  lotion,  consisting 


900  MYODESOPIA. 

of  water  with  a  small  proportion  of  the  spiritus  setheris  nitrosi,  will  answer  , 
in  the  one  case ;  tepid  water,  or  a  tepid  infusion  of  any  aromatic  herb  in  the 
other.     Sponging  the  forehead,  temples,  and  outside  of  the  eyelids,  morning 
and  evening,  with  camphorated  spirit  of  rosemary,  eau  de  Cologne,  or  the 
like,  is  also  to  be  recommended. 

9.  Rust,  it  seems, ^3  continued  to  recommend  the  practice  of  puncturing 
the  cornea  in  cases  of  myodesopia,  a  thing  originally  proposed  with  the  view 
of  allowing  the  cause  to  escape  out  of  the  eye,  and  tried  unsuccessfully  by 
Demours  :  but  which  in  Rust's  hands  was  followed,  we  are  told,  by  the  van- 
ishing of  the  muscle.  If  it  really  were  so,  the  operation  probably  acted  in 
a  similar  way  as  it  is  known  to  do  in  cases  of  ophthalmia,  by  giving  relief  to 
the  turgescent  state  of  the  vessels. 

II.    MYODESOPIA  INSENSITIVA. 

Fixed  spectra. — The  fact,  that  there  occurs  certain  fixed  muscse,  "which,  once  fairly 
formed,  never  change  their  position  either  with  respect  to  one  another  or  to  the  optic 
axis,  naturally  leads  us  to  seek  for  some  natural  example  of  a  feed  spectrum  analogous 
to  the  prototypes  of  the  various  sorts  of  muscse  already  considered,  all  of  which  possess 
a  real  as  well  as  an  apparent  motion.  The  vascular  spectrum,  as  produced  in  the  experi- 
ment of  Purkinje,  and  the  appearances  known  by  the  name  of  accidental  colors,  are  the 
only  examples  of  the  kind  which  occur  to  me. 

Bloodvessels  and  central  spot  of  the  retina,  as  seen  in  the  experiment  of  Purkinje. — The 
eyelids  of  the  unemployed  eye,  say  the  left,  should  not  be  closed ;  but  the  light  should 
be  prevented  from  falling  on  it,  by  the  hand  or  other  covering.  The  right  eye,  then, 
being  steadily  directed  forwards,  a  lighted  candle  (the  room  being  otherwise  dark)  is  to 
be  moved  slowly  upwards  and  downwards  at  the  temporal  side  of  the  eye,  or  right  and 
left  below  it.  In  a  few  seconds,  the  bloodvessels  of  the  retina,  with  all  their  ramifica- 
tions, are  distinctly  seen,  of  a  dark  hue,  projected  on  a  grayish-white  ground,  as  if  about 
a  foot  before  the  eye,  and  greatly  magnified. 

It  is  indispensable  that  the  light  be  in  motion  ;  for  as  soon  as  it  becomes  stationary, 
the  image  breaks  into  fragments  and  vanishes.  Although  an  example  of  a  fixed  spec- 
trum, it  is  to  be  observed,  that  during  the  motion  of  the  light  the  image  also  moves,  and 
in  a  direction  contrary  to  that  of  the  light ;  a  consequence,  I  presume,  of  the  distance 
between  the  vessels  and  the  sentient  layer  of  the  retina.  No  spectrum  arises  when  the 
light  is  moved  to  and  from  the  eye,  nor  when  the  eye  is  alternately  shaded  and  uncovered. 

When  it  is  the  right  eye  which  is  the  subject  of  the  experiment,  the  part  of  the  spec- 
trum corresponding  to  the  entrance  of  the  optic  nerve  appears,  of  course,  to  the  right 
hand  of  the  observer ;  and  from  that  part  two  vascular  trunks  are  seen  to  go  upwards 
and  two  downwards,  whence  they  are  prolonged  in  an  arched  form  towards  the  left, 
vanishing  towards  the  middle  of  the  field.  The  part  of  the  spectrum  corresponding  to 
the  central  spot  of  the  retina,  Purkinje  describes  as  presenting  a  circular  concave 
appearance. 

Purkinje  has  offered  no  explanation  of  this  very  striking  experiment.  The  following 
attempt  to  supply  the  omission,  I  presume  to  be  from  the  pen  of  Mr.  AVheatstone  : — ^° 

"  Were  the  bloodvessels  which  are  spread  on  the  anterior  surface  of  the  retina  entirely 
opaque,  they  would  prevent  the  transmission  of  light  to  the  nervous  matter  beneath 
them,  and  their  distribution  would  be  constantly  visible;  but  they  are  transparent,  and, 
in  ordinary  cases,  the  intensity  of  the  light  which  passes  through  them  does  not  mate- 
rially differ  from  that  which  falls  directly  on  the  retina.  AVhen,  however,  the  retina  is 
fatigued  by  a  strong  light,  the  veins  become  visible,  because  the  retina  is  rendered  insus- 
ceptible to  a  portion  of  the  light  they  transmit ;  but  this  effect  is  only  momentary,  for 
those  parts  which  are  thus  shaded  from  the  more  intense  light  promptly  recover  their 
usual  susceptibilitj',  and  the  images  vanish ;  but  they  may  again  be  made  perceptible  by 
displacing  them  on  the  retina,  and  by  making  them  constantly  change  their  places  the 
images  may  be  rendered  permanent." 

Purkinje  and  Wheatstone  have  pointed  out  methods  by  which  the  more  minute  vessels 
of  the  retina,  along  with  the  central  spot,  may  be  rendered  visible.  The  following  is 
one  of  the  readiest :  — 

Before  one  eye,  directed  towards  a  plate  of  ground-glass,  or  sheet  of  paper,  held  close 
before  a  candle,  move  from  side  to  side,  in  a  tremulous  way,  a  black  card  with  a  hole  in 
it  one-tenth  of  an  inch  in  diameter.  The  image  of  the  light  upon  the  retina  being 
in  this  way  continually  displaced,  an  extremely  complicated  network  of  bloodvessels 
appears,  of  a  grayish-white  color,  in   which  the  ramifications  of  the  upper  trunks  are 


MYODESOPIA.  901 

seen  to  anastomose  with  those  of  the  lower ;  while  in  the  very  centre  of  the  field  there 
is  a  small  dark  circle,  in  which  no  trace  of  vessels  appears,  the  spectrum  of  the  central 
spot. 

Accidental  colors. — In  such  experiments  illustrative  of  the  production  of  accidental 
colors  as  those  referred  to  in  the  preceding  section,  the  spectrum,  though  fixed  when 
the  eye  is  at  rest,  moves  with  the  motions  of  the  eye  upwards  or  downwards,  or  from 
side  to  side,  on  our  calling  into  action  the  appropriate  muscles,  and  this  even  although 
the  eyelids  are  shut.  If  we  make  an  impression,  for  example,  on  the  retina  by  means  of 
a  coloi-ed  wafer,  and  merely  shut  the  eye,  as  the  pupil  is  somewhat  raised  in  this  action 
by  the  eyeball  becoming  equipoised  between  the  rectus  superior  and  inferior,  the  spec- 
trum appears  in  a  horizontal  direction,  or  a  little  elevated,  and  continues  so  till  by  a 
voluntary  exertion  we  turn  the  eye  into  some  other  direction.  Immediately  on  again 
calling  into  activity  the  orbicularis  palpebrarum,  the  eyeball  rolls  upwards,  and  the  spec- 
trum rises. 

The  spectra  in  such  experiments  ai'e  generally  evanescent ;  but  by  increasing  the  light 
by  which  they  are  produced  to  an  intense  degree,  they  may  be  rendered  more  or  less 
durable;  as  in  the  case  of  Sir  Isaac  Newton,  who,  by  looking  at  the  image  of  the  sun 
reflected  from  a  mirror,  produced  a  luminous  spectrum  edged  with  colors,  to  get  quit 
of  which  he  was  obliged  to  shut  himself  up  in  a  dark  room  for  three  days ;  and  in  the 
instance  mentioned  by  BufiFon  of  one  of  his  friends,  who,  having  looked  at  an  eclipse 
of  the  sun  through  a  small  hole,  observed  a  colored  image  of  that  body  upon  all  objects 
for  more  than  three  weeks. 

Persistent  spectra — Fixed  muscce. — There  is  reason  to  believe,  not  only 
that  Jixed  muscce,  as  they  are  termed,  bear,  in  some  instances,  a  resemblance 
to  the  spectra  of  which  we  have  been  speaking,  in  their  form  and  in  the  sort 
of  affection  of  the  retina  upon  which  they  sometimes  depend,  but  that  they 
are  in  certain  cases  nothing  else  than  persistent  spectra,  the  consequences  of 
over-excitement  of  the  nerve  of  vision,  and  exhaustion  of  its  sensorial  power. 
Buffon's  own  case  may  be  quoted  as  an  instance  of  this  kind. 

"I  have  seen,"  says  he,  "black  points,  for  more  than  three  months,  in  so  great  a 
number  that  I  was  very  uneasy  about  them.  I  had  apparently  fatigued  my  eyes  in 
making  and  too  often  repeating  the  preceding  experiments  [on  accidental  colors],  and 
in  looking  sometimes  at  the  sun  ;  for  the  black  points  appeared  at  that  very  time,  things 
which  I  had  never  seen  before.  At  last  they  annoyed  me  so  much,  especially  when  in 
broad  daylight  I  looked  at  objects  strongly  illuminated,  that  I  was  obliged  to  turn  my 
eyes  away ;  yellow,  especially,  was  insupportable  to  me ;  and  I  was  obliged  to  change 
the  yellow  curtains  in  the  room  which  I  occupy,  and  to  put  up  green  ones.  As  I  avoided 
looking  at  all  colors  which  were  very  strong,  and  at  all  brilliant  objects,  gradually  the 
number  of  black  points  diminished,  and  at  present  I  am  no  more  troubled  with  them. 
What  convinced  me  that  those  black  points  arose  from  too  strong  an  impression  of  light 
is,  that  after  looking  at  the  sun  I  always  saw  a  colored  image,  which  for  a  certain  time 
covered  all  objects;  and,  watching  with  attention  the  different  gradations  of  this  colored 
image,  I  observed  that  it  lost  its  color  by  degrees,  so  that  at  last  I  saw  upon  objects 
only  a  black  blotch,  at  first  pretty  large,  but  which  gradually  diminished,  and  ultimately 
was  reduced  to  a  black  point."  3' 

Some  fifteen  years  after  the  attack  thus  described,  Buffon,  who  studied 
much  and  was  very  short-sighted,  had  another,  commencing  with  photopsia, 
followed  by  the  spectrum  of  a  dark  ring  or  disk  before  his  left  eye,  covering 
all  objects  and  preventing  him  from  reading.  After  a  day  and  two  nights 
it  grew  less,  so  as  to  allow  him  to  see  objects  to  the  right  and  below.  For 
fifteen  days  he  could  not  see  the  pen  with  which  he  wrote.  His  eyes  then 
became  inflamed,  which  obliged  him  to  give  them  rest,  and  after  the  space 
of  some  months,  the  spectrum  broke  up  into  fragments,  and  his  sight  was 
restored.^'' 

Various  appearances  of  retinal  or  fixed  muscce. — Fixed  muscJB  are  some- 
times single  ;  often  more  numerous.  They  are  of  different  sizes,  and  present 
a  great  variety  of  forms.  They  are  not  always  fixed  from  the  very  first,  but 
after  affecting  one  side  of  the  optic  axis  may  shift  to  the  opposite  side,  a 
fact  indicating  perhaps  their  dependence  on  an  effusion  of  blood  from  the 
retinal  vessels.     They  are  sometimes  semi-transparent  at  first,  but  afterwards 


902  MYODESOPIA, 

their  color  is  generally  black,  or  at  least  much  darker  than  the  color  of 
the  floating  or  entohyaloid  muscas.  They  are  often  so  black  that  even  when 
both  eyes  are  open,  although  the  musca  affects  only  one,  a  person's  counte- 
nance standing  before  the  patient  seems  obliterated,  or  his  head  cut  off,  or 
the  flame  of  a  gas-lamp  extinguished.  Their  color  changes,  however,  in  a 
remarkable  manner,  appearing  of  a  grayish  white  while  the  eye  is  shut,  and 
instantly  assuming  a  velvet  black  color  on  opening  the  eye  in  the  light. 
Sometimes  on  shutting  the  eye  the  fixed  musca  is  seen  of  the  color  of  the 
object  which  last  impressed  the  retina. 

White  objects,  in  consequence  of  fixed  muscoe,  sometimes  seem  to  have 
black  ill-defined,  large  blotches  on  them.  Sometimes  the  patient  sees  the 
appearance  of  black  letters,  like  T  or  X,  for  instance,  in  the  air.  In  other 
cases,  he  describes  himself  as  seeing  through  a  riddle,  the  interstices  of  which 
become  gradually  less  and  less,  till  the  disease  ends  in  total  blindness. 

A  fixed  musca,  occupying  the  centre  of  the  field  of  vision,  and  gradually 
expanding  its  circumference,  ends  in  one  of  the  most  intractable  varieties  of 
amaurosis.  It  is  to  be  attributed  to  a  change  of  structure  in  the  central  spot 
of  the  retina,  the  evident  result,  in  some  instances,  of  over-excitement  of  the 
eye  in  the  continued  observation  of  minute  objects.  "  The  appearance  I 
see,"  said  a  literary  man  to  me,  who  was  losing  his  sight,  "is  that  of  a  dark 
wafer  covering  the 'middle  of  objects.  It  is  getting  broader  and  broader, 
for  formerly  I  could  read  past  the  edge  of  it,  but  now  I  cannot." 

Miiller  tells  us  that  the  vascular  figure,  observed  in  Purkinje's  experiment, 
is  sometimes  seen  with  a  luminous  character.  "  I  have  frequently  seen,"  says 
he,  "  this  luminous  ramified  figure  in  the  dark  field  of  vision,  when,  after 
ascending  a  flight  of  stairs,  I  have  found  myself  suddenly  in  a  dark  place, 
and  also  when  I  have  suddenly  immersed  my  head  in  bathing.  The  lumi- 
nous appearance  is  evidently  the  effect  of  the  pressure  of  the  vessels  filled 
with  blood  upon  the  retina."*^  Now,  moderate  pressure  on  the  retina  always 
produces  a  luminous  sensation ;  but  if  the  pressure  is  increased,  darkness  is 
the  result.  Patients  sometimes  mention  the  appearance  of  a  spider,  with  its 
legs  stretched  out  from  it,  as  a  spectrum  which  they  observe ;  but  this,  I 
believe,  will  generally  be  found,  when  the  patient  is  directed  carefully  to 
examine  it,  to  be  a  pearly  or  floating  musca.  Were  it  ascertained  in  any 
case  to  have  no  real  motion,  and  not  to  throw  a  double  image  on  the  retina 
when  exposed  to  two  divergent  beams  of  light,  we  should  be  led  to  ascribe 
it  to  a  varicose  state  of  the  bloodvessels  of  the  retina.  That  this  was  the 
cause  of  a  peculiar  appearance  in  a  poor  woman  who  was  under  my  care, 
completely  amaurotic  of  one  eye,  and  fast  losing  the  sight  of  the  other,  seemed 
not  improbable.  "For  some  time,"  said  she,  "I  have  seen  like  two  bushes 
before  this  eye,  and  now  the  two  are  meeting." 

As  the  eyeball  moves,  the  fixed  musca  seems  to  move  with  a  corresponding 
velocity ;  an  example  of  which  we  have  in  carpologia,  or  picking  at  the  bed- 
clothes. The  figure  of  a  mouse  running  along  the  floor  is  a  spectrum,  which  I 
have  known  to  arise  from  an  insensible  portion  of  the  retina,  and  to  be  the 
precursor  of  total  amaurosis.  The  distinction,  then,  of  the  fixed  from  the 
floating  muscJB,  requires  considerable  attention  and  power  of  observation  on 
the  part  of  the  patient.  Sometimes  he  is  affected  with  both  sorts.  Thus, 
Hellwag  tells  us,  that  on  looking  through  a  pin-hole  in  a  card,  he  saw  two 
sorts  of  appearances,  viz :  five  fixed  dark  spots,  which  changed  their  position 
with  respect  neither  to  one  another  nor  to  the  optic  axis,  together  with  a 
semitransparent  movable  web  of  twisted  chains.^' 

Vascular  diseases  of  the  retina  probable  causes  of  fixed  musccB. — That  the 
diseased  state  of  the  bloodvessels  of  the  retina,  in  which  they  become  sud- 


MYODESOPIA.  903 

denly  distended  much  beyond  their  natural  diameter,  or  even  give  way,  so 
that  blood  is  effused  on  the  surface,  or  into  the  substance  of  the  membrane 
{apophxia  retince),  may,  by  compression,  give  rise  to  a  partial  abolition  of 
vision  and  to  fixed  muscae,  is  generally  admitted.  The  same  is  likely  to  hold 
true  of  partial  dilatation  of  its  arteries  and  varicose  enlargements  of  its  veins. 
The  central  artery  has  been  met  with  in  a  state  actually  aneurismal. 

Fixed  viusccB  from  partial  paralysis  of  the  retina. — It  has  been  presumed 
that  the  nervous  substance  of  the  retina  is  liable  to  become  insensible  in  cer- 
tain portions  of  its  extent,  altogether  independently  of  any  affection  of  its 
bloodvessels.  Andrese  compares  this  supposed  state  of  the  retina  to  the  con- 
dition of  the  brain  in  nervous  apoplexy,  and  calls  it  a  loss  of  power  from 
want  of  sufficient  vital  support.  He  says,  that  the  muscle  depending  on  this 
cause  vanish  for  a  time,  under  the  influence  of  different  physical  and  moral 
stimulants,  such  as  a  jovial  meal,  a  glass  or  two  of  wine,  or  cheerful  conver- 
sation. 

Fixed  muscce  from  melanosis  and  neuromata  of  the  retina. — It  can  scarcely 
be  doubted,  that  both  the  small  black  points,  which,  in  certain  cases,  are 
deposited  on  the  concave  surface  of  the  retina,  constituting  what  is  termed 
melanosis  retina,  and  the  larger  red  bodies,  which,  in  other  cases,  are  met 
with  on  its  convex  surface,  and  are  called  neuromata,  must  give  rise  to  fixed 
muscae. 

Case  367. — Langenbeck  relates  the  case  of  a  man,  long  and  exceedingly  troubled  ■with 
muscae.  On  dissectioti,  neither  the  aqueous  humor,  carefully  preserved,  and  examined 
■with  the  microscope,  nor  the  lens,  nor  the  vitreous  humor,  showed  anything  unnatural. 
The  retina,  to  the  naked  eye,  and  the  coats  of  the  eye,  seemed  normal.  The  vessels  of 
the  retina  ■were  not  enlarged,  and  ■were  neither  more  numerous  nor  fuller  of  blood  than 
usual.  On  examining  the  retina  microscopically,  the  ■whole  internal  surface  was  seen  to 
be  covered  with  blackish  or  brown  points,  formed  apparently  of  molecules  of  pigmentum 
nigrum,  accumulated  into  little  globules  about  ten  times  bigger  than  the  medullary  glo- 
bules of  the  retina.  They  were  disposed  equally,  and  in  a  certain  sort  of  order,  over  the 
retina,  following  chiefly  the  course  of  the  bloodvessels.  They  were  detected  in  each  retina, 
but  were  blacker  and  more  numerous  in  the  left. 

The  patient  was  never  altogether  free  from  myodesopia,  although,  at  certain  times, 
especially  after  drinking  spirits,  the  disease  increased.  Certain  of  the  phantasms  which 
he  saw,  floated  before  his  eyes ;  others,  and  these  the  more  numerous,  remained  fixed. 
In  writing,  he  complained  that  the  paper  seemed  sprinkled  over  with  snuff;  and  so  similar 
■were  the  spectra  which  he  saw  to  grains  of  snuff,  that  he  often  tried  to  brush  them  away. 

The  little  tumors,  called  neuromata,  appiar  to  arise  from  chronic  retinitis ; 
they  cover  the  convex  surface  of  the  retina,  being  of  a  red  color,  pellucid, 
and  somewhat  prominent ;  some  of  them  are  visible  to  the  naked  eye  upon 
dissection,  being  twice  as  big  as  poppy  seeds;  others  so  small  as  not  to  be 
seen  without  the  microscope.  They  are  mixed  with  black  points,  and  sur- 
rounded by  strife  of  pigmentum  nigrum.  Some  of  them  are  depressed  in  the 
middle  into  a  sort  of  umbilicus,  and  have  a  black  point  within.  They  are 
embedded  in  the  cortical  substance  of  the  retina,  and  may  perhaps  be  morbid 
enlargements  of  the  medullary  globules  of  the  retina.  The  cellulo-vascular 
layer  of  the  retina,  in  such  cases,  is  thicker  and  firmer  than  natural,  of  a 
whitish  color,  furnished  with  red  vessels,  and  easily  separable  from  the  other 
layers.  Such  is  the  account  of  this  morbid  state  of  the  retina,  which  is  given 
by  Langenbeck. ^^ 

It  is  merely  a  conjecture,  that  neuromata  will  at  an  early  stage  cause  fixed 
muscae.  Ultimately  they  produce  complete  amaurosis,  or,  at  any  rate,  are  met 
with  in  eyes  which  were  completely  deprived  of  sight. 

We  cannot  be  too  cautious  in  coming  to  conclusions  respecting  the  patho- 
logical states  likely  to  give  rise  to  certian  symptoms  which  affect  vision,  or  on 
the  other  hand  respecting  the  symptoms  likely  to  attend  certain  morbid  altera- 
tions of  the  retina.     Retinitis,  for  example,  which,  contrary  to  what  might 


904  MYODESOPIA. 

perhaps  be  expected,  is  not  attended  with  pain,  produces,  by  an  effusion  on 
the  concave  surface  of  the  retina,  a  general  dimness  of  sight,  and  after  this 
abates  under  treatment,  the  appearance,  not  of  fixed,  but  of  floating  muscae. 
Neuromata,  being  seated  on  the  convex  surface  of  the  membrane,  are  more 
dangerous  to  vision  than  melanosis,  which,  on  the  other  hand,  is  more  apt  to 
produce  fixed  muscse,  without  causing  total  blindness.  The  intimate  relation 
which  exists  between  the  different  portions  of  the  retina,  considered  as  a  senso- 
rial surface,  and  the  reciprocal  action  which  they  have  upon  one  another,  are 
probably  much  stronger  on  the  convex  than  on  the  concave  side  of  the  mem- 
brane, belonging,  in  fact,  more  to  its  nervous  than  to  its  vascular  structure. 
Hence,  neuromata  may,  by  irradiation,  produce  complete  amaurosis,  while 
melanosis  merely  causes  fixed  muscae.  The  melanotic  points,  although  ex- 
tremely numerous,  do  not  destroy  vision,  because  they  are  seated  in  the  least 
important  of  the  textures  of  the  retina  ;  the  neuromata,  although  fewer,  so 
as  to  leave  numerous  spaces  where  the  retina  is  probably  uninjured,  abolish 
sight  entirely,  from  the  morbid  condition  of  one  part  of  its  nervous  matter 
having  a  certain  influence  on  the  neighboring  parts,  a  fact  analogous  to  what 
is  known  respecting  the  function  of  the  retina  in  the  healthy  state. 

Diseased  states  of  the  choroid  prohahly  productive  of  fixed  muscce. — If  we 
are  obliged  to  speak  with  some  reserve  even  of  the  retina,  as  the  seat  of  the 
efficient  causes  of  fixed  muscae,  with  still  less  confidence  can  we  assign  such 
causes  to  the  choroid.  Necroscopic  observations  are  here  entirely  deficient, 
so  that  we  can  state  it  merely  as  a  probability,  that  partial  thickenings  of  the 
choroid,  dilatations  of  its  vessels,  or  depositions  on  its  surfaces,  by  pressing 
on  the  retina,  may  cause  photopsia  in  the  first  instance,  and  afterwards  fixed 
muscae. 

Diseased  states  of  the  optic  nerves,  and  of  the  hrain,  prohahly  productive  of 
fixed  muscce. — As  diseases  of  the  optic  nerves,  and  of  the  encephalon,  cause 
luminous  sensations,  even  after  the  eyeball  is  extirpated,  so  they  are  the  causes 
of  dark  spectra,  and  of  partial  amaurosis.  Disease  of  the  brain  is  well  known 
to  produce  hemiopia. 

Case  368. — Dr.  Delafield  relates^  the  case  of  an  elderly  gentleman,  who  afterwards 
became  totally  blind,  one  of  whose  early  symptoms  was,  that,  in  walking,  he  imagined  he 
saw  objects  on  the  ground  which  intercepted  his  path,  and  which  he  endeavored  to  avoid 
by  taking  long  and  high  steps.  These  specti'a  were  perhaps  fixed  muscoe.  On  dissection, 
the  ej-es  seemed  in  all  respects  sound,  and  had  the  plumpness  and  clearness  of  health.  No 
mention  is  made,  however,  of  any  microscopical  examination  of  the  retina.  The  ventricles 
of  the  brain  were  greatly  surcharged  with  fluid,  and  the  optic  nerves  to  and  from  the  gan- 
glion  opticum  [cbiasma  ?]  shrunk,  or  rather  absorbed,  so  that  they  appeared  flat,  and  were 
of  a  straw  color.  Only  the  sheath  of  the  nerve  remained ;  the  medullary  substance  having 
entirely  disappeared. 

[In  some  cases  of  muscae,  both  entohyaloid  and  fixed,  the  exact  character 
of  the  pathological  changes  has  been  demonstrated  by  the  ophthalmoscope. 
Ruete-^  has  given  some  colored  illustrations  of  such,  in  a  recent  publication 
on  the  Physical  Exploration  of  the  Eye,  to  which  we  would  refer  the  reader. 
In  other  cases  where  the  instrument  has  been  employed,  nothing  abnormal 
could  be  detected.  The  symptoms  complained  of  seemed  to  be  entirely  inde- 
pendent of  any  appreciable  change  in  the  interior  structures  of  the  eye,  and 
were  probably  attributable  to  functional  derangement,  or  to  diseases  of  the 
optic  or  brain. — H.] 

Symptoms  coincident  with  fixed  muscce. — In  most  of  the  cases  in  which  fixed 
muscae  are  a  prominent  symptom,  there  will  be  found  a  combination  of  various 
other  subjective  symptoms  ;  such  as  photopsia,  or  the  sensation  of  coruscations 
and  halos  of  light ;  floating  muscae  ;  the  retina  unnaturally  retentive  of  im- 
pressions ;  ocular  spectra  ;  the  alternate  disappearance  and  reappearance  of 
small  objects;  hemiopia;  partial  and  oblique  vision ;  chrupsia  ;  the  sensation 


MYODESOPIA. 


905 


of  an  undulating  cloud  before  the  eyes,  with  occasional  openings  in  it, 
through  which  small  objects  are  seen  by  fits,  and  then  are  obscured  again  ; 
bright  objects  exhibiting  a  tremulous  or  undulating  light  and  shade ;  the  edges 
of  objects  ill  defined  and  shaggy,  as  if  fringed  with  hoar-frost ;  perpendicular 
lines  appearing  disfigured,  printed  letters  broken  or  indented,  and  circular 
objects  deprived  of  their  regular  figure.  What  belongs  to  the  fixed  muscsB 
must  not  be  confounded  with  what  depends  on  other  causes.  An  interesting 
case  of  this  mixture  of  symptoms,  the  reader  may  find  recorded  by  the  patient 
himself,  Mr.  Keir,  in  the  Lancet,  for  October  1,  1842.  The  case  of  Professor 
Boze  affords  another  example  of  the  same  thing.  Besides  the  sensation  of  a 
disk  before  one  of  his  eyes,  objects  appeared  curved,  misshapen,  and  fringed; 
letters  seemed  broken  ;  objects  were  as  if  colored  blue  and  green ;  the  disk 
grew  broader  and  more  opaque,  and  at  last  the  vision  in  one-half  of  the 
retina  was  extinguished,  the  other  half  seeing  as  if  through  a  thick  fog.^^ 

Treatment  of  fixed  muscce. — Most  of  the  cases  of  fixed  muscte  are  incurable, 
as  may  be  concluded  from  the  nature  of  the  efficient  causes  upon  which  they 
depend.  The  cases  susceptible  of  treatment  are  most  likely  to  be  benefited 
by  depletion  of  various  kinds,  mercury,  iodide  of  potassium,  and  counter- 
irritation,  followed  up  by  general  and  local  tonics,  so  as  to  relieve  the  over- 
distended  state  of  the  vessels,  and  restore  them  to  their  natural  diameter.  If 
the  disease  arises  from  the  suppression  of  any  habitual  discharge,  an  attempt 
should  be  made  to  renew  this,  or  to  procure  a  substitute  for  it.  The  best  local 
application  is  cold  water,  applied  to  the  eyes  and  face  by  means  of  folded 
pieces  of  cloth.  Richter  remarks,  that  by  this  means  alone,  the  disease  has 
sometimes  been  completely  removed ;  an  instance  of  which,  indeed,  seems  to 
have  occurred  in  the  case  of  Boerhaave,  as  thus  related  by  himself :  "In  sestu 
soils  summo  mihi  equitanti  per  loca  arenosa  enascitur  magna  macula  infundo 
oculi.  Cogitanti  succurrit  mihi,  medicamentum  optimum  fore  aquam  frigi- 
dissimam,  quae  a  me  applicata  remedio  fuit :  Inflammatio  ergo  procul  dubio 
erat  in  fundo  oculi,  et  saepe  etiara  fit  tali  in  casu,  hinc  optimum  remedium  est, 
quod  subito  retropellendo  omnia  vasa  constringit,  ut  aqua  frigida."*^ 


^  Edinburgh  Medical  and  Surgical  Journal, 
July,  18-15,  p.  38.  On  the  methods  of  examin- 
ing spectra,  see  Histoire  de  TAcadeniie  Roy- 
ale  des  Sciences,  pour  1760,  p.  57  ;  Paris,  1776  : 
Kater,  at  the  end  of  Guthrie  on  Extraction  of  a 
Cataract;  London,  1834:  Jago,  London  Medi- 
cal Gazette,  May  9  and  16,  1845:  Appia,  Ar- 
chives d'Ophthalmologie  ;  Tome  i.  p.  49  ;  Paris, 
1853. 

^  Transactions  of  the  Royal  Society  of  Edin- 
burgh ;  Vol.  XV.  p.  381;  Edinburgh  1843. 

^  Memoires  de  la  Societe  de  Physique  et 
d'Histoire  Naturelle  de  Geneve ;  Tome  v.  p. 
244 ;  Geneve,  1832. 

*  Beer,  Lehro  von  den  Augenkrankheiten ; 
Band  ii.  p.  424  ;  Wien,  1817. 

'  Op.  cit.  p.  382. 
'  Ibid.,  p.  384. 

'  Archives  Generales  do  Medecine ;  Tome 
xxiii.  p.  113  ;  Paris,  1830. 

*  Traite  des  Maladies  des  Yeux;  Tome  iii. 
p.  422;   Paris,  1818. 

"  Icones  Ophthalmologicae,  p.  40  ;  Lipsise, 
1824. 

'°  Memoires  de  la  Societe  de  Physique  et 
D'Histoire  Naturelle  de  Geneve;  Tome  v.  p. 
262;  Genfeve,  1832. 

"  Amnion's  Monatssehrift  fiir  Medicin, 
Augenheilkundeund  Chirurgie;  Vol.  iii.  p.  427; 
Leipzig,  1840. 


'  ^  Grafe  und  Walther's  Journal  der  Chirurgio 
und  Augenheilkunde ;  Vol.  iii.  p.  19;  Berlin, 
1822. 

'^  Edinburgh  Medical  and  Surgical  Journal; 
Vol.  Ix.  p.  399  ;  Edinburgh,  1843. 

'^  Lancet,  September,  13,  20,  1834,  pp.  887, 
924. 

"  Treatise  on  Diseases  of  the  Eye,  p.  582  j 
London, 1841. 

'^  Medico-Chirurgical  Transactions  ;  Vol.  v. 
pp.  206,  272;  London,  1814. 

''  Op.  cit.  p.  383. 

"  Dissertatio  de  Maculis  ante  Oculos  ToTi- 
tantibus;  Helmstadt,  1795  ;  quoted  by  Andreae, 
Grafe  und  Walther's  Journal  der  Chirurgie, 
und  Augenheilkunde  ;  A^ol.  viii.  p.  16  ;  Berlin, 
1825. 

"  Traite  des  Maladies  de  I'CEil,  p.  281; 
Troyes,  1711. 

''■  Op.  cit. ;  Tome  iii.  p.  421. 

'^  Op.  cit.  p.  258. 

"  Ibid.,  p.  260. 

"  Op.  cit.  p.  247. 

"  Elements  of  Physiology,  translated  by 
Baly;  Vol.  ii.  p.  1214;   London,  1842. 

'''  Op.  cit.  p.  20. 

"^  Richter's  Anfangsgriinde  der  Wundar- 
zneykunst;  Band  iii.  p.  514  ;  Gbttingen,  1804. 

"'  Cases  of  Apoplexy  and  Lethargy,  p.  154; 
London,  1812. 


906                                                  SPECTRAL  ILLUSIONS. 

*'  Ammon's  Zeitschrift  fiirdie  Ophthalmolo-  ''  De Retina Observationes  Anatomico-patho- 

gie  ;  Vol.  ii.  p.  47  ;  Dresden,  1832.  logicas,  p.  ]59  ;  Gottingee,  1836. 

^'  Cheliiis,  Handbuch  der  Augenheilkunde  :  ^*  Notes  and  Additions  to  Travers'  Synopsis 

Vol.  i.  p.  371  ;  Stuttgart,  1843.                          '  of  the  Diseases  of  the  Eye,  p.  514 ;  NevV  York, 

^'>  Journal  of  the  Royal  Institution  of  Great  1825. 

Britain;  Vol.  i.  p.  Ill;  London,  1831.  ^''  [Physikalische  Untersuchung  des  Anges 

°'    Mcinoires    de    I'Academie    Royale    des  on  Dr.  C.  G.  Theodor  Ruete.  Tab.  viii. ;  Leip- 

Sciences,  pour  1743,  p.  156  ;  Paris,  1746.  zi^,  1854.— IL] 

^^  Histoire  de   TAcademie  Royale  des  Sci-  "  Histoire  de  rAcaderaie  Royale  des  Sci- 
ences, pour  1760,  p.  65  :  Paris,  1766.  ences,  pour  1760,  p.  54  ;  Paris,  1766. 

"^  Op.  cit.  ;  Vol.  ii.  p.  1211.  "'  Prajlectiones   Publicte  de   Morbis   Oculo- 

'*  Referred  to  by  Andreae,  Op.  cit.  p.  21.  rum,  p.  62  ;  Gottingae,  1746. 


SECTION  X. — SPECTRAL  ILLUSIONS. 


The  phenomena  falling  under  this  head  may  be  referred,  in  one  set  of 
cases,  merely  to  the  insensibility  of  the  eye  to  direct  impressions  of  faint 
light ;  while  another  set  must  he  regarded  as  symptoms  of  disorder  in  the 
nervous  optic  apparatus,  or  in  that  part  of  the  brain  with  which  it  is  con- 
nected. 

I.  Sir  David  Brewster  observes,  that  when  the  eye  is  steadily  directed  to 
objects  illuminated  by  a  feeble  gleam  of  light,  it  is  thrown  into  a  state  nearly 
as  painful  as  that  produced  by  an  excess  of  light.  A  remission  takes  place 
in  the  conveyance  of  the  impressions  ;  the  object  actually  disappears,  and  the 
eye  is  agitated  by  the  recurrence  of  impressions  too  feeble  for  the  performance 
of  its  functions. 

These  facts  "  may  serve  to  explain,"  says  Sir  David,  "  some  of  those  phe- 
nomena of  the  disappearance  and  reappearance  of  objects,  and  of  the  change 
of  shape  of  inanimate  objects,  which  have  been  ascribed  by  the  vulgar  to 
supernatural  causes,  and  by  philosophers  to  the  activity  of  the  imagination. 
If  in  a  dark  night,  for  example,  we  unexpectedly  obtain  a  glimpse  of  any 
object,  either  in  motion  or  at  rest,  we  are  naturally  anxious  to  ascertain  what 
it  is,  and  our  curiosity  calls  forth  all  our  powers  of  vision.  This  anxiety, 
hoM'ever,  serves  only  to  baffle  us  in  our  attempts.  Excited  by  a  feeble  illu- 
mination, the  retina  is  not  capable  of  affording  a  permanent  vision  of  the 
object,  and  while  we  are  straining  our  eyes  to  discover  its  nature,  it  will 
entirely  disappear,  and  afterwards  reappear  and  vanish  alternately."^ 

II.  Certain  spectral  illusions,  as  is  well  known,  attend  delirmm  tremens  or 
mania-d-potu.  The  patient  supposes  his  chamber  to  be  haunted  by  cats, 
snakes,  and  various  other  spectres,  and  often  calls  for  assistance  to  drive 
them  away.  He  imagines  vermin  to  be  crawling  over  his  bed,  and  endeavors 
to  pick  them  off ;  or  frequently  puts  out  his  hand,  as  if  to  catch  something 
floating  before  him  in  the  air.  In  some  cases  of  this  sort,  both  sense  and 
judgment  are  affected  ;  but  in  other  cases,  sense  only.  In  the  latter  cases, 
the  patient  is  readily  convinced  that  he  is  laboring  under  illusions  ;  in  the 
former,  his  delirium  prevents  this  conviction. 

The  explanation  generally  given  of  illusions  of  the  senses,  either  during 
delirium  tremens,  or  under  circumstances  such  as  I  shall  notice  under  the 
next  head,  is,  that  perception  being  in  ordinary  cases  attended  by  some 
unknown  motion  or  change  in  the  brain,  in  delirium  tremens,  and  in  various 
other  states  of  disease,  the  brain  is  so  altered,  that  if  the  person  happens  but 
to  think  of  any  past  impression,  the  same  change  in  the  brain  is  repeated  as 
in  actual  perception. 

III.  Spectres,  or  resemblances  of  natural  objects  often  present  themselves, 
as  it  were,  to  the  eye,  in  cases  where  the  light  is  sufficient,  and  the  state  of 


SPECTRAL  ILLUSIONS.  90T 

general  health  unimpaired.  "We  are  highly  indebted  to  Dr.  Ferrier,'^  of  Man- 
chester, for  the  light  he  has  thrown  on  this  class  of  spectral  illusions.  Ad- 
mitting the  reality  of  spectral  impressions,  occurring  without  any  external 
agency,  he  regards  the  general  law  of  the  system  to  which  the  origin  of  such 
impressions  may  be  referred,  to  be  the  renewal  of  actual  impressions  formerly 
made  on  the  sensorium,  and  has  applied  this  principle  to  the  explanation  of 
visions  and  apparitions.  The  subject  has  been  further  pursued  by  Dr.  Hib- 
bert,  in  his  Sketches  of  the  Philosophy  of  Apparitions.  He  traces  this  class 
of  phenomena  to  a  great  variety  of  causes  ;  as,  highly  excited  states  of  par- 
ticular temperaments,  hysteria,  hypochondriasis,  the  neglect  of  accustomed 
periodical  bloodletting,  febrile  and  inflammatory  affections,  inflammation  of 
the  brain,  &c. 

The  spectral  illusions,  now  referred  to,  are  infinitely  various ;  sometimes 
bearing  the  aspect  of  a  single  person,  or  other  object,  and  in  other  cases, 
imitating  the  impression  which  might  be  produced  by  crowds  of  human 
beings,  moving  before  the  spectator,  or  by  scenes  of  endless  diversity. 
Many  patients  affected  with  such  visions,  are  unable  to  distinguish  them 
from  real  sensations,  and  call  upon  the  spectators  to  look  at  the  objects  of 
their  terror  or  surprise  ;  others,  though  they  can  scarcely  persuade  them- 
selves that  the  impressions  under  which  they  labor  do  not  arise  from  external 
objects,  feel  a  degree  of  diffidence  in  announcing  what  they  see  to  the  by- 
standers, whose  society  they  sometimes  seek  only  in  order  to  dissipate  the 
intruders ;  while  a  third  set  are  perfectly  conscious  from  first  to  last  that 
they  are  laboring  under  a  disease,  which  renders  them  the  subjects  of  false 
perceptions.  In  some  cases  the  patient  observes  that  the  spectral  appearances 
always  follow  the  motion  of  the  eyes  ;  in  other  cases,  where,  probably,  the 
disease  affects  the  sensorium  more  than  the  mere  optic  apparatus,  the  visions 
move  in  succession  before  the  patient,  or  stand  still  before  him,  uninfluenced 
by  the  motion  or  direction  of  his  organs  of  vision. 

Some  patients  see  spectres  only  when  their  eyes  are  open,  and  dispel  them 
by  closing  them  ;  others,  the  reverse.  Those  who  have  once  become  affected 
with  spectral  illusions,  are  very  apt  to  be  troubled  with  them  again,  or  may 
even  fall  into  such  a  facile  state  in  this  respect,  that  they  are  often  at  a  loss 
to  know  whether  what  presents  itself  to  them  in  the  ordinary  intercourse  of 
life  is  reality  or  illusion. 

Treatment. — The  beneficial  effect  of  sleep,  procured  by  opium,  in  banish- 
ing the  phantasms  of  those  laboring  under  delirium  tremens,  is  well  known. 
Other  sorts  of  remedies  will  be  required  in  other  cases,  and  will  sometimes 
operate  in  a  manner  almost  equally  striking.  Witness  the  effects  of  deple- 
tion, in  the  celebrated  case  of  Nicolai,  the  Berlin  bookseller,  who,  for  nearly 
two  months,  was  constantly  affected  with  spectral  illusions. 

"Though  at  this  time,"  says  he,  "I  enjoyed  rather  a  good  state  of  health,  both  in 
body  and  mind,  and  had  become  so  very  familiar  with  these  phantasms,  that  at  last  they 
did  not  excite  the  least  disagreeable  emotion,  but,  on  the  contrary,  afforded  me  frequent 
subjects  for  amusement  and  mirth;  yet,  as  the  disorder,  sensibly  increased,  and  the 
figures  appeared  to  me  for  whole  days  together,  and  even  during  the  night,  if  I  happened 
to  wake,  I  had  recourse  to  several  medicines,  and  was  at  last  again  obliged  to  have 
recourse  to  the  application  of  leeches  to  the  anus. 

"  This  was  performed  on  the  20th  April,  at  eleven  o'clock  in  the  forenoon.  I  was 
alone  with  the  surgeon  ;  but  during  the  operation  the  room  swarmed  with  human  forms 
of  every  description,  which  crowded  fast  one  on  another :  this  continued  till  half-past 
four  o'clock,  exactly  the  time  when  the  digestion  commences.  I  then  observed  that  the 
figures  began  to  move  more  slowly;  soon  afterwards  the  colors  became  gradually  paler; 
every  seven  minutes  they  lost  more  and  more  of  their  intensity,  without  any  alteration  in 
the  distinct  figure  of  the  apparitions.  At  about  half-past  six  o'clock,  all  the  figures  were 
entire'y  white,  and  moved  very  little,  yet  the  forms  appeared  perfectly  distinct ;  by  de- 
grees they  became  visibly  less  plain,  without  decreasing  in  number,  as  had  often  formerly 


908  ASTHENOPIA. 

been  the  case.  The  figures  did  not  move  off,  neither  did  they  vanish,  -which  also  had 
usually  happened  on  other  occasions.  In  this  instance,  they  dissolved  immediately  into 
air ;  of  some,  even  whole  pieces  remained  for  a  length  of  time,  which  also  bj'  degrees 
were  lost  to  the  eye.  At  about  eight  o'clock  there  did  not  remain  a  vestige  of  any  of 
them,  and  I  have  never  since  experienced  any  appearance  of  the  same  kind.  Twice  or 
thrice  since  that  time,  I  have  felt  a  propensity,  if  I  may  be  so  allowed  to  express  myself, 
or  a  sensation,  as  if  I  saw  something,  which  in  a  moment  again  was  gone."* 

Even  a  change  in  the  position  of  the  body,  such  as  may  possibly  modify 
the  state  of  the  circulation  through  the  brain,  has  sometimes  been  known  to 
dissipate  the  phantasms  produced  by  disordered  sensation.  "  I  know  a  gen- 
tleman," says  an  anonymous  writer  on  this  subject,  "at  present  in  the  prime 
of  life,  who,  in  my  opinion,  is  not  exceeded  by  any  one  in  acquired  know- 
ledge and  originality  of  deep  research,  and  who,  for  nine  months  in  succession, 
was  always  visited  hj  a  figure  of  the  same  man,  threatening  to  destroy  him, 
at  the  time  of  going  to  rest.  It  appeared  upon  his  lying  down,  and  instantly 
disappeared  when  he  resumed  the  erect  posture."* 

It  must  prove  highly  beneficial  to  those  who  labor  under  such  disordered 
sensations,  to  be  made  acquainted  with  the  fact,  that  they  are  merely  the  sub- 
jects of  a  peculiar  disease  of  the  internal  optic  apparatus,  the  effect  of  which 
is  to  produce  a  repetition  or  imitation  of  former  impressions.  By  this  means 
the  minds  of  those  may  be  calmed,  who  otherwise  might  be  led  to  ascribe 
their  visions  to  supernatural  powers,  or  who  through  fear  or  terror  might  be 
driven  to  insanity.^ 


'  Edinburgh  Journal  of  Science;  Vol.  iii.  p.  logical  Journal,  No.  6  :  Edinburgh  Journal  of 

209  ;  Edinburgh,  1825.  Science,    for  April,  1830 :    Streeten,    Midland 

'  Essay  towards  a  Theory  of  Apparitions;  Medical  and  Surgical  Reporter,  Vol.  ii.  :  Sut- 

London,  1813.  ton's  Tracts  on  Delirium  Tremens,  &c. :  Scott 

'  Nicolai's    Memoir,    Nicholson's    Journal;  on  Demonology  and  Witchcraft,  p.   Ifi;    Lon- 

Vol.  vi.  p.  161;  London,  1803.  don,  1830  :  Brewster  on  Natural  Magic,  p.  37  ; 

*  Nicholson's  Journal;  Vol.  xv.  p.  289;  Lon-  London,  1832:  Craig  and  Craigie,  Edinburgh 

don,  1806.  Medical  and  Surgical  Journal ;  Vol.  xlvi.  pp. 

'  The  reader  who  wishes  to  pursue  the  sub-  334,  353:  Paterson,  Ibid.;  Vol.  Ixx.  p.  170: 
ject  of  Spectral  Illuaiona,  in  addition  to  the  Abercrorabio's  Inquiries  concerning  the  Intel- 
works  already  referred  to,  may  consult  the  fol-  lectual  Powers,  pp.  62,  349  :  Edinburgh,  1830: 
lowing:  Alderson,  Edinburgh  Medical  and  Sur-  Bostock's  Physiology;  Vol.  iii.  p.  204  ;  Lon- 
gical  Journal ;  Vol.  vi.  :  Armstrong,  Ibid.,  Vol.  don,  1830. 
ix. :  Burton  Pearson,  Ibid. :  Simpson,  Phreno- 


SECTION  XI. — ASTHENOPIA. 


Syn. — Asthenopia,  from  a  privative,  o-Ae'voj,  strength,  and  u-^,,  the  eye.  Debilitas  visus. 
Hebetudo  visus.  Impaired  vision,  Tyrrell.  Muscular  amaurosis,  J.  J.  Adams.  Dispo- 
sition a  la  fatigue  des  yeaux.  Bonnet.  Kopyopie,  Petrequin.  Weak-sightedness.  Inca- 
pability of  sustaining  the  accommodation  of  the  eyes  to  near  objects.  Gesichtsschwache, 
German. 

By  asthenopia  is  understood  that  state  of  vision  in  which  the  eyes  are 
unable  to  sustain  continued  exercise  upon  near  objects,  although  the  patient, 
on  first  viewing  such  objects,  generally  sees  them  distinctly,  can  employ  his 
sight  for  any  length  of  time  in  viewing  distant  objects,  and  presents  no 
external  appearance  of  disease  in  his  eyes. 

Symptoms. — The  patient  is  unable  to  continue,  for  any  considerable  length 
of  time,  to  regard  small  or  near  objects,  as  in  reading,  sewing,  and  the  like ; 
but  is  obliged,  partly  from  the  confusion  and  obscurity  which  seem  to  spread 
over  the  objects,  partly  from  a  feeling  of  fatigue  in  the  eyes,  to  interrupt  the 
exertion.  With  most  patients  the  attack  begins  by  a  sensation  of  constraint 
in  the  eyes,  which  they  sometimes  try  to  get  quit  of  by  repeated  nictitation. 


ASTHENOPIA.  909 

Others  complain  of  a  feeling  of  tension  or  of  weight  in  the  eyes,  with  heat, 
lachrymation,  and  double  vision.  If  the  patient  persists  in  using  the  eyes, 
notwithstanding  the  feeling  of  lassitude  and  the  indistinctness  of  vision,  the 
effort  is  attended  with  heaviness  in  the  head,  and  pain  in  the  eyeballs,  orbits, 
temples,  and  forehead.  A  lady,  by  whom  I  was  consulted,  became  deaf,  if 
she  persisted  in  trying  to  read  or  sew.  The  deafness  never  occurred  by 
itself.  She  was  nervous  and  debilitated  from  mental  agitation  and  menor- 
rhagia. 

In  the  open  air  the  patient  makes  no  complaint,  being  able  to  discern  large 
and  distant  objects  clearly  and  without  fatigue.  When  he.commences  to  look 
at  small  or  near  objects,  he  also  sees  them  in  general  with  perfect  distinctness 
for  a  certain  space  of  time,  till  the  attack  of  asthenopia  comes  on,  which  it 
does  in  diiferent  subjects  in  an  hour,  half  an  hour,  or  even  a  few  minutes. 

After  the  attack  does  occur,  a  very  short  period  of  rest  is,  in  general,  suf- 
ficient to  recruit  the  sight,  so  that  the  power  of  perceiving  small  objects  returns, 
and  the  patient  is  in  a  condition  to  recommence  his  employment.  "When  near 
objects  fade  away,  as  it  were,  from  before  the  asthenopic  sight,  some  patients 
feel  it  a  sufficient  relief  to  turn  their  attention  to  remote  objects,  which  they 
continue  to  see  perfectly;  others  find  remote  objects  also  to  appear  confused, 
and  require  to  shade  their  eyes  till  the  attack  wears  off'.  The  most  complete 
relief  is,  in  all  cases,  obtained  by  shutting  the  eyes.  During  the  time  that 
the  eyes  are  shut,  some  patients  perceive  ocular  spectra  of  the  objects  to 
which  they  had  been  attending  while  their  eyes  were  open,  especially  if  the 
objects  had  presented  remarkable  contrasts  of  light  and  dark  colors. 

As,  in  asthenopia,  the  effort  necessary  for  reading,  writing,  sewing,  and  the 
like,  cannot  be  sustained  for  the  ordinary  length  of  time,  the  patient  is  unable 
to  pursue  with  comfort  any  sedentary  occupation,  requiring  the  close  inspec- 
tion of  near  objects.  By  persisting  iu  attempts  to  do  so,  the  attacks  of  weak- 
ness and  weariness  of  the  eyes  are  apt  to  become  more  frequent  and  of  longer 
duration,  although  we  do  meet  with  instances  of  patients  struggling  under 
their  occupations  for  many  years,  the  asthenopia  continuing  nearly  the  same 
as  when  they  first  began  to  experience  it.  Tailors  and  sempstresses  affected 
with  this  disease  sometimes  manage  to  continue  their  employment  during  the 
first  three  or  four  working  days  in  the  week  with  comparative  ease,  but  in  the 
next  two  or  three  days  they  find  their  sight  so  weak  that  they  can  hold  out 
with  much  difficulty,  or  are  actually  forced  to  drop  work.  The  repose  of 
Sunday  restores  strength  to  their  eyes,  and  enables  them  to  resume  their  occu- 
pations on  Monday.  In  some  instances,  the  state  of  asthenopia  is  so  very 
easily  excited  that  the  patient  is  never  able  to  apply  himself  to  any  trade 
requiring  the  ordinary  use  of  sight,  or  is  never  able  to  learn  to  read.  These 
facts  are  sufficient  to  show  the  serious  nature  of  asthenopia.  It  is  an  infirmity 
much  more  to  be  dreaded  than  many  disorders  of  the  eye  which,  to  superficial 
observation,  present  a  far  more  formidable  appearance. 

The  symptoms  are,  in  general,  altogether  subjective.  On  examination,  the 
membranes  of  the  eye  are  found  to  be  healthy,  the  cornea  and  other  dioptric 
media  clear,  the  pupils  lively,  and  neither  immoderately  dilated  nor  contracted. 
Even  at  the  moment  when  exertion  of  the  eyes  on  minute  objects  has  pro- 
duced the  wonted  attack,  the  pupils  do  not  present  moi'e  than  a  medium  de- 
gree of  dilatation.  In  some  instances,  indeed,  the  eyes  appear  dull,  languid, 
and  inanimate,  having  lost  the  expression  of  force  and  intelligence,  and  ac- 
quired one  of  feebleness  and  indecision ;  but  in  general  they  show  no  marked 
sign  of  disease. 

Asthenopia,  in  the  ordinary  run  of  cases,  is  unattended  by  any  increased 
sensibility,  intolerance  of  light,  or  pain  in  the  organs  of  vision,  unless  the 
patient  is  in  the  way  of  forcing  his  eyes  to  continued  exertion  even  during 


910  •  ASTHENOPIA, 

the  attack.  Then,  indeed,  pain  is  felt  iu  the  eyes  and  head.  Some  patients, 
however,  complain  of  pain  in  the  upper  part  of  the  eyeball,  as  if  it  had  re- 
ceived a  blow,  even  when  their  eyes  are  at  rest.  Pain  down  the  middle  of 
the  forehead  is  also  a  symptom  which  many  mention  as  being  almost  con- 
stantly present. 

The  tongue  is  generally  clean;  sometimes  it  is  tumid,  and  impressed  round 
the  edges  by  the  teeth.  The  appetite  is  tolerably  good,  and  the  bowels  regular. 
The  disease  rarely  appears  to  be  connected  with  any  disordered  state  of  the 
digestive  organs. 

The  habit  of  body  of  asthenopic  patients  is  generally  delicate.  Paleness 
of  the  face  and  coldness  of  the  extremities  indicate  the  feebleness  of  their  cir- 
culation. We  rarely,  if  ever,  meet  with  the  disease  in  robust  or  plethoric 
subjects.  On  the  contrary,  those  who  suffer  from  asthenopia  are,  with  few 
exceptions,  wan  and  ill-fed ;  frequently  thin  girls,  whose  bodies  are  enfeebled 
and  minds  depressed  by  a  sedentary  life,  want  of  air  and  exercise,  and  other 
causes. 

Asthenopia  is  rarely  observed  to  commence  in  those  who  have  already 
reached  the  middle  period  of  life,  but  almost  exclusively  takes  its  origin  in 
childhood  or  youth.  Commencing  at  a  very  early  age,  it  is  apt  to  continue 
through  life. 

Females  are  as  frequently  the  subjects  of  the  disease  as  males  ;  but  it  seems 
very  seldom  connected  with  any  disorder  of  menstruation. 

JDiagnosis. — The  vulgar  are  apt  to  include  every  sort  of  disease  of  the  eye 
under  the  term  weak  sight;  nor  are  medical  authors  free  from  the  error  of 
jumbling  a  variety  of  disorders  under  the  same  appellation. 

The  diseases  with  which  asthenopia  is  most  apt  to  be  confounded  are  photo- 
phobia, incipient  myopia,  presbyopia,  night  or  day  blindness,  and  amblyopia 
or  incomplete  amaurosis. 

1.  Photophobia. — The  photophobia  attending  inflammation  of  the  conjunc- 
tiva, caused  by  the  heat  which  accompanies  strong  artificial  light,  and  espe- 
cially gas-light,  is  sometimes  confounded  with  asthenopia.  The  inflammation 
in  question  is  marked  by  a  hot  and  irritable  state  of  the  eyes,  which  feel  dry 
and  stiff,  and  at  length  become  painful  and  itchy,  so  that  the  patient  is  obliged 
to  be  continually  rubbing  them.  These  symptoms  arise  from  a  suppression 
of  the  secretion  of  the  conjunctiva ;  but  the  disease  being  unchecked  by  rest 
and  other  means,  the  conjunctiva  becomes  much  more  inflamed,  and  begins  to 
secrete  puriform  mucus.  The  patient,  as  in  asthenopia,  is  forced  to  abandon 
the  occupations  he  had  been  pursuing ;  but  the  slightest  attention  will  enable 
the  practitioner  to  distinguish  the  photophobia  of  this  or  of  any  other  ophthal- 
mia from  asthenopia. 

2.  Myopia. — It  sometimes  happens  that  young  persons,  about  the  age  of 
puberty,  after  severely  trying  their  eyes  upon  minute  objects,  as  in  painting, 
embroidering,  and  the  like,  suddenly  become  short-sighted.  They  and  their 
friends  are  alarmed  at  their  being  no  longer  able  to  distinguish  objects  on 
the  opposite  side  of  the  street,  which  a  few  days  before  they  saw  perfectly. 
The  discerning  of  small  objects  is  attended  with  an  unusual  effort;  and,  in- 
stead of  fifteen  or  twenty  inches,  at  which  distance  the  patient  formerly  read, 
the  book  must  be  brought  as  close  to  the  eyes  as  eight  or  ten  inches.  Sud- 
den myopia  is  most  apt  to  occur  in  boys  sent  to  learn  such  trades  as  watch- 
making or  engraving,  or  in  young  ladies  at  school  occupied  with  music, 
painting,  embroidery,  and  other  pursuits,  requiring  continued  and  keen 
employment  of  the  sight.  Suddenly  occurring  in  such  subjects,  myopia  is 
sometimes  taken  for  amaurosis,  but  is  more  apt  to  be  confounded  with  asthen- 
opia. The  application  of  a  concave  glass  discloses  at  once  the  true  nature 
of  the  case. 


ASTHENOPIA.  911 

3.  Presbyopia. — Those  who  have  become  long-sighted  can  at  no  time  see 
near  objects  distinctly,  except  through  convex  glasses.  In  asthenopia  the 
patient  sees  near  objects  distinctly  for  a  certain  space  of  time,  after  which 
they  appear  confused  and  obscure.  It  is  not  wonderful  that  these  two  con- 
ditions should  sometimes  be  confounded.  This  is  especially  apt  to  happen 
when  presbyopia  occurs  in  children,  rendering  them  unable  to  read  at  the 
ordinary  distance,  except  with  convex  glasses.  (See  p.  864.)  The  relief 
afforded  to  the  asthenopic  patient  by  the  employment  of  such  glasses  is  a 
circumstance  exceedingly  apt  to  cause  the  two  diseases  to  be  mistaken  for  one 
another.  The  diagnosis  will  be  plain,  when  it  is  observed,  that  in  asthenopia 
a  short  period  of  rest  renews  the  power  of  distinguishing  near  objects,  while 
in  presbyopia  rest  has  no  effect. 

4.  Night-blindness. — The  distinctly  periodical  attacks  of  night-blindness, 
and  the  restoration  of  sight  on  the  return  of  day,  should  sufiicieutly  distin- 
guish that  disease  from  asthenopia. 

5.  Amblyopia  or  incomplete  amaurosis. — As  it  is  a  maxim  in  classification, 
that  magnitude  affords  no  specific  distinction,*  were  asthenopia  merely  a  less 
degree  of  amblyopia,  they  could  not  with  correctness  be  regarded  as  distinct 
diseases.  The  difference  between  amblyopia  and  amaurosis  being  in  degree 
only,  they  constitute  one  species ;  but  between  amblyopia  or  incomplete 
amaurosis  and  asthenopia,  there  is  reason  to  believe  that  a  specific  difference 
exists,  and  that  they  involve  different  parts  of  the  organ  of  vision. 

In  amblyopia  there  is  constantly  present  an  indistinctness  of  sight,  extend- 
ing to  all  objects,  large  and  small ;  in  asthenopia  vision  becomes  obscure, 
only  after  being  exerted  upon  near  objects.  In  amblyopia  the  patient  gene- 
rally sees  best  after  fixing  his  eyes,  or  steadying  them,  as  he  often  terms  it, 
for  some  time  on  the  object ;  in  asthenopia,  it  is  then  only  that  he  begins  to 
see  ill. 

Asthenopia  has  often  been  treated  as  incipient  amaurosis ;  but  there  is  no 
necessary  connection  between  the  two  diseases,  nor  does  the  one  lead  to  the 
other. 

Complications. — Pure  asthenopia  is  not  uncommon.  It  then  appears  as 
the  effect,  neither  of  any  previous  disease  of  the  eyes,  nor  of  any  constitu- 
tional ailment  implicating  these  organs.  On  the  other  hand,  it  is  by  no  means 
uncommon  to  find  asthenopia  complicated,  either  with  some  other  disease  of 
the  eye,  or  with  some  general  disorder  of  the  nervous,  or  of  the  circulating 
system. 

For  example,  we  frequently  find  asthenopia  affecting  eyes  which  still  show 
traces  of  one  or  other  of  the  ophthalmias,  and  especially  specks  of  the  cornea. 
In  one  case  I  found  inflammation  of  the  anterior  crystalline  capsule  combined 
with  asthenopia.  Some  of  the  subjects  of  this  disease  are  myopic  ;  others 
prematurely  presbyopic.  The  weakness  is,  in  many  cases,  most  troublesome 
during  the  use  of  artificial  light,  and  even  approaches  to  night-blindness  in 
the  suddenness  of  its  evening  exacerbations,  and  the  degree  of  imperfect 
vision  which  attends  it.  The  disease  is  often  accompanied  by  muscat  volitantes, 
sometimes  by  ocular  neuralgia,  or  oscillation  of  the  eyes,  and  not  unfrequently 
by  strabismus. 

Asthenopia  generally  affects  the  two  eyes  pretty  equally.  If  only  one  eye 
is  affected,  and  the  other  good,  the  disease  is  apt  to  pass  undetected.  One 
eye  being  completely  amaurotic,  or  disorganized  from  injury  or  otherwise, 
asthenopia  not  unfrequently  affects  the  other.  It  sometimes  happens  that 
one  eye  is  incompletely  amaurotic,  and  the  other  only  asthenopic.  In  gene- 
ral, an  incompletely  amaurotic  eye  is  free  from  the  characteristic  symptom  of 
asthenopia  ;  but  in  some  instances,  we  find  amblyopia  or  incomplete  amauro- 
sis accompanied  by  asthenopia.    When  this  is  the  case,  the  view  of  all  objects 


912  ASTHENOPIA. 

is  at  all  times  more  or  less  ambiguous,  while  an  attempt  to  read  or  sew  is 
speedily  followed  by  a  new  degree  of  indistinctness,  and  an  incapability  of 
continuing  the  exertion,  which  incapability  a  little  rest  removes.  The  patient 
who  is  so  affected  is  likely  to  complain  of  photopsia,  and  floating  or  fixed 
muscae,  and  his  pupils  will  be  limited  and  sluggish  in  their  movements. 

The  consistence  of  an  asthenopic  eye  is  in  general  normal ;  but,  in  some 
instances,  it  is  too  firm,  while  in  others,  the  cornea  and  sclerotica  are  too 
flexible,  symptoms  denoting  in  the  one  case  a  redundancy,  and  in  the  other  a 
deficiency  of  the  vitreous  fluid. 

Asthenopia  is  often  attended  by  general  debility,  and  by  considerable  depres- 
sion of  the  powers  of  the  mind  as  well  as  those  of  the  body.  In  such  cases 
the  pulse  is  quick,  small,  and  compressible  ;  and  the  patient  is  inanimate,  and 
affected  with  chilliness.  In  some  the  symptoms  denote  an  approach  to 
anaemia.     In  many  the  scrofulous  diathesis  is  manifest. 

Remote  causes. — Having  satisfied  ourselves  by  an  examination  of  the  symp- 
toms, that  the  case  is  one  of  asthenopia,  and  having  ascertained  the  degree 
to  which  the  disease  has  proceeded,  the  period  of  life  when  it  commenced, 
and  the  general  state  of  health  by  which  it  is  attended,  our  next  inquiry 
should  be  into  its  remote  cause.  To  trace  the  disease  correctly  to  this  is  of 
the  greatest  importance,  as  it  is  the  remote  cause  which  affords  some  of  the 
chief  therapeutical  indications. 

1.  In  many  instances  asthenopia  appears  to  be  an  idiopathic  disease,  result- 
ing entirely  from  over-exertion  of  the  sight.  On  inquiry  into  the  history  of 
the  case,  we  find  that,  previously  to  exercising  the  eyes  upon  minute  objects 
without  proper  intermission,  these  organs  were  strong  and  healthy,  having  either 
never  suffered  from  any  of  the  ophthalmias,  or  if  so,  having  perfectly  recovered ; 
and  that,  as  the  patient  has  labored  under  no  chronic  affection  of  the  general 
health,  there  is  no  reason  to  regard  the  w^eakness  of  sight  as  a  symptom  of 
any  other  disorder  of  the  nervous,  or  of  the  circulating  system. 

Young  lads  engaged  as  clerks  or  book-keepers,  or  bound  apprentices  as 
tailors,  watch-makers,  pattern-drawers,  compositors,  or  engravers,  and  young 
women  employed  as  dress-makers  or  sempstresses,  afford  frequent  examples 
of  asthenopia  from  pure  abuse  of  vision.  Students,  and  those  engaged  in 
literary  pursuits,  spending  their  days,  and  great  part  of  their  nights,  in  read- 
ing and  writing,  often  reduce  their  sight  to  such  a  state  of  weakness,  that  it 
is  incapable  of  sustaining  the  shortest  application  to  new  objects.  Individuals 
whose  circumstances  relieve  them  of  any  necessity  to  overwork  their  eyes, 
who  are  sober  and  chaste  in  their  mode  of  life,  and  scrupulous  observers  of 
the  general  rules  of  health,  not  unfrequently  sacrifice  their  sight  to  their 
pai'ticular  tastes  in  literature,  science,  or  the  fine  arts. 

Various  incidental  circumstances  seem  to  aid  the  influence  of  over-use  of 
the  eyes  in  producing  the  impotency  constituting  the  characteristic  symptom 
of  the  disease ;  such  as  working  by  artificial  light,  want  of  the  due  quantity 
of  sleep,  and  excessive  occupation  of  the  mental  faculties. 

For  various  reasons  it  is  always  more  injurious  to  the  eyes  to  overwork 
them  on  minute  objects  by  artificial  than  by  daylight.  This  is  a  topic  which 
has  been  carefully  handled  by  the  late  Dr.  James  Hunter,  whose  work  may 
be  consulted  with  advantage.^  He  ascribes  the  injurious  effects  of  artificial 
light  chiefly  to  the  four  following  causes — viz  :  1.  The  defective  chromatic 
constitution  of  the  rays  of  artificial  light.  2.  Their  greater  heating  power 
in  proportion  to  their  illuminating  effect.  3.  The  formation  and  disengage- 
ment of  carbonic  acid  gas  during  combustion,  which,  being  absorbed  by  the 
lungs,  causes  headache,  and  acts  detrimentally  both  on  the  eyes  and  on  the 
brain  and  nerves  generally.  4.  The  unsteadiness  and  the  generally  disadvan- 
tageous position  and  direction  of  the  artificial  light  employed. 


ASTHENOPIA.  913 

Want  of  sleep  is  sometimes  the  chief  agent  in  producing  the  disease,  as  in 
night-work  of  all  kinds,  and  especially  in  night-study.  When  not  the  chief 
agent,  it,  in  no  small  degree,  aggravates  the  operation  of  other  causes. 
Sleep,  by  suspending  the  sentient  and  muscular  actions  of  the  organ  of 
vision,  repairs  its  vigor.  During  sleep  the  exhausted  substance  of  the  brain, 
nerves,  and  muscles  is  renewed  by  the  assimilating  process.  This  repose  and 
renovation  being  denied,  it  is  inevitable  that  the  powers  of  the  eye  must  be- 
come debilitated.  Even  in  the  dark,  want  of  sleep  is  detrimental  to  the 
sight ;  much  more  if,  amid  the  glare  of  artificial  light,  the  eyes  are  forced  on 
to  exertion,  in  spite  of  the  natural  feelings  of  fatigue.  A  block-cutter,  aged 
22,  consulted  me  for  asthenopia  on  the  15th  of  July,  1843.  His  complaint 
arose  from  being  obliged  during  the  preceding  winter  to  work  not  unfre- 
quently  both  night  and  day.  Prolonged  investigations  with  the  microscope 
by  artificial  light  ai*e  likely  to  be  a  fruitful  source  of  asthenopia,  if  they  do 
not  cause  effects  still  more  serious,  such  as  congestion  or  inflammation  of  the 
choroid  and  retina,  and  ultimately  amaurosis. 

What  may  be  called  the  hothouse  education  of  modern  times,  is  a  fruitful 
source  of  asthenopia.  Nothing  is  so  hurtful  to  the  sight  as  the  combined 
straining  of  the  eyes  and  mind,  to  which  young  people,  and  especially  girls, 
are  so  often  subjected  at  the  period  of  puberty.  A  boy,  twelve  years  of  age, 
was  sent  to  me  by  his  parents,  laboring  under  asthenopia.  He  told  me,  he 
attended  school  from  9  A.  M.  till  4  P.  M.,  with  only  half  an  hour's  inter- 
ruption. The  whole  of  his  evenings  he  had  been  in  the  habit  of  spending 
in  the  perusal  of  the  volumes  of  Chambers's  Edinburgh  Journal^  a  work 
printed  in  small  type.  The  disease  had  increased  rapidly  during  the  three 
weeks  preceding  my  seeing  him.  With  girls,  there  is  no  end  the  live-long 
day  to  instruction  Df  one  kind  or  another — reading,  writing,  the  acquisition 
of  different  languages,  arithmetic,  drawing,  needle-work,  music,  &c.  Asthe- 
nopia appears  frequently  to  arise  from  practising  at  the  piano-forte,  especially 
by  artificial  light.  If  the  exhilarating  recreation  which  the  eyes,  along  with 
the  rest  of  the  body,  and  the  mind,  should  enjoy  in  the  open  air  is  denied, 
and  a  young  person,  at  the  very  period  when  the  process  of  growth  is  going 
on  rapidly,  is  condemned  to  a  perpetual  succession  of  sedentary  tiresome 
occupations,  is  it  to  be  wondered  at  that  asthenopia  should  ensue,  with  pale- 
ness, feebleness,  and  emaciation?  The  natural  development  of  the  system  is 
checked,  a  congested  state  of  the  brain  is  produced,  and  the  martyred  being, 
crippled  in  body  and  mind,  but  too  often  falls  into  incurable  disease. 

TJndue  exercise  of  the  sight,  while  the  person  is  convalescent  from  some 
general  and  acute  disease,  as  influenza,  fever,  &c.,  or  even  from  some  local 
disease,  which  either  by  itself,  or  by  the  treatment  necessary  for  its  removal, 
has  produced  considerable  general  debility,  and  especially  much  reading  in 
such  a  state,  I  have  particularly  traced  as  a  cause  of  asthenopia. 

2.  We  frequently  find  that  asthenopia  has  originated  in  one  or  other  of 
the  ophthalmia?,  from  which  the  patient  had  suffered  at  some  previous  period 
of  life. 

A  child  is  sent  to  school  at  the  age  of  six  or  seven  ;  but  it  is  found  that 
he  cannot  be  taught  to  read,  and  he  is  beaten  for  a  month  or  two,  because, 
though  he  sees  quite  well  out  of  doors,  and  quite  well  when  he  first  takes  up 
his  book,  he  cannot  continue  to  read  for  more  than  a  few  minutes.  On  being 
brought  for  medical  advice,  the  symptoms  are  found  to  be  evidently  those  of 
asthenopia.  On  inquiry,  it  is  stated  by  the  parents,  that  the  child  suffered, 
when  a  few  days  old,  from  purulent  ophthalmia,  which,  being  at  first  neglect- 
ed, was  perhaps  not  overcome  for  a  couple  of  months  ;  or,  that,  when  two  or 
three  years  old,  he  lay  for  weeks  or  months  on  his  face,  with  sore  eyes,  unable 
to  bear  the  least  light.  In  either  of  these  two  cases,  asthenopia  is  "by  no 
58 


914  ASTHENOPIA. 

means  an  uncommon  result,  although  it  may  not  be  discovered  for  several 
years  after  the  existence  of  the  ophthalmia. 

The  ophthalmia  first  referred  to,  or  ophthalmia  neonatorum,  often  extends 
its  influence  to  the  internal  parts  of  the  eye.  It  is  extremely  likely  to  do  so, 
if  it  is  either  neglected  for  a  number  of  weeks,  or  from  inefficient  treatment  is 
allowed  to  fall  into  a  chronic  state.  In  some  subjects,  it  leaves  a  partial 
opacity  of  the  lens  and  capsule  ;  in  others,  an  affection  of  the  choroid  and 
retina.  These  sequela3  are  often  detected  only  when  the  child  is  sent  to 
school.  In  the  former  case,  the  eyes  are  myopic  ;  in  the  latter,  they  are  apt 
to  be  presbyopic  or  amblyopic.  In  either  case,  they  may  in  addition  be 
asthenopic.  The  eyes  may  also  recover  from  the  inflammation,  without  any 
aflection  of  the  transparent  media,  or  other  sequela,  except  asthenopia. 

A  fruitful  source  of  asthenopia  is  to  be  found  in  the  scrofulous  inflamma- 
tions of  the  eyes,  and  especially  phlyctenular  conjunctivitis.  It  is  well  known, 
that  in  this  disease,  not  only  do  serious  changes  take  place  in  the  textures  of 
the  eye,  but  that  an  obstinate  reflex  action  of  the  sphincter  of  the  eyelids  is 
excited  by  the  incidence  of  the  light  upon  the  sentient  nerves  in  an  irritable 
state.  The  asthenopia  which  follows  successive  attacks  of  phlyctenular  oph- 
thalmia, may  be  ascribed  partly  to  the  changes  produced  by  inflammation  on 
the  internal  te.xtures  of  the  eye ;  partly,  and  perhaps  chiefly,  to  the  long- 
continued  pressure  on  the  eyes  by  the  patient,  as  he  lies  with  his  face  on  his 
hands  or  on  the  pillow,  aided  by  the  action  of  the  eyelids  violently  closed  by 
spasm.  I  have  already  mentioned  one  instance  (p.  480),  in  which,  on  the 
photophobia  of  scrofulous  ophthalmia  subsiding,  the  child,  who  was  the  sub- 
ject of  the  disease,  was  discovered  to  be  amaurotic — a  result  which  I  incline 
to  ascribe  to  the  pressure  so  long  exercised  on  the  eyes.  To  the  same  cause 
may,  in  some  measure,  be  attributed  the  impeded  growth  ^f  the  eyes,  which 
attends  a  long-continued  attack,  as  well  as  such  changes  in  the  texture  as  leave 
the  patient  in  some  instances  amblyopic,  and  in  others  asthenopic.  A  girl  was 
brought  to  me,  with  a  small  speck  on  each  cornea,  the  result  of  scrofulous 
ophthalmia  in  infancy.  She  was  now  sixteen  years  of  age,  and  affected  with 
such  a  degree  of  asthenopia,  that  although  she  saw  the  smallest  objects,  she 
bad  never  been  able  to  learn  to  read.  In  cases  of  this  sort,  sometimes  only 
one  eye  is  affected  with  asthenopia;  more  frequently  both.  The  fear  of  so 
serious  a  consequence,  makes  it  important  to  cure  phlyctenular  ophthalmia  as 
speedily  and  perfectly  as  possible. 

It  is  not  the  ophthalmite  of  childhood  alone  which  give  rise  to  asthenopia. 
This  result  may  follow  any  of  the  inflammations  of  the  eye. 

If  the  patient  states  that  his  weakness  of  sight  was  preceded  by  a  frequent 
flashing  of  fire  in  his  eyes,  intolerance  of  light,  and  epiphora,  with  pain  deep 
in  the  eyeballs,  and  extending  from  the  eyes  to  the  occijiut,  and  that  these 
symptoms  were  increased  on  stooping,  or  on  straining  in  any  way  ;  or  if  his 
weakness  of  sight  is  still  attended  by  these  signs,  along  with  muscat  volitantes, 
irregular  pupils,  and  hardness  of  the  eyes,  there  is  reason  to  conclude  that 
congestion  or  inflammation  of  the  choroid  has  existed,  or  still  continues  to 
exist  in  a  chronic  state. 

If  similar  symptoms  have  been  attended  by  a  shifting  of  the  pupil  to  one 
side,  along  with  manifest  thickening,  or  subsequent  thinning  of  the  sclerotica, 
the  asthenopia  is  a  result  of  scrofulous  sclerotitis. 

If  the  pupil  be  contracted,  imperfectly  movable,  and  fringed  with  lymph, 
or  with  projecting  particles  of  pigment,  and  the  iris  discolored  and  bolstered 
forward  towards  the  cornea,  iritis  or  retinitis  has  been  the  cause. 

If,  on  viewing  the  i)upil  through  a  lens  of  short  focus,  red  vessels  are 
descried  ramifying  on  the  anterior  capsule  of  the  lens,  the  asthenopia  has 
originated  in  crystallinitis. 


ASTHENOPIA.  915 

If  the  patient  is  myopic,  the  cornea  hazy,  and  the  eye  hydrophthalmic, 
corneitis  has  been  the  cause. 

Such  names  as  corneitis,  iritis,  &c.,  denote  merely  the  chief  seat  or  focus  of 
certain  ophthalmias,  each  of  which  affects  more  or  less  the  whole  textures  of 
the  eyeball,  internal  as  well  as  external,  and  any  one  of  which  may  lay  the 
foundation  of  asthenopia. 

3.  Injuries  of  the  eye,  and  still  more  readily  injuries  of  the  branches  of  the 
fifth  nerve  round  the  orbit,  are  apt  to  give  rise  to  asthenopia.  A  large  pro- 
portion of  the  patients  who  have  come  under  my  notice  with  this  disease,  have 
presented  cicatrices  in  the  eyebrow  or  in  the  skin  of  the  forehead  ;  and  many 
of  them  have  been  able  to  state,  that,  till  they  had  received  the  wound  leaving  the 
scar,  their  sight  had  been  strong.  The  irritation  or  inflammation  of  the  injured 
eye,  or  injured  branch  of  the  fifth  nerve,  in  such  cases,  may  be  supposed  to  be 
propagated  along  the  optic  nerve  or  along  the  trunk  of  the  fifth  nerve  to  the 
brain,  and  a  reflex  affection  to  be  produced,  implicating  the  third  nerve,  the 
optic  nerve,  or  both. 

4.  Asthenopia  is  often  traceable  to  affections  of  the  encephalon. 

The  irritation  of  the  brain  in  teething  children,  so  frequently  productive  of 
convulsions,  appears  in  many  instances  to  be  the  cause  of  asthenopia. 

A  boy  of  thirteen  years  of  age,  was  brought  to  me  with  asthenopia  and 
presbyopia.  When  six  years  old  he  was  very  ill  with  measles,  and  lay  insensible 
for  some  days.     This  was  the  origin  of  the  affection  of  his  eyes. 

Another  patient  dated  his  weakness  of  sight  to  inflammation  of  the  brain, 
when  he  was  nineteen  years  of  age.  Another  traced  it  to  nervousness,  pro- 
duced by  a  fright. 

A  gentleman,  aged  sixty,  who  came  under  my  care  with  slight  hemiplegia, 
as  this  subsided,  found  himself  asthenopic.  He  saw  the  figures  in  some  small 
prints  which  hung  in  his  room,  and  all  other  distant  objects,  quite  distinctly. 
He  could  read  a  line  or  so  with  the  aid  of  his  convex  glasses,  but  no  more. 
The  letters  seemed  to  him  as  if  they  began  to  tremble,  and  get  mixed,  so  that 
he  was  obliged  to  desist. 

Many  asthenopic  patients  have  consulted  me,  whose  heads  were  hydro- 
cephaliform,  and  some  of  them  considerably  above  the  normal  size.  Tuber- 
cular disease  of  the  brain  is  probably  a  cause  in  some  instances. 

I  have  known  typhus  fever,  and  malignant  cholera,  by  implicating  the  brain, 
prove  causes  of  asthenopia. 

5.  If  asthenopia  is  attended  by  a  heavy,  sunk  appearance  of  the  eyes ;  if 
they  present  a  dark  circle  round  them,  and  feel  hot  to  the  touch  ;  if  the  patient 
has  a  melancholy  expression,  with  an  air  of  absence  and  timidity  ;  if  he 
answers  questions  with  hesitation  ;  if  he  complains  of  pain  and  feebleness  in 
the  back  and  limbs,  and  inability  to  undergo  ordinary  bodily  fatigue ;  these 
are  strong  grounds  to  suspect  the  cause  of  all  his  symptoms  to  be  some  abuse 
or  disorder  of  the  generative  system,  such  as  excessive  venery,  masturbation, 
or  spermatorrhoea.  Under  such  circumstances,  it  may  be  proper  to  suggest 
to  the  patient  the  possibility  of  his  disease  being  connected  with  the  genera- 
tive system.  This  will  perhaps  call  forth  a  declaration,  that  at  no  time  has 
he  suffered  from  venereal  disease  in  any  shape,  along  wath  a  confession  that 
he  may  have  given  cause  for  some  weakness  of  the  generative  organs,  and 
that  for  some  time  he  has  suspected  that  such  was  the  case. 

I  have  often  ascertained,  that  asthenopia,  in  young  men,  is  a  result  of 
excessive  venereal  indulgence,  but  more  frequently  still,  of  masturbation,  or 
of  involuntary  emissions.  I  have  no  doubt,  that  masturbation  is  a  frequent 
cause  of  the  same  complaint  in  females.^ 

Pauli  relates*  the  case  of  two  sisters,  the  one  28  and  the  other  23  years 
old,  both  of  whom,  from  masturbation,  brought  on  asthenopia,  with  melan- 


916  ASTHENOPIA. 

cboly  and  great  debility.  Along  with  other  symptoms,  he  mentions  a  habit 
of  constantly  biting  their  nails,  a  trick  to  which  masturbators  are  particu- 
larly attached,  and  a  repugnance  to  marriage,  which  is  also  characteristic  of 
the  class.  Females  affected  with  asthenopia,  often  labor  under  leucorrhoea  ; 
and  this,  as  well  as  barrenness,  is  in  many  cases  a  consequence  of  abuse  of 
the  generative  organs. 

I  shall  not  insist  on  other  causes  to  which  asthenopia  appears  occasionally 
to  owe  its  origin.  I  may  merely  mention  the  following  as  deserving  atten- 
tion :  congenital  imperfection  in  the  organs  of  vision,  a  bent  position  of 
the  body  during  work,  dyspepsia,  constipation,  agitation,  grief,  and  the  use 
of  alcohol,  opium,  or  tobacco — poisons  which  tend  to  blunt  all  our  sensitive 
and  motive  powers.  Debilitating  influences  of  every  kind  are  apt  to  aggra- 
vate, if  not  to  induce,  asthenopia.  A  young  lady,  for  whom  I  was  consulted, 
was  much  worse  after  sea-sickness,  which  brought  on  a  violent  attack  of 
haematemesis. 

Proximate  cause. — As  pathological  anatomy  has  thrown  no  light  on  the 
seat  or  nature  of  asthenopia,  we  are  left  altogether  to  conjecture,  respecting 
its  proximate  cause. 

That  there  is  no  considerable  change  of  structure  in  the  retina,  no  atrophy 
of  that  part,  as  St.  Yves  imagined,'  is  manifest  from  the  fact,  that  the  power 
of  vision  is  not  permanently  impaired  in  this  disease.  The  minutest  objects 
are  seen,  for  a  time,  as  clearly  as  in  the  natural  state  of  the  eye. 

That  the  sole,  or  even  the  chief,  seat  of  asthenopia  is  the  retina,  is  impro- 
bable ;  that  it  is  in  part  the  seat  of  it,  scarcely  can  be  doubted.  In  reading, 
writing,  and  the  similar  occupations  during  which  asthenopia  is  apt  to  occur, 
the  objects  to  be  viewed  are  small,  the  eyes  are  intensely  employed,  the  pupils 
converged  towards  the  same  point,  and  the  images  of  objects  received  on  the 
very  vertices  of  the  retinsB.  It  follows  that  the  thin  portion,  within  the  lim- 
bus  luteus,  is  the  part  of  the  retina  implicated  in  asthenopia.  In  viewing 
distant  objects,  a  larger  field  of  the  retina  is  employed,  it  is  impressed  by  a 
variety  of  forms,  and  relieved  rather  than  exhausted  by  the  diversity  of  color, 
and  the  contrasts  of  light  and  shade.  In  such  exercise  of  light,  an  attack  of 
asthenopia  never  happens  : — 

"All  day  the  vacant  eye  without  fatigue 
Straj's  o'er  the  heaven  and  earth  ;  but  long  intent 
On  microscopic  arts,  its  vigor  fails." 

That  asthenopia  is  not  wholly  an  affection  of  the  apparatus  by  which  the 
eye  is  adjusted  to  the  vision  of  near  objects,  but  partly  involves  the  retina, 
is  evident  from  the  fact,  that  when  the  eye  is  fatigued  in  asthenopia,  the 
patient  cannot  see  distinctly  or  with  comfort  through  a  small  aperture,  and 
that  cases  of  this  disease  occur  in  combination  with  myopia,  or  with  presbyo- 
pia. Were  it  entirely  a  disease  of  the  apparatus  of  accommodation,  looking 
through  a  small  aperture,  by  rendering  the  use  of  the  accommodating  power 
unnecessary  for  the  time,  would  make  vision  distinct.^  In  myopia,  the  form 
of  the  refractive  parts  of  the  eye  renders  it  permanently  adapted  to  see  near 
objects ;  and  yet  those  who  are  short-sighted  are  liable  to  asthenopia.  Patients 
laboring  under  the  combination  of  presbyopia  and  asthenopia,  by  the  use  of 
convex  glasses  render  the  action  of  the  adjusting  organs  unnecessary,  yet 
are  not  exempt,  while  using  their  glasses,  from  the  attack  of  weak-sighted- 
ness. 

To  say  that  asthenopia  consists  in  fatigue  or  weariness  of  the  retina,  is  to 
say  nothing,  unless  we  were  prepared  to  explain  the  physiology  of  fatigue — 
the  anatomical  change  which  a  sentient  nerve  undergoes,  when  it  has  been  too 
long  wrought  or  over-excited.     That  a  nerve  in  this  condition,  becomes  inca- 


ASTHENOPIA,  91^ 

pable  of  being  accurately  impressed,  or  of  accurately  conveying  impressions 
to  the  sensorium,  is  well  known  ;  but  how  this  impotency  arises,  whether  the 
circulation  of  the  blood  through  the  nervous  structures  fails,  or  the  imponder- 
able agent  of  nervous  power  becomes  exhausted,  or  the  vibrations  of  the 
nervous  elements  cease,  we  cannot  tell,  being  equally  ignorant  of  the  nature 
of  nervous  action  in  health,  and  of  its  failure  under  weakness  or  fatigue. 

The  eye,  in  its  normal  state,  possesses  a  power  of  adjustment,  by  which  it 
is  enabled  to  bring  to  focal  points  on  the  retina  the  diverging  rays  proceeding 
from  near  objects,  as  well  as  the  parallel  rays  proceeding  from  objects  which 
are  remote.  Wherever  the  change  resides,  by  which  the  refraction  effected 
by  the  eye  being  increased,  its  focal  distance  is  shortened,  and  it  is  adapted 
to  the  vision  of  near  objects,  it  is  plain  that  the  asthenopic  eye  is  not  entirely 
deprived  of  the  power  of  effecting  that  change  ;  for  on  first  looking  at  near 
objects,  the  patient  sees  them  perfectly,  and  continues  to  do  so  till  the  attack 
comes  on.  He  then  loses  sight  of  near  objects,  and  becomes  presbyopic. 
His  vision  of  distant  objects  continues  distinct,  but  his  eye  refuses  to  sustain 
the  effort  necessary  for  bringing  the  rays  of  light,  arising  from  objects  within 
a  certain  distance,  to  focal  points  on  the  retina.  The  organ  or  organs  of 
adjustment,  then,  are  affected  in  this  disease;  and  are  probably  the  chief  seat 
of  the  complaint. 

A  hypothesis  which  I  have  formed  on  the  subject  of  adjustment  is,  that 
the  iris  and  the  ciliary  processes  are  antagonists  ;  so  that  when  the  pupil  con- 
tracts, as  it  always  does  on  our  directing  the  eyes  to  near  objects,  the  ciliary 
circle,  by  the  influence  of  its  muscle,  expands  ;  and  when  we  look  at  distant 
objects  the  pupil  expands,  and  the  ciliary  circle  contracts  around  the  lens.^ 
On  the  ciliary  circle  expanding,  the  crystalline  will  be  allowed  to  advance 
towards  the  pupil,  so  as  to  assist  in  shortening  the  focal  length  of  the  eye ; 
on  its  contracting,  the  crystalline  will  again  retire  towards  the  retina.  These 
changes  may  be  accompanied  by  a  change  of  figure  of  the  crystalline,  its 
axis  becoming  elongated  when  it  advances  in  the  eye,  and  shortened  as  it 
retires.  Nor  is  it  improbable  that  the  contraction  of  the  straight  and 
oblique  muscles,  while  it  tends  both  to  elongate  the  axis  of  the  eye,  and 
shorten  the  radius  of  curvature  of  the  cornea,  aids  the  advance  of  the  crys- 
talline. 

The  motions  of  the  ciliary  muscle  and  of  the  iris,  as  well  as  those  of  the 
straight  and  oblique  muscles,  are  under  the  influence  of  the  third  nerve  ;  and 
if  deprived  by  any  cause,  of  their  usual  nervous  stimulus,  their  motions  must 
be  impeded,  and  the  function  of  adjustment  be  imperfectly  performed.  This 
is  the  case  in  asthenopia.  On  exposing  an  asthenopic  eye  to  various  degrees 
of  light,  the  motions  of  its  pupil  may  be  as  vivid  and  extensive  as  those  of 
a  healthy  eye.  On  first  being  turned  towards  a  near  object,  the  pupil  may 
also  be  observed  to  contract :  but  if  we  watch  the  eye,  applied  seriously  to 
the  continued  vision  of  a  near  object,  as  in  reading,  the  pupil  will  be  seen,  in 
general,  to  fall  into  a  medium  state  of  dilatation,  and  not  to  maintain  its  state 
of  contraction,  as  would  the  pupil  of  a  sound  eye  under  the  same  circum- 
stances. The  ciliary  circle  probably  assumes  also  a  medium  degree  of  expan- 
sion. This  state  of  parts  may  be  deemed  sufficient  to  produce  almost  the 
whole  symptoms  of  the  disease.  The  effort  necessary  for  adjustment  cannot 
be  sustained  ;  the  focal  length  of  the  eye  can  no  longer  be  shortened  as  it 
should  be  ;  the  letters  of  the  book  fade  from  before  the  sight,  and  the  feeling 
of  fatigue  creeps  over  the  eye.  It  is  probable  that  the  cause  of  this  weak- 
ness resides,  not  in  the  ciliary  nerves  merely,  nor  in  the  parts  to  which  they 
are  distributed,  but  in  the  third  nerve,  and  the  other  muscular  nerves  of  the 
eye,  generally.  The  contraction  of  the  recti  and  obliqui,  then,  so  necessary 
for  keeping  the  eye  in  the  state  of  libration,  for  directing  it  along  the  lines 


918  ASTHENOPIA. 

of  the  printed  page,  for  converging  the  eyes  to  the  same  point,  and  perhaps 
for  compressing  the  globe  of  the  eye,  so  as  to  maintain  an  increased  distance 
between  the  retina  and  the  cornea,  must,  in  this  case,  gradually  give  way  un- 
der the  effort  demanded,  so  that  these  muscles  fall  into  a  state  of  minimum 
contraction.  The  consequence  is,  that  at  length  the  upper  eyelid  drops,  and 
the  patient  is  obliged  to  indulge  in  that  cessation  from  visual  exertion  which 
experience  has  taught  him  will  renovate  his  exhausted  powers  of  sight,  and 
enable  him,  by-and-by,  to  resume  his  labor. 

Prognosis. — The  prognosis  in  asthenopia  is,  on  the  whole,  unfavorable.  If 
the  disease  has  lasted  for  a  number  of  years,  and  especially  if,  besides,  it  has 
originated  in  one  of  the  ophthalmiae,  in  an  injury  of  one  of  the  branches  of 
the  fifth  nerve,  or  in  some  affection  of  the  encephalon,  it  is  rarely  benefited 
by  any  sort  of  treatment. 

In  cases  of  recent  date,  much  depends  on  the  practitioner's  detecting  the 
remote  cause,  and  on  the  patient's  power  of  abstracting  himself  from  its  in- 
fluence. This  refers  principally  to  the  first  and  fifth  of  the  remote  causes 
already  considered. 

As  far  as  my  experience  goes,  asthenopia  has  very  little  tendency  to  wear 
itself  out. 

If  the  disease  is  connected  with  plethora  or  local  congestion,  the  prognosis 
is  better ;  but  if  the  patient  is  much  debilitated,  or  of  a  scrofulous  constitu- 
tion, it  is  very  unfavorable. 

When  a  certain  degree  of  asthenopia,  more  or  less  in  difi"erent  subjects, 
has  continued  for  several  years,  so  that  it  may  be  regarded  as  confirmed,  it 
seldom  gets  worse,  and  very  rarely  passes  into  amblyopia  or  amaurosis.  The 
medical  cautions  which  the  patient  receives  contribute,  no  doubt,  if  attended 
to,  to  prevent  his  disease  from  gaining  ground,  or  amaurosis  from  super- 
vening. We  may  safely,  then,  to  the  question  so  often  put  to  us,  whether 
the  disease  is  likely  to  end  in  blindness,  answer  in  the  negative ;  and  I  con- 
ceive it  to  be  no  small  matter,  that  we  are  able  to  do  so  on  good  grounds. 
This  is  a  point  of  great  importance,  depending,  however,  entirely  on  the  ac- 
curacy of  our  diagnosis  of  asthenopia  from  incipient  or  incomplete  amaurosis. 
A  lady  consulted  me  respecting  her  eyes,  which  were  asthenopic.  After  I 
had  explained  to  her  the  necessity  of  giving  her  eyes  rest,  and  assured  her 
that  the  disease,  although  probably  incurable,  would  not  end  in  the  loss  of 
sight,  she  informed  me  that  she  had  returned  from  India  on  account  of  the 
affection  of  her  eyes  ;  that  her  medical  attendant  there  had  pronounced  it  to 
be  amaurosis  ;  and  that  she  was  greatly  alarmed  lest  she  should  become 
blind.  Her  mind  was  much  relieved  when  I  explained  to  her  that  the  dis- 
ease was  not  amaurosis,  and  advised  her  to  return  to  her  family  in  India ; 
which  I  afterwards  learned  she  did. 

In  many  cases,  it  is  our  duty  to  declare  the  disease  incurable,  and  to  ex- 
plain to  the  patient  and  his  friends,  that  all  that  can  be  done  for  it  is,  as 
much  as  possible,  to  spare  the  sight  from  exercise  on  near  objects.  If  the 
patient  is  a  young  lad,  bound  apprentice  to  a  sedentary  trade,  and  the  dis- 
ease, from  its  duration  and  its  mode  of  origin,  not  likely  to  yield  to  treat- 
ment, we  may  advise  him  to  turn  shopkeeper,  to  apply  himself  to  country 
work,  or  to  go  to  sea ;  if  a  female,  occupied  constantly  in  sewing,  to  engage 
in  household  affairs,  or  any  other  healthy  active  employment.  Many  a  poor 
man  have  I  told  to  give  up  his  sedentary  trade,  and  drive  a  horse  and  cart ; 
while  to  those  in  better  circumstances,  and  not  far  advanced  in  life,  I  have 
recommended  emigration ;  telling  them,  that,  though  they  never  could  em- 
ploy their  eyes  advantageously  where  much  reading  or  writing  was  required, 
they  might  see  sufficiently  to  follow  the  pastoral  pursuits  of  an  Australian 
colonist. 


ASTHENOPIA.  '     919 

Too  often  it  happens  that  such  advice  cannot  be  followed,  circumstances 
being  such,  that  the  patient  must  either  continue  the  sedentary  employment 
which  keeps  up  the  disease,  or  starve.  It  is  of  the  greatest  importance  for 
him,  however,  to  moderate  his  application.  Without  this  there  is  certainly 
no  cure.     All  other  remedies,  without  rest  to  the  eyes,  will  be  fruitless. 

Prevention. — With  regard  to  the  prevention  of  asthenopia,  it  may  be  re- 
marked, in  general,  that  the  remote  causes  are  carefully  to  be  avoided.  Those 
who,  hitherto  with  impunity,  have  been  exposed  to  one  or  other  of  the  remote 
causes  should  be  particularly  guarded  in  tempting  the  injurious  influences  of 
the  rest.  Thus,  children  who  have  suffered  from  scrofulous  ophthalmia,  if 
put  to  a  trade  requiring  earnest  application  of  the  sight,  are  very  liable  to 
become  asthenopic. 

It  is  impossible  to  limit  the  time  during  which  healthy  eyes  may  be  em- 
ployed with  safety  upon  minute  objects,  as  there  is  a  great  variety  in  their 
power  of  bearing  fatigue.  The  sight  may  be  regarded  as  fatigued,  whenever 
the  person  finds  that  he  requires  to  bring  the  object  nearer  to  his  eyes  than 
usual ;  whenever  the  object  appears  confused  ;  whenever  the  eyeball  or  eye- 
lids become  red,  or  the  eyes  feel  heavy,  hot,  or  affected  with  a  pricking  sensa- 
tion, or  with  a  flow  of  tears.  The  moment  such  symptoms  are  experienced, 
the  person  should  rise  from  his  work ;  relieve  his  eyes  by  turning  them  on 
distant  objects  ;  bathe  them  in  cold  water  ;  and,  if  circumstances  permit, 
expose  them  to  the  external  air. 

Giving  the  eyes  even  a  few  minutes'  occasional  rest  is  of  great  service  in 
preventing  them  from  becoming  weak,  especially  when  employed  in  such  ex- 
hausting occupations  as  reading,  writing,  drawing,  engraving,  sewing,  and 
the  like.  As  important  means  of  preserving  the  sight  from  weakness  may 
be  mentioned,  shifting  the  occupation  from  a  fatiguing  one  to  one  requiring 
a  less  earnest  use  of  the  eyes ;  turning  away  from  the  light,  if  it  is  brilliant, 
or  closing  the  eyes  for  a  few  minutes  ;  changing  the  bent  position  of  the 
body  for  the  erect,  and,  in  place  of  sitting  still,  walking  about  for  a  little ; 
and  avoiding  everything  tight  about  the  body,  as  tight  neckcloths,  stays,  and 
even  shoes,  so  as  to  allow  a  free  and  equable  circulation  of  the  blood.  The 
eyes  should  never  be  forced  to  continued  exertion.  The  eyes  of  children 
especially  should  never  be  fatigued.  They  should  never  be  allowed  to  read 
books  printed  in  small  type. 

Treatment. — 1.  Avoidance  of  the  remote  causes. — As  a  general  principle, 
the  patient  must  endeavor  to  desist  from  everything  which  weakens  the 
nervous  system,  or  exhausts  the  organ  of  vision.  If  he  cannot  altogether 
abandon  the  employing  of  his  eyes  upon  minute  objects,  he  must,  at  least, 
allow  them  the  necessary  periods  of  relaxation,  and,  if  possible,  choose  for 
his  amusements  such  as  may  lead  him  to  the  extended  prospects  and  refresh- 
ing verdure  of  the  country.  If  confinement  within  doors  be  the  cause,  this 
must  be  changed  for  some  active  employment.  Bad  practices  must  be  aban- 
doned, and  every  particular  be  studied  which  is  likely  to  fortify  the  consti- 
tution. Perpetual  exercise  in  the  open  fields  should  be  substituted  for  the 
monotonous  restrictions  of  a  town  life,  and  a  hard  bed  and  early  rising  for 
the  enervating  contrivances  of  luxury  and  indolence. 

2.  Rest  of  the  eyes. — The  patient  ought  never  to  work  long  without  giving 
his  eyes  rest ;  and  ought  to  avoid  as  much  as  possible  the  fixing  of  them  on 
any  minute  objects. 

"Supposing  a  patient  could  work  for  an  hour,"  says  Mr.  Tyrrell,  "but 
not  longer,  without  producing  disturbance  of  vision,  he  should  then  be 
directed  to  work  for  half  an  hour  at  a  time ;  and  to  allow  intervals  of  rest, 
of  a  quarter  of  an  hour  each;  he  can  thus  work  for  two-thirds  of  his  usual  time, 
while  his  cure  proceeds.     *      *      *     The  period  allowed  for  employment 


920  ASTHENOPIA. 

should  be  short  of  that  in  which  application  produces  the  disturbance  of 
vision  ;  and  the  time  devoted  for  resting  the  eyes  should  never  be  less  than 
a  quarter  of  an  hour.  Supposing  that  the  impaired  vision  occur  within  half 
an  houi-,  or  less,  after  the  eyes  have  been  employed  at  work,  it  is  best  for  the 
patient  to  refrain  from  work  altogether  for  a  week  or  two,  until  the  affection 
be  mitigated."^ 

Although  the  abstaining  from  such  employments  as  require  the  eyes  to  be 
exercised  for  any  considerable  length  of  time  on  small  objects  is  one  of  the 
most  evident  indications  in  asthenopia,  and  without  which  any  other  means 
of  cure  are  likely  to  prove  fruitless,  yet  I  fear  that  the  hopes  of  curing  the 
disease  by  rest  alone  will  prove  delusive,  unless  in  incipient  cases,  arising 
solely  from  over-use  of  the  sight. 

We  must  be  aware,  too,  of  deceiving  ourselves  regarding  the  effects  of 
other  remedies  used  during  the  observance  of  rest.  The  good  eftccts  which 
they  may  seem  to  produce  will  often  prove  nothing  else  than  the  restoration 
which  always  takes  place  during  repose.  Whether  it  is  so  or  not  will  readily 
be  ascertained  on  the  very  first  application  of  the  eyes  to  minute  objects. 

3.  Depletion. — The  reduction  of  vascular  action  by  bloodletting  or  leech- 
ing is  very  rarely  indicated  in  asthenopia,  and  ought  to  be  had  recourse  to 
only  when  the  patient  is  robust,  and  the  disease  attended  by  signs  of  local 
congestion. 

4.  Purgatives. — Constipation  frequently  accompanies  asthenopia,  and  is 
likely  to  aggravate  the  affection  of  the  eyes.  A  course  of  purgatives  is  often 
attended  by  remarkably  good  effects,  and  laxatives  in  such  cases  ought  to  be 
continued  regularly  in  moderate  doses. 

5.  Alteratives. — A  deranged  state  of  the  digestive  system,  and  a  faulty 
secretion  from  the  liver,  if  not  remedied  by  ordinary  purgatives,  may  require 
small  doses  of  some  mild  preparation  of  mercury. 

6.  Tonics. — On  the  presumption  that  asthenopia  is  a  disease  of  debility, 
tonics  chiefly  are  employed  for  its  cure,  and  especially  the  preparations  of 
cinchona  and  of  iron.  Sulphate  of  quina  and  the  solution  of  the  oxy  sul- 
phate of  iron  are  among  the  most  effectual.  I  have  known  many  cases 
greatly  relieved  by  these  means.  Sulphate  of  zinc,  from  its  peculiar  influence 
on  the  nervous  tissue,  presumed  by  some  to  be  similar  to  that  of  iron  on  the 
blood,  seems  likely  to  be  of  great  service  in  asthenopia.  I  have  known  a 
perfect  cure  effected  under  a  course  of  cod-liver  oil.  In  proportion  as  the 
patient  gains  strength,  and  the  action  of  the  nervous  system  is  improved,  the 
power  of  vision  is  invigorated.  Change  of  air  and  scene,  by  its  exhilarating 
effect,  will  often  prove  the  best  tonic. 

Y.  Diet. — In  general  the  quantity  of  the  patient's  food  requires  to  be  in- 
creased, and  its  quality  improved.  Nutritive  animal  food  of  easy  digestion 
should  be  given.  The  patient  may  drink  water  freely,  but  use  alcohol  in  no 
form,  unless  it  is  prescribed  as  a  medicine. 

8.  Tepid  and  cold  bathing. — The  cold  bath,  and  especially  a  course  of  sea- 
bathing, I  regard  as  one  of  the  most  efficacious  means  of  cure.  It  is  not, 
however,  always  safe  to  commence  so  energetic  a  remedy  all  at  once ;  it  is 
better  to  try  tepid  and  cold  sponging,  followed  by  careful  friction,  before 
plunging  into  cold  water,  whether  fresh  or  salt. 

9.  Sedatives. — The  only  internal  medicine  of  this  kind  I  have  tried  is  bella- 
donna. I  have  employed  it  frequently  in  the  form  of  tincture.  It  lessens 
the  disposition  to  fatigue  in  the  eyes  in  a  very  remarkable  degree.  It  also 
diminishes  the  tendency  to  seminal  discharges.  The  dose  is  from  five  to 
fifteen  drops  thrice  a  day.  Aconite,  which  so  much  alleviates  nervous  head- 
ache, seems  worthy  of  a  trial  in  asthenopia.  Such  medicines  should  be  had 
recourse  to  only  when  the  disease  is  accompanied  by  pain  and  irritation. 


ASTHENOPIA.  921 

10.  Stimidants. — The  tincture  of  nux  vomica  is  the  only  remedy  of  this 
class  which  I  have  found  useful  in  this  disease.  Any  signs  of  congestion  will 
forbid  the  employment  of  this  medicine. 

11.  Cold  and  loarm  lotions. — Temporary  benefit  is  obtained  by  bathing 
the  eyelids  with  cold  water,  water  acidulated  with  vinegar,  a  mixture  of  a 
small  quantity  of  sulphuric  ether  or  sweet  spirits  of  nitre  with  water,  or  the 
like.  The  subtraction  of  heat  which  follows  such  applications  greatly  relieves 
the  feeling  of  fatigue  in  the  eyes.  Fomenting  the  eyelids  with  warm  water, 
chamomile  tea,  poppy  decoction,  and  other  warm  fluids,  also  affords  temporary 
relief,  and  may  be  used  when  the  weather  is  cold. 

12.  Cold  douche. — Beer  invented  an  eye  fountain,  by  which  a  small  stream 
of  cold  water  was  made  to  play  upon  the  closed  eyelids,  and  which  he  recom- 
mended to  be  used  frequently  during  the  day.  Jiingken  uses  water  impreg- 
nated with  carbonic  acid  gas,  in  the  same  way.  Romberg  has  applied  a  jet 
of  pure  carbonic  acid  gas  to  the  eyes  with  good  effect. 

13.  Spirituous  and  aromatic  vapors. — Exposing  the  eyes  to  stimulating 
vapors,  such  as  that  of  aqua  ammonite,  sulphuric  ether,  or  a  mixture  of  these, 
sometimes  proves  useful.  The  fluid  selected  may  be  poured  into  a  small  cup, 
previously  warmed  by  being  placed  a  few  minutes  in  boiling  water,  and  the 
cup  held  under  the  eye,  so  that  the  vapor  may  rise  into  contact  with  the  con- 
junctiva. This  should  be  continued  till  the  eyes  begin  to  water  and  become 
red,  and  repeated  twice  or  thrice  daily.  Wenzel  objects  to  the  use  of  ammonia, 
and  the  like,  in  this  way,  and  recommends  the  eyes  to  be  fumigated  with  the 
vapor  arising  from  aromatic  resins,  thrown  upon  a  live  coal. 

14.  Counter-irritation. — In  cerebral  cases,  and  in  cases  complicated  with 
congestion  of  the  choroid,  blisters  to  the  temples,  behind  the  ears,  and  to  the 
back  of  the  head,  prove  useful. 

15.  Cauterization  of  the  urethra. — When  asthenopia  depends  on  obstinate 
spermatorrhoea,  or  on  masturbation,  advantage  may  be  derived  from  the  appli- 
cation of  lunar  caustic  to  that  part  of  the  urethra  which  receives  the  ejacula- 
tory  ducts. 3  Spermatorrhoea  appears  to  be  kept  up  by  a  chronic  inflammation 
of  that  part  of  the  urethra,  which  inflammation  the  caustic  removes.  The 
same  remedy  renders  masturbation  painful,  so  that  its  repetition  is  prevented, 
and  the  habit  broken. 

The  length  of  the  urethra  is  to  be  measured  with  the  catheter.  By  means 
of  Lallemand's  porte-caustique,  the  caustic  is  then  to  be  applied  for  an  instant 
to  the  surface  of  the  verumontanum,  immediately  anterior  to  the  prostatic 
portion  of  the  urethra,  and  the  instrument  withdrawn  closed.  This  is  to  be 
followed  by  low  diet,  diluent  drinks,  and  the  hip-bath.  The  inflammation 
caused  by  the  caustic  subsides  in  about  ten  days,  and  then  the  amendment 
begins  to  be  perceived.  The  spermatic  discharges  becoming  fewer,  the  patient 
gains  strength ;  and  among  other  signs  of  improvement,  he  finds  his  sight 
restored  to  its  normal  power  of  sustaining  fatigue. 

16.  Convex  glasses. — Few  patients,  not  even  those  of  them  who  are  mere 
children,  continue  to  be  long  affected  with  asthenopia,  without  making  use 
of  convex  glasses.  One  of  the  strongest  proofs  that  the  seat  of  the  disease 
must  be,  in  part  at  least,  the  apparatus  of  accommodation,  is  the  fact  that 
the  employment  of  such  glasses  relieves  the  symptoms  almost  as  completely 
as  it  does  those  of  presbyopia.  The  only  danger  is,  that  the  patient  begins 
with  glasses  of  too  short  a  focus,  so  that,  when  age  advances,  he  finds  he  has 
forestalled  the  advantage  he  might  otherwise  have  derived  from  glasses 
adapted  to  an  increasing  long-sightedness.  I  have  often  been  consulted  by 
individuals  under  20  years  of  age,  who,  on  account  of  asthenopia,  were  using 
convex  glasses  of  as  short  a  focus  as  eight  or  even  six  inches. 

A  child,  the  subject  of  asthenopia,  engaged  in  learning  his  lessons,  com- 


922  NIGHT-BLINDNESS, 

plains  he  cannot  see,  and  repeats  the  complaint  so  frequently,  especially  by 
caudle-lig'ht,  that  his  father  or  grandfather  at  last  says  :  "Try  my  glasses!" 
The  child  now  sees  perfectly,  and  night  after  night  the  loan  of  the  glasses  is 
required  before  his  task  can  be  finished.  It  would  have  been  better  had 
glasses  been  selected  of  the  longest  focus,  which  would  have  enabled  the 
child  to  read,  or  better  still  had  he  been  put  to  bed,  and  the  lesson  left  till 
dayliglit. 

If  we  are  consulted  in  time  as  to  the  use  of  convex  glasses  for  asthenopia, 
all  the  advice  we  can  give  is,  to  choose  those  of  the  longest  focus,  which 
will  answer  the  purpose  wanted.  They  serve  merely  as  a  palliative,  but  a 
palliative  of  great  importance  to  those  who  but  for  their  aid  could  not  win 
their  bread.  They  seem  to  have  no  effect  in  removing,  neither  do  they  appear, 
in  general,  to  confirm  or  aggravate  the  disease,  if  properly  selected.  A  young 
gentleman,  however,  engaged  in  learning  the  profession  of  the  law,  having  by 
the  advice  of  an  eminent  oculist  had  recourse  in  this  disease  to  the  use  of 
convex  glasses,  and  used  them  for  some  years,  assured  me  he  found  his  sight 
getting  we.aker  and  weaker,  till  he  threw  the  glasses  aside,  after  which,  with- 
out anything  else  being  done,  he  found  a  considerable  improvement  to  take 
place. 


'  Linnrei    Philosopbia   Botanica;    §  260,  p.  '  Nouveau  Traite  dcs  Maladies  dcs  Ycux,  p. 

206  ;  Vienna;,  1755.  334  ;  Paris,  1722. 

^  On  the    Influence   of    Artificial    Light  in  "  Porterfield's  Treatise  on  the  Eye  ;  Vol.  i.  p. 

causing  Impaired  Vision  ;  Edinburgh,   1840.  395  ;  Edinburgh,  1759. 

'  "  Les  femnies  sent  egaletnent  enclincs  H  ees  '  JMedical  Gazette  ;  Vol.  xiii.  p.  6.^1 ;  London, 

mauvaises  habitudes."  Berton,  Traite  Pratique  18."'.4:  Physiology  of  Vision,  p.  185;  London, 

des  Maladies  des  Enfants,  p.  800,  Paris,  1842.  1841. 

"Cetto  nialheureuse  passion  amene  exactenient  '  Practical  Work  on  the  Diseasesof  the  Eye  ; 

les  ineines  resultats  dan?  I'autre  sexe  i  tous  les  Vol.  ii.  p.  30  ;  London,  1840. 

ages."     Lallemand,  Des  Partes  Scminalcs  In-  '    Lallemand,    Op.    cit.  ;  Tome  iii.    p.   392  ; 

Tolontaircs;  Tome  iii.  p.  207 ;  Paris,  1842.  Phillips,  Medical  Gazette;  Vol.    xxx.  p.   587: 

*  Auimon's  Monatsschrift  fiirMedicin;  Band  London,  1843. 
i.  p.  592;  Leipzig,  1838. 


SECTION   XII. — NIGUT-BLINDNESS. 


St/n. — Nocturnal  amaurosis.  Moon-blindness.  Nyctalopia  of  some,  and  hcmcralopia  of 
others;  terms  which  it  were  better  altogether  to  avoid.  Nyctalopia,  more  especially,  has 
been  used  to  signify  both  sceiiiff  by  niyht,  and  night-blindness.  Sometimes  even  the  same 
author  uses  the  word  in  both  these  opposite  meanings.  It  seems  doubtful  whether  it  is  a 
compound  of  \h^  and  i,^  merely,  or  of  vi/f,  a.  privative,  and  Si-\, ;  and  a  similar  doubt  hangs 
over  hemeralopia. 

Case  369. — As  the  servant  to  a  corn-miller  was  employed,  one  evening  near  sunset,  in 
mending  some  sacks,  he  felt  himself  suddenly  deprived  of  the  use  of  his  limbs  and  of  his 
sight.  At  the  time  he  was  attacked  by  this  uncommon  disease,  he  was  not  only  en- 
tirely free  from  any  pain  in  his  head  or  limbs,  but  had  even  a  sensation  of  ease  and 
pleasure  ;  he  was,  as  he  expressed  himself,  as  if  in  a  pleasing  doze,  but  perfectly  sensible. 
He  was  immediately  carried  to  bed,  and  watched  till  midnight;  at  which  time  he  desired 
those  who  attended  him,  to  leave  him,  because  he  was  neither  sick  nor  in  pain.  He  con- 
tinued the  whole  night  totally  blind,  and  without  a  wink  of  sleep.  When  the  daylight  of 
the  next  morning  appeared,  his  sight  returned  to  him  gradually,  as  the  light  of  the  sun 
increased,  till  it  became  as  perfect  as  ever.  When  he  rose  from  his  bed,  he  found  his  limbs 
restored  to  their  usual  strength  and  usefulness,  and  himself  in  perfect  health. 

But  on  the  evening  of  the  same  day,  about  sunset,  he  began  to  see  but  obscurely,  his 
sight  gradually  departed  from  him,  and  he  became  as  blind  as  on  the  preceding  night; 
though  his  limbs  continued  as  Avell  as  in  perfect  health,  nor  had  he,  from  the  first  night, 
any  farther  complaint  from  that  quarter.  Next  day,  with  the  rising  sun,  his  sight  returned ; 
and  this  was  the  almost  constant  course  of  the  disease  for  two  months. 

The  symptoms  which,  from  the  second  night,  constantly  preceded  the  blindness,  were, 


NIGHT-BLINDNESS.  923 

aslight  paia  over  the  eyes,  and  a  noise  in  his  head.  That  he  was  totally  blind  every  night 
■when  these  symptoms  appeai-ed,  was  evident  from  his  not  being  able  to  see  the  light  of  a 
candle,  though  held  close  to  his  eyes  ;  and  that  in  the  day  his  sight  was  perfect,  was  as 
manifest,  from  his  being  capable  of  reading  the  smallest  print,  and  threading  the  finest 
needle. 

The  first  day  that  Dr.  Pye  saw  this  patient,  he  found  his  eyes  perfectly  natural ;  but 
some  time  after,  he  observed  the  pupils,  during  one  of  the  nocturnal  paroxysms,  to  be 
enlarged  about  one-third  beyond  their  natural  diameter.  After  nearly  two  months'  con- 
tinuance of  the  disease,  it  began  to  be  less  regular  in  its  occurrence,  the  patient  retaining 
his  sight  for  a  single  night,  or  for  several  nights  together,  and  then  the  blindness  recur- 
ring. Dr.  Pye  jiut  him  at  last  on  the  use  of  cinchona,  and  thought  it  successful  in  remov- 
ing the  complaint.  It  must  be  observed,  however,  that  the  patient,  while  taking  the 
cinchona,  labored  under  a  spontaneous  diarrhoea,  in  consequence  of  which  he  became 
gradually  weaker  and  weaker.  His  sight  he  retained  from  the  first  day  after  using  the 
medicine ;  but  ten  days  after,  he  became  delirious  and  deprived  of  hearing,  and,  in  five 
days  moi'e,  he  died.' 

I  have  quoted  this  case,  as  a  good  example  of  night-blindness,  a  disease 
which,  though  rare  in  this  country,  is  by  no  means  uncommon  in  warm 
climates,  and  to  which  seamen  appear  to  be  particularly  exposed. 

St/mptoms. — The  first  attack  of  the  disease  generally  excites  great  alarm. 
The  patient  is  busy  perhaps  at  his  occupation,  or  enjoying  himself  in  the  midst 
of  his  family,  when  suddenly  he  finds  his  sight  fail,  and  as  evening  advances 
becomes  almost  completely  blind.  The  medical  attendant  is  immediately  sent 
for,  and  is  often  as  much  amazed,  and  little  less  alarmed  than  the  patient.  He 
probably  finds  the  pupils  dilated,  but  no  vertigo,  pain,  nor  other  sign  indicative 
of  any  serious  affection  of  the  head.  He  perhaps  takes  away  blood,  orders 
some  purgative  medicine,  and  pronounces  a  very  unfavorable  prognosis.  To 
the  joy  of  all  concerned,  the  patient  wakes  in  the  morning  with  his  sight  per- 
fectly restored. 

But  again  on  the  approach  of  evening,  symptoms  are  perceived  of  returning 
blindness.  Objects  appear  as  if  covered  by  a  bluish  or  grayish  mist,  and  in 
the  course  of  a  few  minutes  the  patient  is  obliged  to  grope  his  way  like  a  blind 
man.  Candles  are  brought.  If  he  perceives  that  they  are  present,  they 
appear  as  if  glimmering  through  a  fog,  and  scarcely  ever  enable  him  to  see 
with  distinctness.  The  effect,  however,  of  artificial  light  is  not  uniformly  the 
same  in  this  disease.  Sometimes,  the  patient  has  recourse  to  a  trial  of  various 
sorts  of  glasses,  but  without  avail. 

Night  after  night,  the  blindness  returns,  and  becomes  more  and  more  com- 
plete. For  a  time,  the  restoration  to  vision  through  the  day  appears  to  be 
tolerably  perfect,  but  at  length  the  sight  is  evidently  weak  by  day  as  well  as 
by  night.  The  patient  is  affected  with  photophobia,  and  becomes  near-sighted ; 
his  vision  is  more  and  more  impaired ;  and,  if  neglected  or  mistreated,  the 
disease  ends  in  incurable  amaurosis. 

It  sometimes  happens,  in  incipient  cases  of  night-blindness,  that  the  patient, 
though  unable  to  distinguish  even  large  objects  after  sunset  or  by  moonlight, 
is  restored  to  a  tolerable  degree  of  sight  by  the  use  of  candle-light ;  but  in 
eases  fully  developed,  even  strong  artificial  illumination  is  unable  to  aS'ect  in 
any  degree  the  sunken  sensibility  of  the  retina. 

The  appearances  of  the  eyes  are  different  in  different  cases.  In  many,  there 
is  scarcely  any  change  from  the  appearances  of  perfect  health.  Generally, 
however,  the  pupils  are  dilated  during  the  attack,  and  do  not  contract  on  ex- 
posing the  eyes  to  the  light  of  a  candle  or  of  the  moon.  In  some,  the  pupils 
continue  dilated  even  during  the  day ;  in  others,  they  are  contracted,  and 
evince  a  painful  irritability  on  exposure  to  strong  light.  If  the  patient  hap- 
pens to  look  at  the  direct  rays  of  the  sun,  especially  of  a  tropical  sun,  or  a 
strong  glaring  reflection  of  them,  as  from  the  sea,  pain  and  temporary  blind- 
ness are  induced,  from  which  he  recovers  by  closing  his  eyes  for  a  time,  and 
retiriuff  into  the  shade. 


924  NIGHT-BLINDNESS. 

Night-blindness  does  not  appear  to  be  necessarily  accompanied  by  any  con- 
stitutional symptoms.  That  such  symptoms  are  occasionally  present,  is  evi- 
dent from  the  case  already  quoted,  and  that  a  variety  of  them  may  attend  in 
other  instances,  will  appear  extremely  probable  from  a  consideration  of  the 
remote  causes  of  the  disease. 

Epidemic. — Night-blindness  became  epidemic  in  two  battalions  of  the  19th  Prussian 
regiment  of  the  line,  quartered  at  Ehrenbreitstein  and  Pfaffendorf,  in  July  and  August, 
1834,  and  attacked,  in  all,  138  soldiers.  When  the  di«ease  first  broke  out,  those  aifected 
were  thought  to  be  malingering ;  but  a  close  examination  of  the  symptoms,  and  the  far- 
ther spreading  of  the  malady,  proved  the  incorrectness  of  this  suspicion.  Those  who 
suffered  were  unable  to  find  their  muskets  if  they  for  a  moment  laid  them  out  of  their 
hands  at  night ;  and  they  experienced  so  much  difficulty  in  distinguishing  near  objects  in 
the  dai'k,  that,  when  they  were  posted  as  sentinels,  they  feared  to  pace  up  and  down, 
lest  they  might  not  be  able  to  find  their  sentry-box  again.  When  ordered  to  maixh  or 
perform  any  military  evolution  during  the  night,  the}'  were  constantly  stumbling,  and 
knocking  against  each  other,  in  a  manner  that  could  be  accounted  for  only  by  a  defect  of 
vision.  In  none  did  the  general  health  appear  in  the  least  deranged,  and  in  none  could 
any  morbid  alteration  be  detected  in  the  eye.  The  only  thing  complained  of  was  a  dim- 
ness of  vision  as  the  twilight  of  evening  came  on,  and  which  increased  as  the  night 
advanced.  This  dimness  the  patients  compared  to  that  caused  by  a  film  spread  over  the 
eye. 

Hiibner  invesiigated  this  epidemic,  and  attributed  its  origin  to  the  following  causes  : 
1.  The  great  heat  of  the  summer.  2.  The  fatigue  experienced  by  the  soldiers  in  the 
frequent  ascent  of  the  heights  of  Ehrenbreitstein  and  Pfaffendorf;  a  fatigue  the  more 
sensibly  felt  on  account  of  their  being  all  natives  of  Posen,  which  is  a  flat  country'.  3 
The  frequency  of  their  exercises  and  parades,  on  an  unshaded  and  dazzling  sandy  soil, 
where  also  they  were  exposed  to  the  reflection  of  the  sun's  rays  from  the  surface  of  the 
Rhine.  4.  The  extreme  darkness  of  their  rooms,  which  rendered  tiieir  ej'es  more  sensible 
when  they  went  out  on  duty,  or  for  pleasure.  The  second  and  fourth  causes  were  prob- 
ably the  most  efficient;  for  two  other  companies  of  the  same  battalions,  quartered  in 
the  neighboring  valley  of  Ehrenbreitstein,  entirely  escaped  the  disease.  Their  barrack- 
rooms  were  large  and  well-lighted,  compared  with  the  small,  dark  apartments  in  the 
fortifications  where  the  companies  aflected  with  the  disease  were  lodged. 

The  treatment  was  very  simple,  and  consisted  in  removing  those  affected  to  an  hospital 
in  other  quarters,  where  they  were  no  longer  exposed  to  the  operation  of  the  exciting 
causes ;  and  in  the  application,  generally  and  topically,  of  cooling  remedies,  calculated 
to  diminish  congestion.  To  effect  this,  cold  lotions,  frequently  applied,  low  diet,  and 
rest,  were  sufficient.  In  the  space  of  four  weeks  they  had  all  recovered,  and  were 
enabled  to  resume  their  duty.  There  were  no  relapses ;  a  fact  accounted  for  by  the 
diminished  intensity  of  the  exciting  causes  during  the  month  of  September.^ 

Fleury  and  Frechier  have  given  a  description  of  an  epidemic  night-blindness  which 
occurred  in  the  district  of  Maussane.  Pregnant  women  were  most  affected  with  it,  yet 
no  age  or  sex  was  spared.  The  degree  of  blindness  differed  much  in  ditterent  individuals. 
In  ciome  it  amounted  to  only  a  weakness  of  sight,  coming  on  after  sunset;  while  others 
became  almost  entirely  blind  as  night  advanced,  although  their  sight  had  been  perfectly 
good  during  the  day.  In  a  few  instances,  the  eyes  continued  very  weak  even  during 
the  day.3 

Prognosis. — The  duration  of  the  disease,  when  it  is  left  to  itself,  has  been 
found  to  vary  from  one  night  to  nine  months.  Its  general  period  of  continu- 
ance appears  to  be  from  two  to  three  months.  Sometimes  it  occurs  in  a 
chronic  form,  lasting  for  years,  or  for  life. 

Mr.  Bampfield  states*  that  of  more  than  a  hundred  cases  of  idiopathic, 
and  two  hundred  of  symptomatic  night-blindness,  which  had  occurred  in  his 
practice,  in  different  parts  of  the  globe,  but  chiefly  in  the  East  Indies,  all 
perfectly  recovered.  Hence  he  infers  that,  under  proper  treatment,  the 
prognosis  may  be  always  favorable. 

Europeans  who  have  once  been  affected  with  night-blindness,  in  the  East 
or  West  Indies,  are  particularly  liable  to  a  recurrence  of  the  disease,  so  long 
as  they  remain  in  a  tropical  climate.  Those  who  have  suffered  from  it  at 
some  previous  time,  are  also  apt  to  be  occasionally  attacked  with  dimness  of 
sight  during  short  periods  for  some  nights  together,  or  with  merely  moment- 
ary night-blindness. 


NIGHT-BLINDNESS.  925 

Proximate  cause. — This  periodic  amaurosis  probably  depends  on  some 
peculiar  state  of  the  retina,  rendering  the  eye  insensible  except  to  light  of  a 
certain  degree  of  intensity ;  but  of  the  natui'e  of  that  peculiar  state  it  is 
impossible  for  us  to  form  any  rational  hypothesis.  On  dissecting  the  eye  of 
a  deaf  and  dumb  person,  congenitally  affected  with  night-blindness,  I  saw- 
numerous  black  spots  in  the  substance  of  the  retina,  corresponding  to  the 
appearance  of  melanosis  retins  described  by  Langenbeck^,  and  figured  by 
Ammon.^  In  some  cases,  there  is  reason  to  suspect  that  the  proximate  cause 
does  not  affect  the  eye,  but  the  brain. 

Remote  causes. — 1.  Incomplete  night-blindness  is  not  unfrequently  con- 
genital. 

2.  Scarpa  is  of  opinion  that  night-blindness  is  most  frequently  connected 
with  disorder  of  the  stomach.  When  this  is  the  case,  the  tongue  is  foul, 
the  breath  fetid,  and  the  appetite  deficient. 

3.  Suppressed  perspiration,  owing  to  the  coldness  of  the  night  air,  has 
been  mentioned  as  a  probable  cause. 

4.  Exposure  to  an  unusual  glare  of  light  has  been  known  to  induce  night- 
blindness,  even  in  this  country ;  and  in  warm  climates,  this  cause  frequently 
operates  in  its  production.  Fatigue  and  want  of  sleep  appear  to  act  as 
causes  among  the  Russian  peasantry,  at  a  season  when  the  eye  is  exposed 
with  little  intermission  to  the  constant  action  of  the  light,  the  sun  in  the  end 
of  June  and  during  July  (their  hay  harvest)  dipping  but  very  little  below 
the  horizon,  and  that  only  for  a  short  time.  Insolation,  and  in  particular 
sleeping  with  the  face  or  head  exposed  to  the  rays  of  the  sun,  or  to  a  very 
strong  light,  have  been  particularly  mentioned  as  causes.  De  Servieres 
records"  a  case,  in  which  fixedly  looking  at  the  rising  sun  produced  an  attack 
of  night-blindness  which  lasted  a  month,  and  then  gradually  subsided  with- 
out any  remedy. 

5.  A  residence  on  board  ship  seems  of  itself  to  conduce  to  the  disease.^ 
Almost  all  the  cases  I  have  seen  were  in  young  seamen,  who  had  returned 
from  voyages  to  tropical  climates.     Sleeping  on  deck  is  blamed  as  a  cause. 

6.  Some  authors  have  considered  night-blindness  as  a  symptom  or  as  a 
precursor  of  scurvy.  Subsistence  upon  sea-diet  perhaps  favors  the  one,  as 
it  certainly  induces  the  other. 

T.  It  is  a  popular  notion  in  the  East  Indies,  that  the  eating  of  hot  rice 
brings  on  night-blindness. 

8.  Mr.  Crane  has  published^  cases,  which  go  to  prove  that  this  disease  is 
caused  by  onanism,  spermatorrhoea,  and  inordinate  venery. 

Treatment. — 1.  If  there  are  signs  of  deranged  digestion,  an  emetic  is  cer- 
tainly indicated  ;  after  which  the  bowels  are  to  be  cleared  out  by  laxative 
clysters,  and  the  use  of  purgatives. 

2.  The  Russian  peasants  are  said  to  cure  this  disease,  in  a  week,  or  14 
days  at  most,  by  drinking  a  decoction  or  infusion  of  the  centaurea  cyan  us, 
without  sweetening.     Probably  other  bitter  infusions  might  answer  as  well. 

3.  A  succession  of  blisters  to  the  temples,  tolerably  close  to  the  external 
canthus  of  the  eye,  has  been  strongly  recommended  by  Mr.  Bampfield.  He 
states  that,  under  their  application,  the  retina  appears  to  regain  its  sensibility 
in  the  same  gradual  manner  as  it  had  been  deprived  of  it ;  that  the  first 
blister  commonly  enables  the  patient  to  see  dimly  by  candle-light,  or  to  per- 
ceive objects  without  being  able  to  discriminate  what  they  are ;  that  in  some 
slight  cases,  the  first  blister  effects  a  cure  ;  that  the  second  blister  commonly 
enables  the  patient  to  see  distinctly  by  candle-light,  perhaps  by  bright  moon- 
light, or  even  half  an  hour  after  sunset,  or  that  the  disease  intermits  for  short 
periods  during  the  night;  and  that  a  perfect  recovery  is  often  effected  by 
the  second  blister.     When  this  does  not  happen,  a  third,  fourth,  or  fifth  is 


926  DAY-BLINDNESS. 

to  be  applied ;  and  if  the  disease  still  continues  in  any  considerable  degree, 
a  perpetual  blister  is  to  be  formed  on  each  temple,  and  maintained  till  a  cure 
is  accomplished,  which  generally  takes  place  within  a  fortnight. 

4.  If  the  night-blindness  is  attended  with  symptoms  of  scurvy,  the  use 
of  blisters  should  be  deferred,  until  the  scorbutic  disposition  is  corrected,  by 
proper  diet  and  medicines  ;  not  only  because  well-founded  apprehensions 
ought  to  be  entertained  of  a  scorbutic  ulcer  forming  on  the  blistered  parts, 
but  because  the  night-blindness  gradually  yields  as  the  cure  of  scurvy  pro- 
ceeds. Mr.  Bampfield,  however,  reckons,  that  about  a  third  of  the  cases  of 
scorbutic  night-blindness  resist  the  antiscorbutic  regimen  and  remedies,  and 
require  to  be  treated  ultimately  as  idiopathic  cases. 

5.  A  shade  should  be  worn  over  the  eyes,  both  during  the  treatment,  and 
for  some  time  after  the  cure,  to  defend  them  from  the  painful  irritation  occa- 
sioned by  exposure  to  vivid  lights.  A  cure  has  sometimes  been  effected  by 
the  simple  expedient  of  giving  the  eyes  entire  repose  for  two  or  three  days, 
the  patients  remaining  constantly,  for  that  length  of  time,  in  a  darkened 
room.^" 

6.  The  eyes  ought  to  be  bathed  three  or  four  times  a-day  with  cold 
water. 

7.  If  there  is  no  suspicion  of  the  disease  being  attended  with  any  tendency 
to  sanguineous  congestion  in  the  head,  and  other  remedies  have  failed,  cin- 
chona may  be  tried  as  an  anti-peric^ic.  I  have  found  bebeerine  effectual  in 
such  cases. 

8.  Electricity,  as  a  topical  stimulus  to  the  eye,  has  sometimes  been  employed 
with  success.  Also,  exposing  the  eyes  to  the  vapor  of  ammonia,  every  three 
or  four  hours. 

9.  In  apoplectic  cases,  general  and  local  depletion  will  of  course  take  pre- 
cedence of  all  other  remedies. 

10.  Mr.  Kidd  strongly  recommends"  the  internal  use  of  turpentine,  as 
given  by  Mr.  Carmichael  in  iritis.     (See  p.  531.) 

11.  A  residence  on  shore,  and  a  return  to  Europe,  are  to  be  recommended 
in  obstinate  cases  on  board  ship,  or  in  the  warm  latitudes.  These  are  also 
often  the  only  means  of  preventing  relapses  in  those  w^ho  have  already  repeat- 
edly suffered  from  night-blindness. 


'  Medical  Ob-'ervations  and  Inquiries;  Vol.  schlichen  Auges  ;  Theil  i.  Taf.  xix.  Fig.  9,  10; 

i.  p.  Ill  ;  London,  1763.  Berlin,  1838. 

'^  Quoted    from    Medicinische    Zeitung,    in  '  Rosier,  Observations  sur  la  Physique;  Tome 

Dublin    Journal    of    iMedical    and    Chemical  ix.  p.  379  :  Paris,  1777. 

Science  ;  Vol.  viii.  p.  123.  "  See  case  by  Ileberden,  in  his  Commentarii 

^  Quoted  from  the  Bulletin  de  Thdrapeutique,  de  Morborum  Historia,  cap.  60. 

in  Johnson's  Medico-Chirurgical  Review,  July,  '  Dublin  Journal   of  Medical  Science,  No- 

1842.  p.  193.  vember,  1840,  p.  169. 

*  Medico-Chirurgical  Transactions;  Vol.  v.  '°  See  cases  bj' Wharton,  American  Journal 
p.  47  ;  London,  1814.  of  the  Medical  Sciences,  May.  1S40.  p.  93. 

*  De  Retina  ObservationesAnatomico-Patho-  "  Dublin  Medical  Press,  May  10,  1843,  p. 
lotricie.  p.  158  ;  Gotting»,  1836.  292. 

*  Darstellungen  der  Krankheiten  dcs  men- 


SECTION  Xni. — DAY-BLINDNESS. 

Syn. — Diurnal  amaurosis.     See  synonyms  at  beginning  of  last  section. 

Although  day-blindness  is  enumerated  by  all  systematic  authors  on  the 
diseases  of  the  eye,  very  little  has  been  recorded  on  the  subject  from  actual 
observation.     Scrofulous  intolerance  of  light,  the  photophobia  of  the  albino, 


DAY-BLINDNESS,  92T 

or  the  blindness  of  the  captives  of  Dionysius,  long  shut  up  in  the  dark  and 
suddenly  brought  out  into  the  glare  of  day/  must  not  be  confounded  with  a 
periodical  amaurosis,  the  counterpart  of  that  which  we  have  last  considered. 
Day-blindness  is  mentioned  as  a  symptom  both  of  mydriasis  and  myosis.  In 
the  former  disease,  the  pupil  admits  too  much  light  to  enable  the  patient  to 
see  till  after  sunset.  In  the  latter,  the  contraction  of  the  pupil  is  supposed 
to  relax  in  the  obscurity  of  the  night,  and  the  vision  iu  this  way  to  improve. 
On  the  same  principle,  the  patient  affected  with  incipient  cataract  sees  little 
during  the  brightness  of  the  day,  but  finds  his  sight  in  part  restored  by  the 
dilatation  of  the  pupil,  which  takes  place  in  the  evening. 

Among  the  few  original  observations  tending  to  establish  the  fact  of  there 
being  such  a  disease  as  a  periodic  amaurosis,  which  makes  its  attack  through 
the  day,  and  departs  at  night,  may  be  quoted  the  following  from  Ramazzini. 

"  I  have  repeatedly  observed,"  says  be,  "  among  our  counti-y  people,  and  especially  iu 
boys,  a  thing  sufBciently  strange.  In  March,  about  the  equinox,  boys  about  ten  years  of 
age  were  aifected  with  a  great  degree  of  weakness  of  sight,  so  that  through  the  whole 
day  they  saw  little  or  nothing,  and  wandered  about  the  fields  like  blind  people ;  but  when 
night  came  they  saw  again  distinctly.  This  affection  ceased  without  any  remedy,  and  by 
the  middle  of  April  the  patients  were  completely  restored  to  sight.  I  frequently  observed 
the  eyes  of  these  boys,  and  found  the  pupils  much  enlarged."* 

A  gentleman  related  to  Dr.  Guthrie  that  he  had  witnessed  the  following 
example  of  day-blindness.  Whilst  in  garrison  in  Landau,  in  Alsace,  in  the 
summer  of  1772,  two  hundred  men  of  the  regiment  of  Picardie  were  seized 
with  a  species  of  blindness  during  the  meridian  splendor  of  the  sun,  and 
could  not  see  their  way  when  it  was  not  overcast,  insomuch  that  when  they 
had  strolled  out  into  the  fields  during  a  cloudy  day,  if  the  sun  suddenly  shone 
out,  they  were  absolutely  obliged  to  be  led  by  their  companions  till  a  cloud 
once  more  obscured  the  solar  light,  and  enabled  them  to  pursue  their  course.^ 

These  instances  look  like  an  endemic  or  epidemic  day-blindness ;  but  are 
evidently  too  vague  to  furnish  grounds  for  any  general  conclusions. 

Larrey  records  a  case  of  sporadic  day-blindness,  occurring  in  an  old  man, 
one  of  the  galley-slaves  at  Brest,  who  had  for  thirty-three  years  been  shut  up 
in  a  subterraneous  dungeon.  His  long  residence  in  darkness  had  such  an 
effect  on  the  organs  of  vision,  that  he  could  see  only  under  the  shade  of  night, 
and  was  completely  blind  during  the  day.* 

Another  case,  connected  with  a  venereal  taint,  and  cured  by  mercurial  fric- 
tions, is  related  by  Isbell.^ 

Case  370. — In  a  hand-loom  weaver,  aged  58,  residing  at  Auchtermuchty,  Fifeshire,  ad- 
mitted at  the  Edinburgh  Eye  Infirmary  under  the  care  of  Dr.  Hamilton  and  Mr.  Bell,  and 
whose  right  eye  had  been  destroyed  by  smallpox  in  childhood,  the  vision  of  the  left  eye 
had  been  invariably  good,  until  the  21st  of  February,  1850,  when,  without  pain  or  un- 
easiness of  any  kind,  it  suddenly  left  him.  But,  although  totally  blind  during  the  day, 
he  could  see  nearly  as  well  as  formerly  by  moon  or  star-light.  He  could  not  walk  on  the 
road  by  day  without  stumbling,  and  he  therefore  required  a  guide  ;  at  night,  he  could  do 
so  quite  well.  During  the  day,  he  could  not  see  half  the  length  of  himself;  by  night  he 
could  see  a  house  at  about  200  yards'  distance.  At  night,  looking  at  the  sky,  he  could 
quite  well  discern  the  stars  and  the  moon,  and  the  clouds  jjassing  over  the  moon ;  during 
the  day,  he  could  see  nothing,  a  cloudy  and  clear  sky  being  alike  invisible. 

He  was  recommended  to  keep  a  blister  open  behind  his  ear,  to  apply  two  leeches  twice 
a  week  to  the  under  eyelid,  and  to  take  a  blue  pill,  with  rhubarb,  every  second  night. 
In  the  course  of  eight  or  nine  weeks,  these  pi-escriptions  were  followed  by  slow  and  steady 
improvement;  his  bodily  health,  however,  appearing  to  give  way,  the  remedies  were  dis- 
continued, and  a  milk  diet  and  bitter  infusions  substituted  for  them.  Under  this  treat- 
ment, vision  gradually  improved ;  but  he  was  much  annoj'ed  with  the  sensation  of  au 
object  flitting  before  hira,  on  every  attempt  to  use  the  eye.  At  first  it  was  of  variegated 
colors,  afterwards  almost  black.  A  sojourn  of  several  weeks  at  the  sea- side,  where  he 
had  regular  bathing,  improved  both  his  general  health  and  his  eyesight,  and  the  ocular 
spectra  or  muscae  gradually  disappeared  during  the  summer  and  autumn.     In  October  he 


928  HEMIOPIA. 

was  able  to  resume  his  occupation,  continuing  at  the  loom  without  interruption,  his  vision 
being  as  strong  and  perfect  as  ever.  His  power  of  vision  by  night,  which  had  continued 
during  all  his  illness,  was  not  at  all  aflfected  by  the  recovery  of  his  sight  by  day.^ 


'  Galenus  de  Usu  Partium ;  Lib.  x.  cap.  3.  *  Memoirs  de  Chirurgie  Militaire;  Tome  i. 

"  De  Morbis  Artificum,  cap.  xxxviii.  5  Opera,    p.  6;  Paris,  1812. 
p.  363  ;  Londini,  1718.  '  Edinburgh  Medical  and  Surgical  Journal ; 

'  Duncan's  Medical  Commentaries;  Vol.xix.     Vol.  is.  p.  209;  Edinburgh,  1813. 
p.  290;  Edinburgh,  1795.  '  Monthly  Journal  of  Medical  Science;  Vol. 

xii.  p.  393  ;  Edinburgh,  1851. 


SECTION  XIV. — HE>aOPIA. 

Syn. — Hemiopia,  from  njuiinif,  half,  and  o^-if,  vision.     Visus  dimidiatus. 

Disposition  of  optic  nerves. — It  is  generally  admitted  that  there  is  a  partial  decussation 
of  the  primitive  fibres  of  the  two  optic  nerves  in  the  chiasma ;  that  this  decussation 
aflFects  principally  their  central  and  deep-seated  fibres  ;  and  that  the  lateral  and  superfi- 
cial do  not  cross.  Consequently  these  last  come,  in  each  nerve,  from  the  same  side,  while 
the  former  come  from  the  opposite  side  of  the  brain.  For  the  following  hyopthetical 
view  of  the  subject  we  are  indebted  to  Mr.  Mayo. 

Each  tractus  opticus  is  supposed  to  consist  of  three  bands  of  fibres  or  nerve-tubes — an 
outer,  a  middle,  and  an  inner.  Each  optic  nerve  consists,  likewise,  of  an  outer,  a  mid- 
dle, and  an  inner  series  of  nerve  tubes.  The  inner  series  of  each  is  commissural.  The 
inner  band  of  the  one  optic  tract  bends  round  into  its  fellow,  forming  the  posterior  border 
of  the  chiasm.a  (commissura  arcuala  posterior,  Hannover),  and  unites  the  origin  of  these 
two  nerves.  The  inner  band  of  the  one  optic  nerve  coalesces  in  like  manner  with  its 
fellow,  forming  the  anterior  border  of  the  chiasma  (commissura  arcuata  anterior),  and  unites 
the  two  retime.  Of  the  two  bands  which  remain,  the  middle  crosses  its  fellow  (commis- 
sura cruciata),  and  forming  the  middle  band  of  the  opposite  optic  nerves,  may  be  pre- 
sumed to  be  distributed  principally  to  that  part  of  the  inner  half  of  the  retina,  about 
four-ninths  of  its  whole  extent,  which  springs  from  the  nasal  side  of  the  optic  nerve. 
The  outer  band  of  each  optic  tract  (fasciculus  dexter  et  sinister)  becomes  the  outer  band  of 
the  optic  nerve  of  the  same  side,  and  is  presumed  to  supply  the  temporal  side  of  the 
retina,  including  the  vertex  or  optic  axis,  and  fully  more  than  five-ninths  of  its  whole 
extent. 

The  two  eyes  in  man  converge,  in  all  positions,  towards  a  common  visual  axis.  Retinal 
surfaces  are  of  two  classes;  those  which  can  be  turned  towards  a  common  visual  axis, 
and  those  which  cannot.  To  the  former  belongs  that  part  of  the  human  retina  which  is 
to  the  temporal  side  of  the  termination  of  the  optic  nerve  in  the  eyeball.  To  the  latter 
belongs  the  remaining  part  of  the  human  retina,  and  the  whole  retina  of  those  animals 
in  which  there  is  a  complete  decussation  of  the  optic  nerves,  the  whole  of  the  right  optic 
nerve  going  to  the  left  eye,  and  vice  versa,  as  in  the  cod.  The  retinal  surface  which  can 
be  directed  to  a  common  visual  axis  is  supplied  by  the  optic  nerve  of  the  same  side ;  the 
retinal  surface  which  cannot  be  so  directed  is  supplied  by  the  nerve  of  the  other  side. 
The  first  is  assumed  to  be  the  case  with  the  outer  five-ninths  of  the  human  retina ;  the 
second  with  the  inner  four-ninths,  and  with  the  entire  retina  of  those  animals  in  Avhich 
the  decussation  is  total,  such  as  the  cod. 

In  osseous  fishes,  each  optic  nerve  is  employed  in  looking  to  one  side  only  ;  the  right 
looks  to  the  left,  the  left  to  the  right.  By  analogy,  in  man,  likewise,  the  right  optic 
nerve  should  see  to  the  left  only.  To  determine  whether  this  is  the  fact,  it  is  necessary 
to  consider  which  way  the  retinal  surfaces  in  both  eyes  are  directed.  The  fitting  position 
of  the  eyes,  for  this  examination,  is  that  in  which  they  are  looking  at  a  small  object  held 
immediately  in  front  of  the  face,  at  the  level  of  the  eyes,  and  at  the  nearest  point  for 
distinct  vision.  In  this  position,  almost  the  whole  of  that  portion  of  the  right  retina 
which  lies  to  the  outside  of  the  entrance  of  the  optic  nerve,  is  directed  to  the  left ;  and 
the  exactly  different,  complementary,  or  inner  portion  of  the  left  retina,  likewise,  is 
directed  to  the  left.  Then,  by  analogy,  the  right  optic  tract  should  supply  filaments  to 
the  portions,  so  specified,  of  the  right  and  left  retince  ;  and  that  this  may  be  the  case, 
considering  that  the  outside  of  the  right  optic  nerve,  and  the  inside  of  the  left,  consist  of 
filaments  from  the  right  optic  tract,  seems  anatomically  probable.  If  the  anatomical  re- 
lation between  the  parts  of  the  optic  nerves  and  the  retinal  surfaces,  so  rendered  pro- 


HEMIOPIA.  929 

bable,  turn  out  to  be  correct,  the  simple  expression  of  the  facts  ■will  be — In  vertebral 
animals  the  right  nervfe  is  employed  in  vision  to  the  left,  the  left  in  vision  to  the  right; 
or,  in  those  which  have  single  vision  with  two  eyes,  the  right  nerve  is  employed  in  vision 
to  the  left  of  the  common  visual  axis,  the  left  to  the  right  of  that  axis.' 

Hemiopia  signifies  a  partial  blindness  obscuring  about  a  half  of  the  field  of 
vision.  Generally  it  is  the  right  half  or  the  left  half  of  all  objects  which 
appears  dark,  and  that  whether  they  are  regarded  with  one  eye  only,  or  with 
both.  In  other  cases,  only  one  eye  is  affected.  It  is  necessary  also  to  ob- 
serve, that  the  upper  or  the  lower  half  of  the  field  of  vision  may  appear 
dark ;  or  that  the  patient,  looking  directly  forwards,  may  see  tolerably  well 
wathin  a  certain  angle,  but  nothing  to  either  side.  These  varieties  of  hemi- 
opia are  less  common  than  that  in  which  the  right  or  left  half  of  each  retina 
appears  to  be  insensible  to  light,  but  are  not  less  worthy  of  attention. 

It  would  appear,  from  the  histories  of  hemiopia  on  record,  that  it  is  apt 
to  be  sudden  in  its  attack,  and  to  recur  at  considerable  intervals  of  time. 

Dr.  Wollaston,  a  few  years  before  his  death,  was  the  means  of  directing 
considerable  attention  to  this  disease,  by  his  paper  On  Semi-decussation  of 
the  Optic  Nerves,  published  in  the  Philosophical  Transactions.  He  had  been 
twice  attacked  by  hemiopia,  and  had  occasionally  met  with  it  in  others. 

"It  is  now  more  than  twenty  years,"  says  he,  "since  I  was  first  attacked  with  the 
peculiar  state  of  vision  to  which  I  allude,  in  consequence  of  violent  exercise  I  had  taken 
for  two  or  three  hours  before.  I  suddenly  found  that  I  could  see  but  half  the  face  of  a 
man  whom  I  met ;  and  it  was  the  same  with  respect  to  every  object  I  looked  at.  In 
attempting  to  read  the  name  Johnson,  over  a  door,  I  saw  only  son,  the  commence- 

hient  of  the  name  being  wholly  obliterated  to  my  view.  In  this  instance  the  loss  of  sight 
w^•^s  towards  vc.j  left,  and  was  the  same  whether  I  looked  with  the  right  eye  or  the  left. 
This  blindness  was  not  so  complete  as  to  amount  to  absolute  blackness,  but  was  a  shaded 
darkness  without  definite  outline.  The  complaint  was  of  short  duration,  and  in  about  a 
quarter  of  an  hour  might  be  said  to  be  wholly  gone,  having  receded  with  a  gradual  motion 
from  the  centre  of  vision  obliquely  upwards  towards  the  left. 

"  Since  this  defect  arose  from  over-fatigue,  a  cause  common  to  many  other  nervous 
affections,  I  saw  no  reason  to  apprehend  any  return  of  it;  and  it  passed  away  without 
any  need  of  remedy,  without  any  further  explanation,  and  without  my  drawing  any 
useful  inference  from  it. 

"  It  is  now  about  fifteen  months  since  a  similar  affection  occurred  again  to  myself; 
without  my  being  able  to  assign  any  cause  whatever,  or  to  connect  it  with  any  previous 
or  subsequent  indisposition.  The  blindness  was  first  observed,  as  before,  in  looking  at 
the  face  of  a  person  I  met,  whose  left  eye  was  to  my  sight  obliterated.  My  blindness  was 
in  this  instance  the  reverse  of  the  former,  being  to  my  right  (instead  of  the  left)  of  the 
spot  to  which  my  eyes  were  directed ;  so  that  I  have  no  reason  to  suppose  it  in  any 
manner  connected  with  the  former  aflFection. 

"The  new  punctum  csBCum  was  situated  alike  in  both  eyes,  and  at  an  angle  of  about 
three  degrees  from  the  centre ;  for  when  any  object  was  viewed  at  the  distance  of  about 
five  yards,  the  point  not  seen  was  about  ten  inches  distant  from  the  point  actually 
looked  at. 

"  On  this  occasion  the  affection,  after  having  lasted  with  little  alteration  for  about 
twenty  minutes,  was  removed  suddenly  and  entirely  by  the  excitement  of  agreeable  news 
respecting  the  safe  arrival  of  a  friend  from  a  very  hazardous  enterprise."'^ 

In  consequence  of  reflecting  ou  these  attacks  of  hemiopia,  Dr.  Wollaston 
was  led  to  adopt  the  following  hypothesis  regarding  the  arrangement  of  the 
optic  nerves;  the  hypothesis,  in  fact,  of  Sir  Isaac  Newton.^ 

"Since  the  corresponding  points  of  the  two  eyes,"  says  he,  "  sympathize  in  disease, 
their  sympathy  is  evidently  from  structure,  not  from  mere  habit  of  feeling  together,  as 
might  be  infen-ed,  if  reference  were  had  to  the  reception  of  ordinary  impressions  alone. 
Any  two  corresponding  points  must  be  supplied  with  a  pair  of  filaments  from  the  same 
nerve,  and  the  seat  of  a  disease  in  which  similar  parts  of  both  eyes  are  affected,  must  be 
considered  as  situated  at  a  distance  from  the  ej'cs  at  some  place  in  the  course  of  the 
nerves  where  these  filaments  are  still  united,  and  probably  in  one  or  the  other  thalamus 
nervorum  opticorum. 

"It  is  plain  that  the  cord,  which  comes  finally  to  either  eye  under  the  name  of  optic 
59 


930  HEMIOPIA. 

nerve,  must  be  regarded  as  consisting  of  two  portions,  one  half  from  the  right  thalamus, 
and  the  other  from  the  left  thalamus  nervorum  opticorum.* 

"  According  to  this  supposition,  decussation  -will  take  place  only  between  the  adjacent 
halves  of  the  two  nerves.  That  portion  of  nerve  which  proceeds  from  the  right  thalamus 
to  the  right  side  of  the  right  eye,  passes  to  its  destination  without  interference  ;  and  in 
a  similar  manner  the  left  thalamus  will  supply  the  left  side  of  the  left  eye  with  one  part 
of  its  fibres,  while  the  remaining  halves  of  both  nerves,  in  passing  over  to  the  eyes  of  the 
opposite  side,  must  intersect  each  other,  either  vrith  or  without  intermixture  of  their 
fibres. 

"  Now,  if  wc  consider  rightly  the  facts  discovered  by  comparative  anatomy  in  fishes, 
we  shall  find  that  the  crossing  of  the  entire  nerves  in  them  to  the  opposite  eyes,  is  in 
perfect  conformity  to  this  view  of  the  arrangement  of  the  human  optic  nerves.  The 
relative  position  of  the  eyes  to  each  other  in  the  sturgeon,  is  so  exactlj^  back  to  back,  on 
opposite  sides  of  the  head,  that  they  can  hardly  see  the  same  object ;  they  can  have  no 
points  which  generally  receive  the  same  impressions  as  in  us;  there  are  no  corresponding 
points  of  vision  requiring  to  be  supplied  with  fibres  from  the  same  nerve.  The  eye  which 
sees  to  the  left  has  its  retina  solely  upon  its  right  side  ;  and  this  is  supplied  with  an  optic 
nerve  arising  wholly  from  the  right  thalamus ;  while  the  left  thalamus  sends  its  fibres  en- 
tirely to  the  left  side  of  the  right  eye  for  the  perception  of  objects  situated  on  the  right. 
In  this  animal  an  injury  to  the  left  thalamus  might  be  expected  to  occasion  entire  blind- 
ness of  the  right  eye  alone,  and  want  of  perception  of  objects  placed  on  that  side.  In 
ourselves,  a  similar  injury  to  the  left  thalamus  would  occasion  blindness  (as  before)  to  all 
objects  situated  to  our  right,  owing  to  insensibility  of  the  left  half  of  the  retina  of  both 
eyes." 

Having  thus  explained  liis  hypothesis,  Dr.  Wollaston  goes  on  to  relate 
the  following  additional  instance  of  hemiopia. 

"A  disorder,"  says  he,  "that  has  occurred  within  my  own  knowledge  in  the  case  of  a 
friend,  seems  fully  to  confirm  this  reasoning,  as  far  as  a  single  instance  can  be  depended 
upon.  After  he  had  suffered  severe  pain  in  his  head  for  some  days,  about  the  left  temple, 
and  toward  the  back  of  the  left  ej'e,  his  vision  became  considerably  impaired,  attended 
with  other  symptoms  indicating  a  slight  compression  on  the  brain. 

"  It  was  not  till  after  the  lapse  of  three  or  four  weeks  that  I  saw  him,  and  found  that, 
in  addition  to  other  affections  which  need  not  here  be  enumerated,  he  labored  under  a 
defect  of  sight  similar  to  those  which  had  happened  to  myself,  but  more  extensive,  and 
it  has  unfortunately  been  far  more  permanent.  In  this  case,  the  blindness  was  at  that 
time  and  still  is  entire,  with  reference  to  all  objects  situated  to  the  right  of  his  centre  of 
view.  Fortunately,  the  field  of  his  vision  is  suflRcient  for  writing  perfectly.  He  sees 
what  he  writes,  and  the  pen  with  which  he  writes,  but  not  the  hand  that  moves  the  pen. 
This  affection  is,  as  far  as  can  be  observed,  the  same  in  both  eyes,  and  consists  in  an  in- 
sensibility of  the  retina  on  the  left  side  of  each  eye.  It  seems  most  probable,  that  some 
effusion  took  place  at  the  time  of  the  oi-iginal  pain  on  that  side  of  the  head,  and  has  left 
a  permanent  compression  on  the  left  thalamus.  This  partial  blindness  has  now  lasted  so 
long  without  sensible  amendment,  as  to  make  it  very  doubtful  when  my  friend  may  re- 
cover the  complete  perception  of  objects  on  that  side  of  him." 

Towards  the  conclusion  of  his  paper,  Dr.  Wollaston  adds  the  following 
notice  of  another  case  of  this  disease. 

"  One  of  my  friends,"  says  he,  "  has  been  habitually  subject  to  it  for  sixteen  or  seven- 
teen years,  whenever  his  stomach  is  in  any  considerable  degree  deranged.  In  him  the 
blindness  has  been  invariably  to  his  right  of  the  centre  of  vision,  and,  from  want  of  due 
consideration,  had  been  considered  as  temporary  insensibility  of  the  right  eye ;  but  he  is 
now  satisfied  that  this  is  not  really  the  case,  but  that  both  eyes  have  been  similarly 
affected  with  half-blindness.  This  symptom  of  his  indigestion  usually  lasts  about  a 
quarter  of  an  hour  or  twenty  minutes,  and  then  subsides,  without  leaving  any  permanent 
imperfection  of  sight." 

Dr.  "Wollaston  died  about  four  years  after  the  publication  of  the  paper 
from  which  these  extracts  are  taken.  Whether  he  had  any  third  attack  of 
hemiopia,  I  know  not ;  but  in  the  account  which  has  been  published  of  the 
appearances  observed  on  inspecting  his  body,  we  find  it  stated,  that  the  optic 
thalamus  of  the  right  side  was  of  an  unusually  large  size,  and  that  ou  making 
a  section  of  it,  little  or  no  vestige  of  its  natural  substance  was  perceptible, 
with  the  exception  of  a  layer  of  medullary  substance  on  its  upper  part.  It 
had  been  converted  into  a  tumor,  as  large  as  a  middle-sized  hen's  egg, 


HEMIOPIA.  931 

towards  the  circumference  of  a  grayish  color,  and  harder  than  the  brain  itself, 
somewhat  of  a  caseous  substance,  but  in  the  centre  of  a  brown  color,  soft, 
and  in  a  half-dissolved  state.  This  diseased  structure  was  not  confined  to 
the  thalamus,  but  extended  to  the  neighboring  portion  of  the  corpus  stri- 
atum. The  right  optic  nerve,  where  it  passes  on  the  outside  of  the  thala- 
mus, was  of  a  brown  color,  more  expanded,  and  softer  than  natural.^ 

The  reader  will  readily  perceive,  that  between  this  state  of  the  brain,  and 
the  previous  symptoms  of  hemiopia,  there  may  or  may  not  have  been  a  con- 
nection ;  for  there  were  two  distinct  attacks  of  the  disease,  at  the  interval  of 
twenty  years,  each  attack  subsiding  entirely  after  fifteen  or  twenty  minutes  ; 
in  the  first  attack  objects  to  the  left  appearing  dark,  and  in  the  second,  those 
to  the  right.  We  know  that  morbid  alterations  in  the  substance  of  the 
brain  often  produce  periodic  diseases,  and  that  certain  additional  causes  of 
excitement  operating  upon  an  unsound  brain,  one  or  other  of  the  functions 
of  that  organ  are  for  a  time  impeded,  till  the  new  cause  ceases  to  operate, 
when  the  individual  immediately  returns  to  his  former  state  of  apparent 
health. 

The  following  remarks  have  occurred  to  me,  in  reflecting  on  Dr.  Wollaston's 
paper  : — 

1.  The  notion  of  a  semi-decussation  of  the  optic  nerves  had  not  merely 
been  entertained  by  several  distinguished  authors,*^  before  Dr.  Wollaston,  but 
had  in  some  measure  been  demonstrated  by  dissection. ^  Even  the  idea  that 
the  two  portions,  of  which  each  optic  nerve  may  be  regarded  as  consisting, 
remain  distinct,  after  they  form  the  retina,  appears  to  belong  to  Sir  Isaac 
Newton.  It  is  supported,  however,  by  Dr.  Wollaston,  by  an  argument  which 
is  new,  and  probably  without  foundation;  namely,  that  any  two  corresponding 
points  of  the  two  retinas  must  be  supplied  with  filaments  either  from  the  right 
or  from  the  left  optic  nerve,  and  that  upon  this  depends  their  correspondence. 
Dr.  Wollaston  appears  to  have  overlooked  the  fact,  that  as  the  optic  nerves 
pass  through  the  sclerotica  and  choroid  considerably  nearer  the  middle  line  of 
the  body  than  the  centre  of  the  globe  of  each  eye,  the  vertices  of  the  two 
retinte  or  the  two  optic  axes,  which,  if  any  two  points  deserve  to  be  considered 
as  such,  are  surely  corresponding  points,  will  not  be  formed  by  the  filaments 
from  the  same  nerve,  but  from  opposite  nerves.  It  has  always  occurred  to  me 
as  more  probable,  that  the  several  portions,  of  which  each  optic  nerve  consists, 
mingle  their  fibres,  and  then  expand  into  the  retina,  so  that  this  membrane  in 
each  eye  should  be  regarded  as  a  plexus,  every  point  of  which  contains  fibres 
derived  from  each  side  of  the  brain,  while  the  fibres  which  are  the  most  essential 
for  vision  are  derived,  for  the  right  side  of  the  two  retinaj,  from  the  right  side 
of  the  brain,  and  vice  versa,  the  remaining  fibres  fulfilling  a  commissural  or 
consensual  office. 

2.  It  is  not,  however,  by  mere  reasoning  upon  a  subject  like  this,  that  we 
can  arrive  at  any  sound  conclusion.  By  far  the  greater  part  of  the  mass  of 
facts,  in  pathological  and  in  what  maybe  called  experimental  anatomy, touch- 
ing this  question,  go  to  prove,  that  injuries  and  diseases  affecting  one  side  of 
the  brain,  instead  of  hemiopia  in  both  eyes,  produce  amaurosis  only  in  the 
opposite  eye.^  The  fact,  also,  which  has  been  already  mentioned  in  the 
beginning  of  this  section,  that  we  meet  with  a  horizontal  as  well  as  a  perpen- 
dicular hemiopia,  appears  scarcely  reconcilable  to  the  hypothesis  of  Dr.  Wol- 
laston. Not  so,  however,  that  other  variety  of  the  disease,  in  which  objects  to 
each  hand  appear  dark,  and  those  only  which  are  placed  within  a  certain  angle 
in  front  are  seen  distinctly ;  for  were  any  tumor  to  press  on  the  anterior  edge 
of  the  chiasma  of  the  optic  nerves,  the  effect  would  be,  according  to  the 
hypothesis  of  semi-decussation,  to  paralyze  the  inner  half  only  of  each  retina. 
I  had  under  my  care  a  patient  with  amaurosis  of  the  inner  half  of  each  retina, 


932  CIRCUMORBITAL   NEURALGIA. 

attended  with  total  loss  of  the  sense  of  smell,  and  an  imperfect  sense  of  taste. 
He  presented  no  other  signs  of  cerebral  disease,  and  I  thought  it  probable 
that  the  imperfection  in  taste  was  owing  to  the  loss  of  the  power  of  smell,  and 
this,  along  with  the  hemiopia,  to  some  pressure  on  the  optic  nerves,  imme- 
diately in  front  of  the  chiasma,  and  on  the  olfactory  nerves. 

Treatment. — Hemiopia,  being  merely  a  peculiar  variety  of  amaurosis,  must 
be  treated  on  similar  principles.  The  patient's  constitution,  whether  plethoric 
or  debilitated,  the  state  of  his  digestive  organs,  the  presence  or  absence  of 
cerebral  symptoms,  as  headache,  vertigo,  &c.,  must  be  taken  into  account,  and 
guide  us  in  the  choice  of  remedies.^ 


'  Medical  Gazette  ;  Vol.  xxix.  pp.  229,  277;  '  Medical  Gazette ;  Vol.  iii.  p.  293 ;  London, 

London,  1841.  1829. 

'^  Philosophical  Transactions,  for  1824;  Part  "  Newton,  Vater,  Ackermann,  Vicq-d'Azyr, 

i.  p.  224.                                                    '  Caldani,  Cuvier,  &c. 

^  Query  15th,  at  the  end  of  the  Optics.  ''  Josepbus    et  Carolus  Wenzel   de  Penitiori 

*  Although  the  tractus  opticus  first  becomes  Structura  Cerebri,  pp.  109,  333;  Tab.  vi.  fig.  1; 

apparent  at  the  under   surfaces  of  the  corres-  Tubingae,  1812. 

ponding  optic  thalamus,  the  origin  of  the  optic  *  Serres,  Anatomic    Compar6e  du  Cerveau ; 

nerves  is  now  acknowledged   to  be,  not  in  the  Tome  i.  p.  331  ;  Paris,  1827. 

parts   called  thalarai    nervorum    opticorum,  as  °  On   hemiopia,  consult   Arago,  Annales  de 

Dr.    Wollaston    believed,    but    in   the   corpora  Chimie;   Tome  xxvii.  p.   109:  Crawford,  Lon- 

quadrigemina,  parts  analogous  to  the  optic  lobes  don  Medical  and  Physical  Journal;  Vol.  liii.  p. 

of  birds,  reptiles,  and  fishes.  48  :  Pravaz,  Archives  Generales  de  Medecine ; 

Tome  viii.  p.  59;  ix.p.  485. 


CHAPTER  XXV. 


DISEASES  OF  THE  FIFTH  NEKYE,  AFFECTING  THE  ORGAN 

OF  VISION. 


SECTION  I. — PAINFUL  AFFECTIONS  OF  THE  FIFTH  NERVE. 

§  1.  Neuralgia  of  the  ocular  and  orbital  branches  of  the  fifth  nerve. 

Sijn. — Neuralgia,  from  nZpv,   nerve,  and  Sxy)-,  pain.     Prosopalgia,  from  irfQa-aimv,  face, 
and  dxyof,  pain.     Tic  douloureux,  Fr. 

The  branches  of  the  first  and  second  divisions  of  the  fifth  nerve,  distributed 
to  the  eye,  eyelids,  and  circumorbital  region,  are  more  frequently  the  seat  of 
severe  pain  than  any  other  nerves  of  the  body. 

Distribution  of  the  fifth  nerve. — It  may  not  be  improper  to  recall  to  mind,  that  the  super- 
ficial situation  of  these  nerves  exposes  them  more  than  most  others  to  mechanical  injuries, 
and  to  the  impression  of  cold:  their  being  transmitted  through  narrow  fibrous  or  osseous 
passages  may  also  contribute  to  the  frequency  of  their  painful  affections.  The  fifth  nerve, 
by  means  of  its  motive  root,  stimulates  the  muscles  of  mastication,  and  by  means  of  its 
sensitive  root  gives  sensibility  to  the  teeth,  and  to  the  whole  surfaces  of  the  face,  internal 
and  external.  Whatever  sensibility  the  facial  and  other  motor  nerves  of  the  face  possess, 
they  derive  from  the  fifth.  This  nerve  passes  through  every  muscle  of  the  face,  to  gain 
the  skin,  to  vrhich  it  is  ultimately  destined.  It  penetrates  into  the  organs  of  smell,  vision, 
hearing,  and  taste,  communicating  common  sensibility  to  the  varied  textures  of  these,  the 
organs  of  special  sensibility.  By  means  of  fibres  from  the  great  sympathetic,  which  join  the 
fifth  nerve  anteriorly  to  the  Gasserian  ganglion,  this  nerve  is  regarded  a  presiding  over  the 
nutrition  of  the  parts  to  which  it  is  distributed. 

Besides  the  ciliary  nerve,  a  branch  of  the  nasal,  which  (joining  a  branch  from  the 
motor  oculi  to  form  the  lenticular  ganglion)  gives  sensibility  to  the  interior  of  the  eye- 


CIRCUMORBITAL  NEURALGIA.  933 

ball,  we  have  six  branches  of  the  fifth  radiating  from  the  orbit  to  the  surrounding  parts, 
viz :  the  infratrochlear,  the  supratrochlear,  the  supra-orbitary,  the  lachrymal,  the  malar, 
and  the  infra-orbitary. 

In  the  consideration  of  neuralgia  of  the  fifth  nerve,  we  set  aside  those 
instances  in  which  pain  is  communicated  through  its  medium,  in  consequence 
of  inflammation  or  of  disorganizing  diseases  of  the  eye  and  its  appendages. 

Varieties. — It  is  of  importance,  in  a  practical  point  of  view,  to  distinguish 
the  following  varieties  of  neuralgia  of  the  branches  of  the  fifth  nerve,  passing 
through  the  orbit,  and  distributed  to  the  eyeball,  eyelids,  and  neighboring 
parts. 

1.  The  simplest  and  most  frecjuent  variety  is  an  acute  affection  of  the  ulti- 
mate ramifications  of  the  nerve,  and  chiefly  of  those  distributed  above  the 
orbit,  attacking  individuals  in  every  respect  healthy  and  robust,  and  arising 
distinctly  from  the  influence  of  cold.  The  paroxysms  in  this  variety  observe 
a  quotidian  type,  the  general  period  of  the  pain  being  from  eight  or  nine 
A.  M.  till  five  or  six  P.  M. 

The  branches  of  the  frontal  and  lachrymal  nerves  are  those  chiefly  afi'ected 
in  this  variety  of  neuralgia.  During  the  paroxysm  the  eye  reddens  and  dis- 
charges tears.  The  pain  reaches  its  point  of  greatest  severity  about  noon, 
after  which  it  gradually  relaxes,  and  generally  abates  so  much  as  not  to  pre- 
vent sleep  during  the  night. 

The  average  duration  of  this  acute  peripheral  neuralgia  is  eight  or  ten 
days.  It  yields  readily  to  proper  external  and  internal  remedies,  and  is 
liable  to  recur  only  after  renewed  exposure  to  the  original  exciting  cause.  It 
prevails  most  during  the  east  winds  of  spring.  I  have  never  seen  any  reason 
to  suppose  it  to  be  in  any  way  connected  with  ague  or  its  causes. 

2.  In  the  next  variety  a  cicatrice  of  the  eyebrow,  or  other  neighboring 
part,  marks  the  seat  of  some  previous  injury,  which  had  implicated  one  or 
other  of  the  branches  of  the  fifth  nerve.  In  cases  of  this  kind  the  cicatrice 
is  more  or  less  indurated,  and  painful  to  the  touch  ;  the  pain  radiates  along 
the  nerve,  when  the  cicatrice  is  pressed,  and  a  firm  cord  may  sometimes  be 
traced  from  the  cicatrice,  both  along  the  forehead,  in  the  course  of  the  distri- 
bution of  the  nerve,  and  also  backwards  into  the  orbit. 

The  pain  in  such  traumatic  cases  is  not  confined  to  the  nervous  branches 
which  had  been  injured,  but  affects  other  branches  of  the  fifth  nerve.  Even 
distant  nerves  sometimes  become  the  seat  of  neuralgia  from  such  a  cause. 

3.  Tubercular  and  calcareous  depositions  in  contact  with  branches  of  the 
nerve,  or  contained  within  their  neurilemma,  have  proven  the  causes  of 
neuralgia.* 

4.  It  seems  to  be  generally  admitted  that  there  is  a  variety  of  neuralgia 
of  the  face,  either  depending  on  ague  or  originating  in  the  same  causes,  and 
especially  in  malarious  influence. 

This  febricose  neuralgia  will  be  met  with  chiefly  in  fenny  districts,  and  be 
characterized  by  the  symptoms  of  pyrexia  by  which  it  will  be  attended,  or 
with  which  it  will  sometimes  alternate,  and  by  the  periodicity  of  its  attacks. 
It  may  be  expected  in  some  cases  to  follow  a  regular  quotidian,  tertian,  or 
quartan  type,  while  in  other  instances,  it  may  be  irregular  in  its  paroxysms, 
occurring  perhaps  once  in  eight  days,  or  even  at  longer  intervals,  and  vary- 
ing much  in  the  severity  and  duration  of  its  attacks. 

5.  What  has  been  called  rheumatic  or  arthritic  neuralgia  generally  affects 
the  branches  of  the  fifth  pair,  going  to  the  teeth  long  before  it  attacks  the 
orbital  branches  of  the  same  nerve ;  the  teeth  have  decayed,  and  many  of 
them  have  dropped  out ;  the  patients  are  in  general  old  and  feeble,  and  have 
long  suffered  from  dyspepsia,  their  eyes  are  covered  with  varicose  vessels, 


934  CIRCUMORBITAL   NEURALGIA. 

their  crystalline  lenses  have  become  glaucomatous,  and  their  retinfc  are 
unsound. 

The  theory  of  the  febricose,  as  well  as  of  the  rheumatic  or  arthritic 
variety,  supposes  the  affected  branches  of  the  nerve  to  form  a  focus  of 
attraction  for  a  morbific  matter  generated  in  the  blood,  each  paroxysm  being 
followed  by  a  period  of  convalescence,  which  lasts  until  the  morbid  matter 
has  been  again  sufficiently  accumulated  to  induce  the  same  degree  of  irrita- 
tion of  the  nerves.'^ 

6.  Some  neuralgise  owu  a  central  origin,  the  painful  paroxysms  being  asso- 
ciated with  a  variety  of  symptoms  indicative  of  serious  organic  changes 
within  the  head.  The  causes  of  this  variety  of  neuralgia  are  often  productive 
of  pressure  on  other  nerves,  as  well  as  irritation  of  the  fifth ;  they  terminate 
in  such  alterations  of  tissue  as  leave  the  parts  formerly  the  seat  of  pain  in  a 
state  of  anaesthesia,  and  in  some  rare  cases  are  attended  with  exophthalmos,* 
or  even  with  visible  deformation  of  the  cranium.  It  is  remarkable  that  in 
cases  of  this  kind,  although  the  efficient  cause  is  central,  there  may  be  no 
pain  within  the  head,  but  only  at  the  periphery  of  the  nerve,  namely,  iu  the 
face. 

The  last  five  varieties  of  neuralgia  follow  a  chronic  course. 

Symptoms. — In  the  commencement  of  neuralgia,  the  pain  occurs  only 
momentarily,  and  perhaps  not  oftener  than  once  or  twice  in  the  24  hours. 
The  upper  eyelid,  the  middle  of  the  eyebrow,  the  nasal  extremity  of  the  super- 
ciliary arch,  the  inner  canthus,  or  the  temple,  is  its  most  frequent  seat.  The 
side  of  the  nose,  the  lower  lid,  the  check,  the  ball  of  the  eye,  and  the  parts 
behind  the  eye,  are  less  commonly  affected  in  incipient  cases.  As  the  disease 
proceeds,  the  pain  becomes  more  violent,  but  still  continues  only  for  an 
instant,  and  is  often  compared  by  the  patient  to  an  electric  shock.  Gradu- 
ally its  attacks  are  more  frequently  repeated,  last  longer,  although  rarely 
above  half  a  minute,  and  attain  a  degree  of  overpowering  severity.  The 
pain  is  often  referred  to  a  single  spot. 

In  chronic  cases,  we  observe  that  during  a  paroxysm,  the  eyebrows  are 
knit,  the  lids  firmly  closed,  the  angle  of  the  mouth  drawn  towards  the  ear, 
the  jaws  pressed  together,  and  respiration  as  much  as  possible  suppressed. 
The  muscles  in  the  immediate  vicinity  of  the  pain  are  sometimes  affected  with 
a  degree  of  quivering,  tremor,  or  slight  convulsion  ;  but  this  is  not  an  inva- 
riable symptom,  and  when  it  does  occur  seems  to  be  merely  an  effect  of  the 
violence  of  the  pain.  The  pain  is  not  equally  violent  during  the  whole  time 
of  an  attack.  In  general,  it  increases  by  degrees,  and  is  most  severe  a  short 
time  before  it  ceases.  The  disease  may,  in  some  cases,  be  said  to  be  con- 
tinued ;  but  in  general  it  is  remittent,  and,  in  many  instances,  completely 
intermittent,  so  that,  whenever  the  fit  is  over,  the  patient  feels  perfectly  free 
from  uneasiness  in  the  part,  which  but  an  instant  before  was  the  seat  of 
excruciating  pain.  We  meet  with  cases,  however,  in  which  a  degree  of  un- 
easiness still  continues,  although  the  agonizing  pain  is  gone.  In  long  con- 
tinued cases,  the  parts  to  which  the  pain  is  referred  become  swollen  from 
serous  effusion  into  the  cellular  tissue,  and  so  exquisitely  tender  in  general 
that  they  cannot  bear  the  slightest  touch.  Firm  pressure  can  sometimes  be 
borne,  and  even  gives  relief,  while  a  gentle  touch  will  excite  a  fit  of  pain. 
Sir  Charles  Bell  mentions  a  case  in  which  the  patient,  on  the  recurrence  of 
the  pain,  pressed  one  finger  firmly  on  the  infra-orbitary  hole,  another  upon  the 
inner  canthus,  a  third  upon  the  frontal  nerve,  and  a  fourth  before  the  ear ; 
and  thus  he  stood,  fixed  in  posture,  though  trembling  with  exertion.*  Facial 
neuralgia  sometimes  alternates  with  severe  nervous  pain  in  other  parts  of  the 
body. 

The  symptoms  occasionally  attendant  on  neuralgia  of  the  fifth  nerve,  and 


CIRCUMORBITAL   NEURALGIA.  935 

indicative  of  serious  organic  changes  within  the  cranium,  are  amaurosis,  in- 
flammation of  the  conjunctiva  and  sclerotica,  inflammation  of  the  iris,  or,  at 
least,  discoloration  of  the  iris  with  contracted  pupil,  easily  distinguishable 
from  any  of  the  ophthalmite,  inflammation  of  the  cornea  with  onyx  ending  in 
ulceration,  palsy  of  the  muscles  of  the  eyeball,  and  of  the  levator  palpebrse 
superioris,  and  deformity  of  the  bones  forming  the  back  and  roof  of  the  throat. 
The  inflammation  and  other  changes  of  the  eye  in  such  cases  resemble  very 
much  the  effects  produced  in  Magendie's  experiment  of  dividing  the  trunk  of 
the  fifth  nerve ;  and  after  a  time  the  pained  parts  become  insensible  to  exter- 
nal impressions.  In  one  case  of  this  sort,  which  came  under  my  care,  the 
uvula  was  drawn  entirely  to  one  side,  and  a  tumor  was  felt  behind  the  veil  of 
the  plate,  which  I  regarded  as  perhaps  owing  to  a  dilated  state  of  one  of  the 
sphenoid  sinuses.  In  such  cases,  the  patient  by  and  by  manifests  a  stumbling 
walk,  and  a  drawling  speech,  he  has  epileptic  fits,  his  intellect  becomes  de- 
ranged, and  at  last  a  stroke  of  apoplexy  is  the  immediate  precursor  of  death. 

Constitutional  symptoms. — It  is  chiefly  in  confirmed  cases  that  symptoms 
of  this  kind  are  present.  When  the  disease  has  continued  for  a  length  of 
time  without  amelioration,  and  the  attacks  are  frequent,  the  patient  becomes 
restless  and  melancholy,  insensible  to  the  pleasures  of  society,  and  incapable 
of  occupation.  The  appetite  for  food  fails,  digestion  is  impaired,  the  bowels 
are  constipated,  the  body  becomes  emaciated,  the  sexual  passion  is  extin- 
guished, and  the  patient  is  almost  totally  deprived  of  sleep.  In  some  in- 
stances, facial  neuralgia  is  accompanied  with  febrile  symptoms ;  in  others, 
with  nervous  debility,  great  coldness  of  the  body,  especially  of  the  extremities, 
and  sluggish  pulse. 

Subjects. — No  age  is  exempt  from  circumocular  neuralgia.  Men  are  more 
frequently  alfected  with  it  than  women.  It  is  by  no  means  the  nervous  or 
hypochondriac  that  are  most  exposed  to  it. 

Causes. — In  the  acute  variety,  the  disease  arises  from  causes  similar  to  those 
which  produce  rheumatic  ophthalmia,  and  especially  continued  exposure  to 
draughts  of  cold  air.  In  chronic  cases,  we  observe  a  variety  of  occasional 
circumstances  which  operate  in  reproducing  the  paroxysms;  as  the  motions 
of  the  face  in  speaking,  chewing,  or  swallowing,  simple  touching  of  the  part, 
the  shocks  which  the  body  is  apt  to  undergo  in  walking  or  riding,  the  blow- 
ing of  the  wind  over  the  face,  the  sudden  opening  or  shutting  of  a  door,  and 
many  others.  The  paroxysms  are  much  more  frequent  during  the  day,  on 
account  of  the  presence  of  many  more  exciting  causes,  than  during  the  night. 
The  complaint  is  much  aggravated  during  the  prevalence  of  easterly  or  north- 
easterly winds. 

When  neuralgia  is  the  result  of  a  wound,  there  is  reason  to  think  that 
inflammation  of  the  nerve,  with  hypertrophy  and  induration  of  its  neurilemma, 
has  been  produced. 

In  rheumatic  or  arthritic  cases,  the  symptoms  are  often  relieved  after  the 
removal  of  carious  teeth,^  or  the  fangs  of  decayed  teeth,  or  the  exfoliation  of 
portions  of  the  alveoli,  showing,  as  happens  also  in  traumatic  cases,  how  the 
effects  of  disease  in  one  portion  of  the  trigeminus  may  be  reflected  to  another. 

When  along  with  neuralgia  there  are  paralytic  symptoms,  affecting  the 
muscles  of  the  eyeball,  the  eyelids,  or  the  face,  it  is  probable  that  there  is 
pressure  on  certain  of  the  motor  nerves,  as  well  as  on  the  fifth,  from  thicken- 
ing of  the  dura  mater  or  of  the  cranium,  spiculte  of  bone  projecting  from  the 
inner  table,  or  the  like.^  As  examples  of  the  anatomical  changes  found  on  dis- 
section in  chronic  cases,  may  be  mentioned,  aneurisms  of  the  cerebral  vessels, 
an  aneurism  of  the  carotid  artery  by  the  side  of  the  sella  turcica,  pressing  on 
the  Gasserian  ganglion,  scirrhous  and  other  tumors  in  the  pons  Varolii,  and 
atrophy  of  the  trunk  of  the  fifth  nerve.'     In  such  cases  it  is  generally  plain 


936  CIRCUMORBITAL  NEURALGIA. 

during  life  that  neuralgia  does  not  constitute  the  original  disease,  and  that  the 
evil  does  not  reside  in  the  branches  of  the  nerves  to  which  the  pain  is  referred, 
but  at  its  origin  in  the  brain,  or  at  any  rate  within  the  cavity  of  the  cranium. 
In  most  of  these  cases  dissection  has  shown  the  disease  to  lae  seated,  not  in 
the  nerve-tubes,  but  amid  the  gray  substance  of  some  of  the  nervous  centres. 
By  investigating  the  history  of  the  patient's  previous  health,  we  shall  find 
reason,  in  some  cases,  to  suspect  syphilitic  nodes,  or  exostoses,  within  the 
skull ;  and  in  every  case,  we  must  direct  our  attention  not  merely  to  the  par- 
ticular symptoms  for  which  the  patient  seeks  relief,  but  to  the  state  of  the 
functions  generally.  If  the  explanation  of  the  symptoms  be  obscure,  we 
must  watch,  with  more  than  ordinary  attention,  their  progress,  or  their  retro- 
cession, under  the  influence  of  remedies  we  prescribe. 

Treatment. — The  means  which  are  found  most  successful  appear  to  have  been 
discovered  solely  by  experience.  Although  some  of  them  are  empirically 
specific  also  in  intermittent  fever,  practitioners  appear  to  have  had  recourse 
to  them  in  neuralgia,  without  any  reference  to  their  power  over  ague. 

1.  Great  relief  is  obtained,  especially  in  acute  cases,  from  warm  fomenta- 
tions. A  pretty  large  basin  of  boiling  water  being  placed  on  a  table  before 
the  patient,  he  is  directed  to  throw  a  sliawl  over  his  head  and  over  the  basin  ; 
he  is  then  to  hold  the  head  so  that  the  pained  part  shall  receive  the  steam 
of  the  boiling  water,  as  long  as  any  steam  rises ;  and  after  that,  to  dip  a 
sponge  into  the  water,  wring  it,  and  hold  it  to  the  seat  of  pain.  This  is  to 
be  continued  as  long  as  it  affords  relief,  and  repeated  when  the  paroxysms 
threaten  to  recur. 

Poppy  decoction,  laudanum  and  water,  chamomile  decoction,  and  the  like, 
may  be  used  in  fomentation. 

2.  It  is  proper  to  attend  to  the  state  of  the  patient's  stomach  and  bowels, 
before  having  recourse  to  tonics,  or  any  other  class  of  remedies.  Dr.  Vaidy 
has  recorded  a  case,  cured  by  the  emetic  and  purgative  effect  of  three  grains 
of  tartrate  of  antimony.  On  purging  with  calomel  at  bedtime,  followed  next 
morning  by  salts  and  senna,  or  compound  powder  of  jalap,  copious  dark 
stools  are  often  evacuated,  and  followed  by  much  relief. 

3.  We  arQ  highly  indebted  to  Mr.  Hutchinson,  of  Southwell,  for  the  intro- 
duction of  the  precipitated  carbonate  of  iron,  as  a  remedy  in  neuralgia.  I 
have  used  it  in  a  variety  of  cases,  both  acute  and  chronic.  In  the  former  it 
has  scarcely  ever  failed  to  prove  successful.  In  painful  affections  of  the  cir- 
cnmorbital  region,  accompanying  glaucoma  and  amaurosis,  I  have  also  found 
it  serviceable.  In  cases  apparently  connected  with  serious  organic  changes 
within  the  cranium,  it  has  not  appeared  to  be  productive  of  any  effect. 

As  the  precipitated  carbonate  of  iron  is  innocuous,  we  may  commence  with 
a  large  dose.  I  generally  order  from  half  a  drachm  to  a  drachm  every  hour, 
in  a  wineglassful  of  water.  Treacle  is  a  good  vehicle,  as  it  tends  to  counter- 
act the  constipating  effect  of  the  iron.  Mr.  Hutchinson  mentions  a  case  in 
which  half  a  drachm  three  times  a  day  produced  little  perceptible  benefit;  he 
increased  the  dose  to  a  drachm  twice  a  day,  when,  after  three  days,  a  very 
sensible  abatement  of  the  number  and  violence  of  the  paroxysms  was  observed ; 
he  again  increased  the  dose  to  four  scruples  twice  a  day,  in  which  the  patient 
persevered  regularly  for  ten  weeks,  at  the  expiration  of  which  time,  not  the 
slightest  vestige  of  the  disease  remained.  He  gives  several  other  cases,  in 
which  little  or  no  effect  was  produced  by  smaller  doses  than  four  scruples 
twice  a  day.     Mr.  Hutchinson's  pamphlet  is  well  worthy  of  perusal.^ 

4.  "When  carbonate  of  iron  fails,  I  am  in  the  habit  of  exhibiting  pretty 
large  doses  of  sulphate  of  quina.  Two  or  three,  and  sometimes  even  five  or 
six  grains  require  to  be  given  thrice  a  day,  or  oftener.  This  medicine  proves 
most  efificacious  in  intermittent  cases.^     I  have  known  the  daily  dose  of  24 


CIRCUMORBITAL  NEURALGIA.  937 

grains,  repeated  for  a  few  clays,  cure  the  disease,  where  iron  first  and  then 
belladonna  had  failed. 

5.  Another  remedy  of  great  utility  in  the  treatment  of  this  disease  is  bella- 
donna, the  suggestion  of  which  we  owe  to  Mr.  Bailey,  of  Harwich.  It  is  a 
medicine  of  so  much  activity,  that  it  must  be  given  with  a  cautious  hand. 
The  form  which  I  have  occasionally  adopted  for  internal,  as  well  as  frequently 
for  external  use,  is  a  vinous  tincture,  prepared  by  macerating,  for  four  days, 
one  ounce  of  the  extract  in  one  pint  of  white  wine.  Of  this,  as  a  dose,  I 
begin  with  five  drops  thrice  a  day,  increasing  gradually  to  15  drops.  Em- 
ployed in  this  manner,  the  wine  of  belladonna  is  found  to  soothe,  and  often 
entirely  to  remove  neuralgia  of  the  fifth  nerve,  especially  in  cases  deemed 
rheumatic  or  arthritic.  The  use  of  this  medicine,  however,  induces  a  very 
peculiar  sense  of  thirst  and  constriction  in  the  throat ;  and  in  larger  doses 
than  those  above  mentioned,  it  brings  on  cramp  of  the  stomach,  dilatation  of 
the  pupils,  temporary  blindness,  vertigo,  and  a  highly  distressing  feeling  of 
weakness  and  sinking. 

The  cases  related  by  Mr.  Bailey*"  are  extremely  interesting.  He  ventures 
on  two  or  three  grains  of  the  extract  at  once,  and  appears  to  have  been  led 
to  this  mode  of  exhibiting  the  medicine  from  the  difficulty  of  getting  the 
patients  to  continue  smaller  doses  for  any  length  of  time,  in  consequence  of 
its  unpleasant  effects,  while  many  were  completely  and  permanently  relieved 
by  a  single  large  dose.  I  have  found  belladonna  useful  in  almost  every  variety 
of  neuralgia ;  but  of  late  I  have  prescribed  it  less  frequently  than  I  once  did, 
in  consequence  of  finding  so  much  good  produced  by  the  precipitated  carbon- 
ate of  iron. 

6.  Although  in  many  instances,  any  degree  of  affection  of  the  mouth,  from 
mercury,  is  found  to  aggravate  the  symptoms  of  neuralgia,  yet  calomel  and 
opium  have  been  recommended,  and  have  occasionally  proved  useful.  When 
the  disease  depends  on  thickening  of  the  bones  or  membranes  of  the  cranium, 
calomel  and  opium  are  more  likely  to  do  good  than  any  other  remedy.  In  a 
case  attended  with  ulceration  of  the  cornea,  which  arose  without  any  active 
inflammation,  and  apparently  merely  as  a  consequence  of  the  diseased  state 
of  the  fifth  nerve,  I  found  calomel  and  opium  internally,  and  the  lunar  caustic 
solution  externally,  successful  in  procuring  the  cicatrization  of  the  ulcer.  I 
have  also  known  the  pain  subdued  by  salivation.  Having  occasion  to  admi- 
nister calomel  with  opium,  for  rheumatic  ophthalmia,  to  a  nobleman,  long 
troubled  with  severe  neuralgia  of  the  occipital  nerve,  which  had  resisted  all 
sorts  of  treatment,  so  long  as  the  mercurial  influence  continued,  the  neuralgia 
was  completely  relieved. 

7.  Arsenic,  combined  generally  with  opium,  has  often  been  tried  in  this 
disease ;  and  numerous  instances  of  its  efficacy  have  been  recorded."  Fowler's 
solution  and  water  ai'e  mixed  in  the  proportion  of  half  an  ounce  of  each,  of 
which  mixture  16  drops  are  to  be  given  thrice  a  day,  immediately  after  food, 
and  continued  till  the  specific  effects  of  the  mineral  show  themselves. 

8.  Narcotics  of  every  sort  have  been  used  in  neuralgia,  both  internally  and 
externally.  It  is  often  necessary  to  combine  them  with  the  other  classes  of 
remedies,  especially  with  tonics. 

Temporary  relief  is  generally  obtained  from  preparations  of  opium.  Sir 
Henry  Halford  notices  a  case,  however,  in  which  opiates  gave  relief  only  at 
night,  but  failed  in  the  largest  doses  in  the  daytime. 

It  has  been  proposed  to  keep  the  patient  continually  narcotized  for  some 
days.  By  administering  half  a  grain  of  acetate  of  morphia,  with  three  grains 
of  camphor,  every  four  hours  for  three  or  four  days,  the  paroxysms,  by  the 
end  of  that  period,  have  been  more  endurable,  and  have  been  known  to  con- 
tinue so.**^ 


938  HEMICRANIA. 

Mr.  Lawrence  states,"  that  of  all  the  narcotics,  the  only  one  on  which  he 
has  any  reliance  is  coniura.  Given  largely,  and  at  short  intervals,  so  as  to 
produce  some  of  its  peculiar  effects  on  the  nervous  system,  he  has  known  it 
put  a  stop  to  the  paroxysms,  and  for  such  a  length  of  time  that  he  had  come 
to  the  conclusion  that  it  had  cured  the  disease.  In  some  instances,  he  states, 
where  persons  remained  well  for  several  months,  and  even,  in  one  case,  for 
more  than  a  year  after  the  use  of  the  conium,  although  the  pains  again 
returned,  yet  the  agony  was  considerably  controlled  by  this  medicine. 

Fleming's  tincture  of  aconite  possesses  very  considerable  anti-neuralgic 
properties,  whether  given  internally  or  applied  in  friction  to  the  skin.  One 
drachm  of  the  tincture  being  mixed  with  seven  drachms  of  water,  the  incipient 
dose  may  be  ten  minims  thrice  a  day,  increasing  daily  to  the  extent  of  one 
minim  each  dose,  until  the  physiological  effects  of  the  aconite  appear.'* 

An  extract  of  the  seeds  of  stramonium  in  doses  of  half  a  grain,  two  hours 
before  the  paroxysm,  appears  to  have  succeeded,  even  in  cases  where  sulphate 
of  quina,  and  other  remedies  had  failed.'^ 

Narcotic  plasters  sometimes  serve  to  moderate  the  pain.  They  are  made 
with  opium,  conium,  belladonna,  and  the  like.  One  composed  of  soap 
cerate,  extract  of  belladonna,  and  acetate  of  lead,  has  been  recommended.^* 

Ansiaux  relates'^  two  cases,  in  which  a  cure  was  effected  by  the  daily  ap- 
plication of  acetate  of  morphia  to  a  small  blistered  surface,  near  the  seat  of 
the  pain. 

9.  Detraction  of  blood,  such  as  by  leeches  over  or  near  the  spot,  has 
sometimes  proved  useful.'* 

10.  Counter-irritation  sometimes  does  good.  A  blister  may  be  raised  by 
placing  over  the  part  the  lid  of  a  pill-box,  containing  a  bit  of  lint,  moistened 
with  concentrated  aqua  ammonisE.  A  tartar  emetic  plaster  has  been  known 
to  prove  efficacious,  by  causing  pustules  and  ulcers  over  the  pained  part. 

11.  In  the  incurable  cases,  depending  on  organic  changes  within  the 
cranium,  palliatives  must  be  employed.  A  local  vapor  bath,  the  vapor  of 
chloroform  by  way  of  douche,'^  the  inhalation  of  the  vapor  of  sulphuric  ether 
or  of  chloroform,-"  external  applications  of  conium,  or  belladonna,  and  stimu- 
lating liniments  combined  with  laudanum,  afford  temporary  relief ;  but  are 
not  all  equally  safe.  The  inhalation  of  chloroform,  for  example,  in  cases  of 
cerebral  disease,  would  be  attended  with  danger.  Sometimes  such  remedies 
remove  the  pain  permanently,  although  the  organic  change  on  which  the  pain 
depended  is  slowly  advancing.  Friction  with  tar  on  the  pained  part,  and  in 
the  neighborhood,  has  been  found  useful.'^' 

12.  The  division  of  the  affected  nerves,  as  they  make  their  exit  from  the 
orbit,  a  remedy  which,  at  one  time,  was  generally  had  recourse  to,  now  seems 
to  be  abandoned ;  the  benefit  derived  from  the  operation  proving  only 
temporary.  As  a  cessation  for  months  from  severe  suffering,  however,  has 
sometimes  been  obtained  from  this  means,  it  may  in  certain  cases  be  justifi- 
able to  have  recourse  to  it. 

13.  In  cases  of  tubercular  or  calcareous  depositions  in  the  nerves  of  the 
face,  the  extirpation  of  the  growth  is  evidently  indicated.^'' 

§  2.  Hemicrania. 

Syn. — Hemicrania,  from  rijjui-vi,  half,  and  xpav^v,  the  head.     La  Migraine,  Fr.  Neuralgia 

cerebralis,  Romberg. 

Nearly  allied  to  neuralgia,  is  a  painful  affection  which  sometimes  extends  to 
the  forehead  and  face,  and  especially  to  the  orbit  and  eyeball,  assumes  more 
or  less  of  an  intermittent  form,  and  receives,  from  the  circumstance  of  its 
being  generally  confined  to  one  side  of  the  head,  the  name  of  hemicrania. 


HEMICBANIA.  939 

An  inflammation  of  the  eye,  chiefly  sclerotic,  easily  distinguished  from  any  of 
the  ordinary  forms  of  the  ophthalmia3,  sometimes  attends  this  disease.  The 
iris  is  occasionally  discolored,  and  the  pupil  irregularly  expanded  or  con- 
tracted ;  but  there  is  no  effusion  of  lymph.     Vision  is  somewhat  dim. 

The  paroxysms  vary  in'  duration  from  a  few  hours  to  a  day  or  longer. 
They  occur  at  irregular  intervals  of  about  three  or  four  WTeks,  being  pre- 
ceded by  chilliness,  yawning,  and  irritation  of  temper,  and  terminate  gene- 
rally by  vomiting  and  sleep.  Prolonged  during  many  years,  hemicrania 
diminishes  greatly,  or  disappears  entirely,  in  advanced  age. 

The  disease  is  often  connected  with  a  hysteric  diathesis.  It  is  frequently 
an  attendant  on  pregnancy,  or  occurs  during  the  debility  brought  on  by  suck- 
ling. Its  intermittent  character  is  sometimes  to  be  traced  to  a  connection 
with  the  causes  of  ague. 

Dr.  Turenne  supposes  hemicrania  to  depend  on  congestion  of  the  cavernous 
sinus,  causing  pressure  on  the  ophthalmic  division  of  the  fifth  nerve. "^  He 
considers  the  relief  obtained  from  bending  the  head  backwards,  to  arise  from 
the  emptying  of  the  cavernous  sinus.  A  protrusion  of  what  are  called  the 
Pacchionian  glands  into  the  interior  of  the  sinuses  of  the  brain,  has  also  been 
supposed  to  be  a  cause  of  hemicrania,  by  the  impediment  they  offer  to  the 
return  of  the  blood. '^^ 

.  The  remedies  most  efficacious  are  such  as  afford  relief  in  genuine  intermit- 
tents.  Frequently,  when  bai'k  fails,  the  arsenical  solution  is  found  to  act 
most  favorably.  I  have  known  several  cases  completely  cured  by  the  use  of 
sarsaparilla. 

"  In  the  treatment  of  cases  of  this  kind,"  observes  Dr.  Bright, ^^  "  it  is  occa- 
sionally impossible  not  to  feel  anxious,  lest  some  more  fixed  disease  should 
be  giving  rise  to  the  symptoms,  more  particularly  if  other  circumstances,  as 
sickness,  giddiness,  or  loss  of  power  or  sensation,  should  casually  occur.  But 
while  we  carefully  watch  every  new  symptom,  we  must  not  be  induced  too 
easily  to  relinquish  our  remedy,  as  it  frequently  happens  that  several  days 
elapse  before  any  improvement  is  manifest." 

This  last  remark  applies,  whatever  be  the  remedy  we  have  selected. 

Debilitating  remedies,  such  as  abstraction  of  blood  by  leeches,  and  counter- 
irritation,  are  to  be  avoided. 


«  Hamilton,  Dublin  Journal  of  Medical  Sci-  ' '  Grafe  und  WaUher's  Journal  der  Chirur- 

ence.     May,  1S43,    p.    217;    Allan,  Monthly  gie    und    Augenheilkunde  ;  Vol.    iv.  p.  676; 

Journal  of  Medical  Science,  January,  1852,  p.  Berlin,  1822  ;  Collections  from  the  unpublished 

46 .  Medical  Writings  of  C.  H.  Parry,  M.  D.  ;  Vol. 

'  Todd  and  Bowman's   Physiological  Ana-  i.  p.560;  London,  1825. 

tomy,  Vol.  ii.  p.  115,  London,  1847.  '*  British  and  Foreign  Medical  Review  for 

^  Carline,  Dublin  Quarterly  Journal  of  Medi-  1844,  p.  411. 

cal  Science,  August,  1849,  p.  247.  '^Lectures    on   Surgery,   Medical  Gazette; 

*  Nervous  System  of  the   Human   Body,  p.  Vol.  vi.  p.  647 ;  London,  1830. 

cxi.  :  London,  1830.  "  Fleming's  Inquiry  into  the  Properties  of 

'  Emmerich,  Medical  Gazette,  April  7,  1848,  the  Aconitum  Napellus,  p.  23  ;  London,  1845. 

p.  613.  ''  Journal  Complementaire  du   Dictionnaire 

^  Halford's    Essays    and    Orations,    p.    39;  des   Sciences   Medicales ;    Tome   viii.  p.   182; 

London,  1831:  Travcrs's  Further  Inquiry  con-  Paris,  1820. 

cerning  Constitutional  Irritation,  p.  351;  Lon-  "  Medico-Chirurgieal  Review,  January,  1837, 

don,  1835.  p.  235. 

''  Romberg's  Manual  of  the  Nervous  Diseases  "  Clinique  Chirurgicale,  306  ;  Liege,  1829. 

of  Man  ;  Vol.  i.  p.  41;  London,  1853.  '*  Vaidy,  Journal  Complementaire  du  Dic- 

'  Cases  of  Neuralgia  Spasmodica,  commonly  tionnaire  des   Sciences  Medicales;  Tome  viii. 

called    Tic   Douloureux,   successfully  treated;  p.  180;  Paris,  1820. 

London,  1822.  '^  Hardy,  Dublin  Medical  Press,  April  19, 

"  Van  Swieten,  Comraentaria  in  Boerhaavii  1854. 

Aphorismos;  Tome  ii.  g  757.  ^°  Sibson,  Medical  Gazette,  March  31,  1848, 

'°  Observations  relative  to  the  Use  of  Bella-  p.  535. 

donna  in  Painful  Disorders  of  the  Head  and  ■"  Colville,   Edinburgh  Medical  and  Surgi- 
Face;  London,  1818. 


940  OCULAR  ANESTHESIA, 

cal    Journal;     Vol.   x.   p.   288;     Edinburgh,  1829:  Sir  Charles  Bell's  Practical  Essays,  Part 

1814.  i.  p.  83  ;  Edinburgh,  1841. 

'^'^  On  Neuralgia,  consult  Essay  on  the  Ke-  ''"  Lancet,  August  18,  1849,  p.  177. 

mittent   and   Intermittent   Diseases,   by  John  '*  Blandin,  Ibid.,  p.  178. 

Maceulloch,   M.  D.  ;  Vol.    ii.  p.    1;    London,  "»  Reports  of  Medical  Cases  ;  Vol.  ii.  p.  508  ; 

1828:  Anatomy.  Physiology,  and   Diseases  of  London,  18.31. 
the  Teeth,  by  Thomas  Bell,  p.  309;  London, 


SECTION  II. — ANESTHESIA  AND  IMPEDED  NUTRITION  OF  THE  OPTIC  APPARATUS 
FROM  DISEASE  OF  THE  FIFTH  NERVE. 

From  a  privative,  and  aia-dnfi;,  sense. 

Varieties. — Anaesthesia  of  parts  supplied  by  the  fifth  nerve  may  be  external 
or  internal  in  its  origin.  A  wound  of  the  supra-orbitary  or  infra-orbitary 
branch,  for  example,  is  an  external  cause  ;  a  tumor  in  the  pons  Varolii  is  an 
internal  one. 

A  branch  or  two  only  of  the  nerve  may  be  in  such  a  state,  as  shall  cause 
anaesthesia  of  the  parts  to  which  they  are  distributed ;  or  the  whole  nerve 
may  be  affected,  the  motor  root  as  well  as  the  sensitive,  and  then,  in  addition  to 
anaesthesia,  the  muscles  of  mastication  will  be  paralyzed.  Other  nerves  be- 
sides the  fifth  may  be  implicated,  especially  the  facial,  the  sixth,  and  the 
third  ;  and  then  palsy  of  the  face,  or  of  the  muscles  of  the  eye,  will  be  pre- 
sent. Smell,  vision,  and  hearing  may  be  destroyed  by  the  cause  extending 
to  the  olfactory,  optic,  and  auditory  nerves. 

When  disease  within  the  cranium,  such  as  a  tumor  in  the  pons  Varolii, 
affects  the  fifth  nerve,  a  train  of  symptoms  is  produced,  similar  to  the  changes 
which  have  been  observed  to  follow  the  division  of  its  trunk  in  experiments 
on  the  lower  animals.^  Besides  anaesthesia  of  the  skin  of  the  eyelids,  the 
conjunctiva,  the  Schneiderian  membrane,  and  other  parts  supplied  with  com- 
mon sensibility  by  the  fifth  nerve,  and  loss  of  taste  in  the  corresponding  side 
of  the  tongue,  vision  becomes  impaired  or  lost,  the  lachrymal  secretion 
ceases,  and  inflammation  of  the  eye  takes  place,  ending  in  opacity,  ulceration, 
and  bursting  of  the  cornea.  Severe  neuralgia  sometimes  precedes  anaesthesia, 
alternates  with  it,  or  even  accompanies  it ;  so  that  though  the  parts  affected 
are  insensible  to  external  impressions,  such  as  touching  or  scratching  them, 
they  communicate  to  the  sensorium  acute  feelings  of  pain,  arising  from  inter- 
nal morbid  changes  affecting  the  trunk  of  the  nerve.  In  a  case  of  anaesthesia 
shown  by  M.  Montault'^  at  Magendie's  lectures,  the  eye  was  turned  inwards 
in  consequence  of  palsy  of  the  abductor.  So  complete  was  the  loss  of  sensa- 
tion in  the  conjunctiva,  in  this  instance,  that  the  patient  could  seize  his  eye 
with  his  fingers,  and  turn  it  outwards,  without  winking,  without  suffering  any 
pain,  and  even  without  feeling  that  the  eye  was  touched.  In  such  a  case,  the 
reflex  act  of  nictitation  is  not  performed,  even  although  the  facial  nerve  is 
sound,  as  the  feeling  which  leads  to  that  act  in  the  normal  state  is  lost. 
Even  pricking  of  the  bulb  of  the  eye,  or  roughly  touching  it,  does  not  cause 
winking,  although  the  voluntary  power  over  the  lids  remains,  and  the  patient 
closes  the  eye  firmly  when  told  to  do  so.^  In  such  a  state,  foreign  bodies 
lighting  on  the  conjunctiva  not  being  removed,  excite  inflammation ;  but  it 
is  generally  thought  that  the  opacity  and  sloughing  of  the  cornea  are  owing, 
not  so  much  to  this  cause  as  to  the  disturbed  nutrition  of  the  whole  organ, 
from  want  of  the  nervous  energy  naturally  communicated  through  the  fifth 
nerve.  External  stimulants  applied  to  the  eye  in  such  a  state  cause  redness 
of  the  conjunctiva,  but  no  pain. 

The  various  symptoms  follow  each  other,  sometimes  in  one  order,  sometimes 


OCULAR  ANESTHESIA.  941 

in  another.  In  some  cases  the  amaurosis,  in  others  the  neuralgia,  and  in 
others  the  anaesthesia,  is  the  complaint  which  attracts  most  attention ;  some- 
times the  disease  is  looked  upon  merely  as  an  obstinate  ophthalmia,  and  in 
other  instances  it  is  considered  as  a  paralysis.  In  some  instances,  the  de- 
struction of  the  eye  is  prompt ;  in  others,  although  sensibility  to  light  is  lost, 
and  the  surface  of  the  eyeball  and  eyelids  insensible  to  common  stimuli,  the 
coats  and  humors  continue  sound. 

Pathological  anatomy. — Scrofulous  and  other  tumors  pressing  on  the  root 
or  on  the  course  of  the  fifth  nerve,  an  apoplectic  clot,  ramollissement  of  part 
of  the  brain,  induration,  ramollissement  and  atrophy  of  the  Gasserian 
ganglion,  or  of  some  of  the  branches  of  the  nerve,  are  the  changes  which 
have  been  detected  on  dissection,  in  cases  of  anaesthesia. 

Cases. — Numerous  cases  of  anaesthesia  of  the  parts  supplied  by  the  fifth 
nerve  are  recorded.* 

Case  371. — AVhile  the  British  troops  were  quartered  in  Portugal  in  March,  1828,  Lieu- 
tenant   fell  with  considerable  force  from  the  top  to  the  bottom  of  a  flight  of  stairs, 

having  missed  his  step  in  the  dark,  when  the  left  side  of  his  face  struck  with  violence 
against  a  flag.  On  seeing  him  some  hours  after  this  accident,  Mr.  Russell  found  that  all 
that  side  of  his  head  and  face  was  much  swollen  and  bruised.  He  complained  of  head- 
ache and  a  numbness  of  the  face.  He  was  bled,  aperients  were  ordered,  and  fomentations 
to  the  injured  part.  When  the  symptoms  of  injury  of  the  head  had  disappeared,  and 
the  swelling  abated,  he  continued  to  complain  of  numbness  of  the  left  side  of  the  face, 
extending  from  just  below  the  orbit  along  the  ala  nasi  to  the  tip  of  the  nose,  and  to  the 
upper  lip,  exactly  as  far  as  the  centre  of  its  depression,  corresponding  precisely  with  the 
distribution  of  the  facial  division  of  the  second  branch  of  the  fifth  nerve. 

On  searching  for  the  cause,  Mr.  Russell  readily  found  that  the  margin  of  the  infra- 
orbitary  foramen  was  broken  off,  causing  a  sharp  spicula,  which  either  pressed  on  the 
nerve,  or  had  divided  it  at  the  very  point  of  its  exit  upon  the  face. 

Six  months  after  the  accident,  the  side  of  the  face  was  still  quite  insensible  to  the 
touch,  or  even  when  gently  picked  with  a  sharp  point ;  the  razor  skimmed  over  the  left 
side  of  the  upper  lip  unfelt ;  and  when  he  applied  a  vessel  to  his  mouth,  a  sensation  was 
imparted  as  if  its  edge  were  broken  off  at  the  part  touching  the  affected  lip. 

The  expression  of  the  countenance  was  not  at  all  affected,  for  when  he  spoke,  laughed, 
or  sneezed,  the  muscles  of  both  sides  acted  in  perfect  unison.^ 

Case  372. — L.  A.,  a  healthy  girl  about  20,  came  under  the  care  of  Sir  Charles  Bell,  in 
October,  1822.  Seven  years  before  that  period  she  had  received  a  blow  with  a  stick  on  the 
right  eye,  after  which  she  thought  that  the  sight  was  never  so  good.  The  dimness  had 
increased,  but  she  could  still  distinguish  small  objects  till  June,  1822.  At  that  time,  she 
became  affected  with  pain  in  the  right  ear,  deafness,  and  a  discharge  from  the  ear  ;  she 
also  suffered  from  severe  headaches,  aflecting  only  the  right  side  of  the  head,  and  soon 
after,  lost  the  sight  of  the  right  eye  altogether.  She  felt  a  dull  pain  at  the  internal  can- 
thus,  which  seldom  abated,  and  at  times  there  was  a  copious  flow  of  tears.  The  motion 
of  the  iris  remained  perfect.  Things  continued  in  this  state  for  about  two  months,  when 
the  pain  and  discharge  from  the  ear  ceased,  and  in  a  few  days  more  the  surface  of  the  eye 
became  perfectly  insensible  to  the  touch.  This  loss  of  feeling  extended  to  the  lining  of 
the  eyelids,  to  the  skin  covering  them,  and  to  the  skin  of  the  cheek  and  forehead  for  about 
an  inch  around  the  eye  ;  it  did  not  go  beyond  the  middle  line  of  the  face.  When  she  told 
Sir  Charles  that  her  eye  was  dead,  as  she  expressed  it,  he  drew  his  finger  over  its  surface, 
and  so  far  was  this  from  giving  her  pain,  that  she  assured  him  she  could  not  feel  that  he 
was  touching  it  at  all.  The  eyelids  made  no  effort  to  close  while  he  was  doing  this,  but 
the  conjunctiva  appeared  sensible  to  the  stimulus,  as  a  number  of  vessels  on  the  surface  of 
the  eye  became  immediately  injected. 

At  this  time,  a  perpetual  blister  was  applied  behind  the  ear,  and  two  grains  of  calomel 
given  night  and  morning,  with  a  view  of  affecting  her  mouth.  After  a  few  days,  however, 
the  pain  in  the  ear  and  deafness  increased,  but  with  scarcely  any  discharge  ;  and,  at  the 
same  time,  the  sensibility  of  the  eye  and  surrounding  skin  returned.  The  sight  appeared 
totally  gone.  Partial  headaches  continued,  and  at  times  the  patient  felt  pain  at  the  inner 
corner  of  the  eye.  She  had  always  a  perfect  command  over  the  muscles  of  the  face  and 
eyelids,  and  there  was  no  affection  whatever  of  the  muscles  of  the  face. 

On  the  25th  October,  she  had  a  violent  hysteric  fit,  followed  by  a  general  headache.  The 
latter  subsided  after  venesection,  a  cold  embrocation  to  the  vertex,  a  blister  to  the  nape  of 
the  neck,  and  free  purging.     Apprehensive  lest  organic  disease  might  be  extending  itself 


942  OCULAR  ANESTHESIA. 

in  the  head,  Sir  Charles  kept  her  confined  to  bed  and  on  the  lowest  regimen,  and  purged 
her  daily. 

On  the  2d  November,  she  said  she  had  felt  all  night  as  if  there  was  sand  in  the  blind 
eye,  and  that  sometimes  sparks  of  fire  seemed  to  pass  through  it.  There  was  no  change 
in  the  appearance  of  the  eye.  On  the  3d,  when  she  awoke,  these  sensations  were  gone, 
but  she  was  agreeably  surprised  to  find  that  her  sight  was  restored.  When  the  left  eye 
was  closed,  she  could  see  large  objects  very  distinctly  with  the  right,  but  could  not  read 
or  discern  anything  very  small. 

On  the  4th,  she  could  read  small  print,  and  the  sight,  although  not  quite  so  good  as  in 
the  left  eye,  soon  became  pretty  much  as  it  had  been  immediately  after  the  injury. 

The  blow  on  the  eye  had  probably  produced  only  a  predi>^position  to  disease.  The 
gradual  manner  in  which  sight  was  lost,  and  its  sudden  recovery  when  the  system  was  re- 
duced by  severe  evacuation,  point  out  the  connection  of  the  complaint  with  an  increasing 
fulness  of  habit.  The  only  nerves  aflccted  appeared  to  have  been  the  optic,  and  at  one 
time  the  first  division  of  the  fifth. ^ 

Case  373. — A  patient,  under  the  care  of  Dr.  Alison,  was  affected  with  loss  of  common 
sensation  in  the  left  side  of  the  face,  the  left  nostril,  and  left  side  of  the  tongue,  with 
insensibility  of  the  ball  of  the  eye,  and  occasional  bloody  discharge  from  the  left  nostril ; 
and  was  liable  to  attacks  of  pain,  occasionally  accompanied  with  fever,  during  which  the 
pain  was  chiefly  referred  to  the  insensible  parts.  There  were  frequent  attacks  of  inflam- 
mation of  the  left  eye,  with  dimness  of  the  cornea,  which  were  relieved  from  time  to  time 
by  the  usual  antiphlogistic  means  ;  but  at  the  end  of  two  months,  a  line  formed  round  the 
base  of  the  cornea,  which  at  length  sloughed  out,  and  the  contents  of  the  eye  were  entirely 
discharged.  The  muscles  of  the  left  side  of  the  jaw  were  paralytic,  and  felt  quite  flaccid 
when  the  patient  chewed  or  clenched  the  jaws,  but  the  motion  of  the  muscles  of  the  cheek 
was  unimpaired.  After  the  destruction  of  the  eye,  the  paralytic  symptoms  remnined  sta- 
tionary for  a  year  or  more,  there  was  then  a  violent  return  of  headache,  with  fever,  and 
death  in  a  state  of  coma,  after  an  illness  of  a  fortnight. 

On  inspection,  there  was  found  considerable  ramollissement  of  some  of  the  central  parts 
of  the  brain.  The  fifth  nerve  of  the  left  side,  on  being  traced  backwards  from  the  gan- 
glion, was  found,  close  to  the  ganglion,  to  be  of  a  very  dense  texture,  but  beyond  this  it 
was  much  wasted,  and  at  its  junction  with  the  tuber  annulare,  nothing  but  membrane 
seemed  to  remain.'' 

Case  374. — A  young  man,  an  epileptic  in  the  hospital  La  Pilie,  died  on  the  12th  of 
August,  1824,  after  having  been  underthe  care  of  M.  Serres  for  ten  or  eleven  months. 

When  admitted  into  the  hospital,  he  complained,  in  addition  to  epileptic  seizures,  of  slight 
inflammation  of  the  right  eye.  The  inflammation  increased,  the  cornea  became  opaque, 
and  sight,  at  first  disordered,  was  ultimately  lost  by  this  cause.  The  organs  of  sense,  on 
the  riglit  side,  became  successively  deprived  of  their  natural  powers.  This  took  place  in 
June,  1824.  The  right  eye,  eyelids,  nostril,  and  half  of  the  tongue,  were  deprived  of 
sensation,  while  the  same  parts  on  the  left  side  possessed  it  perfectly.  Shortly  after,  the 
disease  was  aggravated  by  a  scorbutic  aff'ection,  which  first  manifested  itself  on  the  right 
side  of  both  maxillas,  on  this  side  laying  the  teeth  bare  by  an  affection  of  the  gums.  Iq 
the  advanced  stage  of  this  disease,  complete  deafness  took  place  on  the  right  side. 

On  dissection,  the  ganglion  of  the  fifth  nerve  on  the  right  side  was  found  to  be  swollen, 
of  a  yellow  color,  and  less  vascular  than  usual ;  and  the  nerve,  where  it  seems  inserted 
into  the  pons  Varolii,  was  changed  into  a  yellow  gelatinous  substance,  like  the  ganglion, 
which  substance  transmitted  small  processes  into  the  pons,  in  the  direction  of  the  fasciculi 
of  the  insertion  of  the  nerve.  The  muscular  branches  of  the  affected  nerve  were  un- 
altered, and  the  action  of  mastication  had  never  been  disturbed.^ 

Treatment. — The  causes  of  anaesthesia  are  not  generally  of  a  nature  to  yield 
to  treatment.  Romberg  relates''  a  case,  however,  in  which  the  disease,  being 
probably  rheumatic  in  its  origin,  yielded  to  the  free  internal  and  external  use 
of  iodide  of  potassium ;  while  in  a  case  recorded'"  by  M.  James,  the  symp- 
toms were  removed  by  the  repeated  application  of  galvanism  to  the  different 
points  aifected." 


'  On  the  experiment   of  dividing    the   fifth  opinion  that  the  violence  inflicted,  either  in  the 

nerve,  and  its  efi'ccts  on  the  eye,  consult  Alcock,  vicinity  of  the   eye  or  actually  to  its    appen- 

Cycloptodia  of  Anatomy  and  Physiology;  Vol.  dages,  is  the  primary  and  immediate  cause   of 

ii.  p.  309  ;  London,    1837.     While    Magendio  the  alterations  which  take  place  in  the  experi- 

acknowledges  that  the  alterations  in  the  nutri-  ments  in  question. 

tion  of  the  eye  from  dividing  the  nerve  arc  less  '^Journal    Ilebdomadaire   des   Progrcs    des 

as  the    section   is  further   from  the  orbit  and  Sciences   Medicalesj  Tome  i.  p.   368;    Paris, 

nearer  to  the  root  of  the  nerve,  Alcock   is   of  1836. 


AMAUROSIS.  943 

'  Romberg's  Manual  of  the  Nervous  Diseases  »  Bell,  Op.  cit. ;  Appendix,  p.  xcviii.;  Lon- 

of  Man  ;  Vol.  i.  p.  195;  London,  1853.  don,  1830. 

"■  Bell's  Nervous  System  of  the  Human  Body;  ^  Ibid.,  p.  c. 

Appendix,  pp.  xxiii.,  Ixxvii.,  Ixxx.,  xciii.,  cv. ;  ''  Abercrombie's  Pathological  and  Practical 

London,  1830:  Mayo's  Anatomical  and  Physi-  Researches  on  Diseases  of  the  Brain,  p.  447: 

ological  Commentaries  ;  No.  2,  p.  12  ;  London,  Edinburgh,  1829. 

1823:  Stanley,  London  Medical  Gazette;  Vol.  ^  Serres,  Anatomie    Compares  du    Cerveau ; 

i.   p.  531;  London,    1828:    Montault,  Journal  Tome  ii.  p.  67  ;  Paris,  1827. 

Generale  de  Medecine,  Avril,  1829  :  Carron  du  ^  Op.  cit.;  VoL  i.  p.  215. 

Villards.  Journal  Complcmentaire  des  Sciences  '"  Quotedfrom  the  Gazette  Medicale  de  Paris, 

Medicales  ;  Vol.  xliv.  p.  13  :  Bishop,  Medical  Octobre  24,  1840,  in   the  British  and  Foreign 

Gazette  ;  Vol.  xiii.  p.  463  :  London,  1833  :  Bur-  Medical  Review,  April,  1841,  p.  524. 

ton,    Ibid.;  Vol.  xvi.  p.   366;  London,    1835  :  "On  anajsthesia  of  the  fifth  nerve,  consult 

Dixon,  Medico-Chirurgical  Transactions  ;  Vol.  Romberg,  Op.  cit.:  Radclyffe  Hall,  Edinburgh 

xxviii.  p.  373  ;  Vol.  xxix.  p.  131 ;  London,  1845,  Medical  and  Surgical  Journal ;  Vol.  Ixx.  p.  1  ; 

1846.  Edinburgh,  1848:    Cowan,    Glasgow    Medical 

Journal ;  Vol.  ii.  p.  146  ;  Glasgow,  1853. 


CHAPTER  XXVI 

AMAUROSIS. 


SECTION  I.  —  GENERAL  ACCOUNT  OF  AMAUROSIS  ;  ITS  DEFINITION,  SEATS, 
CAUSES,  SYMPTOMS,  STAGES  AND  DEGREES,  DIAGNOSIS,  PROGNOSIS,  AND 
TREATMENT. 

Sy/i. — Amaurosis,  from  a/xav^o;,  obscure.  'Afx^\vt>i7r!a,  Hippocrates.  Me^avi'a,  Aristotle. 
Gutta  serena,  Latino-harharous  translators  from  the  Arabic.  Nervous  blindness ;  Optic 
ansesthesia,  Romberg.     Der  schwarze  Staar,  Ger. 

I.  Definition. — By  amaurosis  is  meant  obscurity  of  vision,  depending  on  a 
morbid  condition  of  one  or  several  portions  of  the  optic  nerve — its  root,  its 
course,  or  its  termination.  It  is  an  effect,  therefore,  depending  upon  causes 
entirely  different  from  those  which  prevent  the  rays  of  light  from  entering 
the  eye,  or  passing  through  it  to  the  retina. 

If,  in  consequence  of  morbid  changes,  the  retina  be  no  longer  capable  of 
being  duly  impressed  by  external  objects  through  the  medium  of  light,  if  the 
optic  nerve  be  unable  to  convey  to  the  sensorium  the  impressions  made  upon 
the  retina,  or  if  the  brain  be  deprived  of  the  power  of  receiving  the  impres- 
sions conveyed  by  the  optic  nerve,  the  individual  must  suffer  an  obscurity,  or 
a  total  loss  of  sight,  according  to  the  degree  of  inability  in  these  several 
parts  to  execute  their  functions.  Even  when  he  goes  no  further  into  the 
subject  than  this,  the  reader  must  see  the  necessity  of  distinguishing  different 
cases  of  amaurosis,  according  as  the  retina,  the  optic  nerve,  or  the  brain,  is 
the  part  first  and  principally  affected ;  although  in  many  instances  there  is 
reason  to  believe  all  these  textures  to  be  involved. 

There  is  a  previous  question,  however,  which  ought  to  be  settled  in  all 
cases  of  impaired  or  destroyed  vision,  viz:  Is  there  sufficient  cause  for  the 
symptoms  in  those  parts  of  the  eye  which  lie  in  juxtaposition  with  the  retina, 
namely,  the  vitreous  humor  and  the  choroid,  independently  of  any  primary 
affection  of  the  retina,  optic  nerve,  or  brain  ?  The  oculist  should  attend  to 
this,  and  not  wander  into  a  field  of  uncertainty,  such  as  encephalic  diseases 
but  too  often  prove,  when,  perhaps,  a  sufficient  explanation  of  the  symptoms 
lies  open  to  him  in  the  state  of  the  eyeball  itself.     It  will  be  evident,  on  the 


944  SEATS   OF   AMAUROSIS. 

slightest  consideration,  how  necessary  it  is  to  distinguish  glaucoma  from 
amaurosis,  were  it  for  no  other  reason  than  that  the  patient  may  be  saved 
from  the  pain  and  other  evil  effect  of  remedies  which  can  be  of  no  service, 
but  on  the  contrary  may  injure  his  constitution,  and  must  at  all  events  disap- 
point his  hopes. 

II.  Seats. — In  order  to  prevent,  if  possible,  our  falling  into  false  notions 
regarding  the  seats,  as  well  as  the  symptoms,  of  amaurosis,  it  may  be  proper 
to  recall  to  mind  the  following  anatomical  and  physiological  facts  : — 

1.  The  optic  nei-ves  originate,  a  little  behind  the  middle  of  the  cerebral  mass,  from 
the  corpora  quadrigemiua  ;  and  are,  therefore,  in  communication  with  the  posterior  part 
of  the  medulla  oblongata.  The  broad  slip  of  medullary  substance  or  tractus  opticus,  by 
■which  the  nerve  on  each  side  appears  to  commence,  turns  around  upon  the  outer  edge  of 
the  thalamus  and  adheres  to  it,  crosses  and  adheres  to  the  crus  cerebri,  attaches  itself  to 
the  middle  lobe  of  the  cerebrum,  becomes  intimately  connected  with  the  floor  of  the  third 
ventricle  formed  by  the  tuber  cinereum,  and  unites  with  its  fellow  of  the  opposite  side, 
to  form  the  chiasma. 

2.  Numerous  cases  on  record,  in  which  atrophy  «f  one  of  the  optic  nerves  has  been 
traced  from  a  diseased  eye  to  the  opposite  side  of  the  brain,  fully  establish  the  fact  of  at 
least  a  partial  decussation  of  the  optic  nerves  in  the  chiasma.'  The  outermost  fibres  of 
each  nerve  appear  to  continue  their  course  toward  the  orbits  without  crossing ;  probably 
the  innermost  fibres  pass  from  the  one  side  to  the  other.  (See  p.  'J'28.)  This  arrange- 
ment explains  the  apparently  contradictory  evidence,  afforded  by  pathological  prepara- 
tions, such  as  those  preserved  in  the  Museum  of  the  Richmond  Surgical  School,  Dublin, 
and  referred  to  by  Dr.  Mayne.^  These  preparations  belonged  to  cases,  in  which  one  eye 
had  been  destroyed  either  by  local  disease  or  accident,  many  years  previous  to  death, 
and  where  in  consequence  the  corresponding  optic  nerve  had  become  wasted,  while  the 
opposite  one  continued  healthy.  In  the  majority  of  the  specimens,  the  wasting  had  been 
propagated  backwards  to  the  opposite  tractus  opticus,  while  the  corresponding  tractus 
had  been  spared  ;  in  some  examples,  both  tractus  optici  had  suffered  a  diminution  of 
size,  and  in  general  to  an  unequal  amount;  and  in  one  very  remarkable  instance,  the 
tractus  opticus  of  the  same  side  with  the  shrunken  nerve  had  dwindled  into  a  narrow 
band,  while  the  other  retained  fully  its  natural  dimensions. 

3.  There  is  no  proportion,  and  but  slight  connection,  between  the  optic  thalami  and  the 
nerves  of  vision.  In  the  horse,  ox,  sheep,  &c.,  the  optic  nerves  are  as  large  as  in  man, 
but  the  thalami  in  man  are  much  larger  than  in  those  animals.  On  examining  the  struc- 
ture of  the  thalamus,  a  merely  superficial  layer  of  it  is  found  to  be  attached  to  the  optic 
nerve,  Avhile  the  whole  of  its  interior  fibres  diverge  backwards  into  the  cerebral  convolu- 
tions. When  the  optic  nerve  is  affected  with  atrophy,  the  corresponding  thalamus  is 
diminished  only  in  so  far  as  the  nerve  itself  has  shrunk;  the  interior  of  the  thalamus 
Buffei'S  no  change,  but  the  atrophic  state  of  the  nerve  may  be  traced  back  to  the  corpora 
qu.adrigemina.  In  the  brain  of  a  woman  who  had  died  insane.  Dr.  Spurzheim"  found  the 
thalamus  of  the  left  side  half-converted  into  pus,  the  corpus  striatum  of  the  same  side 
much  shrunk,  but  the  optic  nerve  healthy,  and  resembling  in  all  respects  its  fellow  of  the 
opposite  side,  in  the  vicinity  of  which  no  organic  change  could  be  detected.  The  anterior 
pair  of  quadrigeminal  bodies  were  also  in  their  natural  state.  In  one  instance.  Dr. 
Parry**  found  the  thalami  nearly  obliterated,  with  the  optic  nerves  healthy.  Numerous 
cases  might  be  quoted  of  disease  in  the  thalami,  without  any  affection  of  vision.^ 

4.  Each  optic  nerve,  or  at  any  rate  each  retina,  is  probably  a  plexus,  derived  nearly 
from  the  two  sides  of  the  brain.  There  is  reason  to  believe  that  the  retina  is  in  commu- 
nication with  other  nerves  besides  the  optic  ;  and  that  it  influences  them,  and,  on  the 
other  hand,  is  under  their  influence.  The  optic  nerves,  as  has  been  already  mentioned, 
are  in  connection  with  the  posterior  part  of  the  medulla  oblongata.  The  great  sympa- 
thetic, by  communicating  with  the  spinal  nerves,  derives  the  power  of  exciting  motion 
and  conveying  sensation ;  hence  irritation  of  the  organs  supplied  by  the  great  sympa- 
thetic is  communicated  to  the  spinal  cord  and  to  the  brain,  and  disease  is  excited  in  the 
cerebrum  by  causes  existing  in  the  thorax,  abdomen  or  pelvis.  If  we  trace  the  great 
sympathetic  nerve  upwards  from  the  first  cervical  ganglion,  we  find  that  the  branches  of 
the  nerve  surround  the  internal  carotid  artery,  passing  with  it  into  the  carotid  canal  of 
the  temporal  bone ;  and  that,  having  reached  the  cavernous  sinus,  the  great  sympathetic 
forms  a  ganglion,  whence  are  derived  branches  which  communicate  with  the  sixth  nerve, 
the  third  nerve,  and  the  first  division  of  the  fifth.  One  or  more  branches  of  the  cavern- 
ous ganglion  communicate  directly  with  the  lenticular  ganglion.  Tiedeniann^  thought  he 
traced  branches  from  the  lenticular  ganglion  to  tlie  retina.  The  internal  carotid  artery, 
as  it  mounts  within  the  cranium,  is  still  surrounded  by  branches  of  the  great  sympathetic 


SEATS   OF   AMAUROSIS.  945 

nerve,  which  cling  to  it,  aud  may  be  traced  along  its  ramifications.  The  ophthalmic 
artery,  with  the  rest,  is  invested  with  a  plexus  from  this  nerve,  and  in  this  way  the  arte- 
ries of  the  choroid,  iris,  and  retina,  are  supplied  with  its  influence.  From  the  lenticular 
ganglion  arise  the  nerves  of  the  ciliary  muscle  and  the  iris,  and  Eibes''  supposes  that  he 
has  traced  branches  from  the  ciliary  or  iridal  nerves,  where  they  lie  between  the  sclero- 
tica and  choroid,  penetrating  the  latter  membrane,  and  running  backwards  into  the 
retina. 

5.  When,  in  birds,  one  of  the  optic  lobes  (parts  analogous  to  the  anterior  corpora 
quadrigemina  of  mammiferous  animals)  is  wounded,  the  vision  of  the  opposite  eye 
becomes  weak  or  extinct.  If,  after  a  time,  the  same  experiment  is  performed  on  the 
other  side  of  the  brain,  the  eye  which  formerly  continued  sound,  becomes  blind. s 
:,  6.  If  the  optic  nerve  be  divided  in  any  animal,  anteriorly  to  the  chiasma,  the  pupil  of 
the  eye  on  the  same  side  becomes  very  large  aud  motionless,  and  the  power  of  vision  of 
that  eye  is  immediately  abolished.  Every  trace  of  sensibility  to  light  is  lost,  so  that 
even  on  concentrating  the  light  of  the  sun  by  means  of  a  lens,  and  directing  it  into  the 
pupil,  not  the  least  symptom  of  sensation  is  produced. 

7.  If  the  chiasma  is  divided  longitudinally,  blindness,  with  dilated  pupils,  is  the 
result. 

8.  It  is  generally  acknowledged  that  the  fifth  nerve  communicates  common  sensibility 
to  the  parts  to  which  it  is  distributed ;  and  that,  in  consequence  of  the  communications 
which  it  has  with  the  great  sympathetic,  it  exercises  a  very  remarkable  influence  over  the 
nutrition  of  the  eye.  Hence  it  is  that  injuries  of  the  fifth  nerve  determine  often  a  reflex 
aifection  of  the  retina,  ending  in  blindness.  The  evidence  in  favor  of  the  opinion  of 
Magendie,^  that  the  fifth  is  directly  concerned  in  vision  where  a  special  nerve  exists,  is 
altogether  insufficient.  If  light  acts  in  any  case  as  an  agent  in  exciting  impressions  not 
visual,  the  fifth  nerve  is  probably  the  channel  through  which  such  impressions  are  con- 
veyed.'" 

9.  If  the  trunk  of  the  third  nerve  be  divided  within  the  cranium  of  a  pigeon,  the  pupil 
dilates,  and  cannot  be  made  to  contract  by  exposure  to  intense  light.  The  section  of  the 
fifth  nerve  in  the  same  animal  produces  no  change  in  the  motions  of  the  iris.  In  birds, 
the  third  pair  supplies  the  whole  of  the  nerves  of  the  iris.  AYhen  the  optic  nerves  are 
pinched  within  the  cranium  of  a  pigeon,  the  pupils  contract.  The  same  result  follows 
a  similar  irritation  of  the  third  pair,  but  not  that  of  the  fifth.  When  the  optic  nerves 
have  been  divided  within  the  cranium  of  a  pigeon,  if  the  j^ortion  of  the  nerves  attached 
to  the  eyes  be  pinched,  no  contraction  of  the  pupil  ensues;  but  if  the  portion  adhering 
to  the  brain  be  pinched,  a  like  contraction  of  the  pupil  ensues  as  if  the  optic  nerves  had 
not  been  divided.  If  the  third  pair  has  been  divided,  no  change  in  the  pupil  ensues  on 
irritating  the  entire  or  divided  optic  nerves.  From  these  facts,  it  may  fi^irly  be  con- 
cluded, that  in  the  habitual  variations  of  the  pupil,  an  impression  is  conveyed  along  the 
optic  nerve  to  the  brain,  which  is  followed  by  an  afi'ection  of  the  third  nerve,  causing  the 
pupil  to  contract  or  dilate. " 

10.  Pourfour  dii  Petit  was  the  first  to  observe,  that  in  those  animals  where  the  great 
sympathetic  is  so  closely  connected  to  the  vagus,  that  the  latter  cannot  be  divided  in  the 
neck  without  dividing  also  the  former ;  the  result  of  such  experiment  is,  that  the  con- 
junctiva becomes  red  and  swollen,  the  third  eyelid  is  projected  over  the  cornea,  the  pupil 
becomes  contracted,  and  only  a  small  part  of  the  ej'eball  is  seen  between  the  half-closed 
eyelids.  These  eflects  he  justly  attributed  to  the  division  of  the  trunk  of  the  great  sym- 
pathetic.'^ Similar  experiments,  by  many  succeeding  observers,  and  especially  the 
extirpation  of  the  superior  cervical  ganglion  of  the  great  sympathetic,  have  led  to  the 
conclusion,  that  while  contraction  of  the  pupil  is  owing  to  the  stimulus  conveyed  to  the 
sphincter  fibres  of  the  iris,  through  the  third  nerve,  the  stimulus  for  contraction  of  the 
radiating  fibres,  by  means  of  which  the  pupil  is  expanded,  is  dependent  on  branches 
from  the  sjjinal  nerves,  passing  through  the  superior  cervical  ganglion  of  the  great  sym- 
pathetic. A  remarkable  fact,  recently  announced  by  M.  Bernard,  is,  that  if  the  central 
end  of  the  divided  nerve  is  galvanized,  the  pupil  contracts,  and  the  muscles  of  the  face, 
previously  contracted,  become  relaxed."' 

From  these  anatomical  and  physiological  facts,  the  reader  may  easily  con- 
clude, that  a  strict  inquiry  into  .the  seats  and  symptoms  of  the  different 
varieties  of  amaurosis,  will  necessarily  embrace  a  field  of  considerable  extent, 
and  that  he  need  not  be  surprised  to  meet,  in  the  course  of  such  inquiry, 
with  many  things  which  may  appear  inexplicable,  or  even  contradictory. 

Yision  is  completed  in  the  retina,  optic  nerve,  and  optic  tubercle ;  and 
these  are  the  parts,  one  or  other  of  which  must  always  suffer  in  amaurosis. 
At  the  same  time,  it  happens  in  many  cases  that  the  organic  change  upon 
60 


946  CAUSES   OF   AMAUROSIS. 

which  this  disease  depends,  does  not  primarily  affect  those  textures,  but  some 
of  the  surrounding  ones,  or  even  textures  which  are  remote  from  the  organ 
of  vision.  The  membranes  of  the  brain,  for  example,  may  give  rise  to  a 
tumor,  which  may  press,  through  the  medium  of  the  brain,  upon  the  optic 
apparatus.  The  uterus,  suddenly  ceasing  to  discharge  the  catamenia,  may 
lead  to  an  overcharged  state  of  the  cerebral  vessels,  and  this  may  cause  an 
amaurosis.  Hence  the  distinction  of  idiopathic,  symptomatic,  and  sympa- 
thetic amaurosis. 

Amaurosis  may  be,  1.  Sensorial,  having  its  seat  in  the  retina,  optic  nerve, 
or  optic  tubercle ;  2.  Cerebral,  as  when  it  arises  from  diseases  in  the  hemi- 
spheres of  the  brain,  water  in  the  ventricles,  or  tumors  attached  to  the  dura 
mater  ;  3.  Spinal,  when  it  springs  from  disease  of  the  fifth  nerve,  and  is 
attended  by  ocular  anesthesia  ;  4.  Ganglionic,  as  when  affections  of  the 
digestive  or  the  generative  system  give  rise  to  it. 

III.  Causes,  i.  Efficient  causes. — Amaurosis  may  depend  simply  on 
pressure  communicated  to  the  retina,  optic  nerve,  or  brain,  or  on  some 
organic  change  originating  in  one  or  other  of  these  parts.  It  is  on  this 
twofold  principle  that  I  shall  afterwards  classify  the  efficient  causes  of  the 
disease. 

1.  Congestion,  or  inflammation,  primarily  affecting  any  portion  of  the  nerv- 
ous optic  apparatus,  or  the  secondary  effects  of  inflammation,  or  its  tertiary 
effects  (see  p.  418)  on  the  brain,  its  membranes,  the  pptic  nerve,  or  the 
retina,  may  cause  amaurosis.  It  Is  possible  that  amaurosis  may  sometimes 
be  the  product  of  disorders  originating  in  the  nervous  substance  of  the  optic 
apparatus  ;  but  there  is  reason  to  think  that  much  more  frequently  disorders 
of  the  sanguiferous  system,  operating  on  the  nervous  substance,  cause  the 
disease.  It  is  plain  that  no  sensorial  function  can  be  carried  on  in  a  perfect 
state,  without  the  due  co-operation  of  the  sanguiferous  and  nervous  systems. 
Of  diseases  essentially  nervous,  we  know  very  little ;  the  greater  part  of  the 
morbid  affections  of  the  nervous  system  with  which  we  are  acquainted,  origi- 
nate in  vascular  derangements. 

The  organic  changes  which  directly  produce  amaurosis  are,  in  general, 
congestion  or  Inflammation  in  its  primary  stage,  or  some  of  the  secondary  or 
tertiary  effects  of  inflammation,  such  as  suppuration,  ulceration,  induration, 
ramollissement,  hypertrophy,  atrophy,  &c.  Such  changes  may  be  either 
removable,  as  simple  congestion,  or  inflammation  in  its  first  stage;  or  perma- 
nent, as  ramollissement,  atrophy,  &c. 

2.  The  cause  of  amaurosis  is  evidently,  in  many  cases,  pressure,  impeding 
the  communication  of  nervous  influence,  and  of  vascular  support.  Pressure 
may  produce  amaurosis  immediately  or  mediately.  An  enlarged  pituitary 
gland  will  press  directly  on  the  optic  nerves;  a  tumor  attached  to  the  tento- 
rium will  press  Indirectly  on  the  optic  apparatus.  Pressure  by  an  exostosis, 
or  other  tumor,  is  a  thing  with  which  we  are  familiar  ;  a  gorged  state  of  the 
bloodvessels  we  also  regard  as  a  cause  of  pressure ;  and  even  when  amau- 
rosis is  the  result  of  inflammation,  it  can  scai'cely  be  doubted,  that  the  optic 
apparatus  suffers  pressure,  rendering  it  Incapable  of  fulfilling  its  proper  func- 
tions. Of  the  proximate  cause  of  those  diseases,  which  are  generally 
attributed  to  compression  of  the  brain.  Sir  Charles  Bell  has  promulgated  a 
view  somewhat  different  from  the  common,  maintaining  that  what  is  called 
compression  in  this  instance,  operates  not  on  the  substance  of  the  brain 
itself,  but  simply  by  preventing  that  due  supply  of  arterial  blood,  which  is 
necessary  for  the  performance  of  the  cerebral  functions."  There  can  be  no 
doubt,  however,  that  where  the  bulk  of  any  part  of  the  body  is  diminished 
by  compression;  the  effect  is  an  increased  activity  of  the  absorbents,  as  well 


CAUSES  OP  AMAUROSIS.  94Y 

as  a  diminislied  supply  of  blood  ;  so  that  the  tissues  are  wasted,  aud  cannot 
be  repaired. 

Amaurosis  alwaj^s  results  from  an  organic  cause,  existing  in  the  optic  appa- 
ratus, or  in  the  surrounding  parts.  The  notion  of  such  a  thing  as  afunc- 
tional or  di/immical  aavAuvos'is  may  perhaps  have  originated  in  the  hypothesis, 
entertained  by  many,  that  mental  disorders  are  often  functional  merely,  and 
not  dependent  on  any  structural  derangement  of  the  brain.  This  hypothesis, 
which  even  in  respect  to  mental  affections  is  probably  unfounded,  has  been 
still  more  unwarrantably  extended  to  sensorial  disorders.  While  we  acknow- 
ledge, that  amaurosis  is  occasionally  sympathetic,  or  arises  in  consequence  of 
derangement  of  some  remote  organ,  and  that  it  is  in  some  rare  instances 
sudden  in  its  attack  or  in  its  departure,  yet  it  cannot  admit  of  doubt,  that, 
in'  all  cases,  even  the  sympathetic,  the  loss  of  sight  must  depend  on  some 
change  affecting  the  substance  of  the  optic  apparatus,  and  cannot  result  from 
any  merely  irregular  distribution  of  nervous  energy.  Take,  for  example,  the 
amaurosis  which  arises  from  the  presence  of  worms  in  the  bowels.  The  brain, 
of  perhaps  not  more  than  one  out  of  a  thousand  affected  with  worms,  is  so 
susceptible  of  disease,  that  the  irritation  communicated  to  it  from  the  bowels 
is  sufficient  to  produce  in  it  that  morbid  condition  which  causes  dilatation  of 
the  pupils  and  loss  of  vision;  but  that  the  amaurosis,  in  these  cases,  is  the 
consequence  of  anything  else  than  a  certain  alteration  in  the  structure  of  the 
optic  apparatus,  is  a  proposition  which  scarcely  deserves  a  serious  refutation. 
Neither  can  it  be  admitted,  when  amaurosis  occurs  suddenly,  as  a  disease  of 
relation,  that  it  is  independent  of  organic  derangement,  however  indubitable 
it  may  be  that  the  first  link  in  the  chain  of  causes  has  existed  in  some  remote 
part  of  the  body. 

The  change  which  a  diseased  organ  suffers,  and  by  which  its  function  is 
deranged,  may  be  transient  and  curable,  or  it  may  be  permanent  and  incur- 
able ;  but  this  is  no  good  ground  for  styling  the  former  disease  functional, 
and  reserving  the  name  organic  for  the  latter,  much  less  for  maintaining  the 
absurdity,  that  a  function  may  be  deranged  although  the  organ  of  the  function 
is  sound.  Amaurosis  from  vascular  derangement  is  styled  functional ;  from 
a  tumor  in  the  brain,  organic;  whereas  the  former  is  as  truly  organic  as  the 
latter.  In  congestion  or  in  inflammation,  not  only  are  the  vessels  changed 
in  diameter — the  very  important  organ  which  they  contain,  viz:  the  blood,  is 
changed — and  in  the  parts  around,  there  are  often,  if  not  always,  molecular 
changes  of  the  greatest  importance.'^ 

ii.  Remote  causes. — Amaurosis  springs  from  many  and  various  predis- 
posing and  exciting  causes. 

When  a  strong  predisposition  to  the  disease  exists,  a  slight  exciting  cause 
may  bring  it  on.  Many  fatigue  their  eyes  in  viewing  minute  objects;  but 
out  of  perhaps  500  of  these,  only  one  shall  become  amaurotic,  in  whom  a 
stronger  predisposition  to  the  disease  had  existed.  When  there  is  no  predis- 
position, exciting  causes  which  in  other  circumstances  would  have  produced 
amaurosis,  may  have  no  effect.  In  some,  the  force  of  the  predisposing  cause, 
not  that  of  the  exciting,  produces  the  disease;  in  other  cases,  it  is  the  re- 
verse. Either  cause  may  be  so  obscure,  as  to  escape  detection ;  both  may  be 
inscrutable. 

1.  We  meet  with  instances  of  hereditary  predisposition  to  the  disease;  so 
that  several  members  of  the  same  family,  or  of  successive  families,  lose  their 
sight,  about  the  same  period  of  life.  Beer  knew  several  families  who  had  a 
hereditary  tendency  to  amaurosis.  In  one  of  them,  even  through  three  suc- 
cessive generations,  all  the  females  who  had  not  borne  children  became  blind 
when  they  ceased  to  menstruate.  The  males  of  this  family,-  who,  as  well  as 
the  females,  had  dark- brown  eyes,  also  showed  a  decided  tendency  to  the 


948  CAUSES   OP  AMAUROSIS. 

disease,  altliougli  none  of  them  lost  their  sight. ^^  Innate  or  inherited  causes 
predisposing  to  amaurosis,  occur  ofteuest  in  those  of  a  melancholic,  and  less 
frequently  in  those  of  a  sanguine  temperament.  Scrofulous  subjects,  with 
dark  eyes  and  hair,  are  apt  to  suffer  from  such  predisposition. 

2.  Over-exertion  of  the  sight,  exposure  to  bright  light,  or  great  heat  and 
light,  either  natural  or  artificial,  occupation  upon  minute  objects,  and  employ- 
ment of  the  eyes  during  the  hours  which  ought  to  be  devoted  to  sleep,  form  a 
set  of  causes  which  are  extremely  productive  of  amaurosis.  In  many  instances, 
a  single  imprudent  exposure  of  the  eyes  to  the  operation  of  some  such  cause  as 
those  now  mentioned,  has  been  sufficient  to  extinguish  the  sensibility  of  the 
retina ;  but,  in  general,  it  is  from  long-continued  over-excitement  of  the  organs 
of  vision,  that  they  begin  to  fail,  and  at  last  become  totally  unable  to  continue 
their  office. 

3.  A  third  set  of  predisposing  and  exciting  causes  are  such  as  directly  or 
indirectly  promote  determination  of  blood  to  the  eyes,  or  sanguineous  con- 
gestion, inflammation,  or  serous  effusion,  in  the  head ;  such  as  insolation, 
I'age,  forced  exertions  of  the  body,  occupations  which  require  continued 
stooping,  errors  in  diet,  and  especially  the  abuse  of  wine  and  spirits,  retroces- 
sion of  eruptive  diseases,  suppressed  discharges  of  blood,  perspiration,  pus, 
&c.,  interruption  or  entire  cessation  of  the  menses,  and  slowness  of  the 
bowels.  Typhus  fever,  from  its  congestive  elfects  on  the  brain,  often  leads  to 
amaurosis. 

4.  The  operation  of  poisonous  substances  sometimes  produces  a  sudden 
attack  of  amaurosis.  Belladonna,  stramonium,  and  some  other  narcotics,  in 
large  doses,  ai*e  almost  immediately  followed  by  this  effect.  Other  poisonous 
substances,  applied  to  the  body,  in  small  quantities  every  day,  or  several 
times  every  day,  are  probably  productive  of  a  similar  effect,  only  that  they 
operate  more  slowly.  Tobacco  may  be  justly  signalized  as  a  poison  of  this 
sort;  but  many  others,  and,  in  particular,  mercury  and  lead,  have  been  accused 
of  an  insidious  operation  on  the  nervous  system,  terminating  in  blindness. 

5.  Gastric  and  intestinal  irritation,  acute  or  chronic,  is  in  many  instances 
the  forerunner  of  amaurosis,  and  evidently  operates  as  its  exciting  cause, 
either  by  impeded  and  deranged  assimilation,  or  through  the  medium  of  the 
great  sympathetic  nerve. 

G.  Exhaustion  of  the  body,  such  as  that  which  arises  from  poor  and  unwhole- 
some diet,  chronic  diarrhoea,  neglected  leucorrhcca,  prolonged  suckling,  ma- 
nustupration,  excessive  venery,  and  the  like,  is  a  frequent  cause  of  amaurosis. 
There  is  reason  to  believe  that  local  congestions  and  inflammations  may 
accom])any  the  state  of  general  weakness,  produced  by  the  causes  here 
enumerated  ;  and  from  such  local  affections,  ending  in  atrophy  of  the  optic 
apparatus,  the  amaurosis  which  occurs  under  such  circumstances,  probaljly 
takes  its  origin.  Depressing  mental  affections,  grief,  care,  and  melancholy, 
operate  in  the  same  way  in  ])roducing  the  disease. 

7.  Blows  on  the  head,  injuries  of  the  branches  of  the  fifth  nerve,  and  even 
mere  irritation  of  this  nerve,  have  sometimes  proved  the  remote  causes  of 
amaurosis. 

8.  Those  who  have  suffered  from  scrofulous  or  other  chronic  ophthalmise 
in  childhood,  or  from  other  scrofulous  diseases,  are  very  liable  to  become 
amaurotic,  after  they  begin  to  use  their  eyes  in  earnest,  or  later  in  life,  and 
especially  if  exposed  to  one  or  more  of  the  unfavorable  influences  above 
enumerated. 

Hi.  Complication  of  causes. — Amaurosis  is,  in  general,  a  disease  by  no 
means  simply  constituted,  or  of  which  the  causes  are  easily  and  satisfactorily 
explicable.  If -we  investigate  with  care  the  history  of  the  cases  of  amaurosis 
which  come  before  us,  we  shall  find  that  the  disease  can  seldom  be  attributed 


SYMPTOMS   OF  AMAUROSIS.  949 

to  the  influence  of  any  single  remote  cause  ;  but  that  most  frequently  a  num- 
ber of  circumstances  favorable  to  the  rise  and  progress  of  an  amaurotic  affec- 
tion, have  for  a  length  of  time  been  acting  on  the  individual,  either  consecu- 
tively, or  together.  It  is  chiefly  the  combination  of  manifold  and  complex 
causes,  which  at  once  renders  it  so  difficult  to  discriminate  with  correctness 
between  the  different  species  of  amaurosis,  to  classify  them,  and  in  many 
cases,  to  decide  on  a  proper  line  of  treatment,  and  which  but  too  often  serves 
also  to  frustrate  the  cure,  even  when  the  remedies  are  judiciously  selected, 
and  carefully  applied. 

ly.  Symptoms. — The  symptoms  of  amaurosis  are  essential  or  accidental. 
Such  symptoms  as  neuralgia,  hysteria,  epilepsy,  &c.,  are  accidental  in  many 
cases  to  amaurosis ;  and,  on  the  contrary,  amaurosis  is  often  accidental  to 
these  diseases.  The  distinction  must  be  carefully  attended  to  in  practice. 
From  the  concurrence  of  accidental  symptoms,  a  great  degree  of  perplexity 
may  arise,  if  they  are  not  distinguished  from  those  which  are  essential. 

The  essential  symptoms  of  amaurosis  naturally  arrange  themselves  into 
two  classes  ;  the  objective  or  anatomical,  and  the  subjective  or  physiological. 
The  former  class  includes  those  which  the  observer  discovers  in  the  form, 
color,  texture,  consistency,  vascularity,  and  mobility  of  the  different  parts  of 
the  organ  of  vision,  or  in  the  general  health  of  the  patient ;  the  latter,  those 
which  \}i\Q  patient  himself  experiences,  and  which  must  be  admitted  very  much 
upon  his  own  testimony,  as  impaired  and  deranged  vision,  headache,  giddi- 
ness, &c.  In  general,  it  is  advisable  in  examining  any  case  of  amaurosis, 
first  to  attend  to  the  objective,  and  then  to  the  subjective  symptoms.  Each 
eye  ought  also  to  be  inspected  separately,  while  the  other  is  excluded  from 
the  light.  Even  in  the  history  of  his  loss  of  vision,  we  ought  to  confine  the 
patient  to  one  eye  at  a  time,  unless  both  appear  to  have  become  affected  at 
the  same  period,  and  from  the  same  cause. 

^.  Objective  symptoms. — 1.  The  first  symptom,  which,  in  general,  attracts 
the  attention  of  an  experienced  observer,  is  the  gait  and  cast  of  eye,  of  the 
amaurotic  patient.  He  advances  towards  us  with  an  air  of  doubt  and  uncer- 
tainty in  his  movements,  from  which  the  cataractous  patient  is  generally 
exempt,  and  instead  of  converging  his  eyes  in  the  natural  way  towards  an 
object,  it  is  evident  that  there  is  something  vacant  and  unmeaning  in  his 
look,  the  result  of  the  eyes  being  directed  parallelly,  as  if  towards  an  object 
infinitely  distant.  If  one  eye  is  only  affected,  it  appears  to  diverge  from  its  fel- 
low. This  cast  of  the  eyes,  which  Richter^''  appears  to  confound  with  squint- 
ing, may  exist,  indeed,  only  in  a  very  slight  degree.  It  is,  however,  as  that 
author  well  observes,  the  only  objective  sign  of  amaurosis,  which  never  fails 
to  be  present,  a  fact  peculiarly  valuable,  in  cases  where  we  have  reason  to 
suspect  simulation.  In  some  cases  of  amaurosis,  there  is  not  merely  the  want 
of  direction  and  control  of  the  eyes,  of  which  we  are  now  speaking,  and 
which  is  the  consequence  of  deficient  sensation,  but  there  is  actual  strabismus, 
a  symptom  which  coming  on  after  considerable  loss  of  vision,  with  pain  in 
the  upper  part  of  the  forehead,  points  to  organic  disease  within  the  cranium. 
In  many  cases  there  is  oscillation,  and  in  some  the  eyes  stand  completely 
fixed  in  the  head. 

The  motions  of  the  lids  also,  as  well  as  those  of  the  eyes,  are  not  unfre- 
quently  impeded  ;  in  some,  the  levator  of  the  upper  lid,  and  in  others,  the 
orbicularis  palpebrarum,  being  partially  or  completely  palsied,  according  as 
the  motor  oculi  or  the  facial  nerve  is  prevented  from  communicating  its  influ- 
ence to  the  muscles  which  it  supplies. 

2.  Besides  the  movements  of  the  eyes,  their  prominence,  size,  color,  con- 
sistence, and  form,  deserve  attention.  _We  often  observe  them  unnaturally 
prominent,  or  the  one  more  prominent  than  the  other  ;  they  are  not  unfre- 


950  SYMPTOMS   OP  AMAUROSIS. 

quently  small,  an  effect  of  scrofulous  ophthalmia  in  childhood  ;  their  color  is 
seldom  that  of  the  healthy  eye,  the  sclerotica  being  frequently  of  a  yellowish 
hue,  sometimes  bluish  or  ash-colored,  and  often  covered  with  varicose  ves- 
sels running  either  in  straight  lines  or  tortuously  towards  the  cornea  ;  while 
there  are  few  symptoms  of  amaurosis  so  certain  as  a  change  in  the  consistence 
of  the  eyeball,  it  being  either  considerably  firmer  to  the  touch,  or  greatly 
softer  than  natural.  In  some  instances,  we  find  the  eye  flattened  on  one  or 
several  of  its  sides. 

Some  of  these  changes  may  be  considered  as  causes  and  others  as  effects  of 
amaurosis.  The  loss  of  the  special  function  of  an  organ  of  sense  often  leads 
to  an  enfeebled  state  of  its  organic  functions.  The  consequences  are  a  set  of 
secondary  changes,  which  must  not  be  confounded  with  those,  which,  being 
the  cause  of  the  loss  of  sensibility,  may  be  chWqA  pnmary. 

3.  Sluggish  and  limited  motion  of  the  pupil,  or  entire  loss  of  motion,  often 
attended  with  dilatation,  forms  one  of  the  most  remarkable  symptoms  of 
amaurosis.  The  early  and  incomplete  stages  of  amaurosis  are  rarely  accom- 
panied by  widely  dilated  pupils,  but  only  by  sluggishness  and  a  limited  degree 
of  motion.  After  the  perception  of  light  is  altogether  extinct,  the  opening 
is  generally  found  expanded  and  quite  motionless.  If  the  pupils  are  widely 
dilated  and  fixed,  with  the  eyeballs  of  normal  consistence,  and  the  humors 
clear,  there  is  ]n'obably  hydrocephalus,  or  pressure  from  an  enlargement  of 
the  pituitary  gland,  or  from  some  growth  far  forwards  on  the  base  of  the 
brain.  If  the  pupils  are  in  a  middle  state  of  dilatation,  but  irregular,  and 
sluggish,  and  limited  in  their  motions,  and  especially  if  this  state  is  accom- 
panied with  glaucoma  and  with  discoloration  of  the  iris,  it  is  probable  there 
exists  congestion  or  inflammation  of  the  retina  or  of  the  optic  nerve.  Or  that 
there  is  a  state  of  atrophy  extending  along  the  optic  nerves  within  the  cranium. 
In  this  case  the  belladonna  has  little  effect  in  dilating  the  pupils.  If  one 
pupil  is  widely  dilated,  and  does  not  move  with  the  other  pupil,  there  is  pres- 
sure in  or  behind  the  orI)it,  involving  the  third  nerve  as  well  as  the  optic  of 
the  same  side.  That  a  dilated  state  of  one  pupil  is  not  always  connected 
with  pressure  on  the  brain,  nor  even  with  any  cerebral  disease,  is  evident  from 
the  fact  that  it  is  sometimes  induced  simply  by  a  blow  on  the  eye. 

There  are  two  other  facts  regarding  the  motions  of  the  pupil  in  certain 
amaurotic  cases,  which  have  attracted  much  attention.  The  first  is,  that  the 
pupil  of  a  completely  amaurotic  eye  will  often  move  briskly,  according  to  the 
degree  of  light  acting  on  the  opposite  or  sound  eye,  while,  if  we  expose  the 
amaurotic  eye  by  itself,  its  pupil  remains  perfectly,  motionless,  and  much 
dilated.  The  second  fact,  and  one  accounted  still  more  extraordinary,  is  that 
in  some  cases,  where  the  patient  is  totally  blind,  both  pupils,  according  to 
the  intensity  of  light  to  which  the  eyes  are  exposed,  vary  in  diameter  exactly 
as  in  health." 

The  latter  of  these  facts  has  hitherto  received  no  probable  explanation ; 
for  although  the  direct  influence  of  light'^  has  some  effect  in  causing  motion 
of  the  iris,  the  effect  is  too  small  to  explain  the  extensive  motions  of  the 
pupil  in  such  cases,  while  the  idea'-"  of  the  iris  acting,  by  a  sympathy  with 
the  retina,  independent  of  the  brain,  is  altogether  contrary  to  the  physiology 
of  the  iris,  as  founded  on  experiment.  It  appears  to  be  absolutely  necessary 
for  the  ordinary  motions  of  that  membrane,  not  only  that  the  iridal  or  ciliary 
nerves,  and  one  or  other  or  both  retina3  be  sound,  but  that  a  certain  degree 
of  communication  shall  be  kept  up,  on  the  one  hand,  between  one  or  other  or 
both  retinas  and  the  brain,  and  between  the  brain  and  the  iridal  nerves,  on  the 
other.  It  becomes,  then,  a  question,  whether  the  brain  may  not  be  so  affected 
with  disease,  as  to  be  incapable  of  aqj:ing  as  the  organ  of  visual  perception, 
and  yet  retain  the  power  of  communicating  to  the  third  nerve  the  impulse 


SYMPTOMS   or   AMAUROSIS.  951 

necessary  for  the  usual  motions  of  the  pupil.  If  we  suppose  that  the  function 
of  vision  is  accomplished  only  after  the  optic  nerves  reach  the  corpora  quaclri- 
gemina,  and  thus  communicate  with  the  posterior  part  of  the  medulla 
oblongata,  but  that  the  association  which  undoubtedly  exists  between  the 
optic  nerves  and  the  third  pair,  is  effected  further  forward  on  the  basis  of  the 
brain,  we  shall  be  able  to  afford  at  least  a  plausible  explanation  of  the  fact 
of  the  lively  mobility  of  the  pupils  in  certain  cases  of  complete  amaurosis. 
The  third  pair  makes  its  appeai'ance  immediately  behind  the  tuber  cinereum, 
a  part  of  the  brain  with  which  the  optic  nerves  have  a  manifest  connection. 
The  third  pair  does  not,  indeed,  appear  to  take  its  origin  from  the  tuber 
cinereum,  but  from  the  central  cineritious  substance  of  the  crura  cerebri, 
bearing  an  analogy,  along  with  the  sixth  and  ninth  pairs,  the  portio  dura  of 
the  seventh,  and  the  portion  of  the  fifth  pair  which  escapes  the  Gasserian 
ganglion,  to  the  anterior  roots  of  the  spinal  nerves ;  but  it  is  surely  not  an 
improbable  supposition,  that  the  optic  nerves,  either  where  they  cross  the 
crura  cerebri,  or  more  probably,  where  they  communicate  with  the  tuber 
cinereum,  form  that  link  of  connection  with  the  third  pair,  which  they  are 
universally  acknowledged  to  do  in  some  part  or  other  of  their  course.  A 
disease,  then,  affecting  the  corpora  quadrigemina,  or,  in  other  words,  the 
origin  of  the  optic  nerves,  or  affecting  any  part  of  the  tractus  opticus  between 
the  corpora  quadrigemina  and  the  communication  between  the  optic  nerves 
and  the  third  pair,  wherever  that  communication  is  affected,  will,  according 
to  this  view  of  the  subject,  produce  blindness,  but  may  leave  unimpaired  the 
influence  of  the  optic  nerves  upon  the  third  pair ;  while  the  cases  of  amauro- 
sis, in  which  the  pupils  are  fixed  and  dilated,  are  probably  owing,  either  to 
more  extensive  disease,  or  to  disease  so  situated  as  to  affect  that  part  of  the 
brain  where  the  optic  nerves  communicate  their  influence  to  the  third  pair. 
Amaurosis,  with  lively  pupils,  has  not  unfrequently  been  found  to  depend  on 
disease  of  the  cerebellum.-^ 

If  the  above  be  the  true  explanation  of  the  activity  of  the  pupils,  which 
sometimes  exists  in  cases  of  total  blindness,  it  will  also  serve  to  account  for 
the  motions  of  the  iris  of  an  amaurotic  eye,  when  the  opposite  sound  eye  is 
exposed  to  various  gradations  of  light.  The  right  eye,  we  shall  say,  is  healthy, 
but  the  left,  on  account  of  some  morbid  change  in  the  retina,  or  in  that  por- 
tion of  its  nerve  which  extends  from  the  retina  to  the  chiasma,  is  blind.  Still 
the  right  optic  nerve,  dividing  at  the  chiasma  into  two  portions,  one  to  the 
right  and  the  other  to  the  left  side  of  the  brain,  is  in  communication  with 
both  nerves.of  the  third  pair,  so  that  although  the  pupil  of  the  diseased  eye 
becomes  expanded  and  fixed  when  the  sound  eye  is  kept  shut,  it  instantly 
contracts  when  this  eye  is  exposed  to  light,  and  so  long  as  this  is  the  case, 
performs  exactly  the  same  motions.  This  view  of  the  matter  appears  to  be 
confirmed  by  the  case  of  a  patient  at  the  Glasgow  Eye  Infirmary,  in  whom 
the  retina,  in  consequence  of  an  injury  of  the  eye  received  some  years  before, 
was  thickened,  opaque,  and  separated  from  its  natural  contact  with  the 
choroid.  The  lens  lay  in  the  anterior  chamber,  and  was  removed  by  extrac- 
tion, but  the  eye  remained  perfectly  insensible  to  light.  When  the  diseased 
eye  was  separately  exposed  to  light,  its  pupil  stood  fixed  and  dilated ;  but 
when  both  were  exposed,  the  pupil  of  the  amaurotic  eye  moved  briskly.  We 
had  no  reason  to  believe  that,  in  this  case,  there  was  any  other  part  diseased 
but  the  retina. 

Besides  the  motions  of  the  iris,  which  of  course  must  be  examined,  as  has 
been  already  mentioned,  in  each  eye  separately,  and  with  the  opposite  eye 
excluded  from  light,  there  are  various  other  particulars  respecting  the  iris, 
which  deserve  attention ;  especially,  the  form  and  situation  of  the  pupil,  and 
the  inclination  of  the  iris,  for  sometimes  the  pupil  is  very  irregularly  dilated, 


952  SYMPTOMS   OP   AMAUROSIS. 

at  other  times  it  has  evidently  shifted  from  its  natural  place  towards  one  or 
other  part  of  the  circumference  of  the  iris,  while  this  membrane  itself  is  ia 
some  cases  observed  to  be  bulging  towards  the  cornea,  and  in  others  to  have 
sunk  back,  so  as  to  present  anteriorly  a  concave  or  funnel-like  form. 

4.  A  point  of  great  importance  in  every  case  of  amaurosis  is  the  appear- 
ance and  consistence  of  the  humors.  In  some  instances,  when,  for  example, 
the  disease  is  hydrocephalic,  and  occurs  in  a  young  subject,  the  pupil  presents 
its  natural  black  hue,  but  in  elderly  subjects,  it  is  rarely  the  case  that  some 
degree  of  glaucoma  does  not  accompany  amaurosis.  Such  a  complication 
must,  of  course,  render  the  prognosis  much  more  or  altogether  unfavorable ; 
although,  at  the  same  time,  it  must  be  confessed,  that  some  of  the  most 
hopeless  cases  of  amaurosis  are  attended  with  a  perfectly  healthy  state  of 
the  humors,  the  cause  residing,  not  in  the  eye,  but  in  the  cavity  of  the  orbit 
or  within  the  cranium. 

5.  When  the  pupil  is  either  morbidly  expanded,  or  dilated  by  a  drop  of 
atropine,  it  may  be  possible,  by  concentrating  the  sun's  rays,  or  the  strong 
light  of  a  lamp  or  gas  flame  with  a  double  convex  lens,  and  letting  the  focus 
fall  within  the  eye,  to  discover  in  some  cases  pigmentary  depositions  in  the 
vitreous  humor,  eflusions  of  blood  or  exudations  of  lymph  on  the  surface  or 
in  the  substance  of  the  retina,  or  between  it  and  the  choroid,  varicosity  of 
the  retinal  vessels,  partial  removal  of  the  pigment  in  patches,  separation  of 
the  retina  from  the  choroid  in  consequence  of  sub-choroid  dropsy,  &c.  The 
same  may  be  accomplished  by  means  of  a  beam  of  strong  light,  reflected  from 
a  mirror,  as  is  done  by  the  ophthalmoscopes  of  Helmholtz,  Coccius,  and 
others.  Such  examinations  may  confirm  us  in  an  unfavorable  prognosis, 
already  pronounced  on  other  grounds,  but  are  not  likely  to  be  either  satis- 
factory or  safe  in  the  early  and  curable  stages  of  the  disease. 

6.  It  is  proper  to  observe,  whether  there  be  any  cicatrices  about  the  face 
or  head  of  amaurotic  patients,  marking  the  previous  occurrence  of  such 
injuries  as  may  either,  by  affecting  the  branches  of  the  fifth  pair  distributed 
externally,  have  ultimately  brought  on  a  reflex  disease  of  the  optic  apparatus, 
or  have  more  directly  induced  pressure  on  the  brain,  inflammation  of  its 
membranes,  cerebral  effusions,  or  morbid  formations  within  the  head.  (See 
p.  150.) 

*7.  The  age,  general  aspect,  and  physical  and  moral  constitution  of  the 
patient  must  be  regarded  with  attention.  We  find  all  sorts  of  persons 
amongst  the  amaurotic  ;  from  him  whose  vessels  seem  on  the  point  of  Inirst- 
ing  with  plethora,  and  who  has  long  revelled  in  the  solid  luxuries  of  the 
table,  down  to  the  emaciated  victim  of  famine  or  of  inebriety ;  all  ages,  all 
ranks,  and  professions ;  and  not  unfrequently  it  happens,  that  by  directing 
our  attention  to  the  history  of  the  individual's  mode  of  life,  his  pursuits,  his 
habits,  and  the  diseases  he  has  previously  suffered,  we  are  enabled  to  detect 
the  circumstances  which  have  been  the  predisposing  or  exciting  causes  of 
his  present  complaint,  and  by  the  careful  avoidance  of  which,  for  the  future, 
the  cure  may  be  greatly  promoted.  In  many  cases,  perhaps  in  most,  amau- 
rosis is  only  part  of  a  general  disorder  of  the  nervous  system,  or  of  the  entire 
health.  Observation  of  the  pulse  may  throw  much  light  on  such  cases.  A 
very  slow  pulse,  for  example,  will  naturally  lead  to  the  suspicion  of  some 
chronic  disease  of  the  brain  or  of  the  heart.  As  amaurosis  is  rarely  attended 
by  fever,  quickness  of  the  pulse  will  immediately  direct  attention  to  the  state 
of  the  general  health. 

n.  Subjective  symptoms. — 1.  The  most  important  of  the  subjective  symptoms 
is  impaired  vision.  The  progress  of  this  symptom,  and  the  degree  it  attains, 
vary  in  different  cases ;  for  in  some  instances  the  patient  becomes  suddenly 
and  permanently  blind,  while,   in  others,  the  sight  fails  gradually  during 


SYMPTOMS   OP   AMAUROSIS.  953 

months  or  years,  without  ever  terminating  in  total  loss  of  sight.  Hence  the 
distinctions  of  sudden  and  sloio,  complete  and  incomplete  amaurosis. 

In  the  commencement  of  the  disease,  it  often  happens  that  the  failure  of 
sight  is  observed  only  occasionally,  occurring,  perhaps,  but  seldom,  and  only 
for  a  short  time  {amaurosis  vaga),  assuming  the  form  of  night-hlindness  or  of 
day-hlindness,  or  coming  on  regularly  after  any  continued  exertion  of  the 
eyes  in  the  perception  of  minute  or  luminous  objects.  Sometimes  the  patient 
begins  by  finding  that  with  both  eyes  he  sees  confusedly,  and  better  with  one 
open  and  the  other  closed  (monohlepsis).  Diplopia  is  often  the  first  symptom. 
Many  an  amaurotic  patient  can  read  with  ease  a  few  lines  of  a  printed  book, 
after  which  the  letters  appear  so  confused,  and  the  effort  to  see  them  is  so 
painful,  that  he  is  obliged  to  desist  {asthenopia).  Sudden  and  temporary 
attacks  of  blindness  are  often  connected  with  gastric  derangement,  and  are 
entirely  removed  by  correcting  the  state  of  the  digestive  organs  ;  but  it  must 
also  be  confessed  that  such  transient  attacks  are  sometimes  the  effect  of  inci- 
pient diseases  in  the  brain,  of  the  most  formidable  kind. 

The  failure  of  sight  in  some  cases  extends  to  the  whole  field  of  view,  and 
in  others  only  partially  affects  it.  On  attempting  to  read,  for  example,  more 
or  less  of  the  page  appears  indistinct.  Perhaps  the  patient  loses  sight  of  a 
word  only  here  and  there  (visits  interruptus) ,  or  he  sees  only  one-half  of  the 
page,  while  the  other  half  is  as  if  hid  from  his  view  {hemiopia).  It  not 
unfrequently  happens  that  an  amaurotic  eye  will  still  discern  certain  objects, 
if  they  are  placed  in  one  particular  direction  {visus  ohliquus)  ;  but  if  by  the 
slightest  movement  of  the  eye  or  head,  the  person  once  loses  sight  of  the 
object,  he  finds  that  he  cannot  easily  recover  the  same  point  of  vision.  If 
the  patient  looks  towards  an  object,  it  often  happens  that  he  does  not  see  it, 
it  is  immersed  in  the  amaurotic  cloud ;  but  if  he  directs  his  eye  to  some  other 
object,  situated  above  or  below  or  to  one  or  other  side  of  the  first,  this  comes 
into  view.  This  oblique  vision  is  at  first  of  little  use  to  the  patient,  but 
gradually  the  eye  contrives  to  make  it  more  steady  and  beneficial.  Some- 
times the  patient  catches  sight  of  an  object  while  it  is  in  motion,  but  sees 
almost  nothing  that  is  at  rest.  Some  amaurotic  patients  see  all  objects  dis- 
figured, bent,  mutilated,  lengthened  or  shortened  {visus  dejiguratus).  The 
flame  of  a  candle  sometimes  appears  very  long  to  such  patients,  and  as  if 
separated  into  several  portions. 

The  failure  of  sight  in  amaurosis  occasionally  assumes  somewhat  of  a  myopic 
QY  presbyopic  form.  I  have  known  a  confirmed  amaurotic  patient  see  large 
objects  with  considerable  distinctness,  through  a  double-concave  glass  of  12 
inches  focus  ;  and  another  patient,  who,  totally  blind  in  the  right  eye,  and 
with  the  left  fast  hastening  to  the  same  state,  could  still  with  the  latter 
read  an  ordinary  type,  by  the  aid  of  a  double-convex  glass  of  seven  inches 
focus. 

To  an  amaurotic  eye,  the  size  of  objects  sometimes  appears  much  smaller 
than  to  the  sound  eye.  The  comparison  may  be  made  by  gently  pressing 
aside  one  eye,  so  as  to  produce  double  vision,  when  the  image  belonging  to  the 
left  eye  will  appear  to  the  right  hand,  and  vice  versa.  It  has  been  concluded, 
from  the  diminished  size  of  the  object  as  seen  by  the  amaurotic  eye,  that  it  is 
not  merely  by  the  size  of  the  image  on  the  retina,  that  we  judge  of  the  dimen- 
sions of  objects,  but  that  our  perception  of  magnitude  is  modified  by  the  state 
of  the  retina." 

2.  Intimately  connected  with  the  failure  of  sight  in  amaurosis,  are  the 
various  false  impressions  of  which  the  patients  complain  ;  for  although  many 
maintain  that  they  have  no  sensation  of  anything  intervening  between  them 
and  objects,  and  are  not  distressed  by  any  sort  of  spectra,  yet,  in  other  cases, 
amaurosis  is  more  or  less  attended  by  the  disorders  described  in  a  preceding 


954  SYMPTOMS   OP   AMAUROSIS. 

chapter  under  the  heads  of  pliotopsia,  chrwpsia,  accidental  colors,  and  muscte 
voUtantes.  Photopsia,  in  particular,  is  apt  to  occur  at  the  commencement  of 
the  disease  in  plethoric  individuals,  and  floating  muscat  in  dyspeptic  subjects. 
As  the  disease  advances,  the  field  of  vision  seems  to  become  obscured  by  a 
cloud  (visus  nehidosus),  or  network  (visits  reticidatus),  the  latter  generally 
appearing  gray  or  black,  especially  in  a  good  light,  or  over  any  white  substance, 
but  sometimes  becoming  luminous  in  the  dark,  and  assuming  a  bluish-white 
color,  like  silver,  or  reddish-yellow,  like  gold.  This  is  the  case,  also,  \V\i\\  fixed 
muscce,  arising  from  the  existence  of  insensible  patches  in  the  retina.  They 
appear  gray  or  black  in  daylight,  but  glitter  in  the  dark.  Floating  muscos  are 
merely  coincident  to  amaurosis,  and  form  no  part  of  the  disease  ;  fixed  muscoe 
are  an  index  of  the  retina  being  partially  insensible  to  light,  and  may  also 
occur  when  the  disease  resides  in  the  optic  nerve  or  in  the  brain,  although 
then  a  general  cloud  or  blackness  is  more  likely  to  overspread  the  whole  field 
of  view. 

3.  If  only  one  eye  is  affected,  by  ascertaining  at  what  time  the  patient 
first  became  liable  to  mistakes  in  those  actions  which  require  distances  to  be 
exactly  distinguished,  as  in  pouring  liquor  into  a  glass,  snuffing  a  candle, 
threading  a  needle,  &c.,  we  may  discover  the  date  of  the  disease,  and  thence 
may  be  assisted  in  forming  a  more  just  prognosis.  If  the  patient  has  only 
recently  been  sensible  of  such  mistakes,  the  disease  is  also  recent,  and  is  likely 
to  yield  to  treatment.^ 

4.  The  feelings  of  the  patient  with  regard  to  light  deserve  attention  ;  for 
sometimes  the  early  stages  of  amaurosis  are  accom])anied  by  abnormal  sensi- 
bility to  light,  and  even  pain  on  exposure  to  its  influence  {ocular  hyper cesthesia), 
while,  in  other  cases,  there  are  from  the  very  beginning  a  diminished  sensibility 
of  the  retina,  and  a  constant  desire  on  the  part  of  the  patient  for  a  more 
copious  illumination  of  all  objects,  or  a  thirst  for  light,  as  it  has  been  called. 

5.  An  unwonted  dryness  of  the  eyes  and  nostrils  is  by  no  means  an  uncom- 
mon symptom  in  chronic  retinitis  and  amaurosis ;  and  it  is  observed,  that  in 
general  great  benefit  is  obtained  in  such  cases  if  once  the  secretions  of  the 
lachrymal  gland,  conjunctiva,  and  Schneidcrian  membrane  are  restored. 

6.  Pain  in  the  eyes,  and  still  more  frequently  in  the  head  and  face,  forms 
one  of  the  most  important  symptoms  in  cases  of  amaurosis.  Amaurosis, 
without  pain,  generally  depends  on  atrophy  of  the  optic  nerves.  If  it  be 
attended  with  headache,  either  constant  or  intermittent,  there  is  probably  some 
organic  aQ'ection  of  the  brain,  or  cause  of  pressure  within  the  cranium.  The 
seat,  extent,  and  nature  of  the  pain  are  to  be  carefully  investigated.  It  is 
necessary  to  inquire  whether  it  is  general  over  the  head,  hemicranial,  or  con- 
fined to  one  particular  spot ;  whether  it  is  dull  or  acute;  whether  it  is  attended 
by  throbbing,  relieved  or  aggravated  by  the  horizontal  position,  or  by  taking 
a  deep  inspiration,  increased  during  the  night,  affected  much  by  temperature, 
exercise,  or  diet ;  and  whether  it  is  constant,  intermittent,  or  periodic.  It 
is  also  important  to  ascertain  whether  the  pain  is  accompanied  by  vertigo,  tin- 
nitus aurium,  nausea,  sleeplessness,  a  tendency  to  coma,  and  the  like. 

From  a  careful  observation  of  the  above  signs,  we  may  often  arrive  at  a 
probable  conclusion  respecting  the  state  of  the  cerebral  circulation,  which  is 
often  imperfect,  in  consequence  of  an  altered  structure  of  the  arteries  of  the 
brain ;  or  may  obtain  evidence  of  the  existence  of  some  deposition  or  forma- 
tion within  the  head,  causing  pressure. 

1.  The  state  of  the  other  senses,  as  well  as  that  of  sight,  and  the  state  of 
the  mental  faculties,  ought  to  be  ascertained. 

If- amaurosis  be  attended  with  headache  and  loss  of  smell,  the  cause  is 
probably  a  tumor  in  the  fossa  pituitaria,  or  over  the  cribriform  plate  of  the 
ethmoid  bone.     If  amaurosis  of  one  eye  be  attended  with  loss  of  hearing  on 


DIAGNOSIS   OF   AMAUROSIS,  955 

the  same  side,  and  stiffness  of  the  muscles  of  the  face,  the  cause  is  probably  a 
tumor  attached  to  the  posterior  surface  of  the  petrous  portion  of  the  temporal 
bone,  or  arising  from  the  meatus  auditorius  internus. 

If  amaurosis  has  been  followed  by  an  affection  of  the  mind,  these  diseases 
have  probably  arisen  from  some  cause  within  the  substance  of  the  brain,  such 
as  an  abscess  or  a  tumor ;  if  the  affection  of  the  mind  existed  first,  and  has 
been  followed  by  amaurosis,  the  morbid  cause  has  probably  commenced  in 
the  membranes  or  on  the  surface  of  the  brain,  and  proceeded  inwards.^ 
Indistinctness  of  the  perceptions  and  thoughts,  and  weakness  in  the  voluntary 
and  involuntary  actions,  point  to  disease  of  the  cineritious  substance. 

8.  The  general  health,  and  the  previous  diseases  of  the  individual,  are 
worthy  of  serious  consideration.  Is  the  constitution  scrofulous  ?  Has  the 
person  suffered  from  venereal  complaints,  or  long-continued  courses  of  medi- 
cine for  the  cure  of  syphilis  ?  Had  he  ever  typhus  fever  ?  And  if  he  had, 
how  was  it  treated  ?  Has  he  had  any  serious  disease  of  the  head,  as  phre- 
nitis ;  any  apoplectic,  epileptic,  or  paralytic  affection  ?  Are  there  signs  of 
softening  of  the  brain  or  spinal  cord  ?  Is  there  any  affection  of  the  heart, 
such  as  hypertrophy  or  valvular  disease  ?  Has  the  patient  been  subject  to 
hypochondriasis,  or,  if  a  female,  to  hysteria  ?  Has  the  patient  been  gouty 
or  rheumatic  ?  What  has  been  the  condition  of  the  digestive  organs  ?  If 
the  patient  be  a  female,  what  has  been  the  state  of  the  uterine  system  ?  Has 
the  patient  been  subject  to  any  periodical  or  long-continued  discharge,  which 
has  suddenly  dried  up  ?  These,  and  many  other  points,  which  will  naturally 
suggest  themselves  to  the  mind  of  the  attentive  observer,  ought  to  be  made 
the  subjects  of  deliberate  inquiry. 

V.  Forms,  stages,  and  degrees. — It  is  proper  to  distinguish  acute  from 
chronic  amaurosis  ;  incipient  from  confirmed ;  and  incotnplete  from  complete. 

1.  Almost  every  species  of  amaurosis  presents  in  some  cases  the  acute,  and 
in  others  the  chronic  form.  The  chronic  is  sometimes  the  concluding  stage 
of  the  acute.  More  frequently  the  disease  is  slow  and  insidious  in  its 
approach  and  progress ;  and  when  it  affects  only  our  eye,  may  be  far 
advanced  before  its  existence  is  suspected. 

2.  In  the  incipient  stage,  which  is  generally  one  of  congestion  or  inflam- 
mation, the  disease  is  only  developing  itself;  the  patient,  in  general,  is  not 
completely  deprived  of  sight ;  remedies  will  almost  always  be  useful  in 
checking  the  progress  of  the  complaint,  and  in  many  cases  a  perfect  cure 
will  be  accomplished.  It  sometimes  happens,  however,  that  even  from  the 
very  first  the  blindness  is  complete,  and  the  case  incurable.  In  the  con- 
firmed or  inveterate  stage,  which  is  often  one  of  atrophy,  remedies  may  per- 
haps relieve  some  of  the  attending  symptoms,  but  will  very  seldom  effect  a 
cure.  The  patient  is  not  always  totally  deprived  of  sight,  even  in  confirmed 
cases  of  long  standing ;  but  often  retains  a  perception  of  light  and  shade,  or 
a  certain  degree  of  capability  to  discern  different  gradations  of  light,  certain 
colors,  and  even  objects  well  illuminated  or  strongly  contrasted. 

3.  In  complete  amaurosis,  the  patient  is  unable  to  distinguish  any  object  or 
color  whatever,  and  is  often  insensible  even  to  the  presence  of  light,  Any 
degree  less  than  this  is  incomplete ;  the  patient  distinguishes  large  objects 
dimly,  and  is  able  perhaps  even  to  read  large  letters. 

yi.  Diagnosis. — It  is  chiefly  with  incipient  cataract  that  amaurosis  is 
apt  to  be  confounded.  On  this  subject  I  must  refer  to  what  has  been  said  at 
p.  703. 

Glaucoma  is  often  mistaken  for  amaurosis,  from  the  circumstance  of  being 
always  attended  by  some  of  the  subjective  symptoms  of  this  disease  ;  but  the 
objective  symptoms  of  glaucoma,  such  as  the  apparent  greenness  of  the 
humors,  and  the  hardness  of  the  eyeball,  are  sufficiently  remarkable  to  enable 


956  TREATMENT   OF   AMAUROSIS. 

US  in  general  to  distinguish  it  from  simple  amaurosis.  The  complication, 
however,  of  amaurosis  with  glaucoma  is  extremely  common.  Amaurosis 
also  occurs  in  combination  with  different  varieties  of  cataract. 

yil.  Prognosis. — There  is  scarcely  any  disease  in  which  the  prognosis  is, 
on  the  whole,  so  unfavorable  as  in  amaurosis.  When  the  complaint,  indeed, 
is  recent,  its  cause  evident,  and  the  subject  under  middle  life,  a  complete  cure 
is  not  unfrequently  obtained.  This  is  sometimes  the  case  even  when  the  loss 
of  sight  is  total.  Much  more  frequently  a  partial  amelioration  only  is 
effected ;  the  disease  being  checked,  and  a  share  of  vision  preserved.  In 
confirmed  cases,  it  rarely  happens  that  much  improvement  takes  place,  even 
under  the  best  directed  treatment. 

It  is  only  when  the  disease  is  not  yet  complicated  with  any  material  dis- 
organization, that  amaurosis  yields  to  treatment.  But  in  the  cases  which  do 
yield,  the  degree  of  the  disease  is  not  always  slight,  but  often  serious,  and 
the  attack  not  always  recent,  but  often  of  considerable  standing.  It  is 
chiefly  in  cases  of  an  inflammatory  or  congestive  nature,  that  the  disease  is 
overcome. 

A  sudden  amaurosis  is  generally  less  unfavorable  than  one  which  has 
developed  itself  slowly.  When  the  pupil  is  only  slightly  dilated,  still 
movable,  and  of  its  natural  form,  the  consistence  of  the  eyeball  neither 
firmer  nor  softer  than  in  health,  and  no  glaucoma  i)resent,  we  may  pronounce 
a  more  favorable  prognosis  than  when  the  pupil  is  fixed  in  the  state  either  of 
expansion  or  contraction,  the  eyeball  either  boggy  or  of  preternatm-al  hard- 
ness, or  the  interior  of  the  eye  presenting  a  greenish  opacity.  If  the  attack 
has  been  sudden,  a  want  of  power  in  the  muscles  of  the  eyeball  or  eyelids, 
along  with  the  proper  amaurotic  symptoms,  may  be  regarded  as  a  sign  that 
the  cause  of  the  disease  is  some  general  pressure  within  the  cranium,  which 
energetic  measures  will  probably  remove ;  whereas  the  slow  succession  of 
one  amaurotic  and  paralytic  symptom  after  another  is  more  likely  to  arise 
from  the  progress  of  some  incurable  formation  within  the  head. 

Amaurosis  in  middle  age  is  less  unfavorable  than  it  is  in  childhood  or  in 
old  age  ;  it  is  less  unfavoral)le  if  the  attack  is  acute  than  if  it  were  chronic  ; 
the  prognosis  is  bad,  if  the  disease  is  hereditary,  or  complicated  with  epi- 
lepsy, or  if  the  patient,  when  a  child,  had  suffered  from  scrofula.  Compli- 
cated with  cataract,  amaurosis  is  incurable. 

VIII.  Treatment. — It  is  evident  that,  as  amaurosis  is  a  mere  symptom 
which  we  cannot  attack  in  itself,  it  should  be  our  first  object,  in  the  treat- 
ment of  any  amaurotic  affection,  to  discover  the  eflicient  cause  upon  which  it 
depends,  and  then  to  direct  against  it  the  appropriate  remedies.  As  the 
causes  are  very  various,  and  even  opposite,  so  must  also  be  the  means  of 
cure.  In  every  case,  however,  to  avoid  the  operation  of  the  exciting  cause, 
and  to  give  the  diseased  organs  rest,  must  be  important.  I  some  time  ago 
attended  a  gentleman  affected  with  such  a  degree  of  incomplete  amaurosis, 
that  he  could  not  read  an  ordinary  type.  He  refused  all  medical  applica- 
tions, and  simply  shaded  the  eyes,  and  did  not  employ  them  on  minute 
objects.     In  the  course  of  twelve  months,  he  perfectly  recovered. 

The  means  of  cure  may  be  arranged  in  two  classes,  general  and  local. 

Attention  must  be  directed,  in  the  first  place,  to  the  general  state  of  the 
health.  It  would  be  inconsiderate  indeed,  to  attempt  the  removal  of  amau- 
rosis by  applications  of  a  specific  or  a  local  kind,  so  long  as  any  general  dis- 
order existed,  such  as  one  of  the  circulating  or  digestive  system  ;  and  to  have 
recourse  to  depletory  means  in  the  feeble  and  emaciated,  would  be  equally 
inconsistent  as  to  give  tonics  and  stimulants  to  the  robust  and  plethoric. 

^.  General  Means.  1.  Depletion. — When  we  find  that  an  amaurotic  attack 
is  attended  by  signs  of  inflammation  within  the  cranium,  impeded  circulation 


TREATMENT   OF   AMAUROSIS,  957 

througli  the  brain,  or  what  is  styled  a  determination  of  blood  to  tbe  head, 
such  as  headache,  vertigo,  flushed  countenance,  photopsia,  tinnitus  aurium, 
and  arterial  throbbing  of  the  temples,  and  that  the  pulse  is  full,  and  the  sub- 
ject young  or  plethoric,  we  will  of  course  employ  general  and  topical  blood- 
letting, purge  the  patient,  put  him  on  low  diet,  and  direct  him  to  avoid  all 
mental  or  corporeal  excitement.  It  is  not  in  cases  of  inflammation  or  of  in- 
creased vascular  action  alone  that  depletion  is  useful,  but  also  in  cases  of 
mere  congestion.  Under  depletion,  the  capillaries  gradually  resume  a  suflS- 
cieut  degree  of  contraction  to  allow  a  renewal  of  the  nervous  influence  and  a 
resumption  of  the  sensorial  function. 

If  the  case  is  purely  one  of  pressure  on  the  brain,  from  vascular  distension, 
these  means,  conjoined  with  rest,  will  probably  effect  a  cure.  If  along  with 
vascular  pressure,  there  is  eftusion,  or  even  some  morbid  formation  within 
the  cranium,  still  depletion  will  afford  to  a  plethoric  subject  the  most  effectual 
palliative  relief,  and  act  as  the  best  preparative  for  other  remedies,  especially 
for  the  use  of  mercury.  It  is  impossible  to  lay  down  any  general  rule  regard- 
ing the  point  to  which  the  bleeding  and  purging  plan  is  to  be  carried  in  the 
treatment  of  amaurosis  with  plethora.  We  must  equally  beware  of  stopping 
short  before  our  purpose  is  obtained,  and  the  balance  of  the  circulation 
restored,  and  of  pushing  the  depletion  so  far  that  it  becomes  merely  a  means 
of  weakening  the  patient,  without  promoting  the  cure. 

2.  Mercury  has  long  and  justly  maintained  a  high  character  as  a  remedy 
in  amaurosis."^  It  is  probable  that  it  aids  in  the  cure  chiefly  as  a  sorbefa- 
cient,  promoting,  in  particular,  the  removal  of  eflusions  within  the  cranium, 
and  sometimes  even  of  morbid  formations.  It  cannot  be  doubted,  that  many 
of  the  disordered  states  of  the  optic  apparatus,  which  end  in  amaurosis,  are 
originally  of  an  inflammatory  nature ;  inflammation,  acute  or  chronic,  of  the 
retina  and  optic  nerve  is  often  the  cause  of  the  disease,  and  in  all  such  cases 
there  is  reason  to  believe,  from  what  we  know  of  the  beneficial  effects  of  mer- 
cury in  other  inflammatory  aS'ections  of  the  organ  of  vision,  that  this  medicine 
will  prove  more  serviceable  than  almost  any  other  remedy.  There  are,  of 
course,  cases  of  amaurosis,  in  which,  from  the  sunken  state  of  the  patient's 
general  health,  it  might  prove  injurious  to  employ  mercury ;  neither  will  it 
always  be  necessary  or  proper,  in  those  cases  in  which  we  judge  it  right  to 
try  this  remedy,  to  salivate  the  patient,  although  in  some,  only  salivation, 
continued  for  several  weeks,  will  effect  a  cure.  Mr.  Travers,  speaking  of 
mercury  in  amaurosis,  says:  "I  have  been  witness  to  its  power  in  suddenly 
arresting  the  disease  in  too  many  instances,  not  to  entertain  a  far  higher 
opinion  of  it  than  of  any  other  article  of  the  materia  medica."-^  Mr.  Law- 
rence's testimony  is  not  less  explicit:  "We  must  have  recourse,"  says  he, 
"  to  mercury,  which  appears  to  be  as  decidedly  beneficial  in  these  cases,  as  in 
iritis,  or  general  internal  inflammation."  "When  the  antiphlogistic  treat- 
ment," he  adds,  "  and  a  fair  trial  of  mercury,  have  failed,  I  do  not  know  that 
it  is  possible  to  effect  any  further  essential  good  by  other  means.  "^'' 

[Mr.  Dixon-**  justly  remarks,  that,  "  one  of  the  most  important  results  of  the 
ophthalmoscope  will  probably  be  a  greater  resti'iction  in  the  administration 
of  mercury.  Patients,  who,  for  many  months,  have  lost  the  perception  of 
objects — perhaps  even  of  light  itself — will  no  longer  be  encouraged  to  submit 
to  a  lengthened  mercurial  course  by  the  vague  assurance  that,  '  as  their  case 
is  one  of  amaurosis,  a  full  course  of  mercury  may  give  them  a  chance.'  A 
view  of  the  fundus  of  the  eye  overspread  with  old  coagula ;  of  a  retina  detached 
from  the  choroid  by  effusion  of  scrum,  and  undulating  with  each  movement 
of  the  globe ;  of  an  atrophied  optic  papilla ;  of  a  vitreous  humor  filled  with 
opaque  filaments  and  corpuscles ;  these  and  other  palpable  signs  of  disorgani- 


958  TREATMENT   OP   AMAUROSIS. 

zation  will  force  the  most  devoted  believer  in  the  omnipotence  of  mercury  to 
dethrone  his  idol." — H.] 

3.  Iodine. — In  adults,  the  preparations  of  iodine  have  proved  in  my  hands 
inefficacious ;  but  in  children  their  sorbefacient  eifects  have  been  highly 
advantageous. 

4.  Emetics  arid  nauseants. — That  emetics  should  be  useful  in  cases  of 
amaurosis  depending  on  gastric  derangement,  and  that  nauseants  may  some- 
times prove  serviceable,  appears  highly  probable.  Accordingly  we  find,  that 
in  recent  incomplete  amaurosis,  arising  from  irritation  in  the  digestive  organs, 
Schtnucker,"^  Richter,^"  and  Scarpa,-"  derived  the  best  effects  from  the  emetic 
plan  of  cure ;  and  although  Beer,  and  several  later  observers,  have  been  less 
successful  in  its  employment,  it  still  deserves  attention.  That  it  is  not  calcu- 
lated, more  than  any  other  means  of  cure,  for  general  adoption,  and  that,  in 
some  cases,  it  might  even  prove  decidedly  hurtful,  can  form  no  objection  to  its 
use,  where  the  tongue  is  foul,  the  mouth  bitter,  and  the  patient  complaining 
of  continual  nausea,  without  being  cither  greatly  debilitated,  or,  on  the  other 
band,  plethoric,  and  inclined  to  cerebral  congestion. 

5.  Ei-aciiants,  of  difterent  sorts,  besides  tliose  already  mentioned,  are  re- 
quired in  the  treatment  of  certain  varieties  of  amaurosis;  such  as  emmena- 
gogues,  when  the  disease  appears  to  be  connected  with  impeded  menstruation; 
anthehnintics,  when  it  arises  from  worms;  dictphoretics,  when  suppressed  per- 
spiration is  the  cause. 

6.  Tonics,  such  as  cinchona,  and  the  preparations  of  iron,  form  a  class  of 
medicines  of  great  importance  in  the  treatment  of  amaurosis.  That  this 
disease  in  many  instances  takes  its  origin  in  vascular  exhaustion  and  nervous 
debility,  and  is  corrected,  or  entirely  removed,  by  the  use  of  a  nourishing 
diet,  the  cold  bath,  tonic  medicines,  and  influences  of  a  similar  sort,  must  be 
well  known  to  all  who  have  had  any  considerable  experience  in  the  treatment 
of  eye-diseases,  and  whose  opinions  are  not  warped  by  some  particular  hypo- 
thesis, which  leads  them  i)erhaps  to  regard  amaurosis  as  always  depending 
on  one  kind  of  cause,  and  therefore  to  be  cured  only  by  one  plan  of  treatment. 
It  cannot  be  denied,  that  tonics  would,  in  many  cases,  do  harm,  just  as  bleed- 
ing, purging,  vomiting,  or  the  use  of  mercury  would  do,  if  misapplied ;  but 
this  is  no  reason  why  they  should  be  indiscriminately  rejected. 

Many  cases  of  amaurosis  are  benefited  by  local  derivatives,  such  as  leeches 
to  the  temples  and  blisters  behind  the  ears,  conjointly  with  the  administration 
of  general  tonics.  In  cases  with  debility,  Beer  accused  tonics,  such  as  cala- 
mus aromaticus,  cinchona,  and  steel,  of  aggravating  the  amaurosis,  by  pro- 
ducing an  increased  determination  of  blood  to  the  eyes.  But  if  the  digestive 
functions  are  properly  regulated,  and  topical  derivatives  employed,  tonics 
will,  in  general,  be  found  to  be  advantageous  to  amaurotic  patients  of  feeble 
habit.  ^'^ 

^.  Stimulants. — Many  and  various  internal  stimulants  have  been  employed 
in  the  treatment  of  amaurosis  ;  most  of  them  quite  empirically,  or  on  some 
vague  idea  of  their  possessing  a  power  of  rousing  the  sunken  sensibility  of 
the  nerves ;  others  again  on  the  ground  of  their  power  to  excite  convulsions, 
which,  of  course,  they  do  through  the  instrumentality  of  the  nervous  system. 
Camphor  and  nux  vomica  may  be  mentioned,  as  examples  of  this  class  of 
remedies  for  amaurosis.  It  is  well  known,  that  those  substances,  given  in 
considerable  doses,  excite  violent  tetanic  paroxysms,  not  only  in  the  parts 
animated  by  the  spinal  nerves,  but  also  in  the  muscles  of  the  face,  eyes,  and 
eyelids.  In  the  hope,  perhaps,  that  they  might  also  produce  a  stimulating 
effect  on  t-lie  nerves  of  sense,  these  substances,  and  especially  strychnia  (the 
alkaloid  contained  in  nux  vomica,  and  one  of  the  most  energetic  of  poisons) 
have  been  used  internally  as  well  as  externally  for  the  cure  of  amaurosis. 


TREATMENT   OF   AMAUROSIS.  959 

Arnica  montana,  helleborus  niger,  naphtha,  phosphorus,  and  a  host  of  other 
drugs,  of  similar  properties,  have  been  given  on  the  same  principle  ;  but  it 
is  extremely  doubtful  if  they  have  been  productive  of  the  least  good  effect. 

8.  Antisjjasmodics,  as  opium,  musk,  valerian,  and  the  like,  have  occasionally 
been  used  in  the  treatment  of  amaurosis,  especially  when  this  disease  has  been 
joined  with  epilepsy,  or  hysteria. 

9.  Sedatives,  as  belladonna,  hyoscyamus,  and  aconite,  have  been  tried;  and 
I  have  known  the  first  mentioned  of  these  useful  in  cases  where  the  amaurotic 
symptoms  were  attended  with  pain,  affecting  the  branches  of  the  fifth  nerve. 
It  may  be  regarded  as  a  well-established  fact,  that  if  we  succeed  in  subduing 
the  coincident  disease,  such  as  neuralgia,  epilepsy,  or  hysteria,  the  amaurosis 
is  also  likely  to  yield. 

ii.  Local  Means. — 1.  Counter-irritation,  excited  by  rubefacient  liniments, 
tartar  emetic  ointment,  blisters,  and  issues,  proves  highly  useful  in  almost 
every  variety  of  amaurosis.  A  succession  of  blisters  over  the  head  is  one  of 
the  most  efficient  modes  of  employing  counter-irritation.  Much  advantage 
is  also  dei'ived  from  stimulating  friction  of  the  forehead  and  temples,  blisters 
behind  the  ears,  or  to  the  nape  of  the  neck,  caustic  issues  in  the  same  place, 
a  seton  in  the  neck,  a  tartar  emetic  eruption  between  the  shoulders,  and 
sometimes  even  by  still  more  remote  applications  of  the  same  sort,  as  the 
immersion  of  the  feet  in  warm  water  holding  in  suspension  a  quantity  of 
powdered  mustard  or  cayenne  pepper.  Magendie  recommends  the  appli- 
cation of  blisters  and  moxse  as  close  as  possible  to  some  branch  of  the  fifth 
nerve.  Many  facts,  he  says,  testify  the  efficacy  of  moxce  to  the  temples.  Dr. 
Prichard  recommends-^  an  issue  made  by  dividing  the  scalp  with  the  knife 
from  the  summit  of  the  forehead  to  the  occiput,  and  filling  the  space  with 
peas,  as  by  far  the  most  important  method  of  counter-irritation.  He  relates 
a  case  of  complete  amaurosis,  in  which  an  issue  of  this  sort  was  efficacious 
after  bleeding,  blistering,  and  mercurial  salivation  had  failed.  Small  blisters 
to  the  forehead  and  temple,  the  raw  surface  being  daily  dusted  with  strychnia, 
are  often  employed ;  but  I  must  confess  that  I  have  not  witnessed  any  effect 
which  could  fairly  be  attributed  to  the  strychnia.  I  must  say  the  same  with 
regard  to  friction  round  the  orbit,  with  an  alcoholic  solution  of  veratria. 
That  recoveries  have  followed  the  use  of  external  stimulants,  as  strychnia 
and  veratria,  is  not  to  be  doubted  ;  but  that  these  substances  exercise  any 
specific  effect  in  amaurosis,  different  from  simple  irritation,  is  extremely  pro- 
blematical. 

2.  Sternutatories  have  been  used  with  some  advantage,  especially  in  cases 
where  the  mucous  secretion  from  the  conjunctiva  and  Schneiderian  mem- 
brane appeared  to  be  partially  suppressed.  Mr.  Ware  has  published'*  a 
considerable  number  of  cases,  in  which  the  chief  means  of  cure  was  a  mercu- 
rial snuff.  He  recommends  one  grain  of  turpeth  mineral  to  be  mixed  with 
twenty  grains  of  powder  of  liquorice,  and  about  a  fourth  of  this  to  be  snuffed 
up  the  nose  two  or  three  times  a  day.  In  cases  where  the  nostrils  are  par- 
ticularly dry,  the  patient  may  promote  the  efficacy  of  the  sternutatory,  by 
previously  inhaling  the  steam  of  warm  water  through  the  nostrils. 

3.  Stimulating  vapors,  directed  against  the  eyes,  have  been  recommended, 
especially  in  cases  where  there  are  evident  signs  of  great  local  debility,  with- 
out any  appearances  of  congestion  or  plethora.  A  little  sulphuric  ether,  or 
aqua  ammoniiB,  may  be  poured  into  the  palm  of  the  hand,  and  held  under 
the  eyes  till  the  fluid  has  evaporated  ;  and  this  may  be  repeated  several  times 
daily.     The  vapor  of  prussic  acid  is  entirely  useless  in  amaurosis. 

4.  Electricity,  galvanism  and  electro-magnetism  are  likely  to  be  useful  only  in 
cases  of  a  torpid  character,  and  fi"ee  from  excitement.  They  would  be  hazard- 
ous, if  inflammation  were  present,  or  if  they  excited  pain. 


960  TREATMENT   OF   AMAUROSIS. 

Electricity  formerly  enjoyed  a  considerable  reputation  as  a  remedy  in  amau- 
rosis, but  of  late  years  has  been  very  much  neglected.  As  it  is  not  likely  to 
be  trusted  to,  nor  even  tried,  while  the  disease  is  recent,  it  is  not  to  be  won- 
dered at  that  it  should,  like  every  other  kind  of  rernedy,  prove  totally  inert 
in  a  great  majority  of  the  confirmed  or  inveterate  cases,  which,  as  to  a  last 
resource,  may  be  submitted  to  its  influence.  The  cases  related  by  Mr.  Hey^^ 
and  Mr.  Ware,^^  afford  sufficient  ground  for  believing  that  electricity  may 
occasionally  prove  highly  serviceable.  Mr.  Ware  considers  it  more  useful  in 
amaurosis  arising  from  the  effect  of  lightning  on  the  eyes,  than  in  any  other 
variety  of  the  complaint.  The  mode  of  application  is  chiefly  by  directing 
the  electric  aura  against  the  eyes,  drawing  it  from  them  during  the  insulation 
of  the  patient,  and  sometimes  by  taking  small  sparks  from  the  eyelids  and 
integuments  round  the  orbits. 

Galvanism  has  been  much  lauded  by  Magendie.  He  says  that  in  complete 
amaurosis,  the  only  result  from  the  galvanic  current  is  that  of  rendering  the 
patient  indistinctly  sensible  to  the  presence  of  light  during  the  experiment ; 
but  in  incomplete  amaurosis,  galvanism  applied  to  the  branches  of  the  fifth 
nerve,  has  sometimes  produced  a  perfect  cure.  He  employs  electro-puncture. 
This  is  done  by  passing  down  fine  needles  through  any  of  the  branches  of 
the  frontal  or  superior  maxillary  nerves  ;  a  slight  pricking  sensation  indicates 
that  the  nerve  is  pierced  ;  a  galvanic  current  is  then  passed  along  the  needles, 
through  the  branches  of  the  fifth  nerve. 

The  general  review  which  we  have  thus  taken  of  the  seat,  causes,  symp- 
toms, and  treatment  of  amaurosis,  is  sufficient  to  show  that  the  subject  is 
surrounded  with  difficulties,  and  that  there  is  a  necessity  for  exercising  the 
most  minute  and  careful  observation,  if  we  hope  to  make  any  advancement  in 
the  knowledge  of  this  class  of  diseases.  Each  individual  case  of  amaurosis, 
to  do  it  justice,  would  require  to  be  considered  at  leisure,  and  in  all  its  bear- 
ings— to  be  made,  in  fact,  a  subject  of  study.  It  is  but  too  evident,  that 
many  who  have  written  upon  amaurosis,  laboring  probably  under  a  distaste  for 
what  they  had  found  to  be  an  irksome  task,  namely,  the  investigation  of  com- 
plicated phenomena,  have  endeavored  to  cut  the  matter  short,  and  introduce, 
into  a  subject  which  does  not  admit  of  it,  some  easy,  simple  arrangement  of 
their  own.  Feeling  themselves  unable  to  grapple  with  the  infinite  diversities 
of  this  class  of  diseases,  they  have  endeavored  to  reduce  the  phenomena  of 
amaurosis  to  some  contracted  notions  of  their  own,  and  satisfying  themselves 
with  a  few  artificial  distinctions,  have  actually  discouraged  the  attempt  to 
follow  nature  with  that  perseverance,  without  which,  in  a  subject  like  this,  no 
real  progress  can  be  made. 


*  Joseplnis  et  Carolus  Wenzel  de  Penitiori  '  Miigendie,  Journal  de  Physiologic,  Tome 
Structura  Cerebri,  p.  334;  Tab.  vi.  fig.  2  ;  Tu-  iii.  p.  376;  Paris,  1S23:  Serres,  Anatomio  Com- 
bingM,  1S12  :  Cloquet,  Pathologie  Chirurgicale,  paree  du  Cerveau,  Tome  i.  p.  331;  Paris,  1827. 
p.  131;  PL  X.  fig.  3:  Paris,  1831.  '  Magendie,  Journal  de    Physiologie,  Tome 

"  CvclopaHlia  of  Anatomy  and  Physiology;  iv.    pp.   ISG,    302;  Paris,    1824:    Desiuoulins, 

Vol.  iii.  p.  771 :  London,  1844.  Anatomic  des  Systemes  Nerveux,  Tome  ii.  p. 

^  Anatomy  of  the    Brain,  p.  80;    London,  712;  Paris,  1825. 

1826.  '°  Alcock,  Cyclopajdia  of  Anatomy  and  Phy- 

*  Collections  from  the  unpublished  Medical  siology  ;  Vol.  ii.  p.  308;  London,  1S37. 
Writings  of  C.  H.  Parry,  M.  D.j  Vol.  i.  p.  304;  "  iVIayo's    Anatomical    and     Physiological 
London,  1825.  Commentaries,  No.  ii.  p.  4;  London,  1823. 

'  Sec  Bright's  Reports  of  iledical  Cases,  Vol.  "  Mcmoires  de  rAcademie  lioyale  des  Sci- 
ii.  pp.  202,  615,  620;  London,  1831:  Andral,  encos,  pour  1727,  p.  1.  Amsterdam,  1733. 
Clinique    Medicale,    Tome    v.   pp.   338,   483;  'M^alentin,  De  Functionibus  Nervorum  Cere- 
Paris,  1833.  bralium,  p.  109;  Bcrnw,  1839;  Reid's  Physi- 

^  Zeitschrift  fUr  Physiologie,  Vol.  i.  p.  255  ;  ologieal    Anatomical,    and    Pathological    Rc- 

Heidelberg,'l824.  searches,   p.  291;  Edinburgh,  1848:     Gazette 

■"  Ribes,  Memoires  de  la    Societe   Medicale  Medicale  de  Paris,  4  Decembre,  1852,  p.  775. 
d'Emulation,  Tome  vii.  p.  99  ;  Paris,  1811. 


CLASSIFICATIONS   OF   THE   AMAUROSES.  961 

"  Institutes  of  Surgery,  Vol.  i.  p.  176 ;  Edin-  ^^  Heister    do    Cataracta,    Glaucomate,    et 

burgh,  1838.  Amaurosi,  p.    331 ;    Altorfii,    1713  :    Medical 

''  On  the  pretended  distinction  of  amaurosis  AVorks  of  Richard  Mead,  M.  D.  pp.  204,  506  ; 

into   functional   and   organic,    see  Edinburgh  London,  1762. 

Medical  and  Surgical  Journal,  October,  1851,  '^  Op.  cit.  p.  305. 

p.  318.  °''  Lectures  in    the   Lancet,  Vol.   x.  p.  578; 

'^  Lehre  von  den  Augenkrankheiten,  Vol.  ii.  London,  1826. 

p.  443  ;  Wien,  1817.  °*  [Diseases  of  the  Eye,  by  James  Dixon,  p. 

'^  Anfivngsgriinde    der    Wundarzneykunst,  189  ;  London,  1855.] 

Vol.  iii.  p.  423  ;  Gottingen,  1804.  °'  Vermischte  chirurgische  Schriften,  Vol.  ii. 

''  De  Haen,  Ratio  Medendi,  Pars  6*",  p.  255;  p.  3  ;  Berlin,  1786. 

Vienna),  1763:    Janin,  Memoires   et  Observa-  ^°  Op.  cit.;  Vol.  iii.  p.  443. 

tions  sur  I'ffiil,  p.  426 ;  Lyon,  1762  :  Dendy  on  "  Trattato  delle  principali    Malattie    degli 

the  Cerebral  Diseases  of  Children,  p.  30  ;  Lou-  Occhi.  Vol.  ii.  pp.  227,  230;  Pavia,  1816. 

don,  1848.  "  Edwards,  Lancet,  3  November,  1838,  p. 

"  Janin,  Op.  cit. p.  428.  227. 

^''  Travers'  Synopsis  of  the  Diseases  of  the  ^'  Report  of  the  Sixth  Meeting  of  the  British 

Eye,  p.  188;  London,  1820.  Association  for  the   Advancement  of  Science; 

^'  Andral,  Clinique  Medicale,  Tome  v.  pp.  Transactions  of  the  Sections,  p.  10  7;  London, 

682,  693,  710  ;  Paris,  1833.  1837. 

^*  Kater,   Philosophical  Magazine,  Novem-  "''  Observations  on  the  Cataract  and  Gutta 

ber,  1834,  p.  375  :  Ibid.,  June,  1835,  p.  409.  Serena,  pp.  407,  410,  417,  &c.  ;  London,  1812. 

*^  Porterfield's  Treatise  on  the  Eye,  Vol.  ii.  ^'  Medical  Observations  and  Inquiries,  Vol. 

p.  389  ;  Edinburgh,  1759.  v.  p.  1  ;  London,  1776. 

•.  =^'  Rennet's    Inaugural    Dissertation  on  the  "  Op.  cit.  pp.  379,  381,  &c. 
Physiology  and  Pathology  of  the  Brain,  p.  56; 
Edinburgh,  1837. 


SECTION   n. — CLASSIFICATIONS   OF   THE   AMAUROSES. 

Some  will  have  no  classification ;  but  insist  that  amaurosis  is  always  one 
and  the  same.  Others  have  adopted  the  division,  already  noticed,  into  func- 
tional and  organic,  whereas  every  case  of  amaurosis  is  both.  Mead  divided 
the  varieties  of  amaurosis  into  inflammatory,  paralytic,  and  those  which  arise 
from  pressure.  Beer  has  classified  the  different  species  according  to  their 
symptoms  ;  and  it  may  not  be  improper  to  examine  his  classification  somewhat 
minutely.  The  principle  is  evidently  good  ;  determining  the  seat  and  nature 
of  the  disease,  by  the  particular  symptoms  present. 

Beer  admits  four  classes  :  the  Jirst  including  amaurosis,  characterized  only 
by  subjective  symptoms,  or,  in  other  words,  by  impaired  vision,  without  any 
diseased  appearances  in  the  organ  of  vision  ;  the  second,  amaurosis  charac- 
terized, not  by  impaired  vision  only,  but  by  changes  in  the  texture  of  some 
part  of  the  optic  apparatus  ;  the  third,  amaurosis  characterized  by  impaired 
vision,  with  changes  in  the  form  and  activity  of  some  part  of  the  optic  appa- 
ratus ;  and  the  fourth,  amaurosis  in  which  the  characteristics  of  the  first  three 
classes  are  combined. 

It  does  not  admit  of  denial,  that  we  occasionally  meet  with  cases  of  amaurosis,  pre- 
senting such  differences  in  the  symptoms,  as  Beer  has  chosen  for  the  groundwork  of  his 
classification.  For  instance,  it  sometimes  happens  tliat  in  the  amaurosis  from  exhaustion, 
there  is  scaixely  an  objective  sj'mptom  to  be  discovered,  and  we  are  obliged  to  admit  the 
existence  of  the  disease  almost  solely  on  the  testimony  of  the  patient,  the  case  evidently 
falling  within  Beer's  first  class.  The  only  instance  which  Beer  has  introduced  into  his 
second  class,  as  characterized  by  loss  of  vision,  with  change  in  texture,  is  amaurosis  de- 
pending on  absorption  of  the  pigmentum  nigrum.  Hydrocephalic  amaurosis  very  fre- 
quently presents  no  other  symptom  than  loss  of  sight,  and  fixed  dilated  pupil,  so  that  it  is 
referable  to  Beer's  third  class.  Amaurosis,  again,  from  an  injury  to  the  eye,  is  often 
attended,  in  addition  to  loss  of  sight,  by  irregular  immovable  pupil,  laceration  of  the 
tunics,  and  enlargement,  or,  on  the  contrary,  atrophy  of  the  eyeball.  Such  a  case  will 
undoubtedly  belong  to  the  fourth  class.  I  trust,  however,  that  I  shall  not  be  accused  of 
rashness,  nor  of  disrespect  for  the  labors  of  my  teacher,  when  I  state  my  belief,  that  the 
cases  arranged  under  his  four  classes  are  not  uniformly  attended  by  the  symptoms  which 
he  has  assigned  to  them  ;  but  that  those  species  of  amaurosis,  which  he  has, set  down  as 
61 


962  CLASSIFICATIONS   OP   THE   AMAUROSES. 

characterized  by  subjective  symptoms  only,  are  sometimes  attended  by  objective  signs 
also,  while,  on  the  other  hand,  those  changes  in  the  texture  and  form  of  certain  parts  of 
the  optic  apparatus,  which  he  has  considei-ed  as  characteristic  of  other  species,  are  some- 
times merely  coincident,  and  not  essential.  The  amaurosis,  for  example,  which  originates 
frtm  over-excitement  of  the  eye,  or  from  plethora,  which  Beer  places  in  his  first  class,  is 
often  attended  by  fixed  dilated  pupil,  a  circumstance  which  should  assign  it  a  place  in  the 
third  class.  The  amaurosis  from  rage  is  merely  a  variety  of  the  plethoric  or  apoplectic, 
and  may  or  may  not  present  the  glaucomatous  appearance  of  the  humors,  on  account  of 
which  he  has  placed  it  in  his  fourth  class. 

Glaucoma,  one  of  the  changes  upon  which  Beer  has  founded  his  classification,  is  by  no 
means  an  essential  part  of  any  amaurosis.  Neither  is  fixed  dilated  pupil  anything  more 
than  a  frequent  coincidence.  In  the  hydrocephalic  amaurosis,  for  instance,  the  pupil, 
though  generally  expanded  and  motionless,  is  not  always  so.  It  must,  therefore,  evi- 
dently form  an  insuperable  objection  to  any  classification  founded  on  symptoms,  that 
sometimes  they  are,  and  at  other  times  they  are  not  present. 

Beer  admits  as  species,  an  epileptic,  and  a  paralytic  amaurosis ;  whereas  the  epilepsy 
and  amaurosis  in  the  one  case,  and  the  palsy  and  amaurosis  in  the  other,  ought  to  be 
regarded,  not  as  standing  in  the  relation  of  cause  and  eifect,  but  merely  as  coincident 
effects  arising  from  one  and  the  same  cause,  namely,  some  morbid  change  or  formation 
within  the  cranium. 

While  Beer's  classes  refer  to  the  appearances  presented  in  different  cases, 
his  distinctions  of  species  are  founded  in  general  on  the  causes,  efficient  or 
remote,  of  the  disease. 

The  following  is  a  classification  of  the  principal  varieties  of  amaurosis, 
arranged  according  as  the  efficient  causes  of  the  disease  affect,  1.  The  retina, 
2.  The  orbital  portion  of  the  optic  nerve,  or  3.  The  encephalon,  including 
the  optic  nerves  from  their  origin  to  the  foramina  optica : — 

I.  RETINA. 

I.    PRESSURE   ON   THE   RETINA. 

I.  Pressure  on  the  convex  surface  of  the  retina. 

1.  Sub-sclerotic  dropsy.     (See  page  662.) 

2.  Inflammation  and  thickening  of  the  choroid.     (See  p.  568.) 

3.  Sub-choroid  dropsy.     (See  p.  662.) 

II.  Pressure  on  the  concave  surface  of  the  retina. 

1.  Yitreous  dropsy.     (See  p.  665.) 

2.  Displaced  crystalline  lens.     (See  p.  Y43.) 

3.  "Varicosity  of  the  retinal  bloodvessels.     (See  p.  847.) 

4.  Apoplexy  of  the  retina. 

•  II.    STRUCTURAL   CHANGES   IN   THE   RETINA. 

1.  Wounds  of  the  retina.     (See  pp.  408,  412.) 

2.  Concussion  and  laceration  of  the  retina.     (See  p.  410.) 

3.  Retinitis,  acute  and  chronic.     (See  p.  555.) 

4.  Ramollissemeut  of  the  retina. 

5.  Hypertrophy  of  the  retina. 

6.  Atrophy  of  the  retina. 

T.  Neuromata  of  the  retina.     (See  p.  847.) 

8.  Melanosis  of  the  retina.     (See  p.  847.) 

9.  Ossification  of  the  retina.     (See  p.  648.) 

II.  ORBITAL  PORTION  OF  THE  OPTIC  NERYE. 

I.    PRESSURE   ON   THE   OPTIC   NERVE. 

I.  Pressure  by  orbital  diseases. 

1.  Hyperostosis  or  exostosis  of  the  orbit,  or  of  the  sphenoid  bone 

near  the  foramen  opticum.     (See  pp.  83,  84.) 

2.  Solid  and  encysted  tumors  in  the  orbit.     (See  p.  326.) 

3.  Aneurism  by  anastomosis  in  the  orbit.     (See  p.  346.) 

II.  "Pressure  more  immediately  affecting  the  optic  nerve. 
1.  Aneurism  of  the  arteria  centralis  retinse. 


CLASSIFICATIONS   OF  THE   AMAUROSES.  963 

2.  Tumors  attached  to  or  contained  within  the  envelops  of  the 
optic  nerve. 

n.    STRUCTURAL   CHANGES   IN   THE   OPTIC   NERVE. 

1.  Wounds  of  the  optic  nerve.     (See  pp.  55,  63,  311,  414.) 

2.  Rupture  of  the  optic  nerve. 

3.  Inflammation  of  the  optic  nerve. 

4.  Hypertrophy  and  general  or  partial   induration  of  the  optic 

nerve. 

5.  Atrophy  of  the  optic  nerve. 

6.  Encephaloid  tumor  of  the  optic  nerve.     (See  p.  685.) 
T.  Melanosis  of  the  optic  nerve.     (See  p.  691.) 

III.  ENCEPHALON,  including  the  optic  nerves  from  their  origin  to 
the  foramina  optica. 

I.  PRESSURE   ON   THE   ENCEPHALON. 

1.  Fractured  and  depressed  cranium. 

2.  Hyperostosis  or  thickening  of  the  cranium. 

3.  Exostosis  of  the  inner  table  of  the  cranium. 

4.  Fungous,  osseous,  and  other  tumors  of  the  dura  mater.     (See 

p.  181.) 

5.  Congestion  of  the  encephalic  bloodvessels. 

6.  Apoplexy,  from  encephalic  heemorrhagy,  &c. 
1.  Aneurism  of  the  encephalic  arteries. 

8.  Enlarged  pituitary  gland. 

II.  STRUCTURAL   CHANGES   IN   THE   ENCEPHALON. 

1.  Injuries  of  the  encephalon,  in  woundS'  through  the  orbit  (see 

p.  53),  in  fi'actures  of  the  cranium,  with  depression  (p.  51),  in 
gunshot  wounds  (see  p.  63),  &c. 

2.  Wounds  of  the  optic  nerve  within  the  cranium. 

3.  Rupture  of  the  chiasma  by  contre-coup. 

4.  Concussion  and  laceration  of  the  brain. 

5.  Inflammation  of  the  membranes  of  the  brain,  producing  adhe- 

sions, thickening,  depositions  of  serum,  lymph,  pus,  &c. 

6.  Inflammation  of  the  chiasma. 
1.  Inflammation  of  the  brain. 

8.  Abscess  in  the  brain. 

9.  Ramollissemeut  of  the  brain. 

10.  Induration  orscirrhus  of  the  brain. 

11.  Hypertrophy  of  the  brain. 

12.  Atrophy  of  the  brain. 

13.  Hydrocephalus,  superficial  and  ventricular. 

14.  Enlarged  pineal  gland. 

15.  Scrofulous  tubercules  in  the  brain. 

16.  Encysted  tumors  in  the  brain. 

It.  Cartilaginous,  osseous,  and  other  tumors  in  the  brain ;  encepha- 
loid cancer,  melanosis,  &c. 

APPENDIX. 

As  an  appendix  to  the  above  classification  may  be  mentioned  some  of  the 
complications  of  amaurosis :  as  with — 

1.  Puerperal  convulsions, 

2.  Syncope. 

3.  Epilepsy. 

4.  Hysteria. 

5.  Disease  of  spinal  cord. 


964  CLASSIFICATIONS   OF   THE   AMAUROSES. 

6.  Hallucinations,  as  in  delirium  tremens. 

7.  Mania. 

Those  species  of  amaurosis  to  which  references  are  attached  in  the  above 
Table  have  already  been  considered,  and  do  not  require  to  be  brought  under 
review.  Neither  is  it  necessary  to  treat  formally  of  all  the  remaining 
species.  Hypertrophy,  atrophy,  and  ramoUissement  of  the  retina,  for  instance, 
are  consequences  of  retinitis,  the  existence  of  which,  in  conjunction  with 
amaurosis,  is  established  by  dissection  ;  but  it  would  be  superfluous  to  con- 
sider these  states  separately,  because  we  are  at  present  ignorant  of  any 
diagnostic  signs,  by  which,  during  life,  the  one  can  be  discriminated  from 
the  other. 

In  many  instances  of  amaurosis,  there  is  reason,  both  from  the  nature  of 
the  exciting  cause  and  from  the  symptoms,  to  conclude  that  the  disease 
affects  the  whole  nervous  optic  apparatus — retina,  optic  nerve,  and  portion 
of  the  brain  in  connection  with  the  optic  nerve.  This  is  especially  the  case 
when  the  disease  is  of  the  inflammatory  or  congestive  kind.  The  following 
may  prove  exciting  causes  of  congestion  or  inflammation  of  the  nervous  optic 
apparatus  ;  some  of  them  operating  directly  or  locally,  others  indirectly  or 
sympathetically.  When  the  cause  is  indirect  or  sympathetic,  the  transference 
of  disease  from  the  remote  organ,  such  as  the  stomach  or  the  uterus,  is  in 
some  cases  sudden  and  in  others  slow. 

1.  Intense  light. 

2.  A  stroke  of  lightning. 

3.  Over-exercise  of  the  sight. 

4.  Irritation  from  teething,  worms,  disordered  bowels,  &c.,  as  in  the 
inflammation  of  the  brain  in  children,  called  acute  hydrocephalus. 

5.  Febrile  diseases ;  as,  continued  fever,  scarlatina,  measles,  &c. 

6.  Passions  of  the  mind  ;  as,  rage,  grief,  fear,  &c. 
"I.  Insolation,  or  coup  de  soleil. 

8.  Suppressed  evacuations  ;  as,  of  the  menses,  haemorrhoids,  milk,  mucus 
of  the  Schneiderian  membrane,  purulent  matter  of  ulcers,  &c. 

9.  Suppressed  eruptions,  acute  or  chronic. 

10.  Cold,  and  suppressed  perspiration. 

11.  Narcotic  and  other  poisons. 

12.  Disorders  of  the  digestive  organs,  acute  or  chronic. 

13.  Albuminuria,  or  Bright's  disease  of  the  kidney.  ' 

14.  Continued  loss  of  the  fluids  of  the  body;  as,  in  scorbutus,  diabetes, 
protracted  suckling,  masturbation,  &c. 

15.  Affections  of  the  fifth  nerve  ;  as,  irritation,  wounds  (see  p.  150),  and 
morbid  changes  within  the  cranium  (see  pp.  874,  879.) 

Those  only  who  have  attempted  to  classify  the  causes  of  amaurosis  can 
form  an  estimate  of  the  difficulties  attached  to  the  subject.  Considerable 
difficulty  arises  from  the  fact,  that  the  nature  of  many  of  the  causes  is  of  a 
mixed  kind  ;  they  are  structural  changes,  for  example,  of  some  portion  of  the 
encephalon,  and  yet  they  operate  on  the  optic  apparatus  chiefly  by  mechani- 
cal pressure.  Hydrocephalus,  and  the  various  sorts  of  tumors  which  form 
in  the  brain,  are  instances  of  such  cases. 

If  such  difficulty  occurs  in  reasoning  on  the  causes  of  amaurosis,  how  much 
more  difficult  the  task  of  determining  in  the  living  subject  the  particular  seat 
of  organic  change,  and  the  special  nature  of  that  change !  Those  who  will 
hear  of  no  classification  of  the  amauroses,  but  insist  that  the  disease  is  always 
one  and  the  same,  deny,  in  fact,  the  possibility  of  recognizing  them  by  their 
symptoms  :  they  regard  the  combinations  and  successions  of  morbid  phe- 
nomena which  attend  amaurosis  in  different  cases  as  too  complicated,  too 
Tariable,  or  too  obscure,  to  enable  the  observer  to  establish  a  diagnosis.     It 


AMAUROSIS  FROM  APOPLEXY   OF  THE   RETINA,  965 

is  acknowledged  that,  even  with  the  greatest  care,  the  diagnosis  is  difficult  : 
how  much  more  so  if  the  practitioner  is  careless,  indifferent,  or  ignorant ! 

[The  ophthalmoscope  will  often  prove  our  only  means  of  determining  the 
cause  or  nature  of  amaurosis  in  cases  whose  history  is  obscure,  incoherent,  or 
even  erroneous,  from  the  inattention  of  the  patient  to  its  premonitory  signs, 
his  stupidity,  or  his  imagination.  But  even  here,  our  diagnosis  can  not 
always  be  positive — with  this  instrument  we  will  be  able  to  detect  healthy  or 
diseased  states  of  the  interior  structures  of  the  eye — to  determine  whether 
the  amaurosis  is  ocular  or  not,  and  if  so,  whether  it  arises  from  permanent 
organic  change  of  structure,  the  result  of  previous  diseased  action,  or,  is  the 
result  of  inflammatory  disease  still  present,  and  by  the  removal  of  which 
the  functions  of  the  eye  may  be  restored.  Further  than  this,  the  instru- 
ment cannot  aid  us,  and  we  will  then  be  compelled  to  rely  alone  on  a  careful 
consideration  of  the  numerous  and  often  complicated  phenomena  presented 
in  each  individual  case  for  a  determination  of  its  nature  and  cause. 

For  the  pathological  changes  to  be  observed  by  this  instrument  in  cases  of 
amaurosis,  the  result  of  deep-seated  inflammatory  action  in  the  ball,  we  would 
refer  the  reader  to  pp.  552,  554,  558,  and  567. — H.] 

That  so  little  has  been  achieved  in  the  pathology  of  amaurosis  arises  chiefly 
from  the  difficulty  of  obtaining  inspections,  after  death,  of  the  bodies  of  those 
who  have  labored  under  the  disease.  When  such  opportunities  do  occur,  the 
three  following  remarks  should  be  borne  in  mind  : — 

1.  That  it  is  an  important  question  for  consideration,  when  morbid  ap- 
pearances present  themselves  in  the  eye,  the  optic  nerve,  the  brain,  or  the 
neighboring  structures,  after  death,  in  amaurotic  cases,  whether  the  altera- 
tions detected  were  causes  or  effects  of  the  amaurosis.  Wasting  of  the  optic 
nerve,  for  example,  may  be  a  cause,  but  is  often  an  effect. 

2.  No  dissection  of  an  amaurotic  case  can  be  regarded  as  complete,  unless 
the  brain,  whole  course  of  the  optic  nerve  within  the  cranium  and  within  the 
orbit,  and  the  retina,  be  carefully  examined,  and,  at  least  the  retina,  micro- 
scopically. To  show  the  necessity  of  having  recourse  to  the  microscope,  I 
may  mention  that  melanosis  of  the  retina  consists  generally  in  depositions  so 
small  as  not  to  be  visible  to  the  naked  eye. 

3.  If  nothing  be  detected,  we  must  not  conclude  that  the  disease  has  been 
functional  merely,  and  not  organic — a  mere  change  in  action,  and  not  a 
change  in  the  parts  which  perform  the  action.  Haller's  remark  respecting 
dissections  of  maniacs  may  well  be  extended  to  those  of  amaurotic  patients  : — 
"  Id  utique  adparet,  plerumque  in  mentis  vitiis  encephalum  pati :  et  si  ali- 
quando  rariori  exemplo  non  visum  est  pati,  potuit  vitium  in  minoribus 
elementis  latuisse,  aut  incisori  patientia  defuisse."^ 


Elementa  Physiologise,  Tom.  v.  p.  574;  Lausannre,  1763. 


SECTION   in. — ILLUSTRATIONS   OF  SOME   OF   THE   SPECIES   OP   AMAUROSIS. 

§  1.  Amaurosis  from  apoplexy  of  the  retina. 
Fig.  Ammon,  Thiel  I.  Taf.  XV.  Fig.  21. 

By  apoplexy  of  the  retina  is  understood'  a  morbid  condition  of  that  mem- 
brane, in  which  its  bloodvessels  becoming  suddenly  distended,  or  actually 
ruptured,  its  nervous  substance  is  thereby  compressed,  and  its  sensorial 
power  diminished  or  abolished. 

A  suppression  of  the  natural  excretions  of  the  body,  and  various  otlier 


966  AMAUROSIS   FROM  APOPLEXY  OP  THE  RETINA. 

causes  of  determination  of  blood  to  the  head  and  eyes,  are  supposed  to  give 
rise  not  unfrequently  to  affections  of  the  vessels  of  the  retina,  and  thereby  to 
amaurosis.  Chronic  affections  of  this  sort,  however,  ai'e  to  be  distinguished 
from  those  which  are  sudden,  and  the  latter  only  are  to  be  counted  apoplectic. 
The  latter  are  likely  to  be  promptly  removed,  and  vision  restored,  by  blood- 
letting, while  the  amaurosis  depending  on  chronic  distension  of  the  retinal 
vessels  derives  no  benefit  from  that  practice. 

The  causes  of  apoplexy  of  the  retina  are  generally  violent,  and  operate 
either  in  causing  a  sudden  flow  of  blood  towards  the  head  and  eyes,  or  in 
impeding  its  return.  A  fatiguing  journey  under  the  scorching  heat  of  the 
sun,  a  sudden  suppression  of  the  menstrual  discharge,  and  the  like,  are  apt 
to  produce  such  an  effect.  I  have  known  the  disease  arise  from  violent 
sneezing ;  the  chief  symptom  being  a  red  spectrum. 

Case  375. — A  lady  was  sent  to  me  for  consultation  by  Dr.  Cocks,  of  Dundee,  having  had 
two  attacks  of  apoplexy  of  the  retina,  from  the  bursting  apparently  of  a  bloodvessel  of  that 
membrane,  in  consequence  of  fits  of  retching  while  she  was  in  the  state  of  pregnancy. 

Case  376. — Langenbeck  relates  the  case  of  a  miller,  a  robust  plethoric  man,  who  being 
overcome  in  a  struggle  to  secure  a  thief  whom  he  caught  in  his  mill,  the  thief  attempted 
to  strangle  him,  by  twisting  his  neckcloth,  and  by  pressing  with  his  knuckles  against  the 
carotids.  The  miller's  hearing  and  sight  failed  ;  he  fell  senseless  to  the  ground  ;  every- 
thing about  him  appeared  black  ;  and  he  was  left  blind.  Vision  returned  speedily  to  the 
one  eye,  but  the  other  remained  for  a  time  totally  amaurotic,  although  ultimately  it  also 
recovered.2 

Case  ill. — A  gentleman,  aged  upwards  of  seventy,  tall,  thin,  and  healthy,  having 
walked  for  a  considerable  distance,  holding  an  umbrella  against  wind  and  rain,  was 
thrown  into  a  profuse  perspiration.  Having  stopped  in  a  shop  to  make  some  purchases, 
and  laid  his  hat  on  the  counter,  he  felt  chilled,  and  got  into  an  omnibus  to  return  home, 
•when  he  suddenly  perceived  a  dark  spectrum  before  his  right  eye,  as  large,  apparently, 
as  the  eye  itself,  and  covering  the  centre  of  the  field  of  view.  Even  on  shutting  the  eye, 
it  still  appeared.  After  some  days  it  assumed  nearly  an  octagonal  shape,  and  after 
leeches  to  the  temple,  and  repeated  small  blisters,  it  gradually  cleared  away. 

Confusion  of  sight,  so  that  suddenly  the  patient  is  deprived  of  the  power 
of  discerning  small  objects,  and  the  appearance  of  a  dark  spectrum  before 
the  affected  eye,  are  the  most  remarkable  symptoms.  The  spectrum  is  not 
always  red ;  sometimes  it  is  of  a  greenish  hue,  or  perfectly  black.  It  is 
generally  large,  and  of  an  irregular  form.  We  might  expect  that  numerous 
punctiform  extravasations  of  blood  in  the  retina,  as  Desmarres*  found  in  one 
case  on  dissection,  would  give  rise  to  the  appearance  of  fixed  muscte. 

The  suddenness  of  the  amaurotic  attack,  with  flushing  and  turgescence  of 
the  vessels  of  the  face,  a  full  slow  pulse,  and  vertigo,  may  generally  render 
the  diagnosis  distinct.  Should  apoplexy  of  the  brain  occur  at  the  same 
time,  the  diagnosis  will  be  obscured  ;  for  blood  effused  in  the  brain  may  pro- 
duce incurable  amaurosis,  although  the  retina  is  little  affected. 

If  the  vessels  of  the  retina  are  merely  over-distended,  but  not  ruptured,  a 
cessation  of  the  cause,  and  the  employment  of  bloodletting,  may  completely 
remove  the  amaurosis.  But  if  a  blow  on  the  eye,  strangulation,  or  any  other 
cause,  has  produced  rupture  of  the  retinal  Jjloodvessels,  the  total  or  partial 
amaurosis  hence  arising,  being  produced  by  blood  extravasated  between  the 
retina  and  the  vitreous  body,  and  partly  imbibed  by  the  latter,  can  yield  only 
as  the  blood  is  absorbed,  which  is  generally  accomplished  very  slowly. 

§2.  Amaurosis  from  aneurism  of  the  arteria  centralis  retince. 

It  was  an  ingenious  conjecture  of  Mr.  Ware,  that  dilatation  of  the  central 
artery  of  the  optic  nerve  might  sometimes  be  the  cause  of  amaurosis.  He 
had  often  suspected  that  this  might  be  the  cause,  in  those  instances  where  the 
disease  came  on  suddenly,  and  in  which,  though  all  objects  placed  directly 
before  the  eyes  are  totally  invisible,  there  remains  some  small  sense  of  light, 
so  as  to  give  a  confused  perception  of  objects  sidewise. 


AMAUROSIS   FROM  DISEASED   OPTIC  NERVES.  961 

The  conjecture  is  so  far  confirmed  by  a  pathological  preparation,  in  the 
possession  of  Professor  Schmiedler,  of  Friburg,  viz  :  an  aneurism  of  the  cen- 
tral artery  of  each  retina,  taken  from  a  princess  of  Baden,  who  was  long 
blind,  and  to  whom  Plenck,  Richter,  and  the  first  surgeons  of  Germany,  had 
been  called.  She  only  saw  a  little  on  looking  downwards.  The  aneurism 
compressed  the  optic  nerves.* 

A  similar  case  is  recorded  by  Grafe.^  The  patient  was  a  female,  yho  lost 
her  sight  under  the  symptoms  of  photophobia  and  feeling  of  pulsation  in  the 
orbit.  The  central  artery  of  the  retina,  within  the  optic  nerve,  was  dis- 
tended to  the  diameter  of  a  stalk  of  grass,  and  the  bloodvessels  of  the 
retina  were  varicose. 

§  3.  Amaurosis  from  tumors  attached  to  or  contained  within  the  envelops  of 

the  optic  nerve. 

Mr.  Wardrop  has  given"  a  figure  of  a  preparation,  from  Mr.  Heaviside's 
museum,  in  which  a  tumor  appears  in  the  neurilemma  of  the  optic  nerve. 
No  further  history  of  the  patient  was  known,  than  that  he  was  amaurotic  of 
the  corresponding  eye. 

§  4.   Ajnaurosis  from  structm-al  changes  in  the  optic  nerves. 

That  variety  of  amaurosis  which  arises  from  some  morbid  change  in  the 
substance  or  in  the  sheath  of  the  optic  nerve,  is,  according  to  Beer,  de- 
veloped very  slowly,  and  rarely  in  both  eyes.  It  is  attended  by  the  sensation 
of  a  black  cloud,  which  seems  gradually  to  become  more  and  more  dense, 
and  by  such  a  degree  of  visus  defiguratus  as  is  extremely  distressing  to  the 
patient.  He  rarely  complains  of  much  pain,  either  in  the  eye  or  head,  but 
only  of  a  feeling  of  obtuse  pressure  in  the  posterior  part  of  the  orbit, 
although  not  the  slightest  degree  of  projection  of  the  eyeball  is  to  be  ob- 
served. Even  at  the  very  commencement,  the  pupil  is  extremely  enlarged, 
the  iris  completely  immovable,  and  the  pupillary  edge  irregular.  Glaucoma 
takes  place,  followed  by  glaucomatous  cataract,  and  at  last,  the  eyeball 
becomes  sensibly  smaller  than  natural. 

The  following  are  some  of  the  morbid  changes  extending  along  both  the 
orbital  and  the  encephalic  portion  of  the  optic  nerve,  which  have  been  de- 
tected on  dissection  :  induration  of  the  optic  nerve,  unnatural  adhesion 
between  it  and  its  sheath,  the  medullary  substance  of  the  nerve  ash-colored 
and  wasted  by  hydatids  between  the  nerve  and  its  sheath,  calculous  concre- 
tions within  the  sheath.  Most  of  these  changes  are,  no  doubt,  the  results  of 
chronic  inflammation,  such  as  may  arise  from  a  great  variety  of  causes. 

As  it  is  fully  established,  that  destruction  of  the  eye  frequently  leads  to 
atrophy  and  other  diseased  states  of  the  optic  nerve,  it  is  necessary  always 
to  ascertain,  in  our  dissections,  whether  the  case  before  us  has  been  one  of 
disorganization  of  the  eye  from  inflammation,  leading  to  atrophy  of  the  optic 
nerve,  or  one  of  diseased  nerve,  leading  to  amaurosis  and  atrophy  of  the  eye. 

Case  378. — Mrs. ,  aged  83,  had  been  comiDletely  blind  from  amaurosis  for  30  years 

before  her  decease  in  1817.  She  had  also  been  subject  to  irregular  gout,  which  assumed 
a  variety  of  forms,  and  some  mouths  before  her  death  she  was  attacked  with  palsy  of  one 
side. 

On  opening  the  head,  aqueous  effusion  was  found  below  the  tunica  arachnoidea,  and  in 
both  ventricles.  One  part  of  the  cerebrum  was  observed  to  be  of  a  pulpy  texture,  but 
these  appearances  were  most  probably  connected  with  the  recent  paralytic  attack,  and 
not  at  all  with  the  amaurotic.  All  the  nerves,  with  the  exception  of  the  optic,  had  the 
usual  appearance.  On  examining  the  membrnnous  sheaths  of  these  nerves,  it  was  ascer- 
tained that  their  medullary  matter  had  been  completely  removed.  This  change  had  taken 
place  even  nearer  to  the  brain  than  where  the  nerves  cross  each  other.  The  arteries  of 
the  brain  were  in  most  parts  altered  in  their  structure ;  their  coats  were  speckled  with 
white  spots,  and  their  textui'e  was  more  rigid  and  firm  than  natural.     Both  the  carotids, 


968  AMAUROSIS  FROM   TRACTURED   CRANIUM. 

where  these  vessels  are  in  contact  with  the  optic  nerves  at  the  foramina  optica,  were 
found  to  be  remarkably  dilated,  suggesting  the  idea  that  the  absorption  of  the  nerves  was 
connected  with  the  enlarged  state  of  the  arteries.  The  absorption,  however,  of  the  optic 
nerves  nearer  the  brain  could  not  be  accounted  for  on  this  notion ;  so  that  it  was  not  easy 
to  conjecture  whether  the  enlarged  state  of  the  vessels  was  the  cause  or  the  eifect  of  the 
absorption  of  the  optic  nerves.  A  similar  tendency  to  enlargement  was  noticed  where 
the  cerebral  arteries  enter  the  cranium,  and  perhaps  it  might  have  been  traced  in  other 
situations,  if  a  more  minute  search  had  been  made. 

The  t^^n  sister  of  this  lady  died  in  her  81st  year,  and  for  eight  or  ten  years  before  her 
death  had  been  also  completely  amaurotic.  Though  her  general  health  was  more  entire 
than  is  usual  at  such  an  advanced  age,  she  had  completely  lost,  not  only  her  sight,  but 
also  the  sense  of  smell,  taste,  and  hearing.  She  could  not  distinguish  animal  from  vege- 
table food,  nor  one  sort  of  fluid  from  another.  No  opportunity  was  obtained  of  inspection 
after  her  death. 

Dr.  Brown,  who  communicates  these  particulars  to  Dr.  ^lonteath,  states,  that  the  only 

daughter  of  Mrs was  alive,  and  had  been  totally  blind  from  amaurosis  for  several 

years,  being  then  in  her  5Gth  year.     Dr.  Monteath  adds,  that  he  had  been  consulted  by 

the  son  and  grandson  of  Mrs. ,  both  of  whom  had  weak  eyes.     The  grandson,  in 

particular,  had  a  very  distressing  degree  of  congenital  amblj'opia.  Any  exertion  of  his 
eyes  induced  temporary  blindness,  and  though  he  could  sometimes  see  a  minute  object, 
at  other  times  he  would  walk  directly  against  a  table  or  chair.' 

Case  379. — A  gentleman,  aged  78,  died  under  my  care,  after  having  been  completely 
amaurotic  for  several  years.  Ilis  pupils  had  retained  their  natural  size,  but  were  immov- 
able. His  lenses  were  glaucomatous.  For  several  months  before  his  death,  he  was 
occasionally  troubled  with  spectral  illusions,  always  of  an  agreeable  cast.  Debility, 
vertigo,  and  delirium  succeeded,  with  headache,  for  which  the  application  of  leeches  and 
blisters  was  used,  with  relief. 

On  dissection,  the  cranium  was  found  to  be  very  thick.  There  was  a  very  copious 
serous  effusion  under  the  tunica  arachnoidea,  on  the  upper  surface  of  the  cerebrum. 
The  lateral  ventricles  were  very  considerably  distended  with  watery  fluid.  The  thalami, 
on  their  upper  surface,  appeared  small  and  elongated.  There  was  a  pretty  firm  adhesion 
between  the  lower  surface  of  the  anterior  lobes  of  the  cerebrum  and  the  upper  surface 
of  the  optic  nerves.  The  substance  forming  the  adhesion  felt  gritty,  as  if  from  a  deposit 
of  calculous  matter.  The  optic  nerves  were  flat  and  atrophic,  especially  behind  the 
chiasma,  where  they  seemed  entirely  deficient  in  medullary  substance.  In  fact,  they 
were  so  wasted,  that  they  could  not  be  traced  further  than  the  crura  cerebri.  They  had 
a  watery  and  membranous  appearance.  The  corpora  quadrigemina  seemed  to  be  natural. 
The  brain  was  of  moderate  consistence.  The  basilar,  vertebral,  and  some  of  the  other 
arteries  were  in  a  cartilaginous  state. 

§  5.  Ajnaurosis  from  fractured   cranium   loith   depression,    or  from   san- 
guineous extravasation  in  consequence  of  injury. 

The  insensibility  attending  pressure  on  the  brain  from  these  causes  may  be 
more  or  less  complete ;  for,  in  some  instances,  the  patient  lies  unconscious, 
indeed,  of  what  is  passing  around  him,  but  capable  of  being  roused  by 
strong  impressions  on  his  senses,  while,  in  other  cases,  the  loss  of  sense  is  so 
complete,  that  the  skin  may  be  pinched,  a  lighted  candle  held  close  to  the 
eye,  and  the  loudest  sound  applied  to  the  ear,  without  any  evident  eifect. 

Where  the  cause  of  these  symptoms  is  simply  a  fractured  and  depressed 
portion  of  the  cranium,  they  show  themselves  immediately  after  the  infliction 
of  the  injury ;  but  where  they  depend  on  extravasation  of  blood,  either  accom- 
panying fracture  or  independent  of  it,  the  collection  of  blood  may  form 
slowly,  and  a  considerable  interval  of  time  elapse  before  the  patient  becomes 
insensible. 

Sir  B.  C.  Brodie^  observes,  that  "it  sometimes  happens,  that  there  is  a 
destruction  of  sensibility  in  one  part  of  the  system,  while  the  general  sensi- 
bility is  impaired  only  in  a  slight  degree  ;"  and  he  illustrates  this  remark  by 
the  following  instance,  in  which  the  sensibility  of  the  optic  nerves  was  chiefly 
affected. 

Case  380. — An  old  man,  who  had  been  run  over  by  a  cart,  was  admitted  into  St. 
George's  Hospital.  Thefre  was  a  fracture  with  depression  of  one  of  the  parietal  bones. 
He  was  sensible,  but  slow  in  giving  answers,  and  peevish,  and  it  was  observed  that  he 


AMAUROSIS  FROM  DISEASED   CRANIUM   AND  DURA  MATER.       969 

•was  totally  blind.  Mr.  Gunning  removed  a  portion  of  the  parietal  bone  -with  the  trephine, 
and  elevated  the  depression ;  but  the  operation  produced  no  change  in  the  symptoms. 
About  36  hours  after  the  accident,  the  pulse  became  frequent,  and  he  was  delirious.  He 
remained  entirely  deprived  of  the  faculty  of  vision;  believing  that  he  saw  imaginary 
objects,  but  totally  unconscious  of  the  existence  of  those  actually  before  his  eyes.  At 
the  expiration  of  the  fifth  day,  he  died. 

On  examining  the  body,  the  membranes  of  the  brain  were  found  inflamed,  and  smeared 
with  pus  and  lymph.  In  the  basis  of  the  cranium  there  was  a  transverse  fracture  extend- 
ing across  the  sphenoid,  the  fractured  edges  being  displaced,  in  such  a  manner  as  to  press 
on  the  optic  nerves  immediately  behind  the  orbits,  and  to  explain,  in  the  most  satisfactory 
manner,  the  total  loss  of  sight. 

Prognosis. — Among  those  who  recover  from  fractured  skull  with  depres- 
sion, or  from  extravasation  of  blood  within  the  cranium  in  consequence  of 
an  injury  of  the  head,  there  are  some  in  whom  the  symptoms  wholly  subside 
in  the  course  of  a  few  days,  and  others  in  whom  certain  remains  of  one  or 
more  of  the  symptoms  still  exist  after  the  lapse  of  many  years.  Such  variety 
in  restoration  is  remarkably  the  case  with  regard  to  the  sentient  power  of  the 
eye,  the  mobility  of  the  pupil,  and  the  activity  of  the  muscles  supplied  by 
the  third  nerve. 

Treatment. — It  is  unnecessary  to  say  anything  here  on  the  surgical  treat- 
ment of  fractured  cranium  with  depression.  The  medical  means  most  likely 
to  assist  in  restoring  vision  in  such  cases  are  rest,  abstinence,  bloodletting, 
laxatives,  and,  after  a  time,  an  alterative  course  of  mercury.  Benefit  will 
also  be  derived  from  keeping  up  a  continued  discharge  from  the  neighbor- 
hood of  the  head, 

I  6.  Amaurosis  from  morhid  changes  in  the  membranes,  or  in  the  hones  of  the 

cranium. 

There  are  various  states  of  the  dura  mater,  and  of  the  bones  of  the  skull, 
capable  of  producing  amaurosis ;  such  as  ossifications  of  the  dura  mater, 
especially  when  they  are  in  the  form  of  sharp  spicul^e,  atheromatous  thicken- 
ings, fungous  tumors  of  that  membrane,  and  exostosis  proceeding  from  the 
inner  table  of  the  skull.  We  have  no  means  of  positively  ascertaining  during 
life  the  existence  of  such  organic  changes. 

The  symptoms  are  exceedingly  similar  to  those  attendant  on  diseased  forma- 
tions in  the  brain.  Severe  cephalsea,  or  fixed  pain  in  the  top  of  the  head, 
palsy  of  some  of  the  muscles  of  the  eye,  either  the  abductor  or  the  muscles 
stimulated  by  the  third  nerve ;  other  of  the  special  senses  affected  besides 
sight ;  weakness  and  stiffness  in  the  limbs,  followed  by  pain,  spasms,  and 
convulsions,  are  symptoms  which  lead  to  the  suspicion  of  pressure  on  the 
basis  of  the  brain,  or  on  the  pons  Varolii.  The  symptoms  increase  for  a 
time  very  slowly ;  first  one  eye  is  affected,  then  the  other ;  then  the  organs  of 
hearing.  In  many  of  the  cases  there  takes  place  at  last  a  protrusion  of  the 
eyes  out  of  the  orbits  ;  a  symptom  indicative  of  great  derangement  in  the 
bones  forming  the  basis  of  the  cranium,  of  the  dura  mater  covering  the  sella 
turcica,  or  of  the  upper  part  of  the  orbits.     (See  Case  101,  p.  119.) 

The  morbid  changes  of  the  bones,  which  induce  amaurosis,  are  found 
chiefly  in  the  basis  of  the  cranium.  In  these  cases  caries  is  sometimes  met 
with,  but  much  more  frequently  exostosis  of  different  forms.  In  some 
instances,  innumerable  spicute  of  bone  project  into  the  cavity  of  the  cranium, 
so  sharp  that  they  readily  wound  the  finger.  Beer  preserved  the  skull  of  a 
lady  who  had  been  totally  blind,  and  for  some  weeks  before  her  death  insensi- 
ble, in  which  there  was  scarcely  any  part  within  the  cranium  which  was  not 
studded  with  sharp  exostosis.  In  such  cases  the  bones  are  sometimes  very 
thin,  the  dipliJe  being  almost  completely  wanting.  In  an  amaurotic  boy,  who 
for  a  short  time  before  his  death  was  insane,  Beer  found,  on  dissection,  a  spine 


970     AMAUROSIS   FROM  DISEASED   CRANIUM  AND   DURA   MATER. 

of  considerable  length  by  the  side  of  the  sella  turcica,  perforating  the  optic 
nerves  at  their  junction. 

Those  who  have  suffered  from  rachitis  in  youth,  from  syphilis,  or  from 
gout  in  middle  age,  are  more  liable  than  others  to  thickening  and  other 
morbid  changes  in  the  bones  of  the  cranium. 

Falls  or  blows  on  the  head  slowly  bring  on  affections  of  the  coverings  of  the 
brain. 

In  all  the  cases  mentioned  by  Beer,  it  appears  that  the  complaint  in  the 
head  and  eyes  began  after  sudden  cooling  of  the  head,  followed  by  rheumatism, 
which,  though  shght  in  its  commencement,  had  fixed  itself  in  the  fibrous 
investment  of  the  skull. 

The  morbid  formation,  which  I  have  ventured  (page  128)  to  call  chloroma, 
and  which  appears  to  be  of  a  fibro-plastic  nature,  is  found  to  affect  in  some 
cases  the  pericranium ;  in  others  the  dura  mater,  and  occasionally  both  these 
membranes  at  once.  Sucli  appears  to  be  the  nature  of  a  pecuUar  set  of  cases 
described^  by  Sir  Everard  Home,  and  attributed  by  him  to  the  spread  of 
inflammation  from  the  dura  mater  to  the  pericranium.  The  cases  in  question 
w^re  attended  by  the  symptoms  common  to  pressure  on  the  brain  from  other 
causes,  and  amongst  these  by  amaurosis,  and  were  relieved  by  cutting  down 
upon  the  cranium,  so  as  to  remove  the  tension  of  the  parts  covering  it.  In 
one  fatal  case  of  this  kind.  Sir  Everard  found  the  pericranium  thickened  into 
a  mass  of  fibrous  bony  texture ;  and  corresponding  to  this  part  internally, 
there  was  a  similar  thickening  and  induration  of  the  dura  mater.  Most  of 
the  cases  referred  to  had  been  treated  by  long  courses  of  mercury  without 
benefit,  and  in  some  of  them  with  aggravation  of  the  symptoms. 

The  prognosis  in  amaurosis  resulting  from  morbid  changes  in  the  mem- 
branes or  bones  of  the  head  is,  I  need  scarcely  say,  extremely  unfavorable. 
The  gradual  development  of  complete  blindness,  and  not  only  death,  but  a 
very  mournful  death,  is  to  be  dreaded.  Nor  does  the  healing  art  possess  any 
means  which  can  be  effectually  employed  in  diminishing,  much  less  removing, 
the  organic  changes  upon  which  the  disease  depends,  except,  perhaps,  in  one 
or  two  cases.  These  cases  are,  when  the  symptoms  evidently  originate  either 
in  consequence  of  some  accident,  such  as  a  blow,  or  in  some  evident  constitu- 
tional disorder,  and  especially  syphilis. 

The  following  case,  related  by  the  late  Mr.  "Wilson,  of  London,  shows 
what  may  sometimes  be  done,  even  in  circumstances  which  might  appear 
almost  desperate  : — 

Case.  381. — In  November,  180G,  Mr.  Wilson  was  requested  by  a  surgeon  of  his  acquaint- 
ance to  visit  a  gentleman,  who  had  been  affected  with  a  long  and  severe  illness.  Mr.  W. 
received  the  following  account  of  the  case  : — 

In  the  spi'ing  of  1803,  when  influenza  was  very  prevalent,  Mr.  C,  a  muscular  man, 
about  28  j'ears  of  age,  and  of  rather  a  sanguineous  temperament,  was  attacked  with  a 
very  severe  deep-seated  pain  in  the  orbit  of  the  left  eye.  A  physician  of  eminence  was 
consulted,  by  whom  a  rigidly  antiphlogistic  plan  was  recommended.  This  was  persevered 
in  for  a  considerable  time  without  benefit.  The  case  was  then  deemed  nervous,  and  medi- 
cines adapted  for  the  relief  of  nervous  diseases  were  employed  in  large  quantities.  The 
patient  was  ordered  to  remove  to  Hampstead  for  the  benefit  of  the  air.  This  plan  not 
succeeding,  other  medical  opinions  were  taken,  and  various  remedies  tried ;  but  the 
patient  gradually  became  worse.  The  sense  of  hearing  in  the  left  ear  was  now  totally 
lost.  The  levator  of  the  left  upper  eyelid  became  paralyzed,  and  a  great  degree  of  stra- 
bismus was  produced  by  the  rectus  externus  having  also  lost  its  power.  The  pupil  of 
the  left  eye  became  much  and  constantly  dilated,  and  the  sight  of  that  eye  was  lost.  The 
right  angle  of  the  mouth  was  permanently  drawn  to  the  right  side.  An  extreme  hoarse- 
ness took  place,  and  his  articulation  became  so  indistinct  that  he  could  not  be  understood 
even  by  his  friends.  He  lost  the  power  of  swallowing  solids,  and  swallowed  fluids  with 
very  great  difficulty,  as  the  attempt  brought  on  a  distressing  sense  of  suflbcation.  A 
vessel  was  constantly  placed  at  lus  side  to  receive  the  saliva,  which  he  could  neither 
swallow  nor  eject  from  his  mouth,  and  which  he  therefore  endeavored  to  push  out  with 


AMAUROSIS  FROM  DISEASED   CRANIUM   AND  DURA  MATER.      9tl 

his  tongue.  His  bowels  were  most  obstinately  constipated,  requiring  the  frequent  use  of 
drastic  purges. 

Upon  visiting  the  patient,  Mr.  Wilson  found  his  right  hand  and  arm  folded  up,  and 
with  the  leg  of  the  same  side,  in  a  state  of  complete  paralysis.  Very  violent  pain  in  the 
orbit  of  the  left  eye  still  continued,  and  there  was  also  considei-able  pain  in  the  vertebras 
of  the  neck,  and  at  the  top  of  the  shoulder.  When  in  bed  he  could  not  raise  his  head 
from  the  pillow;  he  could  scarcely  sleep  at  all,  and  had  no  respite  from  excruciating  pain; 
in  short,  his  dissolution  was  hourly  expected.  Mr.  W.  learned  also,  that  before  the  com- 
mencement of  the  disease,  he  had  at  two  or  three  different  times,  chancres  and  incipient 
buboes,  and  that  for  these  he  had  used  mercury,  until  the  symptoms  disappeared,  and 
the  surgeon  who  attended  him  pronounced  his  cure  to  be  complete.  In  the  summer 
preceding  his  illness,  be  had  strained  his  back  in  leaping;  a  short  time  after  which,  a 
bubo  formed  in  the  right  groin.  This  was  particularly  attended  to,  under  the  supposition 
that  it  might  prove  venereal.  It  suppurated  and  healed  without  mercury  having  been 
used. 

Observing  something  particular  in  the  figure  of  one  of  his  legs,  Mr.  Wilson  requested 
leave  to  examine  it ;  and  when  the  stocking  was  removed,  perceived  a  cicatrice  of  con- 
siderable extent,  and  that  the  tibia  was  much  enlarged.  The  patient  did  not,  however, 
feel  any  pain  in  this  bone.  He  expressed  in  writing  with  his  left  hand,  that  several  years 
before,  he  had  received  a  severe  blow  on  this  leg,  and  that  a  large  piece  of  bone  had  come 
away  ;  he  could  not  recollect  whether  he  took  any  mercury  at  that  time,  and  he  did  not 
think  that  his  surgeon  considered  the  disease  in  the  bone  as  venereal.  He  did  not 
remember  having  had,  at  any  time,  spots  on  his  skin  or  a  sore  throat.  His  present  ail- 
ment, he  said,  had  never  been  considered,  by  any  of  the  medical  persons  whom  he  "had 
consulted,  as  venereal,  nor  had  the  use  of  mercury  ever  been  proposed  for  its  cure. 

On  examining  his  neck,  Mr.  Wilson  found  several  of  the  vertebi'se  much  enlarged.  He 
discovered  also  a  large  swelling  in  the  acromion  of  the  right  scapula,  and  a  considerable 
enlargement  of  the  whole  of  the  spine,  and  greater  part  of  the  superior  costa,  of  that 
bone.  As  the  muscles  were  wasted,  a  swelling  was  readily  perceived  in  the  os  brachii,  a 
little  above  the  attachment  of  the  deltoid  muscle.  The  right  clavicle  possessed  at  least 
three  times  its  usual  thickness. 

From  the  possibility  of  these  swellings  being  venereal,  Mr.  Wilson  felt  justified  in  pro- 
posing the  immediate  use  of  mercury.  The  patient's  relations  were  apprehensive  that 
his  extreme  weakness,  and  the  apparently  rapid  approach  of  death,  would  render  the 
expei-iment  useless ;  but  willingly  consented  to  the  attempt  being  made,  as  without  some- 
thing being  done,  and  that  quickly,  death  seemed  inevitable. 

Accordingly,  one  drachm  of  the  strong  mercurial  ointment,  with  five  grains  of  camphor, 
was  rubbed  upon  his  skin  every  night,  and  a  seton  was  inserted  in  the  back  of  his  neck. 
In  four  days  his  mouth  became  affected  from  the  mercury ;  in  ten  days  he  swallowed 
with  less  difiiculty  ;  he  slept  well,  and  his  pains  were  nearly  gone.  In  a  fortnight,  the 
enlargement  of  the  clavicle  was  evidently  lessened,  and  his  muscles  were  much  fuller  and 
firmer.  He  had  also  recovered  his  speech,  so  far  as  to  make  himself  understood.  The 
quantity  of  the  ointment  was  now  increased  to  a  drachm  njght  and  morning,  and  the  use 
of  it  was  continued  for  eleven  weeks ;  towards  the  latter  part  of  which  time,  when  he 
could  swallow  with  ease,  he  took  about  eight  ounces  of  the  compound  decoction  of  sar- 
saparilla  daily,  and  now  and  then  some  preparation  of  Peruvian  bark. 

During  this  course,  although  the  patient's  mouth  was  affected  with  a  considerable 
degree  of  soreness,  he  gathered  health  and  strength  daily,  and  before  it  was  discontinued 
had  grown  fat.  His  muscles  had  acquired  very  nearly  their  original  plumpness  and 
strength,  and  the  limbs  their  former  capability  of  motion.  The  pains  were  wholly 
removed,  and  the  thickening  of  the  bones  very  much  reduced.  His  power  of  swallowing 
and  moving  the  right  extremities,  seemed  at  first  to  increase,  in  the  same  proportion  as 
the  swellings  of  the  cervical  vertebrae  diminished.  But  though  these  swellings  afterwards 
became  stationary,  the  powers  of  the  muscles  were  completely  restored.  His  cure,  with 
the  following  exceptions,  was  perfect,  and  had  remained  so  for  more  than  two  years.  The 
pupil  of  the  left  eye  continued  more  dilated  than  that  of  the  right,  and  the  eyelid  coiild 
not  be  raised  quite  so  high  as  formerly  ;  but  he  could  distinguish  objects  and  colors  in 
some  measure  with  the  left  eye,  and  even  small  objects  when  he  used  plain  green  specta- 
cles, and  employed  that  eye  only.  When  he  used  both  eyes,  his  vision  was  confused,  as 
he  then  saw  objects  double.  He  still  spoke  with  a  very  hoarse  voice,  but  his  articulation 
was  sufficiently  distinct. '" 

Case  382. — Dr.  Abercrombie  records"  the  case  of  a  man,  aged  47,  whose  complaints 
began  in  Slay,  1816,  with  headache,  and  weight  in  the  head,  aggravated  by  stooping,  and 
increasing  gradually,  notwithstanding  copious  evacuations.  In  August  his  sight  began 
to  fail,  with  giddiness  ;  in  September,  he  could  see  objects  only  in  a  very  strong  light ; 
in  December,  perfect  blindness,  the  pain  still  continuing  constant  and  severe  j  in  the 


912 


AMAUROSIS  FROM  CEREBRAL   CONGESTION. 


middle  of  January,  stupor  and  forgetfulness  ;  followed,  on  the  31st  of  that  month,  by 
coma  and  death. 

On  dissection,  a  tumor,  the  size  of  a  large  egg,  was  found  attached  to  the  tentorium,  in 
such  a  manner,  that  part  lay  above,  and  part  below  it ;  the  falx  likewise  entering  into 
its  substance  above.  Internally  it  was  firm,  resembling  somewhat  the  structure  of  the 
kidney.     There  were  four  ounces  of  fluid  in  the  ventricles. 

Case  383. — A  person,  whose  sex  and  age  are  not  mentioned,  having  for  a  long  time 
been  deprived  of  the  sense  of  smell,  and  latterly  of  that  of  sight,  died  comatose. 

On  dissection,  a  tumor,  which  Professor  Cruveilhier  considered  carcinomatous,  was 
found  to  arise  from  the  dura  matter  where  it  covers  the  upper  surface  of  the  ethmoid 
bone.  The  tumor  (Fig.  148)  extended  backwards  a  little  upon  the  sella  turcica,  and 
latterly  on  the  roof  of  each  orbit.  It  had  a  mammillated  appearance  externally,  had 
completely  destroyed  the  trunks  of  the  olfactory  nerves,  compressed  the  optic  nerves, 


Fig.  148. 


Fig.  149. 


and  hollowed  out  for  itself  a  cavity  in  the  inferior  surface  of  the  brain.  The  layer  of 
cerebral  substance  in  contact  with  the  tumor,  was  in  a  soft  state.  A  vertical  section  of 
the  diseased  mass  (Fig.  140)  shows  the  radiated  disposition  of  fibres  which  it  presented, 
similar  to  what  is  observed  in  other  cases  of  carcinoma.  Some  vascular  ramifications, 
apparently  veins,  followed  the  direction  of  the  fibres.  This  figure  also  shows  that  the 
tumor  had  sent  down  some  prolongations  into  the  nasal  fosste,  where  it  had  the  same 
mammillated  appearance  and  the  same  texture.'^ 

§  '7.     Amaurosis  from  cerebral  congestion. 

It  appears  to  be  universally  admitted,  not  only  that  amaurosis  may  occa- 
sionally result  from  a  sanguineous  overflow  to  the  brain,  or  an  impeded 
return  of  the  blood  from  that  organ,  but  that  one  of  the  most  common  causes 
of  the  disease  is  simple  turgescence  of  the  vessels  supplying  the  internal  optic 
apparatus. 

Symptoms. — The  first  symptoms  with  which  congestive  amaurosis  generally 
shows  itself,  are  a  feeling  of  fulness  in  the  eyeballs,  and  almost  uninterrupted 
photopsia.  These  symptoms  are  speedily  followed  by  stupefying  headache, 
generally  accompanied  by  vertigo,  and  tinnitus  aurium,  and  keeping  pace 
with  a  striking  diminution  in  the  power  of  vision.  In  some  cases,  the  patient 
is  deprived  of  sleep  ;  in  others,  he  is  affected  with  lethargy.  When  the 
internal  carotids  are  chiefly  affected,  lethargy  is  generally  a  prominent 
symptom  ;  when  the  vertebrals,  pain  in  the  occiput."  The  patient  is  com- 
monly of  an  athletic  habit,  and  presents  signs  of  general  plethora.  In  some 
instances,  however,  the  reverse  of  this  is  the  case  ;  for  example,  in  pregnant 
women,  w^ho  sometimes  have  been  known  to  suffer  towards  the  end  of  several 
successive  pregnancies  from  this  amaurosis.  The  signs  of  local  plethora  are 
always  present.  The  eye  appears  fuller  than  natural  ;  it  seems  to  project 
unusually  from  the  orbit ;  the  patient  moves  it  less  than  in  health  ;  its  sur- 
face is  suffused  with  red  vessels  ;  the  face  is  flushed,  and  the  temporal,  and 


AMAUROSIS   FROM   CEREBRAL   CONGESTION.  9t3 

sometimes  even  the  carotid  arteries  are  felt  strongly  throbbing.  The  pupil, 
in  the  incipient  stage,  may  not  be  much  affected,  being  neither  unnaturally 
dilated  nor  contracted,  and  still  varying  with  tolerable  liveliness  according 
to  the  degrees  of  light  to  which  the  eye  is  exposed. 

As  the  disease  advances  into  the  confirmed  stage,  the  headache  becomes 
irregular,  being  sometimes  severe,  at  other  times  scarcely  felt.  The  patient 
now  complains  principally  of  a  thick  gauze  or  network,  which  renders  every 
object  before  him  indistinct.  In  clear  light,  the  network  seems  uniformly 
obscure ;  but  in  the  dark,  it  is  fiery  and  shining,  sometimes  appearing  reddish, 
and  at  other  times  bluish.  This  symptom  is  increased  by  every  cause  which 
increases,  even  for  an  instant,  the  local  plethora.  For  instance,  if  the  patient 
presses  much  when  at  stool,  the  network  seems  thicker  for  some  minutes  after; 
and  if  this  cause  or  similar  causes  of  increased  local  congestion  be  frequently 
repeated,  and  the  existing  plethora  not  removed  by  proper  remedies,  vision 
soon  becomes  totally  extinguished.  This  indeed  almost  constantly  follows, 
even  when  there  are  no  such  occasional  augmentations  of  the  plethora,  if  re- 
course is  not  had  to  proper  treatment ;  but  not  so  rapidly  as  when  such  oc- 
casional causes  are  allowed  to  come  into  frequent  operation.  At  last,  all  trace 
of  sensibility  to  light  is  lost.  The  patient  continues  to  complain  of  stunning 
headache.  He  complains  also  of  a  feeling  as  if  the  eyeballs  were  increasing 
in  size ;  and  they  actually  feel  firmer  to  the  touch  than  natural.  The  pupil 
becomes  fixed,  though  rarely  much  dilated.  The  patient  stares  on  vacancy, 
presenting  in  a  striking  manner  the  peculiar  fixed  look  of  the  amaurotic. 

Exciting  causes. — Every  influence  capable  of  producing  or  increasing  a 
continued  or  frequently  repeated  determination  of  blood  to  the  head,  may  be 
regarded  as  an  exciting  cause  of  this  amaurosis.  Those  who  are  of  a  ple- 
thoric habit  are  generally  able  to  produce  a  slight  degree  of  it  at  will.  When 
they  stoop  forwards,  hang  down  the  head,  tie  their  neckcloth  tight,  or  by  any 
means  increase  the  circulation  of  blood  through  the  brain,  or,  perhaps,  to 
speak  more  correctly,  when  they  impede  in  any  way  the  return  of  that  fluid 
towards  the  heart,  they  excite  the  sensation  of  muscce  volitantes,  or  even  com- 
plete temporary  blindness.  Boerhaave  relates  the  case  of  a  man  who,  when- 
ever he  was  intoxicated,  labored  under  complete  amaurosis.  The  disease 
came  on  by  degrees,  increasing  with  the  quantity  of  wine ;  and  after  the  in- 
toxication went  off,  his  vision  returned."  Many  plethoric  persons  regularly 
find  their  vision  impaired  during  the  quickened  circulation  from  a  full  meal 
and  a  few  glasses  of  wine ;  while  those  of  a  meagre  habit  not  unfrequently 
find  their  vision  benefited  by  the  same  causes. 

The  following  influences  may  be  enumerated  as  likely  to  prove  remote 
causes  of  congestive  amaurosis ;  pregnancy,  tedious  and  difficult  parturition, 
raising  and  carrying  heavy  loads,  long  continued  occupations  which  strain  the 
eyes  while  the  head  is  bent  forwards,  employments  requiring  at  once  keen 
exercise  of  sight  and  activity  of  thought,  rage  and  other  violent  passions  of 
the  mind,  the  sudden  suppression  of  some  wonted  sanguineous  discharge,  sup- 
pressed menses,  the  neglect  of  periodic  bloodletting  to  which  the  individual 
has  been  accustomed  at  a  certain  period  of  the  year,  the  removal  by  ligature 
or  otherwise  of  hijemorrhoids  from  which  discharges  of  blood  had  become 
habitual,  violent  and  long-continued  vomiting,  a  forced  march  in  hot  weather, 
very  hot  baths  even  of  the  feet  only,  remaining  long  in  an  over-crowded  as- 
sembly, an  excessive  and  unaccustomed  debauch,  frequent  constipation  of  the 
bowels,  violent  pressing  while  at  stool,  lying  with  the  head  uncommonly  low 
during  the  night,  large  scrofulous  or  other  swellings  in  the  neck,  by  which 
the  jugular  veins  are  compressed,  impeded  reception  of  the  venous  blood  by 
the  heart  from  contraction  of  the  right  auriculo-ventricular  opening.  If  two 
or  more  of  these,  or  similar  causes,  operate  together,  and  more  especially  if 


914  AMAUROSIS   FROM   CEREBRAL   CONGESTION. 

they  come  to  operate  suddenly  ou  an  individual,  perhaps  constitutionally  in- 
clined to  fulness  about  the  head,  then  the  risk  of  congestive  amaurosis  is  much 
increased. 

Proximate  cause. — Plethora  is  described  as  an  excessive  fulness  of  vessels, 
as  a  redundancy  of  blood,  as  redness  of  a  part  from  distended  bloodvessels, 
as  redness,  heat,  and  tumor  even,  either  of  the  whole  or  of  a  part  of  the  body, 
from  the  same  cause ;  and  yet  as  something  different  from  inflammation.  The 
absence  of  acute  pain  appears  one  of  the  chief  distinctions  of  plethora  from 
inflammation  ;  but  added  to  this  is  the  fact,  that  though  plethora  often  ends 
in  the  rupture  of  the  affected  vessels,  it  frequently  terminates  without  any 
such  event,  while  inflammation,  though  it  is  sometimes  resolved,  is  in  general 
attended  by  the  effusion  of  serum,  or  of  coagulable  lymph,  the  formation  of 
pus,  ulceration,  gangrene,  or  even  by  several  of  these  events  in  succession. 

"Plethora  and  sanguineous  determination  of  the  head,"  says  Dr.  Burrows,*^ 
"are  often  used  synonymously  in  medical  language;  but  they  differ  widely, 
inasmuch  as  determination  may  exist  without  plethora,  and  plethora  without 
determination.  Blood  may  be  sent  to  the  brain  with  a  preternatural  velocity, 
and  act  simply  by  augmented  motion  but  be  as  readily  returned  by  the  veins : 
this  is  determination.  It  may  be  sent  either  with  a  natural  velocity,  or  a 
degree  greater  or  less  than  is  natural ;  and  from  some  obstructing  cause  be 
not  returned  by  the  veins  in  that  due  i)roportion  in  which  it  has  been  con- 
veyed to  the  brain — accumulation,  therefore,  occurs:  this  is  plethora." 

The  pathology  of  plethora  of  the  brain,  and  of  its  frequent  effect,  apoplexy, 
is  by  no  means  satisfactorily  understood;  for  while  many  observations  would 
lead  us  to  suppose  that  inflammation  of  the  arterial  tunics,  and  deposition  of 
atheromatous  or  calcareous  matter  between  their  middle  and  innermost  layers, 
are  intimately  connected  with  these  diseases,  if  not  actually  their  proximate 
causes,  leading  in  apoplectic  cases  to  rupture  of  vessels  and  extravasation  of 
blood,  the  numerous  instances,  in  which,  after  death  from  apoplexy,  no  dis- 
eased appearances  whatever  are  detected  within  the  cranium,  show,  that  there 
not  only  remains  room  for  farther  investigation  of  the  subject,  but  that  no 
general  conclusion  can  at  present  be  adopted  without  danger  of  falling  into 
some  serious  mistake.  The  symptoms,  vulgarly  supposed  to  be  indicative  of 
an  overflow  of  blood  to  the  head,  or  of  increased  vascularity  of  the  brain,  are 
common  to  very  opposite  states  of  that  organ. 

Prognosis. — So  long  as  congestive  amaurosis  is  in  the  incipient  stage,  and 
the  power  of  vision  not  greatly  impaired,  the  practitioner  may  venture  to  give 
a  favorable  prognosis.  In  the  confirmed  stage,  or  when  the  power  of  vision 
is  nearly  or  completely  extinguished,  the  prognosis  is  extremely  unfavorable. 
Even  when  the  disease  is  only  of  a  few  days'  standing,  if  no  power  of  vision 
be  present,  there  can  be  but  little  hope  of  its  recovery.  When  the  patient 
has  continued  for  several  months  in  this  state,  it  scarcely  ever  happens  that 
even  the  slightest  restoration  of  sight  is  effected.^" 

Treatment. — Slight  incipient  attacks  are  often  cured  by  rest,  purgatives, 
and  a  spare  diet.  In  more  threatening  cases,  general  bloodletting  ought  to 
be  practised  from  one  of  the  veins  of  the  arm,  the  jugular  vein  or  temporal 
artery.  This  may  be  followed  uo,  if  it  seems  necessary,  by  local  bloodletting, 
as  cupping  on  the  back  of  the  neck,  cupping  on  the  temples,  or  the  appli- 
cation of  leeches  to  the  head.  Purgatives  are  particularly  useful.  An  entire 
abstinence  from  animal  food  must  be  observed,  as  well  as  from  all  alcoholic 
fluids.  Cold  applications  are  to  be  made  to  the  head,  which  ought  previously 
to  be  shaved.  Complete  rest  of  the  eyes,  and  of  the  whole  body,  and  a  careful 
prevention  of  irritation  from  light  must  be  enjoined. 

Depletion,  then,  and  the  antiphlogistic  treatment,  in  all  its  parts,  are  the 
means  upon  which  we  are  to  depend,  in  the  early  period  of  this  amaurosis. 


APOPLECTIC  AMAUROSIS.  9Y5 

They  will  seldom  fail  us,  if  had  recourse  to  within  the  first  two  or  three  days, 
and  employed  with  the  necessary  vigor. 

If  the  complaint  has  been  neglected  for  some  time,  or  treated  without  de- 
pletion, which  we  need  scarcely  distinguish  from  neglect,  we  should  even  yet 
have  recourse  to  bloodletting.  If  depletion  has  been  fully  tried,  but  without 
benefit,  the  prospect  is  extremely  bad.  Excitation  of  the  absorbent  system 
ought  now  to  be  tried,  especially  by  means  of  mercury  and  counter-irritation. 
The  mouth  should  be  made  sore  by  a  course  of  calomel,  or  blue  pill ;  the  head 
blistered ;  and  an  issue  opened  by  caustic,  on  the  nape  of  the  neck. 

Should  this  treatment  also  fail,  there  still  remain  many  other  remedies 
which  might  be  employed  ;  but  the  use  of  stimulants  must  be  pursued  with 
more  than  ordinary  caution,  as  they  might  readily  produce  renewed  congestion, 
or  even  induce  apoplexy. 

§  8.  Amaurosis  with  apoplexy,  from  encephalic  hcemorrhagy,  &c. 

When  cerebral  plethora  is  neglected,  it  is  exceedingly  apt  to  end  in  that 
sudden  abolition  of  the  powers  of  sense  and  motion,  to  which  we  give 
the  name  of  apoplexy.  Among  the  usual  symptoms  of  this  state,  we  find  loss 
of  vision,  and,  most  frequently,  dilated  pupils. 

In  a  pathological  point  of  view,  apoplexy  resolves  itself  into  three  varieties, 
viz  :  apoplexy  with  extravasation  of  blood,  apoplexy  with  serous  effusion,  and 
apoplexy  without  any  evident  morbid  appearance  on  dissection.  The  last 
mentioned.  Dr.  Abercrombie  calls  simple  apoplexy.  Where  a  person  is 
attacked  by  apoplexy,  and  no  morbid  appearances  are  found  on  dissection  of 
the  brain,  the  cause  is  to  be  sought  for  in  an  interruption  of  the  balance  be- 
twixt the  arterial  and  venous  system  of  the  organ.  Amaurosis  may  result 
from  any  of  the  three,  and  may  be  one  of  the  earliest,  or  one  of  the  latest, 
symptoms  to  disappear. 

It  is  not  improbable  that,  in  many  cases  not  suspected  to  be  apoplectic, 
amaurosis  is  the  result  of  the  rupture  of  several  small  vessels,  throwing  out 
blood  separately,  and  this  either  coalescing  into  one  clot,  or  forming  many 
small  lodgments,  on  or  in  the  brain  ;  in  the  latter  case,  attended  with  lacera- 
tions of  its  substance.  Slight  apoplectic  attacks  may  not  attract  the  patient's 
attention,  till  he  finds  his  vision  seriously  impaired.  This  is  apt  to  be  followed 
by  palsy  and  loss  of  memory. 

The  suddenness  of  the  attack,  and  the  circumstances  in  which  the  patient 
is  placed  at  the  time,  may  lead  us  to  conclude  that  the  cause  is  of  the  nature 
of  apoplexy.  For  instance,  a  man  consulted  me  who  became  suddenly  blind 
of  the  left  eye,  while  attending  a  public  meeting,  brilliantly  illuminated  with 
gas,  and  where  he  had  been  overheated  and  excited.  After  a  time,  amaurosis 
of  the  right  eye  followed,  with  partial  palsy  of  the  tongue.  I  saw  another 
man,  incompletely  amaurotic  for  ten  years  in  his  right  eye,  who  became  sud- 
denly affected  with  incomplete  amaurosis  of  the  left  eye,  after  blowing  a  pair 
of  Highland  bagpipes  for  half  an  hour,  which  he  found  required  great  exer- 
tion of  the  lungs.  I  saw,  in  consultation  with  Dr.  Rainy,  a  gentleman  who, 
on  a  journey,  rising  in  the  morning,  and  looking  out  at  the  window  of  the  inn, 
found  one  eye  totally  amaurotic,  a  few  months  after  which  he  became  hemi- 
plegic.  James  Gregory,  the  celebrated  inventor  of  the  reflecting  telescope, 
was  suddenly  struck  blind,  in  his  SHh  year,  while  observing  the  satellites  of 
Jupiter,  and  died  a  few  days  after. 

In  a  case  of  apoplexy  related'''  by  Mr.  Williams,  coagulated  blood  was 
found  to  have  penetrated  the  very  substance  of  one  of  the  optic  nerves. 

The  treatment  of  apoplectic  amaurosis  does  not  differ  in  any  essential  par- 
ticular from  the  plan  above  recommended,  for  the  same  disease,  arising  from 
cerebral  congestion. 


9T6  APOPLECTIC   AMAUROSIS. 

Case  384. — Mr.  Stevenson  was  called  to  attend  a  patient  between  40  and  50  years  of  age, 
who  was  found  lying  on  the  ground  in  an  apoplectic  fit.  This  person  was  tall  and  thin, 
his  countenance  pallid,  and  his  habits  remarkably  temperate  and  regular  ;  consequently  it 
could  not  have  been  thought  likely  that  he  should  fall  a  sacrifice  to  apoplexy.  Notwith- 
standing the  various  and  active  means  that  were  employed  for  his  recovery,  he  expired 
within  12  hours  after  the  attack. 

In  the  forenoon  of  the  following  day,  Mr.  Stevenson  examined  the  contents  of  the  cra- 
nium, and  found  not  only  the  most  decisive  marks  of  vascular  congestion  in  the  meninges, 
but  likewise  a  large  accumulation  of  discolored  serous  fluid  in  the  ventricles  of  the  brain, 
and  a  mass  of  coagulated  blood  so  situated  as  to  compress  the  chiasma.  This  explained 
the  cause  of  his  total  blindness,  and  of  the  fully  expanded  state  of  his  pupils  ;  although, 
when  Mr.  Stevenson  first  saw  him,  he  was  not  entirely  destitute  of  the  power  of  sensation 
and  feeling.'* 

Case  385. — Ann  Nowlan,  aged  43,  married,  was  admitted  into  Sir  Patrick  Dunn's  Hos- 
pital, in  Dublin,  said  to  be  laboring  for  some  days  under  fever,  for  which  she  had  got  from 
a  physician  cordial  diaphoretic  medicines.  When  she  became  Dr.  Law's  patient,  she  pre- 
sented the  following  symptoms:  Distressing  supra-orbital  headache;  pulse  100,  weak ; 
tongue  loaded  with  a  dark-brown  crust  at  base  and  in  the  centre,  red  and  glazed  at  point 
and  edges  ;  stomach  irritable  and  painful  on  pressure  ;  skin  of  natural  temperature  ;  no 
petechias  ;  great  depression  of  spirits.  Twelve  leeches  were  applied  to  the  epigastrium. 
An  eff'ervescing  draught,  with  tincture  of  opium,  was  given.  A  cold  lotion  was  applied 
to  the  forehead. 

These  means  did  not  relieve  the  headache,  nor  the  sickness  and  irritability  of  the 
stomach.  On  closely  examining  the  symptoms,  Dr.  Law  was  led  to  regard  the  headache 
as  the  first  and  principal  link  in  the  morbid  chain,  and  the  other  complaints  as  its  efi"ects. 
The  patient  admitted  having  been  long  subject  to  headache.  She  liad  a  strength  of  voice 
and  power  of  moving  herself,  apparently  incompatible  with  the  other  symptoms,  as  charac- 
teristic of  fever.  Acting  upon  this  view,  leeches  were  applied  to  the  left  temple,  to  which 
she  principally  referred  the  pain.  She  derived  temporary  relief  from  their  application. 
Blisters  were  next  tried,  and  they  also  relieved  for  a  time.  Dr.  Law  now  determined  to 
bring  the  system  under  the  influence  of  mercury,  and  ordered  for  this  purpose  a  combi- 
nation of  calomel  and  James's  powder.  No  sooner  had  the  mouth  become  sore,  than  the 
headache  entirely  ceased,  and  the  loaded  tongue  became  clean.  The  complete  exemption 
from  pain  lasted  only  so  long  as  the  mouth  continued  sore  ;  for  no  sooner  had  the  mer- 
curial influence  subsided,  than  the  pain  returned,  although  much  less  constant  and  less 
intense.  When  the  pain  returned,  the  tongue  resumed  the  loaded  appearance.  The 
mercury  was  again  resorted  to,  and  removed  the  pain,  never  to  return. 

The  patient  now,  for  the  first  time,  directed  Dr.  Law's  attention  to  a  failure  of  the 
sight  of  her  left  eye,  of  which  she  said  she  had  the  perfect  use  when  she  came  into  the 
hospital.  The  pupil  was  found  to  be  permanently  dilated.  Dr.  Law  applied  repeated 
blisters,  and  sprinkled  some  with  strychnia,  but  the  eye  became  quite  amaurotic. 

The  patient  had  now  enjoyed  a  long  exemption  from  headache,  and  seemed  to  labor 
only  under  great  depression  of  spirits,  when  she  was  suddenly  seized  with  a  fit.  She  was 
found  in  a  state  of  complete  insensibility  ;  the  respiration  extremely  labored,  but  without 
stertor ;  the  pulse  weak  and  slow ;  face  not  flushed ;  no  throbbing  of  the  carotids.  The 
temporal  arterj'  was  opened,  and  about  ten  ounces  of  blood  were  drawn  in  a  full  stream, 
when  the  pulse  began  to  fail.  A  compress  and  bandage  were  applied,  but  the  bleeding 
was  with  difiiculty  restrained.  The  face  now  flushed,  the  carotids  began  to  pulsate 
strongly ;  and  while  a  turpentine  enema  was  about  to  be  administered,  the  patient 
expired,  about  two  hours  from  the  time  of  the  seizure. 

Innpection. — A  considerable  quantity  of  black  fluid  blood  issued  on  dividing  the  scalp. 
The  superficial  vessels  of  the  brain  were  very  full  and  congested.  When  the  brain  was 
removed  from  its  situation,  not  less  than  six  ounces  of  fluid  blood  were  found  etfused  at 
its  base.  A  large  coagulum  occupied  the  place  of  the  locus  perforatus,  or  floor  of  the 
third  ventricle,  which  seemed  to  have  been  completely  destroyed.  Both  crura  cerebri 
were  elongated  and  displaced,  and  their  consistence  was  diminished  by  the  violence  they 
had  sustained.  The  lateral  ventricles  were  distended  with  two  clots  of  blood,  which  lay 
in  contact  with  one  another,  in  consequence  of  the  destruction  of  the  septum  lucidum. 
The  right  thalamus  was  natural ;  the  centre  of  the  left  was  softened  and  broken  down, 
and  contained  a  clot.  The  basilar  artery  was  healthy,  but  the  middle  arteries  of  the 
brain  presented  many  ossified  points.  There  was  no  appearance  of  disease  in  the  optic 
nerves. '9 

Case  386. — The  late  Earl  of  Liverpool,  in  consequence  of  exposure  to  cold,  suflfered 
from  crural  phlebitis,  attended  by  remarkable  slowness  of  the  pulse,  which  was  forty- 
four  in  a  minute.  The  sight  of  his  left  eye  became  affected,  and  soon  after  he  had  a 
series  of  attacks  of  apoplexy,  which  proved  fatal. 


ANEURISMAL  AMAUROSIS,  911 

The  left  iliac  vein  was  found  completely  impervious,  and  a  large  cavity  filled  with 
serum  occupied  the  brain  over  the  right  ventricle.*^ 

Case  387. — Dr.  Abercrombie  mentions^'  the  case  of  a  gentleman,  who,  after  an  apo- 
plectic attack,  lost  his  sight,  and  continued  in  a  state  of  perfect  blindness  for  about  seven 
years.  After  that  time,  while  one  day  out  in  his  carriage,  he  suddenly  recovered  sight ; 
and  it  was  found  that  he  had  entirely  retained  his  skill  in  drawing,  for  which  he  had 
been  distinguished  before  the  attack. 

In  this  case,  a  clot  may  have  pressed  on  the  optic  nerves,  but  becoming 
shrunk,  had  at  length  shifted  its  situation,  and  allowed  the  nerves  to  be  freed 
of  pressure.  A  fall  on  the  head,  it  has  been  stated,  has  restored  light  to  an 
amaurotic  patient,  probably  from  displacing  a  clot.*^ 

§  9.  Amaurosis  from  aneurism  of  the  encephalic  arteries. 

Mr.  Ware  was  of  opinion,  that  amaurosis  might  not  unfrequently  be  owing 
to  dilatation  of  the  circulus  arteriosus.  "Should  then  the  dilatation,"  says 
he,  "take  place  in  the  posterior  portion  of  the  circulus  arteriosus,  so  as  to 
compress  the  nervi  motores  oculorum,  the  consequence  will  be,  that  the 
eyelids,  and  probably  the  eyes  also,  will  lose  the  power  of  motion.  But  if 
the  dilatation  happens  in  the  anterior  portion  of  the  circulus,  as  the  com- 
pression will  then  be  on  the  optic  nerves,  the  sight  must,  of  course,  be 
destroyed.  And  should  the  dilatation  take  place  in  both  portions,  so  as  to 
occasion  a  compression  both  on  the  optic  nerves  and  the  nervi  motores  ocu- 
lorum at  the  same  time,  while  the  eyelids  will  hereby  be  rendered  immovable, 
the  eyes  also  will  be  deprived  of  sight  and  motion  together.  "^^ 

Whether  this  is  actually  a  frequent  cause  of  amaurosis,  it  is  impossible  to 
say.  Indeed,  the  want  of  accurate  dissections  is  one  great  cause  of  the 
obscurity  which  hangs  over  the  subject  of  amaurotic  diseases.  That  aneurism 
of  the  cerebral  arteries  is  occasionally  a  cause  of  amaurosis,  is  established 
by  the  following  case,  related  by  Mr.  Spurgin. 

Case  388. — A  laborer,  aged  fifty-seven,  became  suddenly  insensible,  whilst  at  work, 
about  the  beginning  of  March,  but  quickly  recovered  without  assistance,  and  resumed 
his  employment.  Three  weeks  after,  he  had  another  fit,  and  remained  in  a  state  of 
stupor  three  or  four  days.  He  complained  of  constant  pain  at  the  top  of  the  head,  much 
increased  by  stooping,  and  which  frequently  deprived  him  of  sleep.  His  countenance 
appeared  dejected,  heavy,  and  sallow.  He  was  exti-emely  morose  and  sullen,  ofteu 
refusing  to  return  any  answer  to  questions,  and  frequently  finding  fault  with  his 
attendants.  The  pupils  were  much  dilated,  but  both  contracted  slowly  upon  the 
approach  of  a  strong  light.  The  right  eye  was  affected  with  cataract,  but  he  could 
distinguish  light  from  darkness  with  this  eye.  His  pulse  was  generally  about  ninety, 
and  weak.  He  was  purged  freely,  and  a  blister  was  applied  to  the  nape  of  the  neck. 
These  remedies  somewhat  relieved  him  ;  but  after  a  few  days  the  pain  became  as 
constant  and  distressing  as  ever.  He  had  now  eight  ounces  of  blood  taken  from  the 
neck  by  cupping,  which  greatly  mitigated  the  pain.  Four  days  after  this,  while  sitting 
at  dinner,  he  again  became  comatose  and  insensible ;  his  respiration  hard  and  stertorous  ; 
his  pulse  full  and  slow.  The  pupil  of  the  right  eye  was  dilated;  the  left  constricted; 
both  immovable.  He  was  now  bled  freely  fi-om  the  arm,  and  blistered;  but  became 
rapidly  worse,  and  died  next  morning. 

On  dissection,  it  was  found  that  the  dura  mater  adhered  more  strongly  to  the  cranium 
than  usual,  and  its  surface  presented  a  blackish  blue  appearance  from  the  veins  beneath. 
Adhesions  had  formed  between  this  membrane  and  the  arachnoid,  and  between  the  latter 
and  the  pia  mater.  The  veins  of  the  pia  mater  were  much  enlarged,  and  distended  with 
blood.  Three  or  four  fungous  patches  had  risen  from  the  surface  of  the  cerebrum 
through  the  membranes,  and  adhered  to  the  bone.  Upon  raising  the  falx,  it  was  found 
united  to  both  hemispheres,  and  these,  below  the  falx,  to  each  other.  A  considerable 
quantity  of  deeply  tinged  bloody  fluid  escaped  from  the  left  ventricle  as  soon  as  pene- 
trated, and  a  small  coagulum  was  found  entangled  in  the  plexus  choroides.  In  removing 
the  upper  surface  of  the  right  hemisphere,  the  right  lateral  ventricle  was  cut  into,  being 
raised  above  its  ordinary  level,  and  a  quantity  of  coagulated  blood  was  discovered, 
amounting  to  three  or  four  ounces.  The  right  corpus  striatum  bad  become  enlarged  to 
more  than  twice  its  natural  size.  The  surface  of  this  body,  and  th«  sides  of  the  ventricle, 
were  abraded  and  pulpy,  leaving  a  pinkish  green  appearance.  Removing  the  brain  from 
62 


978  AMAUROSIS   FROM  ENLARGED  PITUITARY   GLAND. 

the  cranium,  a  long  red  streak  was  seen  upon  the  under  surface  of  the  right  anterior 
lobe,  and  under  this  an  abscess  was  discovered,  of  rather  more  than  an  inch  in  length. 
Immediately  behind  this,  to  the  other  side  of  the  olfactory  nerve,  and  before  the  junction 
of  the  optic  nerves,  an  aneurism,  of  the  size  of  a  hazel-nut,  of  the  right  anterior  cerebral 
artery,  was  found  pressing  upon  the  right  optic  nerve.  The  coats  of  the  aneurism  were 
very  thick,  and  its  cavity  contained  a  small  coagulum.  It  had  burst  on  its  upper  surface 
into  the  lateral  ventricle. 

The  sheath  of  the  right  optic  nerve,  particularly  at  the  entrance  of  the  nerve  into  the 
eye,  was  found  thickened  and  distended  with  blood,  and  adhered  firmly  to  the  proper 
substance  of  the  nerve.  The  veins  were  much  enlarged  on  the  back  of  the  sclerotic. 
The  choroid  had  its  usual  appearance ;  but  the  retina  presented  a  pinkish  gray  color,  and 
the  ramifications  of  the  central  vein  could  be  readily  seen  over  its  whole  surface,  as  far  as 
the  lens.  The  posterior  capsule  of  the  lens  was  opaque;  the  lens  semi-opaque,  and 
wasted  to  one-half  its  natural  size.^ 

§  10.  Amaurosis  from  eyilargement  of  the  pituitary  gland. 

Lying  beneath  and  behind  the  chiasma  of  the  optic  nerves,  the  pituitary 
gland,  in  a  state  of  morbid  enlargement,  necessarily  comes  to  press  upon  the 
nerves,  and  has  sometimes  been  found  to  have  produced  almost  their  complete 
absorption.  In  some  cases  a  tumor  is  developed  between  the  two  laminae  of 
the  dura  matter  which  inclose  the  gland,  the  gland  and  the  optic  nerves  being 
displaced  by  the  tumor.^ 

Numerous  cases  of  amaurosis  from  enlarged  pituitary  gland  are  on  record. 
In  some  of  them,  the  affection  of  sight  was  one  of  the  earliest  symptoms ; 
while,  in  others,  it  did  not  occur  till  a  variety  of  other  signs  of  encephalic 
disease  had  manifested  themselves.  Along  with  the  amaurosis,  which  gene- 
rally affects  both  eyes,  and  after  being  incomplete  for  some  time  suddenly 
becomes  complete,  the  patient  complains  of  pain  or  weight  in  the  forehead, 
and  severe  pain  in  the  temples,  apathy,  loss  of  memory,  emaciation,  and 
general  weakness.  Neither  convulsions,  nor  hemiplegia,  seems  liable  to 
occur  from  enlargement  of  the  pituitary  gland,  but  the  parts  in  contact  with 
the  diseased  mass  are  excited  by  its  presence  to  inflammation,  so  that  at  last 
the  symptoms  present  a  combination  of  those  of  encephalitis  with  those  of 
pressure  on  the  brain. 

On  dissection,  the  gland  is  found  much  enlarged,  sometimes  dilated  into 
the  form  of  a  cyst,  or  containing  pus,  and  the  parts  around  it  much  inflamed. 
In  some  cases,  the  infiindibulum  is  the  seat  of  the  enlargement,  as  in  a  case 
recorded  by  De  Haen.*^ 

Case  389. — John  Austin,  a  baker,  a  strong  muscular  man,  of  temperate  habits,  aged 
38,  had  for  three  years  been  aftlicted  with  dimness  of  sight,  accompanied  at  intervals 
with  severe  pain  in  the  fore  part  of  the  head,  and  a  sense  of  burning  and  fulness  of  the 
orbits.  He  received  no  benefit  from  leeches,  blisters,  and  other  remedies ;  on  the  con- 
trary, the  application  of  leeches  appeared  rather  to  increase  his  sufferings.  His  strength 
a-nd  general  health  continued  very  good,  he  was  up  during  the  greater  part  of  the  night, 
and  frequently  carried  very  heavy  loads  during  the  day.  The  digestive  organs  had  been, 
for  the  most  part,  regular  in  their  functions,  excepting  at  slight  intervals,  and  then  only 
from  such  causes  as  might  be  considered  wholly  independent  of  any  existing  local 
affection. 

On  Sunday,  25th  of  May,  1823,  he  complained  that,  during  the  preceding  five  or  six 
weeks,  the  dimness  of  vision  had  considerably  increased ;  that  the  pains  had  been  much 
mor«  severe,  and  that  he  had  felt  a  strong  inclination  to  sleep,  so  much  so,  that  if,  during 
the  day,  he  sat  down  for  a  few  minutes  to  refresh  himself,  he  fell  asleep,  being  unable  to 
prevent  it,  and  would  continue  so  until  disturbed.  For  two  or  three  days,  he  had  been 
completely  blind  in  the  right  eye,  and  that  morning  found  himself,  for  the  first  time, 
totally  blind  in  both.  For  a  week  or  ten  days  he  had  been  able  to  distinguish  objects, 
but  upon  going  to  bed  the  previous  evening,  the  only  object  he  could  discern  was  the 
candle,  and  that  not  distipctly.  On  examining  the  eyes,  no  very  apparent  disease  mani- 
fested itself;  the  pupils  didnot  contract  on  the  application  of  a  strong  light;  they  appeared 
rather  small,  but  perfectly  clear.  The  patient  complained  of  some  loss  of  appetite. 
Pulse  96,  and  small.     On  the  supposition  that  some  of  the  more  prominent  symptoms 


AMAUROSIS   FROM   ENLARGED   PITUITARY  GLAND.  9T9 

depended  on  a  disordered  state  of  the  stomach,  he  was  ordered  an  emetic,  and  after  its 
operation  five  grains  of  calomel,  to  be  followed  next  morning  by  an  opening  draught. 

Next  day,  his  headache  was  not  so  considerable,  and  in  a  small  degree  he  had  recovered 
sight  in  the  left  eye  ;  he  could  see  the  windows,  and  on  placing  the  hand  before  his  eye, 
he  could  distinguish  something,  although  unable  to  teU  what  it  was.  The  medicines 
were  repeated. 

On  the  27th,  he  complained  of  being  much  weaker,  and  consequently  kept  his  bed, 
which  he  had  not  done  previously.  His  headache  was  better ;  his  vision  as  on  the  26th  ; 
he  slept  constantly  and  snored  loudly.  Six  leeches  were  ordered  to  the  temples,  the  calo- 
mel and  opening  medicine  were  continued,  and  a  blister  was  applied  to  the  nape  of  the 
neck. 

On  the  28th,  an  eminent  oculist  being  called  in,  he  considered  the  illness  to  arise  from 
congestion  in  the  cerebral  vessels,  and  ordered  20  ounces  of  blood  to  be  taken  from  the 
arm,  with  a  saline  draught  every  four  hours.     The  patient  fainted  when  he  was  bled. 

On  the  29th,  he  was  more  inclined  to  sleep ;  was  roused  with  difficulty,  but  when 
awake,  spoke  sensibly,  and  answered  questions  proposed  to  him.  Since  the  bleeding,  the 
pulse  bad  been  120,  and  weaker ;  and  the  patient's  debility  greater.  A  physician  who 
was  called  in,  ordered  him  to  lose  24  ounces  of  blood  from  the  arm,  the  saline  medicine  to 
be  continued  ;  4  grains  of  calomel  to  be  taken  at  bedtime,  and  an  opening  draught  on  the 
following  morning.     Next  day,  at  half  past  twelve,  the  patient  died. 

On  dissection,  the  membranes  of  the  brain  were  found  quite  healthy ;  some  degree  of 
fulness  of  the  vessels  existed,  but  it  was  only  trifling ;  the  fluid  in  the  ventricles  was  about 
the  natural  quantity ;  on  raising  the  anterior  lobes  of  the  brain,  a  tumor  was  found 
arising  from  the  situation  of  the  pituitary  gland,  and  pressing  upon  the  optic  nerves ;  it 
was  of  considerable  size,  forming  a  nidus  in  the  anterior  lobes ;  the  optic  nerves  were 
expanded  upon  it,  the  right  more  than  the  left;  the  olfactory  nerves  were  likewise  very 
much  pressed  upon.^ 

Case  300. — A  person  of  the  name  of  Bardon,  aged  36,  was  admitted  into  the  JUotel 
Dieu  at  Paris,  on  the  8th  of  September,  1827.  His  pupils  were  greatly  dilated,  the  right 
being  still  slightly  movable,  the  left  not  at  all.  The  left  eye  was,  in  fact,  completely 
lost;  the  right  just  served  for  discerning  large  objects,  without  enabling  the  patient  to 
distinguish  their  size,  form,  or  color.  For  eight  years  he  had  been  subject  to  violent 
pains  in  the  head,  and  a  year  and  a  half  before  his  admission  in  the  Hotel-Dieu  had  been 
obliged  to  give  up  his  occupation,  which  required  him  to  be  frequently  employed  in  writ- 
ing. His  countenance  was  p.ale,  and  constitution  lymphatic.  He  was  bled,  and  had  a 
seton  inserted  in  the  neck,  without  much  benefit.  Blisters  were  next  applied  to  the  fore- 
head and  temples,  followed  by  sensible  amendment,  so  that  in  three  weeks  he  could  dis- 
tinctly perceive  persons  passing  at  a  considerable  distance.  The  same  means  were 
continued,  and  the  patient  remained  in  the  same  state  till  the  13th  of  November.  Upon 
that  day,  he  complained  of  headache,  and  severe  pains  in  the  eyes  and  ears.  On  the 
loth,  fifteen  leeches  were  applied  behind  the  ears;  the  headache  subsided,  but  the  other 
pains  continued.  On  the  21st,  two  or  three  minutes  after  speaking  to  one  of  his  medical 
attendants,  he  suddenly  expired. 

In  the  interval  between  the  junction  of  the  optic  nerves  and  the  pons  Varolii,  and. 
between  the  vessels  forming  the  circle  of  Willis,  there  was  a  cist,  the  size  of  a  small 
hen's  egg,  partly  fibrous,  partly  osseous,  filled  with  a  yellowish  substance,  mixed  with 
blood,  about  a  third  of  this  substance  being  solid  and  somewhat  resembling  a  tubercle, 
the  rest  fluid  and  oleaginous.  This  cyst  had  flattened  and  almost  destroyed  the  optic 
nerves.  Indeed,  what  remained  of  these  nerves  adhered  along  its  inner  side  to  the  cyst, 
by  some  altered  cerebral  substance,  and  anteriorly  lost  itself  upon  the  osseous  part  cor- 
responding to  the  commissure  of  the  nerves.  Further  forwards,  the  nerves  were  found 
in  a  wasted  state  passing  into  the  orbits ;  but  between  this,  their  anterior  portion,  and 
the  posterior,  there  was  no  other  continuity  than  what  was  formed  by  the  cyst.  There 
was  no  trace  of  the  pituitary  gland,  its  situation  being  entirely  occupied  by  the  cyst. 
The  retina  within  the  eye  was  thin,  reddish,  and  almost  transparent.^ 

This  case  is  published  by  Magendie,  with  the  following  query  prefixed  to  it: 
Can  vision  he  preserved  notwithstanding  the  destruction  of  the  optic  nerves  ? 
It  is  probable,  that  the  patient  had  either  deceived  himself,  regarding  the  de- 
gree of  vision  which  he  recovered  after  the  application  of  the  blisters  ;  or, 
that  if  he  was  actually  able  to  perceive  persons  passing,  as  is  stated  in  the 
case,  eight  days  before  his  death,  the  progress  of  the  disease  during  that  period 
had  been  exceedingly  rapid. 


980  AMAUROSIS   FROM   CONCUSSION. 

§  11.  Amaurosis  from  concussion,  or  other  injury  of  the  head. 

Injuries  of  the  head,  many  of  these  appearing  to  be  slight  and  occasioning 
at  first  no  apprehension,  are  probably  much  more  frequently  productive  of 
amaurosis  than  is  generally  suspected. 

It  not  unfrequently  happens,  in  cases  of  concussion  of  the  brain,  or  other 
injury  of  the  head,  sufficient  to  stun  the  patient,  that  for  a  time  he  remains 
completely  insensible  to  external  impressions.  The  recovery,  which,  in 
general,  speedily  takes  place,  is  sometimes  complete  ;  while,  in  other  cases, 
the  state  of  total  insensibility  is  followed  by  one  in  which  the  sensibility  is 
impaired,  but  not  destroyed.  The  patient  is  not  affected  by  ordinary  impres- 
sions, but  can  be  roused  to  perception.  The  pupils,  in  this  stage,  contract  on 
exposure  to  light,  and  are  sometimes  more  contracted  than  under  ordinary 
circumstances.  These  symptoms  may  wholly  subside  in  the  course  of  a  few 
hours,  or  they  may  continue  for  three  or  four  days.  In  the  latter  case,  it  fre- 
quently occurs,  that  the  patient  regains  his  sensibility  for  a  time,  and  then 
relapses  into  his  former  condition.  Where  inflammation  of  the  brain  follows 
concussion,  it  sometimes  happens  that  there  is  no  interval  of  returning  sense, 
the  symptoms  of  concussion  being  gradually  converted  into  those  of  inflam- 
mation. But  it  is  also  often  the  case,  that  there  is  a  considerable  interval  of 
that  sort,  or  even  a  period  of  apparent  health,  before  the  symptoms  of  inflam- 
mation show  themselves.  Years  may  elapse  before  the  patient  l3ecomes  aflfer-ted 
with  any  serious  indications  of  cerebral  disease. 

The  inflammation  which  succeeds  to  concussion,  and  other  injuries  of  the 
head,  may  be  more  or  less  extensive,  and  more  or  less  acute ;  afTecting  the 
whole  contents  of  the  cranium,  and  rapidly  proving  fatal,  or  limited  to  some 
particular  part  of  the  brain,  and  inducing  death  only  after  a  series  of  the  most 
distressing  symptoms,  as  violent  headache,  amaurosis,  palsy,  convulsions,  and 
the  like.  These  symptoms  occur  sometimes  in  one  order,  and  sometimes  in 
another.  Our  knowledge  of  diseases  of  the  brain  is  not  yet  sufficiently  exact, 
to  enable  us  to  refer  the  symptoms  which  occur,  to  the  particular  seats  or 
terminations  of  the  inflammatory  action. 

The  appearances  on  dissection  consist  in  lacerations  of  the  summits  of  the 
cerebral  convolutions,  increased  vascularity,  extravasations  of  blood,  serous 
eff'usions,  indurations,  softening  or  ramollissement,  diffuse  or  encysted  ab- 
scesses, &c. 

Case  391. — A  young  gentleman,  at  12  years  of  age,  received  a  rap  at  scliool  -with  the 
edge  of  a  flat  ruler,  because  he  was  dull  at  his  learning.  The  blow  was  on  the  right  side 
of  the  head,  and  a  small  wound  was  the  consequence,  which,  for  the  space  of  six  years, 
nothing  would  heal.  It  then  healed,  and  he  very  soon  afterwards  perceived  that  his  sight 
was  beginning  to  fail.  In  this  respect,  he  continued  to  decline,  till,  at  length,  he  became 
quite  blind.  Added  to  this,  he  now  began  to  suffer  from  epileptic  fits,  which  most  fre- 
quently returned  upon  him  every  day. 

The  only  thing  considered  likely  to  afford  any  prospect  of  real  advantage,  was  the  re- 
moval of  a  portion  of  bone  by  the  trephine.  There  was  no  particular  appearance  in  the 
cicatrice  of  the  old  wound,  where  the  blow  had  been  received;  nor,  on  exposing  the  bone, 
was  it  found  diseased,  or  even  discolored.  On  removing  the  piece  separated  by  the  crown 
of  the  trephine,  some  blood  and  serous  fluid  escaped  from  between  the  skull  and  dura 
mater.  This  membrane,  however,  did  not  appear  to  have  lost  its  healthy  color.  By  the 
next  day,  the  pupil  of  each  eye  had  recovered  its  natural  sensibility,  dilating  and  contract- 
ing, according  to  the  degree  of  light.  The  blindness  remained  absolute,  as  before  the  ope- 
ration. The  patient's  strength  hourly  declined ;  a  degree  of  low  fever  supervened;  and 
on  the  third  day  after  the  application  of  the  trephine,  he  was  seized  with  an  unusually 
severe  fit,  soon  after  which  he  expired. 

On  opening  the  head,  the  cranium  was  to  appearance  everywhere  healthy,  and  so  was  the 
dura  mater.  Below  the  part  where  the  dura  mater  had  been  exposed  by  the  trephine,  and 
consequently  opposite  the  seat  of  the  original  wound,  the  pia  mater  had  evidently  suffered 
from  chronic  inflammation,  but.this  appearance  was  circumscribed.     On  cutting  into  the 


AMAUROSIS   FROM   OVER-EXERCISE   OF   SIGHT.  981 

brain,  it  was  found  indurated  to  a  considerable  degree,  and  this  induration  had  extended 
itself  to  the  whole  of  the  middle  lobe  of  the  cerebrum,  commencing  upon  the  surface  of 
the  hemisphere,  and  passing  through  the  brain  down  to  the  basis  of  the  cranium. ^^ 

Case  392. — A  j'oung  lady,  when  about  15  years  of  age,  received  at  play  a  slight  tap, 
rather  than  a  blow,  on  the  right  side  of  her  head.  It  gave  her  at  the  moment  rather  severe 
pain ;  but  she  disregarded  it,  and  no  immediate  consequences  of  any  kind  followed,  more 
than  a  common  headache,  commencing  always  in  the  part  which  had  been  struck.  For 
above  30  years  she  continued  subject  to  these  attacks,  and  then,  though  naturally  very 
lively,  began  to  grow  heavy,  and  sometimes  stupid  and  sleepy,  without  any  known  ad- 
ditional cause.  This  disposition  continued  gradually  to  increase,  till,  for  the  last  year  and 
a  half  of  her  life,  it  was  very  difiBcultto  keep  her  awake;  but  when  she  was  awake,  though 
it  was  but  for  half  an  hour,  she  displaj'ed  all  her  natural  brilliancy  of  conversation.  Then, 
all  at  once,  she  would  drop  asleep  again,  not  to  be  roused.  In  this  way  she  went  on  till  a 
perpetual  comatose  state  took  place,  and  she  died  convulsed.  Her  vision  had  become  very 
much,  although  very  gradually,  impaired. 

On  dissection,  as  soon  as  the  scalp  was  removed  from  over  the  right  parietal  bone,  a 
portion  of  the  bone,  about  the  size  of  a  crown  piece,  directly  under  the  part  where  the 
blow  had  been  received,  and  to  which  she  had  invariably  pointed  as  the  seat  of  her  pain, 
was  observed  to  be  of  a  very  dark  color.  On  removing  the  right  parietal  bone,  the  part  of 
it  which  appeared  discolored,  was  found  to  be  transparent,  and  almost  wholly  absorbed. 
It  derived  the  dark  color,  which  it  at  first  presented,  from  the  portion  of  the  right  hemi- 
sphere of  the  brain,  directly  under  it,  being  perfectly  black ;  the  dura  mater  at  this  part 
being  altogether  removed  by  absorption,  the  color  appeared  through  the  bone.  Had  she 
lived  much  longer,  the  bone  also  would  have  been  quite  absorbed,  and  the  brain  itself 
would,  in  all  probability,  have  protruded.  The  portion  of  brain  under  the  seat  of  the 
injury  was  indurated  and  scirrhous,  and  this  change  had  taken  place  through  the  whole  of 
the  middle  lobe  of  the  cerebrum.  The  color  was  dark  livid.  Every  other  part  of  the 
brain  was  perfectly  sound,  nor  was  there  any  disease  in  the  thorax  or  abdomen.  The  dis- 
ease above  described,  had  so  pressed  on  the  optic  nerves  at  their  origin,  as  to  make  them 
as  flat  as  a  piece  of  tape,  thereby  occasioning  the  loss  of  sight,  which,  for  some  time 
before  death,  had  amounted  to  almost  total  darkness.*' 

§  12.  Amaurosis  from  congestion  or  injlammation  of  the  nervous  optic  appa- 
ratus, brought  on  hy  exposure  of  the  eyes  to  intense  light,  or  by  over-exercise 
of  the  sight. 

This  is  one  of  the  most  frequent  varieties  of  amaurosis,  resulting  sometimes 
from  a  single,  short,  or  even  momentary,  exposure  to  very  vivid  light ;  in 
other  cases,  from  long-continued,  or  frequently  repeated,  examination  of  lu- 
minous objects,  or  from  intense  exercise  of  the  sight  upon  things  moderately 
or  imperfectly  illuminated.  Persons,  for  example,  have  been  struck  blind 
from  viewing  an  eclipse  of  the  sun.  Long-continued  exposure  of  the  eyes  to 
the  light  reflected  from  a  country  covered  with  snow,  the  frequent  use  of  tele- 
scopes or  microscopes,  reading  or  writing  for  many  hours  together,  especially 
by  caudle-light ;  these,  and  such-like  are  the  fruitful  causes  of  this  variety  of 
amaurosis,  and  are  more  apt  to  produce  their  injurious  effects  on  the  organs 
of  vision,  if  the  eyes  are  naturally  weak,  or  the  individual  inclined  to  cerebral 
congestion.  Literary  men,  engravers,  and  others,  whose  occupation  is  at  once 
sedentary,  and  requires  constant  exercise  of  the  sight,  are  frequently  affected 
with  this  amaurosis. 

The  symptoms  are  variable,  but  chiefly  subjective.  The  congestion  or 
inflammation,  upon  which  they  depend,  affects  the  retina,  the  optic  nerves, 
and  the  cerebral  portion  of  the  optic  apparatus.  Neglected,  it  ends  in  atrophy 
of  these  parts. 

The  treatment  consists  principally  in  rest,  depletion,  mercury,  and  counter- 
irritation. 

Case  393.— Consulted  first  July,  1844,  in  the  case  of  Miss  F.,  aged  16.  I  found  that, 
after  working  at  Berlin  worsted  work,  she  had  become  affected  with  pain  in  the  left  side 
of  the  head,  and  such  dimness  of  sight  of  the  left  eye,  that  with  it  she  made  out  with 
difficulty  the  large  letters  forming  the  heading  of  a  newspaper.  The  right  eye  was  also 
rather  dim.  I  applied  leeches  round  the  eye,  blistered  behind  the  ear,  and  gave  three 
blue  pills  daily.     This  not  affecting  the  mouth  so  speedily  as  I  expected,  I  changed  the 


982  AMAUROSIS   FROM   WORMS  IN   THE  INTESTINES. 

blue  pills  for  pills  of  two  grains  of  calomel  with  half  a  grain  of  opium.  These  soon 
aflFected  the  mouth,  and  vision  immediately  began  to  improve.  The  mouth  became  very 
sore,  with  profuse  salivation.  By  the  end  of  July  the  patient  read  the  smallest  type  with 
the  left  eye. 

Case  394. — The  celebrated  Dr.  Reid,  Professor  of  Moral  Philosophy  in  the  University 
of  Glasgow,  in  May,  1761,  being  occupied  in  making  an  exact  meridian,  in  order  to  observe 
the  transit  of  Venus,  rashly  directed  to  the  sun,  by  his  right  eye,  the  cross  hairs  of  a  small 
telescope.  He  had  often  done  the  like  in  his  younger  days  with  impunity,  but  suffered 
from  it  on  this  occasion.  He  soon  observed  a  remarkable  dimness  in  that  eye ;  and  for 
many  weeks,  when  he  was  in  the  dark,  or  shut  his  eyes,  there  appeared  before  the  right 
eye  a  lucid  spot,  which  trembled  like  the  image  of  the  sun  seen  by  reflection  from  water. 
This  appearance  grew  fainter,  and  less  frequent  by  degrees,  but  some  very  sensible  effects 
of  the  injury  remained.  The  sight  continued  dim ;  the  nearest  limit  of  distinct  vision 
was  rendered  more  remote  than  in  the  other  eye ;  and  a  straight  line  appeared  to  the  right 
eye  to  have  a  curvature  in  it.^' 

Case  395. — A  soldier,  unacquainted  with  the  proper  method  of  observing  an  eclipse  of 
the  sun,  employed  for  that  purpose  a  piece  of  opaque  glass,  with  a  transparent  point  in 
its  centre.  Notwithstanding  the  vivid  and  painful  impression  he  experienced  from  the 
solar  rays  which  passed  through  the  lucid  part  of  the  glass,  he  continued  to  look  at  the 
sun  till  the  end  of  the  eclipse.  He  was  soon  afterwards  seized  with  vertigo,  and  pain  on 
the  right  side  of  his  head,  corresponding  to  the  eye  which  he  had  employed,  and  found 
himself  almost  entirely  deprived  of  the  sight  of  that  eye.  Some  few  weeks  afterwards, 
finding  that  the  acute  pain  of  his  head  still  continued,  he  came  under  the  care  of  Baron 
Larrey,  who  observed  that  the  vessels  of  the  eye  were  injected  with  blood ;  the  pupil  a 
little  less  than  that  of  the  opposite  eye,  preserving,  however,  its  natural  movements ;  vision 
very  obscure,  or  almost  lost.  After  two  bloodlettings,  one  from  the  temporal  artery,  and 
tho  other  from  the  jugular  vein,  Larrey  ordered  blisters  to  the  temple,  and  to  the  nape  of 
the  neck.  Ice  was  then  applied  to  the  head,  followed  by  moxas,  which  completely  re-esta- 
blished the  patient's  sight ;  but  he  still  retained  a  feeling  of  dull  pain  over  all  the  right 
side  of  the  head.'^ 

Case  396. — A  West  Indian,  of  middle  age,  who  lived  freely,  and  was  accustomed  to  an 
indolent  life,  after  having  been  for  four  hours  on  horseback,  expo.sed  to  a  burning  sun, 
began  almost  immediately  to  notice  a  dimness  of  sight  in  his  right  eye,  which  rapidly 
increased,  so  that  at  the  end  of  a  fortnight  his  sight  was  entirely  lost.  There  was  never 
any  pain  or  inflammation  in  the  part.  Eighteen  months  after  the  commencement  of  the 
malady,  the  eye,  though  perfectly  blind,  presented  no  appearance  of  disease,  except  that 
the  pupil  contracted  imperfectly  on  exposure  to  light.''^ 

Case  397. — A  captain  in  the  navy  had  made  much  use  of  his  right  eye,  for  many  years, 
in  observations  with  telescopes  and  sextants.  About  a  week  before  he  applied  to  Mr. 
Travers,  he  observed  a  mist  before  this  eye,  which  increased  until  it  was  so  dense,  that 
he  could  neither  distinguish  the  features  of  his  friends,  nor  the  large  letters  of  a  title 
page.  The  eye  was  free  from  inflammation,  the  pupil  large  and  sluggish ;  he  had  no  pain 
either  in  the  eye  or  the  head.  He  was  bled  copiously  from  the  arm  and  temple,  and 
briskly  purged  with  calomel  and  jalap,  at  short  intervals.  Blisters  were  applied  to  the 
temples.  He  then  rubbed  in  a  drachm  of  the  strong  mercurial  ointment  for  several  nights 
in  succession ;  this  produced  a  copious  flow  of  saliva  and  violent  diarrhcea,  so  that  no 
benefit  was  obtained.  By  a  calomel  and  opium  pill  taken  night  and  morning,  his  gums 
were  immediately  made  sore.  In  three  days  the  mist  began  to  clear,  and  he  was  delighted 
to  find  that  he  could  tell  the  hour  by  his  watch.  He  continued  improving  so  rapidly,  that 
at  the  expiration  of  ten  days,  he  could  read  an  ordinary  print  with  perfect  facility,  and 
the  pupil  had  recovered  its  ordinary  magnitude  and  activity.^ 

Case  398. — Mr.  Allen  mentions  the  case  of  a  master  of  a  printing-office,  who  became 
blind.  He  had  corrected  the  press,  and  was  otherwise  engaged  in  reading,  for  18  hours 
out  of  the  24,  a  practice  which  he  continued  for  12  months,  notwithstanding  an  evident 
failure  of  his  sight.  At  the  end  of  this  time,  the  amaurosis  was  so  complete,  that  he 
could  not  distinguish  one  object  from  another,  but  was  merely  capable  of  perceiving  the 
light,  so  as  to  find  his  way  in  the  streets.  He  continued  in  this  state  for  several  years, 
but  ultimately  recovered  sight.     The  treatment  is  not  mentioned.^ 

§  13.  Amaurosis  from  congestion  or  injlammation  of  the  nervous  optic  appara- 
tus excited  by  the  presence  of  icorms  in  the  intestines. 

Among  the  symptoms  generally  enumerated  as  indicative  of  the  presence 
of  worms  in  the  bowels,  are  dilatation  of  the  pupil,  want  of  lustre  in  the  eye, 
blueness  under  the  lower  eyelid,  epiphora,  paleness  of  the  countenance,  head- 


AMAUROSIS   FROM   SUPPRESSION   OF   THE   MENSES.  983 

ache,  throbbing  in  the  ears,  and  disturbed  sleep ;  while,  in  certain  cases,  we 
are  told  that  amaurosis,  deafness,  and  apoplectic  or  epileptic  fits,  arise  from 
the  same  cause.  The  presence,  however,  even  of  the  majority  of  these  signs 
cannot  be  regarded  as  conclusive  evidence  of  the  existence  of  worms ;  nor  any 
signs,  except  the  actual  detection  of  the  worms  in  the  alvine  excretions,  or  in 
the  matter  vomited  by  the  patient.  It  must  also  always  admit  of  doubt,  whether 
the  amaurotic  symptoms  present  in  those  who  are  troubled  with  worms,  do 
not  spring  from  some  other  cause,  as  hydrocephalus  or  some  morbid  forma- 
tion within  the  cranium.  One  of  my  medical  friends  informs  me,  that,  he 
some  time  ago  treated  a  child,  who  was  amaurotic,  and  who  at  the  same  time 
passed  numerous  lumbrici,  to  which  he  was  led  to  attribute  the  affection  of 
the  eyes.  The  amaurosis,  however,  did  not  yield  to  anthelmintic  remedies ; 
the  child  died,  and  on  dissection  the  pituitary  gland  was  found  dilated  into  a 
tumor,  which  pressed  upon  the  optic  nerves,  and  had  caused  the  absorption 
of  their  medullary  substance. 

That  amaurosis  from  worms  is  not  a  frequent  disease,  may  be  concluded 
from  the  fact,  that  Bremser^^  merely  quotes  from  Hannseus,  that  a  little  girl 
of  four  years  of  age,  who  had  lost  the  powers  of  seeing  and  of  speaking,  was 
cured  by  the  use  of  vermifuges ;  and  from  Remer,  that  two  persons,  affected 
with  amaurosis,  were  cured  by  the  evacuation  of  ascarides.  Rognetta^^  quotes 
from  Weller,  the  case  of  a  little  girl,  aged  six,  who  had  been  for  three  years 
completely  amaurotic.  Every  other  means  having  failed,  anthelmintic  pow- 
ders were  given,  in  consequence  of  which  the  child  passed  thirteen  lumbridi 
in  six  days.  By  the  continued  use  of  purgatives,  vision  was  in  a  great  mea- 
sure restored.  In  a  case  recorded  by  Petrequin,^"*  a  cure  was  effected  chiefly 
by  the  employment  of  the  seeds  of  the  santonicum,  or  artemisia  judaica. 

Case  399. — I  have  seen  only  one  instance  of  amaurosis  caused  by  worms.  It  occurred 
in  a  girl  seven  years  of  age,  a  patient  at  the  Glasgow  Eye  Infirmary.  After  an  attack  of 
inflammation  of  the  eyes,  attended  by  headache,  her  vision  was  left  dim,  when  suddenly 
her  pupils  became  widely  dilated  and  immovable.  The  abdomen  was  much  swollen. 
About  a  month  previously  to  this  she  had  passed  a  lumbricus.  A  mixture  of  castor  oil  and 
oil  of  turpentine  being  given  in  doses  of  half  an  ounce  every  third  morning,  she  passed  at 
different  times  nine  lumbrici,  and  vomited  two,  after  which  the  belly  became  soft,  the  pupils 
contracted  when  the  eyes  were  exposed  to  the  light,  and  in  the  course  of  a  few  months' 
treatment  vision  was  restored. 

Case  400. — Delarue  relates  the  case  of  a  young  country  lad,  who  being  brought  to  the 
Hotel-Dieu  at  Clermont-Farrand,  was  found  to  be  blind,  his  pupils  much  dilated,  the 
expression  of  his  countenance  wild,  his  face  swollen  and  injected  ;  and  his  mind  affected 
by  times  with  fits  of  excitement.  He  was  reported  to  have  been  bit  by  a  mad  dog,  and 
was  placed  in  a  room  on  the  ground-floor  appropriated  to  hydrophobic  patients.  He 
refused  to  take  drink  or  food  of  any  kind,  and  died  the  first  night  after  entering  the  hos- 
pital.    On  dissection,  the  intestines  were  found  to  contain  above  160  lumbrici.^^ 

§  14.  Amaurosis  from  congestion  or  inflammation  of  the  nervous  optic 
apparatus,  consequent  to  suppression  of  the  menses. 

"When  amaurosis  occurs  as  a  disease  of  conversion,  or  as  a  consequence  of 
the  suppression  of  any  wonted  evacuation,  it  is  often  difficult  to  say  whether 
the  disease  of  the  brain,  to  which  the  affection  of  the  optic  apparatus  is  to  be 
attributed,  is  congestive,  inflammatory,  or  hydrocephalic.  In  a  practical 
point  of  view,  this  difficulty  is  not  very  important,  as  the  relief  of  the  brain, 
by  bloodletting  and  purging,  and  the  recall  of  the  suppressed  evacuation  or 
original  disease,  would  still  remain  the  chief  indications,  whatever  was  the 
nature  of  the  cerebral  affection. 

Case  401. — The  following  case  is  related  by  I\Ir.  Brown  of  Musselburgh.  The  patient 
was  a  female  about  40  years  of  age.  Upon  walking  a  considerable  distance,  in  very 
warm  weather,  the  catamenia  appeared,  nearly  upon  the  termination  of  her  walk.  Being 
very  much  heated,  she  drank  a  full  draught  of  cold  skim-milk,  which  almost  instantly 
brought  on  oppression  about  the  proecordia,  headache,  and  a  total  cessation  of  the  men- 


984  AMAUROSIS   FROM    SUPPRESSED   PERSPIRATION. 

strual  discharge.  In  a  few  hours  more,  the  head.ache  became  excruciating,  and  symp- 
toms of  hemiplegia  presented  themselves,  with  an  attack  of  amaurosis  in  the  left  eye. 

By  means  of  a  copious  local  and  general  bleeding,  blisters,  and  purging,  considerable 
relief  was  obtained ;  but  the  affection  of  the  eye  remained  the  same.  When  the  period 
of  menstruation  returned,  no  discharge  occurred.  Being  of  opinion  that  no  complete 
cure  could  be  effected,  unless  the  recurrence  of  the  catamenia  could  be  obtained,  Mr. 
Brown  directed  his  attention  chiefly  to  this  object.  At  the  end  of  six  months,  they 
reappeared,  which  was  followed  soon  after  by  the  complete  restoration  of  sight.'"' 

Case  402. — A  lady,  aged  30,  about  the  5th  June,  1824,  was  exposed  to  cold  and  fatigue 
during  the  flow  of  the  menses,  which  ceased  prematurely.  After  this,  she  was  for  some 
days  observed  to  be  remarkably  languid,  dull,  and  depressed.  The  pulse  was  natural  ; 
she  complained  of  slight  headache  ;  but  her  appearance  had  excited  an  apprehension 
rather  of  aberration  of  mind  than  of  any  bodily  complaint;  and  in  this  manner  the  nifec- 
tion  went  on  for  nine  or  ten  days.  Dr.  Abercrombie  saw  her  on  the  loth  ;  she  was  then 
odil  in  her  manner,  abrupt  and  absent,  but  quite  sensible  when  spoken  to;  she  complained 
of  slight  headache;  pulse  a  little  frequent.  On  the  16th  she  was  much  oppressed; 
and  on  the  17th,  in  a  state  of  nearly  perfect  coma,  which  continued  on  the  18th.  On  the 
19th,  after  free  purging  with  croton  oil,  she  came  out  of  the  coma  entirely,  was  quite 
sensible  to  everything,  and  no  alarming  symptom  remained,  except  that  she  sometimes 
saw  objects  remarkably  distorted,  and  sometimes  double  At  other  times,  her  vision  was 
quite  natural ;  the  pulse  was  frequent,  and  the  tongue  loaded.  In  this  state  she  con- 
tinued for  several  days  ;  she  then  complained  again  of  headache  ;  there  was  occasional 
incoherence  ;  the  sight  was  more  indistinct,  with  dilated  pupil ;  and  the  pulse  increased 
in  frequency.  The  pulse  continued  to  rise,  with  much  incoherent  talking,  and  sioking  of 
strength  ;  and  she  died  on  the  20th,  without  coma. 

The  ventricles  were  distended  with  fluid,  and  there  was  extensive  ramoUissement  of  the 
septum  and  fornix.     There  was  no  other  morbid  appearance.^' 

Case  403. — A  young  woman,  who  had  been  for  a  length  of  time  aff"ected  with  amenor- 
rhoea,  and  had  sufi'ered  repeated  and  sudden  attacks  of  congestion  in  diff"erent  organs, 
had  notwithstanding  felt  herself  pretty  well  for  some  time,  when  one  morning  she  awoke 
blind.  At  first  it  was  supposed  that  she  was  jesting,  but  the  reality  of  the  case  soon 
became  manifest.  Leeches  were  applied  behind  the  ears,  pediluvia  were  used,  and  laxa- 
tives given  ;  and  by  the  twelfth  day  some  amelioration  had  taken  place.  M.  Dcsmarres, 
on  being  now  called  in,  found  the  pupils  completely  motionless  and  considerably  dilated, 
and  the  perception  of  light  absolutely  extinguished.  The  patient  continued  blind,  not- 
withstanding the  use  of  many  energetic  remedies.*^ 

Along  with  amaurosis  from  a  suppression  of  the  menses,  arising  from 
disease,  may  be  mentioned  the  loss  of  vision  which  sometimes  occurs  from 
pregnancy. 

Case  404. — Beer  saw  a  young  Jewess  who,  in  her  first  three  pregnancies,  which  fol- 
lowed closely  on  each  other,  even  from  the  first  began  to  grow  blind,  in  the  third  or  fourth 
month  became  completely  amaurotic,  and  the  first  two  times  remained  so  till  she  was 
confined,  but  did  not  recover  her  sight  after  the  third.^ 

§  15.    Amaurosis  from  congestion  or  injlammation  of  the  nervous  optic 
apparatus,  consequent  to  suppressed  purulent  discharge. 

Case  405. — A  wagoner,  aged  45  years,  undertook  a  journey  in  wet  and  cold  weather. 
The  discharge  from  ulcers  of  his  legs,  which  had  for  many  years  continued  open,  was 
suppressed,  and  he  became  blind.  Fourteen  days  after,  he  was  brought  to  the  hospital. 
He  saw  nothing,  not  even  a  brightly  lighted  window.  The  pupil  was  oblong  and  extremely 
dilated.  Beer  immediately  pronounced  the  most  favorable  prognosis,  especially  as  there 
were  present  internal  sensations  of  light  in  the  eye,  without  varicosity,  and  without 
change  in  the  humors.  He  had  cured  more  than  20  such  amaurotic  patients,  by  restoring 
the  purulent  discharge.  The  prescriptions  were  sinapisms,  of  the  size  of  the  hand,  to 
the  ulcers  of  both  legs,  pediluvia  with  mustard,  and  internally  three  of  the  following 
powders  daily — li  Sulpkuris  aurati  antimonii  gr.  i.  Camphorx  gr.  ii.  Florum  sulpMiris  gr. 
vi.  Sacchari  gr.  x.  Misce.  The  sinapisms  were  renewed  daily,  and  on  the  10th  day  vision 
began  to  return.  The  sinapisms  acted  severely  on  the  ulcers,  which  became  deep  cavities, 
with  dark-colored  edges.     In  80  days,  vision  was  almost  completely  restored." 

§  16.   Amaurosis  from  congestion  or  inflammation  of  the  nervous  optic 
apparatus,  consequent  to  suppressed  perspiration. 

Cases  are  related  by  various  authors,-in  which  amaurosis  appeared  to  arise 


AMAUROSIS   FROM   StlPPRESSED   PERSPIRATION.  985 

from  exposure  to  cold,  or  sudden  suppression  of  perspiration.  Thus,  Arra- 
chart  mentions  the  case  of  a  young  woman,  who  during  the  excessive  heat  of 
summer,  having  carried  a  load  of  clothes  to  the  river,  and  arriving  in  a  state 
of  profuse  perspiration,  plunged  her  hands  into  the  water.  The  cold  seized 
her,  her  skin  became  instantly  dry,  and  in  less  than  a  quarter  of  an  hour  she 
was  deprived  of  sight.  He  relates  also  the  case  of  a  very  corpulent  young  man 
who,  having  remained  for  a  long  time  in  a  room  strongly  heated  by  a  stove, 
had  the  imprudence  to  go  out  while  completely  perspiring.  The  cold  air 
suddenly  suppressed  the  perspiration.  He  went  to  bed  with  violent  head- 
ache, and  next  morning  awoke  blind.  In  both  cases,  the  pupils  remained 
black,  dilated,  and  immovable,  the  eyes  fixed  and  stupid,  and  the  body  op- 
pressed and  actionless.*^ 

I  was  consulted  by  a  gentleman  who,  in  consequence  of  having  taken  a 
shower  bath,  a  thing  to  which  he  was  quite  unaccustomed,  while  heated,  be- 
came affected  with  headache  and  incomplete  amaurosis. 

Treatment. — The  general  treatment  consists  in  depletion  by  bloodletting 
and  purging,  followed  by  the  use  of  diaphoretics  and  alteratives.  Calomel 
with  opium,  Dover's  powder,  guaiac,  camphor,  and  sarsaparilla,  prove  essen- 
tially serviceable. 

Amongst  external  applications,  vesicatories  hold  the  chief  place.  They 
are  to  be  applied  alternately  behind  the  ear,  on  the  temple  and  on  the  fore- 
head, so  that  a  continued  succession  of  them  may  be  kept  up. 

Case  406. — An  intemperate  liver,  much  exposed  to  cold  weather  in  his  occupation  of 
driving  a  wagon  with  fish  into  London  during  the  night,  first  became  aflfected  with  a 
severe  pain  in  his  forehead,  and  lost  the  sight  of  one  eye.  Continuance  in  his  old  habits 
soon  brought  the  other  eye  into  the  same  state.  He  continued  to  suffer  from  violent  pain 
and  tension  over  the  forehead,  for  which,  being  admitted  int«  University  College  Hospital, 
under  the  care  of  Mr.  Liston,  he  was  bled  and  blistered  with  advantage.  He  was  subject 
to  fits,  and  eventually  perished  from  fever.  On  examining  the  brain  the  cause  of  the 
amaurosis  was  at  once  apparent;  the  anterior  lobes  of  the  cerebrum  were  coated  over 
with  lymph,  which  glued  the  dura  mater  to  the  brain,  enveloping  and  compressing  the 
optic  nerves.*^ 

Case  407. — J.  Powell,  a  very  healthy  old  man,  77  years  of  age,  had  been  for  many 
years  subject  to  an  excessive  perspiration  from  the  feet,  more  especially  upon  taking  any 
exercise.  This  tendency  had  for  several  years  been  so  great  an  inconvenience,  as  to 
oblige  him  sometimes  to  change  his  stockings  several  times  in  the  course  of  the  day.  He 
"was  one  day  advised  by  a  neighbor  to  apply  the  fresh  leaves  of  dock  to  his  feet,  and  was 
assured  that  this  would  effectually  cure  his  complaint.  Accordingly  he  laid  a  single  dock 
leaf  to  the  sole  of  each  foot,  and  very  soon  perceived  that  they  had  taken  effect.  He  felt 
a  sensation  of  tingling  and  irritation  whenever  the  leaves  came  in  contact  with  the  skin. 
Within  half  an  hour  after  they  were  applied,  he  experienced  great  uneasiness  and  pain  in 
the  head.  This  pain  soon  became  very  distressing,  particularly  over  his  eyes,  which  it  is 
remarkable  were  so  quickly  affected,  that  before  the  leaves  had  been  applied  an  hour,  he 
was  nearly  totally  blind. 

On  being  admitted  into  St.  George's  Infirmary,  it  appeared  that  he  could  perceive  a 
strong  light,  and  could  make  out  the  figure  of  an  opaque  object,  placed  between  him  and 
a  clear  light.  Such  objects  appeared  involved  in  a  thick  mist.  During  the  following 
night,  the  pain  in  the  head  totally  deprived  him  of  sleep;  but  he  had  no  constitutional 
disturbance,  or  disposition  to  fever.  Next  day,  he  was  much  the  same.  There  was  no 
action  of  the  iris  of  either  eye,  on  exposure  to  various  degrees  of  light.  The  pupils 
remained  fixed,  in  a  state  of  permanent  contraction.  He  was,  however,  still  able  to  per- 
ceive when  he  was  brought  near  a  window;  but  this  was  all  he  could  make  out. 

A  blister  was  applied  behind  each  ear,  and  others  to  the  lateral  parts  of  the  feet. 
Small  doses  of  calomel  were  ordered  at  short  intervals,  with  a  view  to  bring  his  system 
under  the  mercurial  influence.  As  soon  as  the  blisters  began  to  operate  and  become 
painful,  he  perceived  the  pain  in  the  head  and  affection  of  sight  relieved.  By  the  time 
they  were  dressed,  at  the  usual  period  of  twenty-four  hours  after  their  application,  he 
was  able  to  distinguish  many  objects  with  tolerable  precision,  which  were  before  totally 
invisible.  Dressings  of  an  irritating  kind  were  applied,  as  it  was  deemed  necessary  to 
keep  up  a  considerable  discharge  for  some  time.     It  was  also  directed,   that  his  feet 


986  AMAUROSIS  FRO'M  POISONS, 

should  be  immersed  in  warm  water,  morning  and  evening,  and  afterwards  wrapped  very 
warmly  in  flannels,  to  restore,  if  possible,  the  wonted  freeness  of  perspiration. 

Under  this  treatment,  the  patient  was  gradually  restored  to  health,  losing  the  distress- 
ing pain  in  his  head,  while  he  every  day  found  his  sight  improve.  The  mercurial  course 
afi"ected  his  mouth  rather  smartly,  and  under  its  influence  he  had  the  comfort  to  find  him- 
self entirely  relieved  of  the  little  remaining  headache,  and  very  nearly  the  whole  of  the 
affection  of  his  eyes.  He  had  previously  enjoyed  a  clearness  of  sight  very  rare  at  his 
age,  and  after  his  recovery,  his  vision  became  nearly,  though  not  quite  as  good  as  it  had 
been  before  the  suppression  of  the  perspiration  from  his  feet.  On  leaving  the  infirmary, 
he  was  recommended  to  wear  a  piece  of  oiled  silk,  wrapped  round  each  foot,  with  a  view 
to  encourage  the  insensible  perspiration." 

§  17.   Amaurosis  from  congestion  of  the  nervous  optic  apparatus,  produced 

hy  poisons. 

Almost  all  substances  included  under  the  classes  of  narcotic  and  narco- 
tico-acrid  poisons,  along  with  other  effects  on  the  nervous  system,  produce, 
when  taken  in  certain  quantities,  dimness  of  sight  and  dilated  pupils.  Dila- 
tation and  fixedness  of  the  pupils  follow  the  application  of  some  of  these 
substances  even  to  the  skin  merely,  and  of  this  we  take  advantage  in  the 
treatment  of  several  of  the  diseases  of  the  eye  ;  but  it  does  not  appear,  that, 
employed  in  this  way,  belladonna  and  hyoscyamus  produce  any  other  effect 
upon  the  function  of  vision,  than  a  degree  of  obscurity  and  dazzling,  such 
as  the  mere  influx  of  light  through  a  much  dilated  pupil  might  produce. 
Taken  internally,  however,  these  poisons,  as  well  as  many  of  their  congeners, 
cause  complete  insensibility  of  the  retina,  accompanied  by  dilatation  of  the 
pupils  in  most  instances,  but  sometimes  by  contraction.  They  also  cause 
flushing  of  the  face,  delirium,  spectral  illusions,  coma,  convulsions,  and,  if  not 
speedily  counteracted,  dgath. 

The  effects  of  large  doses  of  belladonna  have  been  frequently  witnessed, 
in  consequence  of  children  and  adults  being  tempted,  by  their  fine  color  and 
bright  lustre,  to  eat  the  berries  of  that  plant.  Dryness  of  the  throat  is  an 
almost  uniform  symptom  in  such  cases,  and,  along  with  difficulty  in  swallow- 
ing, is  much  complained  of  by  the  patient.  The  delirium  is  generally  extra- 
vagant, and  accompanied  with  immoderate  and  incontrollable  laughter, 
sometimes  with  constant  talking,  but  occasionally  with  complete  loss  of  voice. 
The  eyeballs  are  red  and  prominent.  Yision  is  more  or  less  affected  ;  some- 
times so  much  so  that  even  the  brightest  light  cannot  be  distinguished.  The 
torpor  or  lethargy  which  follows  the  delirium,  occurs  more  or  less  quickly, 
but  in  general  not  for  several  hours  after  the  poison  is  taken.  Convulsions 
rarely  appear  to  be  produced  by  belladonna.  The  effects  of  this  poison  are 
by  no  means  so  quickly  dissipated  as  those  of  opium.  The  blindness,  espe- 
cially, is  often  a  very  obstinate  symptom,  sometimes  remaining  long  after  the 
affection  of  the  mind  has  disappeared.  For  days,  and  even  weeks,  the  pupils 
continue  dilated,  and  vision  disordered.''^ 

Similar  effects  are  produced  by  large  doses  of  hyoscyamus  or  stramonium.*'' 
Blindness,  with  dilated  pupils,  also  attends  poisoning  by  dulcamara,  white 
hellebore,  tobacco,  and  several  other  substances.*"  Opium  and  alcohol*'  also 
induce  insensibility  of  the  retina,  accompanied  at  first  with  contraction,  but 
on  the  approach  of  death,  with  dilatation  of  the  pupils. 

It  becomes  a  question  of  great  importance,  How  do  the  narcotic  and  nar- 
cotico-acrid  poisons  act  in  the  production  of  amaurosis  ?  Do  they  operate, 
through  the  medium  of  the  nervous  system,  on  that  part  of  the  brain  which 
forms  the  immediate  organ  of  visual  perception,  on  the  optic  nerve,  the 
motor  oculi  which  animates  the  iris,  and  the  other  nerves  connected  with 
the  eyeball  and  eyelids  ?  Or  do  they  merely  induce  congestion  of  the  vessels 
of  the  brain,  and  sometimes  extravasation  of  blood  within  the  head?  They 
probably  act  in  both  these  ways.     Congestion  of  the  cerebral  vessels  is  com- 


AMAUROSIS   FROM  POISONS.  987 

monly,  though  perhaps  not  invariably,  found  on  dissection,  after  death  from 
a  narcotic  or  narcotico-acrid  poison,  and  must  undoubtedly  tend  to  produce 
insensibility  in  cases  of  poisoning,  as  it  does  in  cases  of  apoplexy  or  cerebral 
plethora.  But  that  the  amaurotic  effects  of  the  poisonous  substances  in  ques- 
tion are  to  be  ascribed  wholly  to  congestion  does  not  appear  probable,  when 
we  take  into  account  the  dilatation  of  the  pupils,  which,  often  in  the  course 
of  not  many  minutes,  follows  the  application  of  belladonna  to  the  skin  of  the 
eyelids,  and  which,  whether  it  is  to  be  regarded  as  produced  by  nervous  com- 
munication or  by  absorption,  can  scarcely  with  any  degree  of  plausibility  be 
supposed  to  arise  from  cerebral  oppression. 

I  have  already  had  occasion  repeatedly  to  hint  my  suspicion,  that  one  of 
the  narcotico-acrids,  which  custom  has  foolishly  introduced  into  common  use, 
namely  tobacco,  is  a  frequent  cause  of  amaurosis.  A  majority  of  the  amau- 
rotic patients,  by  whon;  I  have  been  consulted,  have  been  in  the  habit  of 
chewing,  and  still  oftener  of  smoking,  tobacco  in  large  quantities.  It  is  dif- 
ficult, of  course,  to  prove  that  blindness  is  owing  to  any  one  particular  cause, 
when  perhaps  several  causes,  favorable  to  its  production,  have  for  a  length  of 
time  been  acting  on  the  individual ;  and  it  is  especially  diflQcult  to  trace  the 
operation  of  a  poison,  daily  applied  to  the  body,  for  years,  in  such  quantities 
as  to  produce,  at  a  time,  only  a  very  small  amount  of  deleterious  influence, 
the  accumulative  effect  being  at  last  merely  the  insensibility  of  a  certain  set 
of  nervous  organs.  At  the  same  time,  we  are  familiar  with  the  consequences 
of  minute  portions  of  other  poisons,  which  are  permitted  to  operate  for  a 
length  of  time  on  the  constitution,  such  as  alcohol,  opium,  lead,  arsenic,  mer- 
cury, &c.  ;  and  we  can  scarcely  doubt,  that  a  poison  so  deleterious  as  tobacco, 
must  also  produce  its  own  peculiar  injurious  effects. 

The  essential  oil  of  tobacco  is  so  virulent  a  poison,  that  small  animals  are 
almost  instantly  killed,  when  wounded  by  a  needle  dipped  in  it,  or  when  a 
few  drops  of  it  are  let  fall  upon  their  tongue.  Dr.  Paris^'^  records  the  case  of 
a  child,  whose  death  was  occasioned  by  her  having  swallowed  a  portion  of 
half-smoked  tobacco,  which  was  taken  from  the  pipe  of  her  father,  and  in 
which  there  no  doubt  existed  a  quantity  of  essential  oil,  which  had  been 
separated  by  the  act  of  smoking ;  for  in  the  process  of  smoking,  the  oil  is 
separated,  and  being  rendered  empyreumatic  by  heat,  is  thus  applied  to  the 
fauces  in  its  most  active  state.  That  the  regular  application,  in  this  way,  of 
a  poison  of  such  power,  perhaps  five  or  six  times  daily  for  months  or  years  to- 
gether, should  at  length  be  productive  of  serious  effects  on  the  nervous  system, 
and  especially  on  the  brain,  cannot  surely  be  matter  of  wonder.  Indeed  it 
would  be  surprising  if  it  were  otherwise. 

Dr.  Prout  supposes  some  poisonous  principle  to  be  developed  in  certain 
individuals  by  tobacco.  Hence  their  cachectic  looks,  and  the  dark,  and  often 
greenish  yellow  tint  of  their  blood.  He  believes  tobacco  to  disorder  the 
assimilating  functions  in  general,  but  particularly  the  assimilation  of  the  sac- 
charine principle.  "It  happens  with  tobacco,"  says  he,  "  as  with  deleterious 
articles  of  diet ;  the  strong  and  healthy  suffer  comparatively  little,  while  the 
weak  and  predisposed  to  disease  fall  victims  to  its  poisonous  operation,"^" 

In  estimating  the  bad  effects  of  tobacco,  the  loss  of  saliva  which  the  use  of 
it,  by  chewing  or  smoking,  occasions,  must  be  taken  into  account. 

The  Germans  accuse  a  variety  of  bitter  substances,  employed  either  for 
food  or  medicine,  as  productive  of  amaurosis ;  but  with  what  degree  of  justice, 
I  cannot  pretend  to  say.  Beer  enumerates  bitter  almonds,  the  root  of  suc- 
cory, quassia,  and  centaurium,  amongst  this  class. 

Lead-colic  is  not  unfrequently  attended  by  amaurosis,  as  well  as  by  deaf- 
ness, vertigo,  delirium,  epilepsy,  and  other  nervous  symptoms.^* 

Treatment. — 1.  If  amaurosis  be  the  consequence  of  a  large  dose  of  a  nar- 


988  AMAUROSIS   FROM   POISONS. 

cotic,  which  still  remains  in  the  storaach,  we  onght  in  general  to  begin  by 
giving  a  dose  of  tartar  emetic,  or  sulphate  of  zinc,  in  as  small  a  quantity  of 
water  as  possible ;  for,  as  long  as  the  narcotic  remains  in  the  stomach,  the 
addition  of  any  fluid  which  would  not  immediately  be  rendered  by  vomiting, 
would  only  dissolve  the  poison,  if  it  has  been  swallowed  in  the  solid  state, 
and  add  to  its  activity.  Vinegar,  especially,  which  has  been  found  so  useful 
in  removing  the  disease  which  arises  from  opium,  only  adds  to  its  activity,  if 
it  be  given  before  the  poison  has  been  rendered  from  the  stomach.  When  no 
danger,  however,  of  this  kind,  is  to  be  apprehended,  as  is  the  case  in  alcoholic 
poisoning,  injections  into  the  stomach,  by  means  of  the  stomach-pump,  and 
the  immediate  abstraction  of  the  injected  fluid,  along  with  the  poisonous  sub- 
stance, are  to  be  preferred.  After  the  contents  of  the  storaach  have  been 
evacuated,  a  strong  purgative  ought  to  be  administered,  especially  if  we  sus- 
pect that  the  narcotic  has  begun  to  traverse  the  intestines. 

2.  Bloodletting,  both  general  and  local,  is  of  great  use  in  eases  of  amau- 
rosis from  narcotic  poisons.  This  remedy  probably  proves  serviceable,  chiefly 
by  relieving  the  tendency  to  cerebral  congestton,  which  uniformly  accompanies 
the  amaurosis. 

3.  The  disease  produced  by  the  narcotic,  and  of  which  the  amaurosis  is  a 
part,  ought  next  to  be  combated  by  strong  doses  of  coffee,  camphor,  vinegar, 
and  the  vegetable  acids. 

4.  Cold  applications  to  the  head  and  eyes  have  been  found  useful.  The 
cold  affusion  on  the  head  is  particularly  advantageous,  when  the  symptoms 
are  owing  to  the  ingestion  of  opium  or  of  alcohol. 

5.  In  inveterate  cases,  after  premising  bloodletting  and  purging,  a  course 
of  mercury  may  be  tried,  with  counter-irritation  of  different  sorts,  sternuta- 
tories, and  electricity.  The  prognosis  in  this  stage,  is  very  unfavorable  if 
the  pupils  are  fixed,  the  retina  insensible,  and  the  external  vessels  of  the  eye 
varicose. 

6.  The  purgative  plan  of  curing  lead-colic  is  generally  successful  in 
removing  the  amaurosis,  which  sometimes  attends  that  complaint. 

Case  408. — On  the  24th  May,  1815,  Mr.  J.  II.,  aged  nineteen,  unaccustomed,  except 
for  a  day  or  two  before,  to  the  eflFects  of  tobacco,  smoked  one,  and  a  part  of  a  second 
pipe,  without  employing  the  usual  caution  of  spitting  out  the  saliva;  and  partook,  at  the 
same  time,  of  a  little  porter.  He  became  affected  by  syncope,  with  violent  retching  and 
vomiting.  He  returned  home,  complained  of  pain  in  the  head,  undressed,  and  went  to 
bed.  Soon  afterwards  he  was  taken  with  stupor  and  laborious  breathing.  The  medical 
attendant  found  him  in  the  following  state :  The  countenance  was  suffused  with  a  deep 
livid  color;  the  eyes  had  lost  their  brilliancy;  the  conjunctivne  were  injected;  the  right 
pupil  was  exceedingly  contracted;  the  left  was  much  larger  than  usual,  and  had  lost  its 
circular  form;  both  were  unaffected  on  the  approach  of  light.  The  hands  were  joined, 
and  in  a  state  of  rigidity ;  the  arms  bound  over  the  chest ;  and  the  whole  body  affected 
with  spasmodic  contraction.  The  breathing  was  stertorous;  pulse  about  eighty  or  eighty- 
two,  and  nearly  natural  in  other  respects.  No  more  vomiting ;  no  stool  or  urine  passed  ; 
no  palsy. 

Fourteen  ounces  of  blood  were  immediately  taken  from  the  temporal  artery,  and 
vinegar  was  administered.  He  revived  evidently;  the  countenance  became  less  livid; 
the  spasmodic  affection  of  the  hands  ceased  ;  respiration  became  less  stertorous.  An 
ipecacuanha  emetic  was  given,  and  operated  once,  and  afterwards  some  purgative  medi- 
cine was  administered. 

He  dozed  through  the  night.  Next  morning  he  was  affected  with  syncope  during  the 
efforts  made  to  get  out  of  bed  to  go  to  stool.  He  complained  very  much  of  pain  of  the 
bead  and  eyes ;  the  eyes  and  eyelids  appeared  red  and  suffused.  Tongue  loaded  and 
brownish.  One  stool.  Pulse  eighty  and  natural.  Continued  to  doze.  The  feet  cold  in 
the  morning.     Sixteen  ounces  of  blood  were  taken  from  the  arm. 

On  the  third  day,  he  still  dozed,  and  complained  of  pain  in  the  head,  nausea,  and  a 
tendency  to  faint.  Countenance  more  natural ;  pupils  natural,  and  contract  on  exposure 
to  light.  Pulse  seventy-two.  A  loose  stool  passed  insensibly  in  bed.  In  the  evening, 
he  again  became  affected  with  a  degree  of'Stupor,  spasms  of  the  hands,  and  stertor  in 


AMAUROSIS   FROM  DISORDERED  DIGESTIVE   ORGANS.  989 

breathing.  Six  ounces  of  blood  were  drawn  from  the  temporal  artery,  -vinegar  was 
given,  a  blister  applied  to  the  forehead,  and  mustard  cataplasms  to  the  feet,  with  much 
relief  to  the  symptoms. 

On  the  fourth  day,  he  appeared  much  as  on  the  preceding  morning.  There  was  some 
pain  of  head,  but  no  sickness  or  vomiting.     After  this  he  gi'adually  recovered. " 

Such  is  an  instance  of  acute  amaurosis  from  tobacco ;  chronic  cases  may 
be  met  with  every  day  at  any  eye  infirmary,  generally  in  that  stage  in  which 
there  is  reason  to  suppose  the  retina  and  optic  nerve  to  be  more  or  less  in  a 
state  of  atrophy. 

One  of  the  best  proofs  of  tobacco  being  a  cause  of  amaurosis  is  in  the 
great  improvement  in  vision — sometimes  complete  restoration — which  ensues 
on  giving  up  the  use  of  this  poison.  A  man  having  called  on  me,  who  was 
rapidly  becoming  blind,  I  explained  to  him  that  the  cause  was  the  smoking 
of  tobacco,  and  seriously  advised  him  to  drop  it.  Pie  returned  some  months 
after,  in  great  spirits,  so  well  that  he  was  able  to  read.  My  advice  had 
produced  a  deep  impression  on  his  mind  ;  he  had  used  no  medicine,  but  had 
from  that  hour  renounced  tobacco,  and  came  to  thank  me.  Such  a  case  is 
rare ;  so  wedded  are  those  who  use  tobacco  to  the  indulgence,  that  it  may 
literally  be  said  that  they  would  rather  smoke  than  see.  To  attempt  to  cure 
by  medical  means  the  amaurosis  of  such  persons,  while  they  persist  in  sub- 
jecting themselves  to  the  cause  of  the  disease,  is  idle. 

§  18.     Amaurosis  from    congestion    or   inflammation  of  the   nervous   optic 
apparatus,  depending  on  acute  or  chronic  disorders  of  the  digestive  organs. 

Many  of  those  who  are  liable  to  dyspepsia  make  mention  of  certain  symp- 
toms affecting  the  organs  of  vision ;  as,  distension  and  stiffness  of  the  eye- 
balls, dazzling  and  mistiness  before  the  eyes,  musca;  volitantes,  and  the  like. 
These  symptoms  are  generally  attended  by  headache,  and  sometimes  by 
vertigo,  and  gradually  subside  as  the  stomach  recovers  its  wonted  activity. 
The  French  distinguish  by  the  name  of  eblouissement,  a  sudden  temporary 
loss  of  sight,  sometimes  nearly  complete,  and  attended  generally  with  severe 
pain  in  the  stomach,  and  sometimes  in  the  forehead.  Such  fits  occur  from 
time  to  time  in  the  course  of  the  day.  They  alarm  the  patient,  especially 
when  they  suddenly  attack  him  in  the  street.  In  some  cases,  the  sympathetic 
effects  of  indigestion  are  not  so  transient,  consisting  in  dilatation  of  the 
pupils,  sluggishness  in  the  motions  of  the  iris,  and  a  continued  dimness  of 
sight.  The  patient  complains,  at  the  same  time,  of  constant  acid  or  foul 
eructations,  with  painful  heartburn,  a  feeling  of  pressure  at  the  scrobiculus 
cordis,  distension  of  the  abdomen,  a  great  degree  of  flatulence,  thirst, 
nausea,  general  uneasiness  and  restlessness ;  the  mouth  is  bitter,  the  tongue 
foul,  and  the  pulse  accelerated. 

All  these  symptoms,  including,  among  the  rest,  the  amaurotic,  speedily 
subside,  in  general,  after  the  use  of  some  absorbent  and  laxative  medicine,  aa 
magnesia  usta,  or  the  carbonate  of  magnesia,  a  mixture  of  these  with 
rhubarb  and  ginger,  or  the  like.  Those  who  are  subject  to  Eblouissement, 
have  recourse  to  a  dose  of  calomel,  followed  by  a  purge,  which  frees  them 
from  such  attacks  for  a  time. 

In  some  instances,  it  is  between  the  optic  apparatus  and  the  bowels,  more 
than  the  stomach,  that  the  sympathy  exists,  which  gives  rise  to  temporary 
amaurosis.  Tiederaann^^  quotes  from  Helwich  the  case  of  a  hypochondriacal 
man  who  became  blind  under  severe  spasmodic  attacks  with  costiveness. 
After  the  use  of  clysters,  the  blindness  left  him. 

Frequently  repeated  and  neglected  attacks,  however,  of  the  kind  above 
noticed,  especially  in  sedentary  persons,  careless  perhaps  of  their  diet,  and 
inattentive  to  the  means  of  preserving  health,  lead  at  last  to  more  serious 


990  AMAUROSIS   FROM   DISORDERED   DIGESTIVE   ORGANS. 

consequences.  The  optic  apparatus  is  at  first  aifected  only  with  a  sympa- 
thetic congestion  ;  but,  as  in  all  other  sympathetic  affections,  if  often 
repeated,  the  eye  retains  at  length  the  morbid  action,  and  permanent  amau- 
rosis is  developed.  Each  succeeding  attack  of  the  purely  sympathetic  kind, 
continues  longer  than  the  preceding,  and  at  last  the  congestion  of  the  brain 
ends  in  such  structural  changes  as  do  not  yield  to  mere  evacuations  of  the 
stomach  and  bowels.  The  bowels  grow  habitually  inactive,  the  biliary 
organs  are  impeded  in  the  discharge  of  their  office,  the  appetite  is  impaired, 
digestion  weakened,  the  mind  becomes  habitually  fretful,  and  the  spirits 
depressed.  Under  such  circumstances,  allowed  to  continue  without  interrup- 
tion for  years,  there  is  not  unfrequently  produced  a  slowly  increasing 
weakness  of  sight,  terminating  at  last  in  confirmed  amaurosis.  In  Milton, 
whose  case  I  apprehend  to  have  been  one  of  this  sort,  the  affection  of  vision 
•went  on  for  ten  years  before  it  ended  in  blindness  ;  and  it  sometimes  happens 
that  even  a  longer  period  elapses,  before  the  disease  is  fully  developed. 
The  patient  during  all  this  time,  complains  of  a  constantly  increasing  imper- 
fection of  sight,  without  being  rendered  unable,  perhaps,  to  continue  his 
usual  employments.  Though  generally  slow  in  its  progress,  yet  there 
sometimes  occur  eases,  in  which  this  species  of  amaurosis  is  rapid,  or  even 
metastatic. 

The  pupil  is  dilated,  the  motions  of  the  iris  very  sluggish  and  limited,  the 
sclerotica  tinged  of  a  yellowish  or  dnsky  hue,  the  vessels  of  the  conjunctiva 
often  turgescent.  Every  object  seems  to  the  patient  to  be  enveloped  in  a  thick 
cloud,  and  not  unfrequently  he  sees  only  parts  of  the  objects  at  which  he  is 
looking.  Dull,  stupefying  headache  generally  accompanies  the  failure  of  sight, 
extending  over  the  whole  head,  and  depriving  the  patient,  even  when  a  con- 
siderable share  of  vision  remains,  of  all  pleasure  in  those  employments  which 
require  the  exercise  at  once  of  sight  and  thought. 

Amaurosis,  arising  from  disorders  of  the  digestive  organs,  is  not  always 
easily  distinguished  from  that  which  depends  on  structural  changes  in  the 
encephalon,  attended  with  a  train  of  symptoms  which  are  referred  to  the 
stomach,  but  which  really  depend  on  disease  in  the  brain.  Patients  are  very 
apt  to  deceive  themselves  under  such  circumstances  regarding  the  seat  of 
their  diseases.  They  perhaps  refer  all  their  sufferings  to  the  stomach,  but 
after  death,  not  a  trace  of  disease  is  detected  in  the  viscera  of  the  abdomen, 
while,  in  the  membranes,  or  in  the  substance  of  the  brain,  there  are  indubitable 
marks  of  such  structural  changes  of  long  standing,  as  were  sufficient  to  pro- 
duce the  amaurotic  affection,  and  must  at  the  same  time  have  operated  sym- 
pathetically on  the  stomach. 

Treatment. — A  relinquishment  of  whatever  appears  to  have  laid  the  founda- 
tion of  the  affection  of  the  digestive  organs  is  the  most  important  particular 
in  the  treatment  of  this  amaurosis;  whether  the  cause  has  been  severe  and  pro- 
tracted study,  irregularities  in  diet,  the  use  of  alcoholic  and  other  poisons, 
want  of  exercise,  impure  air,  or  the  like.  The  patient's  food  should  be  plain 
and  easily  digested,  he  must  pay  particular  attention  to  keep  his  bowels  regular, 
he  ought  to  take  daily  exercise  in  the  country  on  foot  or  on  horseback,  and 
court  the  society  of  the  cheerful  and  well-informed. 

Depletion,  and  especially  the  application  of  leeches  to  the  temples,  will  be 
found  of  much  service.  The  head  is  to  be  shaved,  and  kept  wet  with  cold 
cloths.  Counter-irritation,  by  blisters  behind  the  ears,  is  sometimes  necessary. 
Alterative  doses  of  mercury  will  often  be  useful,  and  much  advantage  will  be 
reaped  from  the  use  of  tonic  medicines,  judiciously  selected  and  combined. 

Beer  strongly  dissuades  from  the  use  of  emetics  and  nauseating  medicines 
in  the  treatment  of  amaurosis  depending  on  chronic  disorder  of  the  digestive 
organs  ;  also,  from  all  external  stimulants,  and  from  electricity  or  galvanism. 


AMAUROSIS   FROM  DISORDERED   DIGESTIVE   ORGANS.  991 

Case  409. — Scarpa  relates  the  case  of  a  girl,  aged  16  years,  of  delicate  constitution,  and 
■who  had  not  menstruated,  who  towards  the  end  of  May  became  affected  with  such  a  de- 
gree of  morbid  appetite  that  she  could  scarcely  satisfy  it  by  swallowing  every  sort  of  gross 
food  in  large  quantity,  especially  bread  made  of  Indian  corn.  Fatigued,  also,  by  the  hard 
labor  of  the  country,  to  which  she  was  not  yet  accustomed,  her  sight  began  to  grow  dim. 
Her  immoderate  appetite  suddenly  ceased,  she  felt  a  bitter  taste  in  her  mouth,  and  began 
to  experience  a  sense  of  weight  in  the  region  of  the  stomach,  accompanied  by  nausea  and 
continual  headache.  She  then  lost  the  sight  of  the  right  eye  entirely,  and  in  a  great 
measure  that  of  the  left.  The  pupils  were  considerably  dilated,  and  almost  immovable  to 
the  sti'ongest  light.     She  seemed,  also,  as  if  she  had  an  incipient  strabismus. 

On  the  4th  of  June,  she  took,  in  table-spoonfuls,  a  solution  of  four  grains  of  tartar 
emetic  in  5  ounces  of  water,  which  produced  a  great  and  continued  degree  of  nausea,  but 
no  vomiting,  except  of  a  little  viscid  whitish  matter.  On  the  5th,  the  same  emetic  was 
repeated  in  the  same  manner.  It  produced  a  more  copious  vomiting  than  on  the  preceding 
day ;  but  always  of  mucous  whitish  matter.  The  headache  was  considerably  relieved,  as 
well  as  the  sense  of  weight  in  the  region  of  the  stomach.  The  nausea,  however,  and 
furred  tongue  continued  as  at  first.  The  pupil  appeared  a  little  movable  to  bright  light, 
and  with  the  right  eye  the  patient  could  distinguish  whether  it  was  light  or  dark.  She 
began  to  expose  the  eyes  to  the  vapor  of  ammonia  every  two  or  three  hours.  On  the  6th, 
she  had  little  pain  in  the  head,  and  the  mouth  was  less  bitter.  The  pupil  had  acquired 
some  degree  of  motion.  She  Avas  ordered  to  continue  the  ammoniacal  vapor,  and  to  take 
three  resolvent  powders,  consisting  of  cream  of  tartar,  with  a  small  proportion  of  tartar 
emetic,  daily.  On  the  7th,  she  had  very  little  headache.  The  powders  produced  nausea 
for  some  hours,  then  two  copious  stools.  The  pupil  contracted  a  little,  and  the  patient 
could  discern  the  outlines  of  large  objects.  By  the  8th,  the  headache  was  entirely  gone, 
as  well  as  the  bitter  taste  and  furred  state  of  the  tongue.  The  pupil  also  was  more  sensi- 
ble. The  patient  continued  to  take  the  resolvent  powders  on  the  9th,  10th,  11th,  and  12th, 
and  to  use  the  ammonia.  On  the  13th,  she  complained  again  of  headache  and  bitterness 
of  the  mouth,  with  foul  tongue.  Instead  of  the  powders,  Scarpa  prescribed  an  emetic  of 
half  a  drachm  of  ipecacuanha  with  a  grain  of  tartar  emetic ;  in  consequence  of  which  the 
patient  vomited  much  yellowish-green  matter.  The  headache  ceased  immediately,  and 
the  girl  could  then  distinguish  sufficiently  well  the  objects  that  were  presented  to  her.  On 
the  14th,  she  felt  herself  very  well.  The  pupil  of  the  right  eye,  which  had  been  the  most 
amaurotic,  was  even  more  contracted  than  that  of  the  left.  On  the  15th,  the  patient  re- 
sumed the  use  of  the  resolvent  powders,  and  continued  the  external  application  of  the 
ammoniacal'  vapor.  On  the  16th,  she  could  distinguish  with  the  right  eye  >i  small  needle. 
During  the  17th,  18th,  19th,  and  20th,  the  powders  produced  two  copious  stools  daily, 
without  at  all  weakening  the  patient.  She  had  a  good  appetite,  and  digested  well.  On 
the  21st,  a  decoction  of  cinchona,  with  infusion  of  valerian  root,  was  substituted  for 
the  resolvent  powders.  She  was  able  in  a  few  days  to  see  the  most  minute  objects,  as  well 
with  the  one  eye  as  the  other.  She  had  acquired  a  good  complexion,  and  the  strabismus 
had  almost  entirely  disappeared.  She  was  dismissed  perfectly  cured,  but  advised  to  con- 
tinue the  use  of  the  vapor  for  a  week  longer,  to  take  morning  and  evening  a  powder,  com- 
posed of  one  drachm  of  cinchona,  and  half  a  drachm  of  valerian,  to  observe  a  regular  diet, 
and  to  avoid  the  scorching  rays  of  the  sun. 5' 

Case  410. — A  gentleman  of  feeble  habit,  was  subject  to  occasional  attacks  of  obstinate 
constipation,  each  accompanied  by  amblyopia,  sometimes  proceeding  to  complete  amaurosis. 
When  Mr.  Edwards  was  first  called  to  visit  this  patient,  he  found  him  completely  amau- 
rotic. He  had  some  time  before  complained  of  excruciating  headache,  and  every  solid  and 
fluid  medicine  directed  by  his  medical  attendant  had  been  rejected  by  his  stomach.  To  the 
previously  existing  amblyopia  complete  amaurosis  succeeded,  during  the  vomiting,  which 
may  be  called  spontaneous,  in  contradistinction  to  that  produced  by  an  emetic  in  another 
attack.     The  patient  now  became  delirious. 

Leeches  were  applied  to  the  abdomen,  and  the  bowels  were  relieved  by  enemata.  By 
these  means,  and  the  application  of  cold  to  the  head,  the  patient  fully  and  speedily  re- 
gained his  sight  and  faculties. 

In  this  attack,  the  co-existence  of  headache  and  delirium,  and  the  recovery  by  antiphlo- 
gistic treatment,  Mr.  Edwards  considered  as  sufficiently  indicative  of  active  local  conges- 
tion, or  incipient  inflammation  in  the  nervous  structure  of  the  eyes.  This  was  coincident 
with  great  debility,  and  the  amaurosis  was  not  completed  till  vomiting  occurred. 

After  an  interval  of  six  weeks,  another  attack  of  visceral  obstruction  succeeded ;  the 
accompanying  amaurosis  was  incomplete;  vomiting  was  absent.  The  amaurotic  affection 
lingered  for  a  considerable  time,  surviving  the  removal  by  enemas,  &c.,  of  the  primary 
irritant  longer  than  in  the  preceding  attack,  in  which  the  vascular  congestion  was  almost 
purely  sympathetic  and  temporary. 

By  some  errors  in  regimen,  the  patient  in  a  few  weeks  again  relapsed.     There  were 


992  AMAUROSIS   FROM   DISORDERED   DIGESTIVE   ORGANS. 

constipation,  tense  hypochondria,  nausea,  headache,  and  amblyopia.  Mr.  Edwards  now 
tried  the  continental  practice,  by  giving  an  emetic.  The  result  was  a  discharge  of  much 
yellow-greenish  matter,  but  the  amaurosis  immediately  became  complete.  The  bowels 
were  relieved  by  enemas,  but  still  the  blindness  continued  much  longer  than  in  any  pre- 
vious attack,  and  was  only  at  length  removed  by  the  application  of  many  leeches  to  the 
temples,  and  continued  evaporating  lotions  to  the  head. 

In  each  of  the  attacks,  the  degree  of  amaurosis  was  determined  by  the  presence  or 
absence  of  vomiting,  the  complete  being  synchronous  with  spontaneous  vomiting,  as  in  the 
first  attack,  and  with  the  action  of  an  emetic,  as  in  the  last ;  where  there  was  no  emetic 
action  as  in  the  second  attack,  the  amaurosis  was  incomplete. 

Mr.  Edwards  considers  the  emetic  practice  to  be  contraindicated  in  amaurotic  affec- 
tions, alleging  in  support  of  this  opinion,  the  tendency  of  obstinate  vomiting,  in  incipient 
pregnancy,  to  cause  amblyopia  or  even  complete  amaurosis  ^* 

Case  411. — Thomas  Crighton,  aged  23,  was  admitted  into  St.  Bartholomew's  Hospital, 
on  account  of  a  palsy  of  his  limbs.  About  a  year  before,  while  the  use  of  his  limbs  was 
yet  unimpaired,  he  was  attacked  repeatedly  with  violent  pain  in  the  bowels,  uniformly 
preceded  by  costiveness,  and,  generally,  terminated  by  a  copious  discharge  of  loose, 
fetid,  black  stools.  The  relief  afforded  by  the  diarrhoea  was  speedy  and  uniform.  In  the 
course  of  six  months  his  lower  extremities  became  affected  with  occasional  twitchings, 
and  he  found  that  he  could  not  regulate  their  motions  in  walking:  this  increased  to  such 
a  degree  as  to  make  him  incapable  of  taking  any  exercise.  He  had,  at  the  commence- 
ment of  his  illness,  a  confusion  of  vision,  and  a  constant  and  violent  pain  in  the  hend. 
The  former  symptom  increased  so  much,  that  he  could  discern  no  object  distinctly :  a 
candle,  for  instance,  although  held  near  him,  appeared  as  large  as  the  moon.  The  sen- 
sation of  his  lower  extremities  continued  perfect;  but  the  actions  of  the  bladder  were  no 
longer  under  the  control  of  the  will :  the  urine  sometimes  flowed  involuntarily,  and,  at 
others,  was  retained  for  some  hours,  with  considerable  pain.  He  afterwards  began  to 
lose  the  use  of  his  upper  extremities  :  the  left  hand  and  arm  were  more  affected  than  the 
right;  but  there  was  no  difference  in  the  affection  of  the  leg  on  the  same  side.  His 
speech,  also,  became  much  impaired ;  he  hesitated  and  faltered  considerably,  and  the 
tones  of  his  voice  were  irregular,  so  that,  at  length,  he  could  scarcely  make  himself 
understood.  At  the  time  of  his  admission  into  the  hospital,  there  was  an  entire  loss  of 
voluntary  motion  of  the  lower  extremities,  and  a  great  diminution  of  that  of  the  upper. 
The  bowels  were  deranged ;  there  was  constant  headache ;  the  speech  was  very  indis- 
tinct ;  and  vision  so  imperfect,  that  he  could  not  read  the  largest  print. 

An  issue  was^iade  in  the  neck,  and  some  medicines  were  prescribed,  under  the  direc- 
tion of  the  physician.  As  the  treatment  did  not  prove  beneficial,  Mr.  Abernethy  was 
desired  to  examine  the  spine,  and  found  such  a  curvature  and  projection  of  the  spinous 
processes  of  the  upper  lumbar  and  lower  dorsal  vertebrae,  that  he  thought  the  bodies  of 
those  bones  were  diseased.  He  was,  therefore,  inclined  to  attribute  the  paralysis  of  the 
lower  extremities  to  the  disease  of  the  spine;  and,  consequently,  directed,  that  issues 
should  be  made  on  each  side  of  the  projecting  vertebrae.  As  this  supposition  would  not 
account  for  the  paralytic  affection  of  the  parts  above,  and  as  the  bowels  were  deranged, 
Mr.  Abernethy  ordered  two  grains  of  calomel  with  eight  of  rhubarb,  to  be  taken  twice 
a  week,  and  some  infusion  of  gentian,  with  senna,  occasionally. 

After  using  these  medicines  for  about  three  weeks,  the  patient's  bowels  became  regular, 
the  biliary  secretion  healthy,  and  his  appetite  good.  He  could  move  his  hands  and  arms 
nearly  as  well  as  ever ;  and  his  eyesight  was  so  much  improved  that  he  could  read  a 
newspaper ;  indeed,  it  was  nearly  well.  The  functions  of  the  bladder  were  completely 
restored  ;  his  speech  became  articulate ;  and  his  general  health,  in  every  respect  much 
improved.  He  remained  in  the  hospital  about  two  months,  but  with  very  little  amend- 
ment in  the  state  of  the  lower  extremities.^^ 

C'lse  412. — Elizabeth  Healey,  a  slender  delicate  young  woman,  about  25,  of  a  sedentary 
occupation,  emaciated  figure,  and  feeble  melancholic  temperament,  applied  to  Mr.  Lessey 
on  the  9th  of  June,  1820,  for  an  affection  of  the  bowels,  to  which  she  had  been  liable  for 
several  years,  requiring,  even  in  a  state  of  comparative  convalescence,  the  constant  use 
of  purgatives.  Indeed,  the  derangement  of  the  abdominal  viscera  was  so  great  and  per- 
manent, as  to  induce  a  belief  that  it  was  of  an  organic  nature.  In  addition  she  was  liable 
to  frequent  and  severe  cephalalgia,  and  occasionally  to  attacks  of  dyspnoea,  with  spasms 
of  the  chest  and  throat,  which,  on  her  attempting  to  swallow,  produced  alarming  symp- 
toms of  suffocation.  These  attacks  were  sudden  and  violent,  attended  by  great  feebleness 
of  the  voice,  and  succeeded  by  exhaustion.  Her  bowels  had  been  frequently  relieved  by 
mercurial  and  saline  cathartics,  the  attacks  of  cephalalgia  by  venesection  and  the  appli- 
cation of  leeches  and  blisters  to  the  head  and  neck,  and  the  affection  of  the  lungs  by  a 
variety  of  remedies.  She  had  an  attack  of  disordered  bowels  in  January,  1821,  which 
appeared  to  be  yielding  to  remedies,  when""  she  was  suddenly  seized,  on  the  23d,  with 


AMAUROSIS  FROM  LOSS  OP  THE   FLUIDS  OF   THE  BODY.  993 

violent  dyspnoea.  Every  attempt  to  swallow,  or  even  to  speak,  was  followed  by  a  con- 
vulsive spasm  of  the  throat  and  chest,  attended  with  frequent  sobbing.^  A  few  doses  of 
ether  and  opium,  with  a  blister  on  the  sternum,  relieved  the  immediate  urgency  of  the 
symptoms ;  but  still  the  breathing  continued  laborious,  and  the  voice,  which  had  long 
been  feeble,  was  reduced  to  a  scarcely  audible  whisper.  The  derangement  of  her  abdomi- 
nal viscera  returned  ;  her  stools  were  green  and  slimy ;  her  pulse  was  feeble,  and  her 
general  debility  so  great,  that  Mr.  Lessey  despaired  of  her  recovery. 

She  remained  in  this  state,  with  little  variation,  till  the  16th  of  February,  when  the 
difficulty  of  breathing  suddenly  left  her,  and  her  voice  became  distinct,  strong,  and  clear ; 
but  a  sudden  and  violent  pain  seized  her  head,  and,  to  the  astonishment  of  the  people 
around  her,  she  screamed  out  loudly  for  help.  Hastening  to  her  assistance,  they  found 
her  in  an  agony  of  pain,  and  quite  blind.  Mr.  Lessey  immediately  ordered  her  head  to 
be  shaved,  and  a  blister  applied  to  it,  with  a  dozen  of  leeches  to  the  temples,  which 
abated  the  violence  of  the  pain,  but  produced  no  alteration  in  her  sight.  The  eyes  were 
fixed  and  nearly  motionless ;  the  pupil  steady  at  a  medium  point,  between  contraction 
and  dilatation,  and  totally  insensible  to  light.  On  presenting  a  candle  suddenly  to  her 
eyes,  she  exhibited  no  consciousness  of  its  presence,  unless  it  was  sufficiently  near  for  her 
to  feel  the  warmth  of  its  rays.  Blisters  were  applied  to  her  temples,  dressed  with  can- 
tharides  ointment,  and  frequently  repeated,  so  as  to  keep  up  a  discharge  for  weeks.  The 
bowels  continued  torpid,  and  required  the  constant  use  of  purgatives.  Blue  pill  was 
next  tried,  and  her  gums  were  slightly  affected,  but  without  any  effect  on  the  sight.  Her 
voice  continued  strong,  her  breathing  easy,  and,  in  fact,  the  affection  of  the  chest  ap- 
peared to  have  left  her  entirely.  The  pain  in  the  head  was  considerably  abated,  but  the 
vision  remained  so  entirely  lost,  that  all  hopes  of  its  recovery  were  abandoned,  and  she 
was  sent  to  the  Manchester  workhouse  as  an  incurable  amaurotic. 

Three  months  after  her  admission,  she  had  a  severe  attack  both  in  her  chest  and 
bowels,  obstinate  constipation,  dyspnoea,  with  violent  spasm  and  great  difficulty  of  swal- 
lowing. This  attack  lasted  three  weeks  and  subsided  slowly.  At  the  latter  end  of  1822, 
she  had  a  slight  attack  of  pleurisy,  which  yielded  to  bleeding,  blistering,  and  the  usual 
treatment ;  after  which  she  remained  tolerably  free  from  all  her  complaints,  excepting 
slight  headaches. 

Although  she  entertained  little  or  no  hope  of  again  .recovering  her  sight,  yet  she  occa- 
sionally tried  her  eyes  with  a  candle.  On  the  evening  of  the  29th  of  October  she  per- 
ceived no  glimmering  whatever ;  but,  to  her  great  surprise,  on  the  following  evening,  as 
a  person  was  conducting  her  through  the  streets,  she  saw  a  confused  appearance  of  fire, 
and  exclaimed,  ^Yhat  is  the  matter  with  my  eyes  ?  In  the  course  of  a  few  minutes  she  dis- 
covered that  it  proceeded  from  the  gas  lamps,  which  she  saw  indistinctly.  Her  sight 
gradually  improved  during  the  course  of  the  evening.  Next  day,  Mr.  Lessey  found  that 
there  was  considerable  mistiness  and  obscurity  in  her  vision,  with  muscoe  volitantes  of  a 
fiery  hue ;  but  that  she  could  distinguish  the  features  of  her  acquaintances,  and  could 
even  read  the  large  capitals  of  a  handbill,  the  smaller  print  seeming  confused  and  blended 
together.  All  distant  objects  were  mixed  up  with  colored  mists,  and  consequently  indis- 
tinct and  confused. 

On  the  20th  of  November  her  sight  remained  much  the  same.  It  had  got  better,  how- 
ever, during  the  interval ;  but  was  injured  again  by  injudicious  exposure  to  a  highly 
heated  room.  The  colored  mists  still  troubled  her  occasionally;  tlie  muscte  volitantes 
were  sometimes  very  numerous,  and  appeared  mixed,  she  said,  with  white  flakes  like 
snow.  She  could  not  read  better;  but  with  the  help  of  a  double-concave  glass,  she  could 
distinguish  print  which  to  her  naked  eye  was  a  confused  mass.  Her  bowels  and  lungs 
had  been  free  from  disease  for  twelve  months,  and  she  exulted  in  the  prospect  of  ultimate 
recovery.^' 

§  19.  Amaurosis  from  congestion  or  injlammation  of  the  nervous  optic  appa- 
ratus, arising  from  continued  loss  of  the  fluids  of  the  body. 

This  species  of  amaurosis  declares  itself  from  its  commencement  by  the 
sensation  of  a  network  before  the  eyes,  seldom,  if  ever,  attended  by  that 
glittering  or  dazzling  which  accompanies  the  same  symptom  in  some  other 
varieties  of  the  disease.  In  a  gentleman  by  whom  I  was  consulted,  and  who 
blamed  excessive  indulgence  in  venery  as  the  cause  of  his  blindness,  there  was 
no  photopsia,  or  I'evolviug  of  globes  of  light  before  the  eyes ;  but  the  sensa- 
tion of  a  cloud,  which  crept  first  over  the  one  eye  and  then  over  the  other, 
from  the  temple  towards  the  nose,  as  if  the  nasal  part  of  the  retinjB  became 
first  insensible.  During  the  progress  of  the  disease  the  power  of  vision  mani- 
63 


994  AMAUROSIS   FROM  LOSS  OF  THE   FLUIDS  OF   THE  BODY. 

fests  remarkable  dififerences  in  degree,  according  to  the  physical  and  moral 
influences  which  affect  the  individual.  After  a  hearty  meal,  or  a  few  glasses 
of  wine,  or  during  the  influence  of  some  unexpected  elation  of  mind,  the 
patient  sees,  for  a  short  time,  much  better  than  he  did  before  ;  while  an  oppo- 
site effect  is  produced  by  the  depressing  passions,  want  of  food,  continued 
watching,  and  the  like.  Not  unfrequently,  this  amaurosis  first  declares  itself 
by  the  sensation  of  a  mist  before  the  eyes  in  the  evenings,  the  common  artifi- 
cial light  being  too  weak  to  stimulate  sufficiently  the  diminished  sensibility  of 
the  nervous  apparatus  of  vision.  There  is  seldom  any  complaint  of  pain, 
either  in  the  head  or  in  the  eyes,  or  any  feeling  of  fulness  or  weight.  The 
symptoms  generally  creep  on  very  slowly.  The  patients  are  often  melancholic, 
timid,  and  hypochondriacal ;  they  are  subject  to  vertigo,  loss  of  memory, 
incapacity  for  mental  exertion,  capriciousness,  sleeplessness,  gastralgia,  want 
of  appetite,  flatulence,  and  constipation.  There  are  rarely  any  objective 
symptoms,  except,  perhaps,  dilated  pupils,  attended  by  evident  general 
debility,  paleness,  emaciation,  palpitation  of  the  heart,  and  a  weak,  small, 
and  frequent  pulse. 

Causes. — Among  the  most  frequent  causes  of  this  amaurosis  may  be  men- 
tioned imperfect  nutrition,  any  considerable  and  continued  loss  of  the  fluids 
of  the  body,  such  as  occurs  in  haemorrhagy,  ptyalism,  chronic  diarrhoea, 
or  from  immoderate  venery,  spermatorrhoea,  onanism,  undue  lactation,  leu- 
corrhoea,  the  abuse  of  reducing  remedies,  and  the  like.^'^  It  is  occasionally  a 
sequela  of  typhus  fever,  especially  when  this  disease  has  been  attended  by 
profuse  epistaxis,  or  treated  with  remedies  producing  hypercatharsis.  Grief, 
de'sponding  and  other  depressing  passions,  produce  wasting  of  the  body,  with 
cerebral  congestion,  and  amaurosis. 

It  has  already  been  mentioned,  that  plethoric  persons  are  in  general  able 
to  produce  a  degree  of  congestive  amaurosis  at  will,  by  stooping,  for  example, 
or  by  tying  their  neckcloth  tight.  We  also  frequently  witness  a  temporary 
amaurosis  of  an  opposite  kind — namely,  from  exhaustion.  Amongst  the 
symptoms  enumerated  as  caused  by  loss  of  blood  in  pregnant  females  before 
labor,  we  find  vertigo,  singing  in  the  ears,  and  impaired  vision.  If  the  nerv- 
ous system  is  the  seat  of  no  particular  excitement  at  the  time,  we  observe 
that  on  the  sudden  abstraction  of  blood  by  phlebotomy,  the  organs  of  vision, 
and  indeed  all  the  organs  of  sense,  are  strikingly  enfeebled.  In  some  indivi- 
duals the  debility  continues  for  several  days ;  and  if  any  one  of  the  organs  of 
sense  has  been  previously  weaker  than  the  rest,  the  feebleness  of  that  organ 
is  often  increased.  When  syncope  is  produced  by  loss  of  blood,  sight  appears 
to  be  the  sense  which  fails  first,  and  which  recovers  last.  Hearing  is  next ; 
while  smell,  taste,  and  touch  are  less  affected,  and  more  easily  reanimated,  by 
excitation.  They  return  in  a  very  short  time  to  their  natural  state ;  but  it 
is  not  so  with  sight.  It  is  a  popular  opinion,  that  bloodletting  weakens  the 
sight,  and  to  a  certain  length  the  opinion  is  founded  on  fact. 

Treatment. — The  general  object  of  the  treatment  is,  by  diet  and  tonic 
remedies,  to  strengthen  the  digestive  organs  and  remove  the  debility  of  the 
patient.  Although  it  is  but  too  true,  that  the  amaurosis  does  not  always 
yield,  even  when  the  bodily  strength  of  the  patient  is  renewed,  still  the  utmost 
care  must  be  paid  that  debilitating  discharges  are  restrained,  and  bad  prac- 
tices on  the  part  of  the  patient  avoided  ;  while  country  air,  moderate  exercise, 
the  cold  bath,  and  every  other  general  influence  likely  to  restore  vigor,  are 
employed. 

When  spermatic  discharges  are  the  cause,  the  plan  of  cauterizing  the  pro- 
static part  of  the  urethra,  recommended  by  Lallemand,^^  may  be  tried,  and 
followed  up  with  tonics. 


AMAUROSIS  FROM  LOSS   OF  THE   FLUIDS   OF  THE   BODY.  995 

Some  of  the  causes  already  referred  to,  unquestionably  produce  cerebral 
congestion,  which,  notwithstanding  the  debilitated  condition  of  the  constitu- 
tion, requires  the  application  of  leeches  to  the  head  and  of  counter-irritation. 
Mr.  Wade  recommends"^  moxas  burnt  slowly  over  the  integuments  of  the 
head,  a  practice  not  altogether  safe,  as  it  has  been  known  to  cause  caries  of 
the  bones,  and  consequent  death. "^^ 

Local  stimulants,  such  as  ethereal  vapors  directed  against  the  eyes,  have 
been  found  of  use  in  such  cases. 

Success  in  treating  this  disease  will  depend  much  on  the  practitioner's  dis- 
covering the  particular  debilitating  cause  from  which  it  has  originated  ;  and 
when  the  disease  is  recent,  the  mere  avoidance  of  the  cause  will  frequently  be 
sufficient  to  arrest  its  progress.  When  lactation,  for  instance,  is  the  cause, 
weaning  of  the  child  is  the  principal  remedy. 

Case  403. — Arracbart  relates  the  case  of  a  young  man,  who  had  all  his  life  been  accus- 
tomed to  drink  wine  as  his  ordinary  beverage,  but  who,  from  change  of  place,  was  obliged 
to  drink  water.  The  consequence  Avas  diarrhoea,  which  continued  for  nine  months,  when 
the  patient  was  seized  with  fever  of  intermittent  character.  For  this  he  was  bled  twice  at 
the  arm,  and  from  that  moment  his  sight  began  to  fail.  A  third  bleeding,  from  the  foot, 
sensibly  increased  the  weakness  of  sight,  and  immediately  after  a  fourth  bleeding,  also 
from  the  foot,  the  patient  became  altogether  blind.  Large  blisters  were  applied,  and  tartar 
emetic  given,  first  of  all  as  a  vomit,  and  then  as  an  alterative,  during  more  than  a  month, 
without  any  success.  The  exhaustion  of  the  patient  rapidly  increased,  and  still  the  tartar 
emetic  was  repeatedly  employed.  When  Arrachart  was  called  in,  he  prescribed  mild, 
nourishing,  and  easily  digested  food,  and  put  a  seton  into  the  neck.  The  patient's  health 
began  to  improve,  but  his  vision  remaining  as  before,  he  still  continued  to  take  six-grain 
doses  of  tartar  emetic,  without  Arrachart's  knowledge.  These  produced  convulsions, 
without  any  evacuation.  Arrachart  having  discovered  this,  prescribed  some  anodyne 
and  antispasmodic  remedies,  and  recommenced  the  nourishing  plan  of  diet.  In  two  months 
the  patient  began  to  see  a  little  with  the  left  eye,  and  dui'ing  the  course  of  the  next  three 
months  the  vision  of  that  eye  sensibly  improved,  but  the  right  eye  remained  blind.^* 

C(we  404. — A  mason  was  admitted  into  the  IIoiel-Dieu,  under  the  care  of  Dupuytren, 
having  found  himself  deprived  of  sight  the  day  after  his  wedding.  The  cold  bath,  irri- 
tating friction  over  the  dorso-lurabar  region,  and  diffusible  tonics  internally,  were  em- 
ployed, and  vision  was  speedily  restored.^' 

Case  405. — A  country  lad,  of  robust  constitution,  became  the  alternately  favored  para- 
mour of  two  females,  his  fellow-servants,  under  the  same  roof.  He  was  the  subject  of 
gutta  serena  in  less  than  a  twelvemonth.^^ 

Case  406. — Another,  at  an  early  period  of  puberty,  suddenly  fell  into  a  despondency, 
and  shunned  society.  He  never  left  his  chamber  but  when  the  shade  of  night  concealed 
him  from  observation,  and  then  selected  an  unfrequented  path.  It  was  not  discovered 
till  too  late,  that  in  addition  to  other  signs  of  nervous  exhaustion,  a  palsy  of  the  retina 
was  the  consequence  of  habitual  masturbation. ^^ 

Case  407.— Elizabeth  Firman,  aged  20,  applied  to  Mr.  Wells,  on  the  28th  of  January, 
1832,  with  total  loss  of  sight,  complete  palsy  of  the  left,  and  partial  palsy  of  the  right 
upper  eyelid.  From  the  leucophlegmatic  and  relaxed  appearance  of  the  patient,  Mr. 
Wells  was  led  to  suspect  that  leucorrhoea  was  perhaps  the  principal  cause  of  her  com- 
plaints, and  on  inquiry  learned  that,  commencing  to  menstruate  at  the  age  of  16,  she  had 
continued  to  do  so  regularly  for  upwards  of  18  months,  after  which  period  she  became 
very  irregular,  and  had  an  excessive  mucous  discharge,  which  had  greatly  impaired  her 
constitution. 

AhoMi  two  years  before  consulting  Mr.  W.,  she  had  a  severe  ophthalmia,  but  which 
quickly  got  well  under  treatment.  Shortly  after  this,  palsy  of  the  eyelids  supervened, 
and  vision  gradually  became  very  obscure,  until  it  was  wholly  lost,  first  in  the  left  eye, 
and  soon  after  in  tiie  right.  AVhen  the  eyelid  was  raised,  and  the  light  allowed  to  pass 
on  to  the  retina,  neither  contraction  nor  dilatation  of  the  pupil  followed,  but  the  patient 
complained  of  great  pain  at  the  back  part  of  the  orbit.  The  pupil  had  an  oval  shape, 
with  an  irregular  edge. 

For  12  or  18  months  before  consulting  Mr.  AVells,  the  imtient  had  pain  in  the  left  side, 
behind  and  below  the  false  ribs. 

During  the  course  of  the  disease,  she  was  admitted  into  a  public  hospital,  where  she 
remained  for  eleven  weeks,  and  was  treated  by  cupping,  blistering,  and  mercury,  but 
without  benefit.     She  also  tried  electricity,  but  with  no  better  success.     On  the  contrary, 


996  AMAUROSIS  FROM  LOSS   OF   THE  FLUIDS  OF   THE  BODY. 

the  symptoms  increased  under  those  means,  and  the  left  eye  became  totally  insensible  to 
the  strongest  light. 

Although  of  opinion  that  the  whole  symptoms  arose  from  the  affection  of  the  genital 
system,  Mr.  Wells  also  felt  assured  of  the  existence  of  cerebral  congestion,  and  therefore 
began  his  treatment  of  the  case  with  taking  blood  from  the  nape  of  the  neck  by  cupping, 
followed  by  a  brisk  purge  of  calomel  and  jalap. 

Some  days  after,  the  skin  being  dry,  and  the  tongue  furrowed,  he  ordered  ten  grains  of 
nitre  thrice  a  day,  and  every  night  five  grains  of  extract  of  hyoscyamus,  five  of  compound 
extract  of  colocynth,  and  two  of  blue  pill.  A  solution  of  alum  and  sulphate  of  zinc  was 
directed  to  be  injected  into  the  vagina  thrice  a  day.  In  this  plan,  with  the  use  of  occa- 
sional purgatives,  the  patient  persevered  for  more  than  a  month,  with  but  little  change  in 
the  symptoms.  As  she  then  complained  of  pain  at  the  back  of  the  head,  she  was  bled  at 
the  arm  to  18  ounces,  and  the  first  purgative  was  repeated.  She  was  ordered  strictly  to 
attend  to  the  injection,  and  to  take  the  night  pills  for  another  month.  This  she  did,  and 
with  good  effect,  as,  by  the  end  of  that  time,  she  was  able  to  raise  one  eyelid,  and  with 
one  eye  could  distinguish  objects.  Eleven  weeks  from  the  time  Mr.  Wells  first  saw  her, 
she  felt  a  sharp  pain,  which  she  explained  to  be  as  if  something  had  suddenly  parted  at 
the  back  part  of  the  head ;  and  at  that  moment  a  slight  glimmer  of  light  was  first  expe- 
rienced with  the  other  eye.  Mr.  Wells  bled  her  again  to  12  ounces  ;  and  the  power  of 
vision  went  on  gradually  to  return. 

Four  months  from  the  period  of  commencing  the  injection,  she  was  able  to  read  and 
work,  and  her  health  was  greatly  improved.  When  Mr.  Wells  drew  up  the  case,  she  was  as 
well  as  ever  she  had  been  in  her  life  ;  the  leucorrhoca  had  entirely  ceased,  and  menstru- 
ation had  become  regular.  He  mentions,  that  in  addition  to  the  pills,  half  a  drachm  of 
carbonate  of  iron  was  administered  thrice  a  day,  when  the  vision  began  to  return.™ 

Case  408. — Mrs.  S.,  when  in  her  30th  year,  was  brought  to  bed  ;  and  being  a  woman  of 
a  healthy  constitution,  chose  to  suckle  her  child  herself.  This  she  did  for  some  time, 
without  feeling  any  inconvenience  from  it ;  but,  having  continued  it  for  six  weeks,  her 
strength  began  to  fail,  and  continued  to  decline  daily  till  she  became  incapable  even  of 
moving  about  the  house,  without  experiencing  a  very  painful  languor.  About  the  same 
time,  her  sight  also  was  affected ;  at  first  only  in  a  small  degree,  but  afterwards  so  con- 
siderably, that  the  full  glare  of  the  midday  sun  appeared  to  her  no  stronger  than  the 
light  of  the  moon.  At  this  period  of  her  disorder,  no  black  specks  were  perceived  with 
either  eye,  nor  did  objects  at  any  time  appear  covered  with  a  mist  or  cloud.  She  was 
affected  with  a  violent  pain  in  the  neck,  running  upwards  to  the  side  of  the  head ;  and, 
on  this  account,  the  person  who  attended  her  thought  proper  to  take  four  ounces  of  blood, 
by  cupping,  from  the  part  first  affected.  After  this  her  sight  was  worse  than  before,  and 
it  was  not  long  before  she  entirely  lost  the  use  of  both  eyes. 

She  had  been  three  days  in  this  state  of  blindness,  when  Mr.  Wathen  was  first  desired 
to  see  her.  He  found  both  pupils  very  much  dilated,  and  remaining  unaltered  in  the 
brightest  light.  His  first  advice  was,  that  the  child  should  be  weaned  without  loss  of 
tim'e.  He  ordered,  at  the  same  time,  bark  draughts  to  be  taken  by  the  mother  three 
times  in  the  day,  prescribing  also  an  opening  medicine  to  be  taken  occasionally,  on  account 
of  a  costive  habit  of  body,  to  which  she  had  been  almost  constantly  subject  ever  since 
the  time  of  her  delivery.  To  the  use  of  these  remedies  was  added  the  frequent  applica- 
tion of  the  vapor  of  ether  to  the  eyes  and  forehead. 

On  the  fourth  day  after  this  mode  of  treatment  was  adopted.  Mi*.  Ware  visited  the 
patient,  with  Mr.  Wathen.  From  the  account  she  gave  of  herself,  her  strength  and 
spirits  seemed  to  be  in  some  degree  on  the  return ;  and  she  could  now  perceive  faint  glim- 
merings of  light,  though  the  pupils  of  both  eyes  were  in  the  same  dilated  and  fixed  state 
as  before.  The  bark  and  ether  were  continued,  and  next  day  a  strong  stream  of  the 
electric  fluid  was  poured  on  the  eyes,  whilst  several  small  electric  sparks  were  variously 
pointed  about  the  forehead  and  temples.  The  day  after  this,  to  increase  the  effect  of 
the  electricity,  the  patient  was  placed  on  a  glass-footed  stool,  and  the  same  experiments 
repeated  as  before.  This  appeared  to  have  a  considerable  influence  in  promoting  the 
cure.  The  first  trial  was  almost  immediately  followed  by  such  a  degree  of  amendment 
that  the  patient,  to  whose  sight  every  object  had  before  been  confused,  could  now  clearly 
distinguish  how  many  windows  there  were  in  the  room  where  she  sat,  though  she  was 
still  unable  to  make  out  the  frames  of  any  of  them.  On  the  third  day,  soon  after  she 
had  been  thus  electrified,  the  menstrual  discharge  came  on  for  the  first  time  since  she 
had  been  brought  to  bed,  and  continued  three  days,  during  which  it  was  thought  proper 
to  suspend  the  use  both  of  the  bark  and  the  electricity.  Immediately  after  this  they 
•  were  resumed;  and  the  effect  was  that  the  sight  mended  daily.     At  the  end  of  a  week, 

■  she  could  perceive  all  lai-ge  objects ;  and  in  a  short  time  she  could  read  even  the  smallest 
print.     Her  strength,  indeed,  did  not  return  so  quickly ;  on  which  account  she  was  advised 

■  to  remove  into  the  country,  where  the  change  of  air,  with  the  help  of  a  mild  nutritious 
•diet,  soou  restored  her  to  perfect  health." 


AMAUROSIS  FROM  IRRITATION   OP  THE   FIFTH   NERVE.  997 

§  20.  Amaurosis  from  Albuminuria. 

It  was  pointed  out  by  Dr.  Addison,''^  that  the  form  of  cerebral  disorder 
which  most  commonly  supervenes  in  the  progress  of  the  morbid  change  of 
the  kidney,  called  Bright's  disease,  or  albuminuria,  is  very  frequently  pre- 
ceded by  giddiness,  dimness  of  sight,  and  pain  in  the  head ;  and  it  has  since 
been  announced''^  by  Dr.  Landouzy,  of  Rheims,  that,  among  the  signs  of 
that  disease,  deterioration  of  vision  is  an  initial  one,  and  one  which  returns 
or  disappears  as  the  albumen  does  in  the  urine.  The  affection  of  sight  comes 
on  insensibly,  and  never  amounts  to  total  blindness.  It  is  attended  by  puffi- 
ness  of  the  eyelids,  and  frequently  by  diplopia.  The  pupils  are  dilated,  the 
patient  complains  of  the  light,  and  sees  as  if  through  a  veil.  Pain  in  the 
lumbar  regions,  oedema  of  the  lower  extremities,  ascites  and  hydrothorax 
supervene. 

Excess  in  alcoholic  drinks,  premature  venereal  indulgences,  living  or  work- 
ing in  damp  cold  places,  imperfect  nourishment  and  excessive  fatigue,  are  the 
causes  to  which  Dr  Landouzy  has  traced  the  disease. 

Should  amaurosis  appear  in  combination  with  signs  of  hypersemia  or 
inflammation  of  the  kidney,  which  constitutes  the  first  stage  of  albuminuria, 
depletion,  diuretics,  and  counter-irritation  will  be  proper ;  if  it  occur  in  the 
second  stage,  which  is  one  of  decided  alteration  of  structure,  and  of  the 
development  of  morbid  products  in  the  kidney,  the  use  of  diuretics  must  be 
persisted  in,  along  with  active  counter-irritation,  and  the  cautious  employment 
of  alteratives.  In  both  stages,  advantage  is  likely  to  be  obtained  from  the 
employment  of  the  vapor  bath.  Mercury  affects  those  laboring  under  albu- 
minuria with  more  than  ordinary  violence,  and  must  be  given,  if  given  at  all, 
with  great  circumspection. 

§  21.  Atnaurosis  from  irritation  of  branches  of  the  fifth  nerve. 

Congestion  of  the  nervous  optic  apparatus,  excited  by  irritation  of  the  fifth 
nerve,  appears  to  be  by  no  means  an  unfrequent  cause  of  sympathetic  amau- 
rosis ;  numerous  instances  being  on  record,  in  which  the  removal  of  tumors 
in  contact  with  branches  of  the  fifth  nerve,  or  of  carious  teeth,  has  been  the 
means  of  restoring  sight. 

Case  409. — A  healthy  middle-aged  man,  a  ship-painter  by  trade,  desired  Mr.  Howship's 
advice,  in  1808,  on  account  of  a  small  tumor  situated  on  the  crown  of  the  head.  It  was 
at  least  ten  years  since  he  had  first  perceived  it.  He  supposed  it  might  have  been  the  con- 
sequence of  some  blow  on  the  part,  as  those  in  his  line  of  business  were  very  subject  to 
such  accidents.  It  had  never  been  painful,  but  yet  he  thought  his  general  health  was 
giving  way,  as  for  some  years  he  had  been  subject  to  headache,  a  complaint  he  was  never 
.afflicted  with  before.  The  frequency  of  the  headache  was  increasing,  and  his  sight  had 
become  so  weak,  that  for  more  than  two  years  he  had  been  totally  unable  to  I'cad  even 
the  largest  and  clearest  print.  On  pressure,  no  pain,  or  even  sense  of  feeling,  was 
excited  in  the  tumor  on  the  scalp. 

Mr.  Howship  advised  extirpation,  which  was  done  accordingly,  by  two  elliptical  incisions 
through  the  integuments  beyond  the  basis  of  the  tumor,  the  portion  of  included  scalp, 
with  the  tumor  itself,  being  subsequently  dissected  away  from  the  pericranium,  with  which 
it  was  in  contact.  Two  small  vessels  were  tied,  and  the  integuments  brought  nearly 
together,  with  adhesive  plaster.     In  three  weeks  the  wound  was  perfectly  healed. 

On  examination,  the  tumor  proved  to  be  a  strong  cartilaginous  cyst,  seated  in  the  cellu- 
lar membrane  beneath  the  scalp.  The  cavity  of  the  cyst  was  filled  with  a  yellow  purulent 
fluid ;  the  thick  parts  of  which  had  formed  a  curdy  deposit  upon  the  sides  of  the  cavity. 

The  patient  had  not  lost  above  an  ounce  of  blood  in  the  operation,  but  he  rather  unex- 
pectedly felt  his  head  better  the  following  evening,  than  many  months  before.  He  found 
his  uneasiness  and  pain  in  the  head  continue  to  diminish  from  day  to  day,  and  stated, 
with  some  degree  of  surprise,  that  he  had  also  found  his  sight  becoming  much  stronger, 
and  clearer.  By  the  time  the  wound  was  healed,  he  had  lost  all  remains  of  pain  in  his 
head,  and  his  sight  was  so  greatly  improved,  that  he  was  now  again  able  to  read  the  same 


998  HYDROCEPHALIC  AMAUROSIS. 

small  printed  book  that  he  had  been  in  the  habit  of  using  ten  years  before  ;  nor  did  the 
pain  in  the  head,  or  the  affections  of  the  sight  afterwards  return.''^ 

Case  410. — F.  Przesmycki,  aged  30,  who  had  always  enjoyed  good  health,  with  the 
exception  of  occasional  rheumatic  pains  in  the  head  and  joints,  was  suddenly  seized,  in 
the  autumn  of  1825,  with  violent  pain  shooting  from  the  left  temple  to  the  eye  and  side 
of  the  face.  This  pain  was  attributed  to  cold  ;  it  lasted  several  days,  and  then  subsided, 
returning  periodically  without  being  so  severe  as  to  lead  him  to  consult  a  medical  man. 
But  in  two  months  it  recuri'ed  with  such  intensity,  especially  in  the  eye,  that  that  organ 
appeared  to  the  patient  about  to  start  from  its  socket,  and  at  the  same  time  he  became 
sensible  of  having  lost  the  power  of  vision  on  that  side.  This  discovery  induced  him  to 
have  recourse  to  professional  assistance,  and  for  six  months  various  plans  of  treatment 
were  adopted,  without  any  other  advantage  than  that  the  pain  became  periodical  instead 
of  continual.  At  the  expiration  of  this  period,  the  pain  acquired  new  force,  the  cheek 
became  swollen,  and  during  the  night  several  spoonfuls  of  bloody  pus  were  discharged 
from  between  the  conjunctiva  and  the  left  lower  eyelid ;  after  which  the  swelling  subsided, 
and  the  pain  diminished,  but  the  blindness  remained  as  complete  as  before.  In  three 
weeks  a  similar  discharge  took  place,  and  during  the  next  six  months  it  was  occasionally 
repeated.  In  the  winter  of  1826,  the  disease  was  so  severe,  that  at  the  commencement 
of  1827,  the  patient  proceeded  to  Wilna,  with  the  intention  of  having  the  eye  removed, 
if  he  should  find  no  other  means  of  relief. 

M.  Galenzowski,  who  was  now  consulted,  found  the  vision  of  the  left  eye  lost,  the  pupil 
remaining  dilated.  He  conceived  that  pus  had  formed  in  the  maxillary  sinus,  and  made 
its  way  along  the  orbital  part  of  the  superior  maxillary  bone  ;  but  knowing  also  that 
suppurations  of  the  upper  jaw  frequently  depend  upon  carious  teeth,  a  careful  examina- 
tion was  made,  and  a  rotten  tooth  found,  corresponding  to  the  antrum.  This  tooth  was 
extracted,  to  give  a  new  outlet  to  the  purulent  matter,  and  to  the  astonishment  of  M. 
Galenzowski  and  his  patient,  there  was  found  attached  to  its  root  a  splinter  of  wood,  about 
three  inches  long,  and  as  thick  as  the  head  of  a  pin.  The  splinter  is  supposed  to  have 
been  originally  detached  from  a  tooth-pick  of  wood,  as  no  other  probable  explanation 
could  be  given.  On  withdrawing  a  probe,  introduced  into  the  antrum,  there  followed  a 
few  drops  of  sero-purulent  fluid,  and  nine  days  afterwards  the  patient  had  completely 
regained  his  sight.'' ^ 

Case  AW. — Dr.  Vanzandt,  of  St.  Louis,  United  States,  mentioned  to  me  the  case  of  a 
young  man,  affected  with  complete  amaurosis,  excited  by  the  persistence  of  two  decidu- 
ous teeth.  As  soon  as  they  were  extracted,  the  patient  looked  up  as  if  terrified,  and 
found  his  vision  restored. 

§  22.  Hydrocephalic  amaurosis. 

Hydrocephalus  is  either  acute  or  chronic,  and  of  each  of  these  varieties, 
amaurosis  is  generally  a  symptom.  The  third  ventricle,  as  well  as  the  lateral 
ones,  being  dilated,  its  parietes  bulge  in  front,  so  as  to  press  upon  the 
chiasma. 

The  acute  hydrocephalus  of  infants  is  a  disease  which  the  oculist  is  seldom 
called  upon  to  treat,  as  other  serious  symptoms  generally  precede  the  loss  of 
sight.  Strabismus,  however,  is  not  unfrequently  the  earliest  sign  of  acute 
hydrocephalus ;  and  occasionally  it  happens  that  loss  ,of  sight  is  the  first 
symptom  which  creates  alarm.  Dr.  Graves  mentions"^  his  being  called  to 
visit  a  patient,  whom  he  found  to  be  a  fine  boy,  walking  about  in  apparently 
good  health,  but  quite  blind.  Here  amaurosis  was  the  first  symptom ; 
others  followed ;  and  the  child  died  in  a  convulsive  fit  about  a  fortnight 
afterwards. 

Frequent  and  severe  headaches  have  generally  been  troublesome  during  a 
number  of  years,  before  an  adult  is  seized  with  acute  hydrocephalus  ;  at  last, 
one  of  the  usual  attacks  is  attended  by  signs  of  pressure  on  the  brain,  delirium, 
perversion  of  language,  dilated  insensible  pupils,  and  blindness;  coma  follows, 
and  death. 

Depletion,  mercurialization,  and  counter-irritation  are  the  means  of  cure 
to  be  followed  in  adults. 

In  children,  the  disease  is  often  connected  with  a  scrofulous  constitution, 
and  the  general  health  too  much  impaired  to  allow  of  exhausting  remedies. 
If  there  is  pain,  throbbing,  and  heat"  in  the  head,  with  no  other  signs  of 


AMAUROSIS   CONSEQUENT  TO   SCARLATINA,  999 

plethora  or  congestion,  leeches  are  to  be  applied ;  the  scalp  is  to  be  kept 
wet  with  a  cold  lotion ;  and  the  child  is  to  be  purged.  Frequent  small  doses 
of  the  sulphate  of  quina  should  then  be  given,  if  the  child  is  of  a  feeble  con- 
stitution. If  the  disease  has  followed  the  suppression  of  any  eruption,  coun- 
ter-irritation behind  the  ears,  or  on  the  nape  of  the  neck,  is  to  be  employed. 

Hydrocephaloid  symptoms  sometimes  arise  from  exhaustion.  The  child  is 
afflicted  with  stupor,  the  eyelids  are  partially  shut,  and  are  immovable  on  the 
approach  or  even  actual  contact  of  the  finger;  the  respiration  is  irregular,  and 
the  pulse  frequent.  The  cool  and  pale  state  of  the  cheek,  and  the  rise,  as 
often  happens,  of  the  symptoms  from  diarrhoea,  may  suggest  the  hope  that 
the  disease  depends  more  upon  exhaustion  than  actual  disease  within  the  head. 
Nourishment,  a  little  brandy,  and  small  doses  of  carbonate  of  ammonia,  being 
administered,  the  eyelids  become  sensible  to  the  touch  of  the  fingers,  the  re- 
spiration becomes  regular,  and  recovery  takes  place."'' 

Water  in  the  ventricles  is  often  congenital.  In  this  case,  as  the  child  grows, 
the  cranium  enlarges  to  an  unnatural  size,  the  mental  and  sensorial  faculties 
are  more  or  less  impaired,  and  life  is  rarely  prolonged  beyond  a  few  years. 
Amaurosis  with  chronic  enlargement  of  the  head,  the  ventricles  being  dis- 
tended with  water,  is  a  common  occurrence.  Counter-irritation  of  the  scalp, 
and  tonics  internally,  are  sometimes  useful. 

§  23.  Amaurosis  from  injlammation  and  dropsy  of  the  hrain,  consequent 

to  scarlatina. 

This  is  one  of  the  most  remarkable  of  the  hydrocephalic  amauroses. 

It  is  no  uncommon  thing  for  a  child,  recovering  from  scarlatina,  to  be 
seized,  perhaps  after  some  exposure  to  cold,  with  headache,  followed  by 
frightful  dreams,  convulsions,  blindness,  and  coma.  These  symptoms  may 
have  been  preceded  by  albuminuria  and  by  the  oedema  frequently  supervening 
upon  scarlatina,  and,  on  that  account,  are  apt  to  be  ascribed  to  sudden  effu- 
sion in  the  brain ;  but  the  opinion  of  Dr.  Abercrombie  is,  I  think,  undoubt- 
edly correct,  that  the  disease  is  inflammatory,  and  that  the  patient  can  be 
saved  only  by  the  most  vigorous  antiphlogistic  treatment — bloodletting, 
purgatives,  and  the  like.  By  this  plan,  many  cases  perfectly  recover ;  some 
remain  ever  afterwards  liable  to  epilepsy;  others  die,  and  present  the  usual 
appearances  of  inflammatory  affections  of  the  brain. 

Case  412. — A  girl,  eight  years  old,  on  the  morning  of  the  third  day  of  the  dropsical 
disease  consequent  to  scarlatina,  complained  of  headache,  which  in  the  course  of  the  same 
day  became  extremely  violent.  In  the  evening  she  was  seized  with  convulsions,  which, 
according  to  the  report  of  her  mother,  continued  19  hours,  with  scarcely  any  intermission. 
They  then  ceased,  but  returned  in  two  hours.  In  this  interval  it  was  discovered  that  she 
was  blind,  and  that  her  pupils  were  much  dilated.  The  convulsions,  after  they  returned, 
continued  86  hours;  and  the  patient  remained  blind  eight  hours  after  they  left  her.  This 
child  recovered.  Her  swellings,  which  were  confined  to  the  face  and  hands,  disappeared 
while  the  convulsions  were  present,  but  returned  after  they  had  ceased.™ 

Case  413. — A  boy,  13  years  of  age,  on  the  morning  of  the  seventh  day  after  his  face 
had  begun  to  swell,  was  seized  with  headache;  in  the  evening  his  limbs  were  convulsed, 
and  his  sight  was  almost  entirely  lost.  His  memory,  however,  and  the  faculties  of  his 
mind  seemed  unimpaired.  His  convulsions  ceased  after  half  an  hour;  but  they  returned 
in  an  hour,  and  lasted  again  about  half  an  hour.  In  this  way  he  was  alternately  attacked, 
and  relieved,  11  times  in  twenty  hours.  During  the  convulsions,  the  external  swellings 
left  him,  and  he  complained  much  of  a  pain  in  his  belly,  increased  by  pressure.  When 
the  convulsions  had  ceased  altogether,  his  sight  became  less  imperfect;  but  his  coun- 
tenance was  pale  and  his  pulse  feeble  and  very  frequent.  The  following  morning  he 
died.™ 


1000      AMAUROSIS   FROM  MORBID   FORMATIONS  IN  THE  BRAIN. 

§  24.  Amaurosis  from  morbid  formations  in  the  brain. 

Fig.  Hooper,  PI.  X.  XL  XII.  XIII.  XIV.     Dalrymple,  PI.  XXXVI.  Fig.  3. 

The  diseases  here  referred  to  are  tumors,  formed  by  thickening  of  the  in- 
terior membranes  of  the  brain,  or  by  deposition  of  new  matter  between  their 
laminjB,  or  on  their  surfaces ;  also  tubercles,  hydatids  or  cysts,  and  fungous 
growths.  The  reader  will  find  a  good  account  of  the  symptoms  arising  from 
these  various  states  of  disease,  in  Dr.  Abercrombie's  Pathological  and  Prac- 
tical Researches  on  Diseases  of  the  Brain.  He  states,  however,  that  the 
symptoms  are  not  sufficiently  uniform,  to  enable  us  to  refer  them  particularly 
to  the  several  morbid  affections  in  question.  Their  principal  modifications 
he  brings  under  seven  heads;  viz:  1.  Long  continued  and  severe  headache 
without  any  other  remarkable  symptom.  2.  After  some  continuance  of  fixed 
headache,  affections  of  the  senses,  speech,  and  intellect.  3.  Headache,  affec- 
tions of  the  senses,  and  convulsions.  4.  Convulsions  without  any  affection 
of  the  senses.  5.  Paralysis.  6.  Prominent  symptoms  in  the  digestive  organs. 
7.  Vertigo  and  apoplectic  attacks.  The  cases  with  which  Dr.  Abercrombie 
has  illustrated  these  classes  of  symptoms  are  highly  interesting.  It  must  not, 
however,  be  supposed  that  these  classes  of  symptoms  are  at  all  times  distinct, 
and  never  mix  in  one  and  the  same  case.  That  much  remains  to  be  done  in 
regard  to  the  pathology  of  morbid  formations  in  the  brain,  is  evident  from 
the  fact  stated  by  Dr.  Abercrombie,  that  tumors  are  sometimes  met  with  in  that 
organ,  which  have  produced  no  remarkable  symptoms,  while  in  other  subjects, 
tumors  in  the  same  situation,  and  of  no  larger  size,  have  been  accompanied 
by  blindness,  convulsions,  or  paralysis. 

Beer  tells  us,  that  the  amaurosis  resulting  from  morbid  formations  in  the 
brain,  generally  attacks  both  eyes  at  once.  The  blindness  is  developed  very 
slowly,  not  with  the  sensation  of  a  black  cloud,  but  with  visus  defiguratus, 
and  with  indistinctness  and  confusion  in  the  appearance  of  all  objects.  Along 
with  these  symptoms  there  are  repeated  attacks  of  giddiness,  distressing  pho- 
topsia,  and  intolerance  of  light.  The  pupil  for  a  time  is  contracted ;  the  blood- 
vessels on  the  surface  of  the  eye  turgescent;  the  motions  of  the  eye  and  eye- 
lids at  first  convulsive,  but  afterwards  palsied,  so  that  the  eye  is  turned  im- 
movably to  one  side  and  the  upper  eyelid  cannot  be  raised.  The  pupil  now 
becomes  dilated,  and  vision  extinguished.  The  headache  generally  goes  on 
increasing,  and  pain  is  also  felt  in  the  vertebral  column.  The  pain  is  not 
uniform  in  degree,  but  remits  at  times,  and  then  increases  with  such  violence 
that  the  patient  almost  loses  his  reason.  There  takes  place,  at  last,  a  per- 
manent disorder  both  of  the  remaining  external  senses  and  of  the  mental  fac- 
ulties. Hearing  is  the  first  of  the  remaining  external  senses  which  fails ;  then 
follows  smell  or  taste,  and  sometimes  both  about  the  same  time.  At  last, 
the  patient  loses  his  memory,  and  sinks  into  general  insensibility,  or  be- 
comes maniacal.  Hydrocephalus,  and  an  attack  of  palsy,  generally  closes 
the  scene. 

Causes. — Morbid  formations  in  the  brain  rarely  occur  except  in  persons  of 
cachectic  constitution.  Their  exciting  causes  are  blows  on  the  head,  fatigue, 
anxiety,  cold,  and  the  like. 

Treatment. — In  regard  to  the  treatment  of  amaurosis,  attended  with  symp- 
toms leading  us  to  suspect  the  existence  of  some  morbid  formation  in  the 
brain,  it  is  important  to  observe,  that  such  cases  ought  by  no  means  to  be  con- 
sidered as  utterly  hopeless.  Many  cases  of  this  kind  have  their  origin  in 
inflammatory  action  ;  and,  by  proper  treatment,  we  may  often  impede  their 
progress,  prolong  the  life  of  the  patient,  render  him  more  comfortable,  and 
even  preserve  a  certain  degree  of  vision.     The  treatment  will  consist  in  keep- 


AMAUROSIS  FROM   MORBID   FORMATIONS  IN   THE  BRAIN.      1001 

ing  the  system  low  by  evacuations  and  spare  diet,  in  the  cautious  use  of 
alteratives,  cold  applications  to  the  head,  issues  or  setons  in  the  neck,  and  the 
careful  avoidance  of  all  causes  of  excitement. 

Case  414. — Elizabeth  Lindup,  19  years  of  age,  of  robust  make,  and  general  good  health, 
had  continued  for  three  years  to  complain  of  pain  and  swimming  of  her  head,  increased 
by  motion,  and  particularly  by  stooping.  These  symptoms  continued  with  occasional  ex- 
acerbations, accompanied  by  irritation  of  the  stomach,  and  a  suffusion  of  the  eyes  such 
as  is  produced  by  crying,  till  the  22d  of  April,  1810 ;  when  during  her  occupation  of  cook- 
ing a  dinner  she  was  seized  without  any  previous  warning  with  a  fit,  during  which  she  had 
no  convulsions,  but  lay  motionless,  her  inspirations  being  very  long  and  deep,  and  gradually 
becoming  less  so  till  she  recovered.  This  happened  immediately  after  the  completion  of 
the  menstrual  flux,  and  lasted  some  minutes.  Mr.  Morrah  saw  her  before  the  fit  was  quite 
over,  and  was  particularly  struck  with  the  complaint  she  made  of  an  acute  fixed  pain  of 
the  head,  and  with  the  ferrety  appeai'ance  of  the  eyes.  One  month  from  this  time  she 
had  another  fit,  which  seized  her  so  unexpectedly,  that  she  dropped  with  a  pan  of  milk  in 
her  hand ;  and  from  this  time  till  the  20th  of  August,  she  had  a  paroxysm  every  third 
week.  Each  of  these  paroxysms  might  be  said  to  consist  of  two  fits — one  in  the  evening, 
from  which  she  very  imperfectly  recovered,  till  after  a  second,  next  morning,  after  which 
she  continued  free  from  any  fit  for  three  weeks.  On  the  20th  of  August  she  had  three  fits 
in  one  day,  accompanied  by  a  considerable  derangement  of  the  stomach,  and  by  scream- 
ing, and  other  indications  of  great  suffering,  amounting  almost  to  delirium.  A  succession 
of  these  distressing  attacks,  increasing  in  severity,  and  with  stupor  intervening,  continued 
till  the  middle  of  September,  when  she  had  nearly  lost  her  hearing.  Shortly  afterwards 
she  lost  the  sight  of  her  right  eye,  and  in  14  days  more  that  of  her  left.  Her  smell  was  com- 
pletely gone,  the  olfactory  nerves  being  insensible  even  to  the  stimulus  of  hartshorn ;  her 
speech  and  power  of  deglutition  were  very  much  impaired,  and  her  left  side,  of  which  she 
had  previously  complained  as  being  affected  with  rigors,  became  paralytic.  On  Friday, 
the  7th  of  December,  she  fell  into  an  apoplectic  stupor,  which  continued  till  the  Thursday 
morning  following,  during  which  period  she  neither  spoke  nor  took  nourishment.  At  that 
time  she  roused  up,  spoke,  and  swallowed  some  refreshment,  but  soon  relapsed  into  the 
former  state ;  and  on  Friday  evening,  the  14th  of  December,  she  died.  During  the  whole 
period,  with  the  exception  of  October,  she  menstruated  regularly.  The  pulse,  till  towards 
the  conclusion,  was  not  affected  ;  there  was  no  increase  of  heat,  the  bowels  were  rather 
costive,  but  easily  acted  upon,  and  the  bladder  did  its  office.  At  all  times,  however,  the 
girl  labored  under  a  degree  of  nervous  irritability,  unaccountable  in  a  person  of  such 
general  good  health  and  robust  organization. 

On  dissection  the  vessels  of  the  dura  mater  appeared  rather  more  turgid  than  usual. 
On  removing  the  dura  mater,  the  pia  mater  was  seen  elevated  over  the  right  hemisphere 
by  a  tumor,  which  was  found  to  be  a  hydatid  or  cyst,  about  three  inches  long  by  two 
inches  broad,  imbedded  in  the  substance  of  the  brain,  from  which  it  was  liberally 
supplied  with  minute  bloodvessels.  The  left  ventricle  contained  a  little  more  fluid  than 
is  usually  found  in  a  healthy  subject ;  the  right  had  hardly  any,  being  compressed  by  the 
tumor.^ 

Case  415. — Miss  M.  A.  was  afflicted  with  severe  headache  in  the  early  part  of  1820, 
being  then  in  her  17th  year.  She  was  of  a  delicate  frame,  light  hair  and  eyes,  fair  com- 
plexion, and  mild  and  cheerful  disposition.  She  had  previously  enjoyed  good  health, 
menstruated  regularly,  had  not  received  any  blow  or  injury,  and  knew  of  no  cause  to 
which  her  complaint  could  be  assigned.  Common  means  afforded  relief,  and  she  went 
down  into  Cheshire  for  four  months  during  the  summer,  where  she  was  in  the  habit  of 
taking  daily  exercise,  and  on  one  occasion  walked  10  miles  without  much  inconvenience, 
but  was  never  entirely  free  from  headache.  Shortly  after  her  return  to  town  the  pain 
became  very  distressing,  and  she  again  derived  benefit  from  medicines,  and  the  applica- 
tion of  a  blister  to  the  neck.  In  January,  1821,  in  consequence  of  a  severe  return  of 
pain,  leeches  were  applied  to  the  forehead ;  after  which  she  had  a  long  interval  of  com- 
parative ease.  In  February  she  was  at  a  ball,  danced  for  several  hours,  and  appeared  to 
enjoy  herself  much  ;  nor  did  she  apply  for  further  advice  till  the  30th  of  May  following. 
Her  symptoms  then  became  rapidly  worse,  and  the  pain  of  the  head  assumed  a  more  serious 
character.  It  was  usually  referred  to  the  right  temple,  and  she  experienced  a  regular 
exacerbation  every  morning  to  such  a  degree,  that  in  agony  she  would  roll  about  the  bed 
for  an  hour  or  two ;  after  which  the  pain  would  gradually  subside,  and  continue  tolerable 
during  the  day.  She  was  affected  with  vertigo,  occasional  syncope,  great  dread  of 
imao-inary  objects,  a  state  of  high  nervous  irritation,  dulness  of  hearing,  and  indistinct 
vision.  She  became  short-sighted ;  objects  appeared  to  her  larger  than  natural,  and  at  times 
she  was  totally  blind  for  several  seconds.  She  had  quickness  of  pulse,  heat  of  skin,  vio- 
lent pain  in  the  stomach,  sickness,  and  vomiting.     Severe  pains,  unattended  with  any  ex- 


1002      AMAUROSIS   FROM  MORBID   FORMATIONS  IN   THE  BRAIN. 

ternal  appearance  of  inflammation,  attacked  in  succession  various  parts  of  the  body ;  at 
one  time  the  throat,  occasioning  an  extreme  difficulty  of  deglutition;  at  another  the  chest, 
impeding  the  respiration ;  at  another  different  parts  of  the  spine,  particularly  towards  the 
neck ;  also  the  knees,  the  ankles,  and  the  wrists.  Blisters,  cold  applications  to  the  head, 
mercury  in  small  doses,  not  to  the  extent  of  salivation,  and  various  other  means  were  tried, 
but  with  little  or  no  relief.  Her  health  declined  fast,  and  she  became  much  emaciated  from 
the  constant  vomiting. 

On  the  31st  of  August,  1821,  she  was  attacked,  while  in  bed,  with  a  fit  of  strong  con- 
vulsions, attended  with  strabismus  and  screaming,  which  lasted  about  half  an  hour,  and 
left  her  in  a  state  of  stupor.  Next  day  she  had  lost  all  power  over  the  body,  and  could 
not  raise  herself,  or  even  turn  from  side  to  side  in  bed  ;  her  legs  and  arms  she  could  still 
move  a  little ;  her  sight,  which,  though  imperfect,  had  hitherto  enabled  her  to  discern 
objects,  was  now  so  far  lost  that  she  could  perceive  only  the  difference  between  light  and 
darkness.  The  pupils  were  much  dilated,  but  still  slightly  affected  by  light.  Her  deaf- 
ness also  was  greatly  increased.  The  failure  in  sight  and  heai-ing  occurred  first  on  the 
left  side,  being  the  opposite  to  that  in  which  the  pain  was  originally  fixed.  The  bowels 
Tvere  obstinately  costive,  the  vomiting  and  pain  of  stomach  continued,  the  pain  of  the  head 
was  intense,  the  pulse  quick,  respiration  hurried,  skin  hot  and  dry,  sleep  tranquil  and 
without  stertor.  In  the  course  of  a  few  days  she  had  a  repetition  of  the  same  kind  of  fit, 
which  continued  to  return  with  more  or  less  frequency  and  severity,  till  within  a  short 
period  of  her  death,  generally  influenced,  however,  by  the  state  of  the  alimentary  canal. 
Sometimes  she  had  five  or  six  in  a  day,  and  occasionally  she  would  pass  several  days 
without  any  fit.  They  usually  came  on  without  warning;  sometimes  they  appeared  to  be 
produced  by  slight  exertion.  Besides  the  general  convulsive  attacks,  she  was  subject  to 
spasmodic  twitchings  and  startings  of  different  parts  of  the  body.  Sight  and  hearing  were 
soon  lost  altogether;  smell  was  also  entirely  lost ;  and  taste,  if  any  remained,  was  very 
imperfect.  She  expressed  a  desire  for  particular  articles  of  food,  but  always  complained 
of  their  being  insipid,  and  could  seldom  tell  what  she  was  eating. 

Being  deprived  of  the  use  of  all  the  organs  of  sense,  except  touch,  the  only  mode  of 
commuuication  that  could  be  devised  was  the  common  method  of  talking  with  the  fingers, 
the  person  with  whom  she  was  conversing  indicating  each  letter  upon  the  patient's  fingers. 
She  was  soon  able  to  distinguish  by  the  touch  every  person  with  whom  she  was  in  the 
habit  of  talking,  and  acquired  considerable  facility  in  this  mode  of  conversing,  guessing 
the  words  before  they  were  half  spelled.  She  would  thus  keep  one  or  other  of  her  attend- 
ants constantly  employed  when  awake.  She  was  anxious  to  amuse  herself  with  some  kind 
of  manual  occupation,  but  her  arms  were  so  feeble  that  she  could  not  bear  the  fatigue. 
Her  intellect  was  unimpaired,  except  when  under  the  influence  of  the  fits.  Slie  appeared 
to  be  aware  of  her  hopeless  condition,  and  desired  that  her  head  might  be  opened  after 
death.  She  evinced  great  patience  under  her  sufterings,  and  was  even  cheerful  when  the 
pain  was  moderate.  She  was  seldom,  however,  when  awake,  free  from  intense  pain  in  the 
head,  of  a  lancinating  or  throbbing  kind,  not  confined  to  any  particular  part.  The  paiu 
at  the  upper  and  lower  part  of  the  spine,  the  sensation  of  extreme  coldness  down  the  back, 
and  pain  in  the  right,  and  afterw.ards  in  the  left  breast,  were  also  at  times  exceedingly  dis- 
tressing. The  face  was  often  swelled,  and  at  other  times  quite  shrunk.  She  rarely  com- 
plained of  cold,  except  down  the  spine.  The  cheeks  were  subject  to  partial  flushings,  the 
heat  of  skin  was  frequently  oppressive,  and  the  itching  at  times  intolerable.  The  tongue 
was  occasionally  furred,  but  generally  clean.  She  had  no  thirst.  The  appetite,  after  the 
Tomiting  ceased,  became  almost  insatiable,  and  she  recovered  flesh.  The  eyes  retained 
their  lustre,  but  were  quite  insensible  to  light,  and  the  pupils  fully  dilated. 

Subsequently  she  had  repeated  attacks  of  bilious  vomiting,  reducing  her  each  time  to 
a  state  of  extreme  debility,  from  which  she  as  often  rallied  in  a  surprising  manner.  The 
bowels  were  obstinately  torpid,  seldom  acting  without  the  aid  of  cathartics.  She  once 
went  14  days  without  an  evacuation.  Her  symptoms  were  invariably  aggravated  when 
the  bowels  were  constipated.  The  catamenia  ceased  to  appear  after  she  was  confined  to 
bed.  Her  respiration  was  natural  and  easy ;  speech  unaltered  ;  voice  clear  and  distinct ; 
pulse  from  80  to  100,  small,  and  generally  weak ;  sleep  very  easy  and  undisturbed,  ex- 
cept by  her  crying  out  to  be  turned,  after  which  she  would  fall  asleep  again  directly. 
She  could  not  lie  on  her  back,  or  on  either  side,  but  was  unable  to  rest  in  the  same  posi- 
tion above  half  an  hour  at  .a  time,  so  that  she  required  some  person  constantly  in  attend- 
ance to  turn  her ;  and  if  this  was  not  done  as  soon  as  asked  for,  she  often  went  into  a  fit. 
She  never  recovered  the  power  of  her  body,  nor  could  she  move  her  head  in  the  least 
degree ;  but  her  sense  of  touch  continued  perfect.  Several  attempts  were  made  to  raise 
her  gradually  in  bed,  but  they  always  produced  considerable  pain,  and,  if  persisted  in, 
brought  on  a  fit.  The  medicines  exhibited  were  intended  merely  to  relieve  her  sufi'er- 
ings,  except  an  attempt  which  was  made  to  affect  the  system  with  mercury ;  but  the  fits 
increased  so  much  during  its  use,  that  it  was  discoatinued. 


CONGENITAL  AMAUROSIS. 


1003 


Fiff.  150. 


The  above  symptoms  continued  with  more  or  less  urgency  till  February,  1823,  when 
her  powers  began  to  fail  altogether,  the  stomach  rejecting  every  kind  of  food.  No  evacua- 
tion could  be  procured  from  the  bowels  without  the  aid  of  injections ;  the  whole  muscular 
system  seemed  to  lose  its  tone ;  the  limbs  were  drawn  into  a  semiflexed  position,  and  she 
had  scarcely  strength  to  move  them ;  the  lips  were  half  closed,  the  mouth  full  of  aph- 
thous ulcerations,  and  the  teeth  covered  with  sordes ;  the  features  were  distorted ;  she 
slept  with  her  eyelids  half  open ;  the  eyes  became  dim ;  inflammation  came  on  in  the 
left  eye,  which  proceeded  to  ulceration,  and  opacity  of  the  cornea.  She  expressed  no 
pain,  and  was  not  even  aware  that  the  eye  was  afl'ected.  The  urine  and  feces  were  passed 
involuntarily.  She  could  not  swallow  any  food  unless  it  was  reduced  to  a  liquid  form, 
and  then  only  with  difficulty.  She  had  a  troublesome  cough,  which,  from  her  extreme 
debility,  frequently  threatened  sufi'ocation.  Pain  in  the  head  continued  to  distress  her, 
but  the  fits  were  less  frequent,  and  appeared  incapable  of  producing  the  same  convulsive 
action,  from  want  of  power  in  the  muscles.  Her  mental  faculties  also  declined ;  she 
talked  very  little,  and  only  of  her  complaints.  Her  pulse  was  so  feeble  as  to  be  scarcely 
perceptible.  She  still  breathed  freely,  and  slept  much.  In  September,  a  slight  diarrhoea 
came  on.  She  could  now  take  scarcely  any  sustenance,  and  had  become  so  much  ema- 
ciated that  the  skin  was  excoriated  in  several  places  from  pressure.  She  died  on  the  5th 
October,  1823,  having  lingered  more  than  two  years  from  the  first  attack  of  convulsions, 
and  nearly  four  years  from  the  commencement  of  the  headache. 

The  scalp  was  slightly  oedematous.  The  bones  of  the  cranium  were  extraordinarily 
thin,  and  several  short  spiculte  projected  inwards,  from  the  posterior  part  of  each  parietal 
bone.  The  membranes  covering  the  brain  were 
free  from  disease ;  the  substance  of  the  cerebrum 
rather  softer  than  usual ;  from  eight  to  ten  ounces 
of  fluid  in  the  ventricles ;  the  membrane  lining 
the  ventricles  of  a  dingy  yellow  color.  The 
thalami  nervorum  opticorum  were  somewhat  en- 
larged, and  entirely  converted  into  a  fungous  dis- 
ease (Fig.  150),  which  Mr.  John  Hunter,  Jr.,  the 
narrator  of  the  case,  considers  to  have  been  of 
the  natm-e  of  fungus  htematodes.  A  longitudinal 
section  through  one  of  the  thalami  presented 
exactly  the  appearance  of  a  portion  of  coagulated 
blood.  The  corpora  striata  were  not  affected,  but 
the  disease  extended  into  the  adjacent  parts  of 
the  cerebrum  and  cerebellum  below,  and  also  to 
the  lower  and  posterior  edge  of  the  falx  major. 
The  optic  nerves  were  of  a  darker  color  than 
usual,  but  did  not  appear  to  be  altered  in  texture. 
The  other  cerebral  nerves  presented  no  deviation 
from  their  natural  structure.  The  spinal  marrow, 
as  far  as  could  be  traced  through  the  foramen 

magnum,  was  perfectly  healthy.  There  were  several  sharp  ridges  of  bone  at  the  basis 
of  the  cranium,  and  the  irregularities  were  all  very  strongly  marked.  No  diseased 
appearance  was  found  in  the  thorax  nor  abdomen,  except  a  number  of  small  biliary  con- 
cretions.^' 

§  25.    Congenital  amaurosis. 

Fig.  Ammon,  Theil  III.  Taf.  XVI.  XVII.  XVIII. 

Infants  of  a  few  months  have  often  been  brought  to  me,  on  account  of  a 
suspicion  of  their  being  blind.  This  suspicion  is  generally  founded  on  the 
child's  being  observed  neither  to  follow,  nor  to  be  amused  by  the  light  of  a 
candle ;  but  this  cannot  be  depended  on  as  a  sign  of  congenital  amaurosis, 
unless  it  is  attended  by  a  rolling  motion  of  the  eyes,  or  by  some  abnormal  form 
of  the  head,  indicative  of  defective  development  of  the  brain. 

In  many  cases,  where  the  suspicion  of  blindness  was  founded  merely  on 
defective  attraction  of  the  eyes  by  luminous  objects,  but  in  which  the  pupils 
were  lively,  I  have  known  a  gradual  improvement  take  place  in  the  course  of 
some  months.  In  some  instances,  the  improvement  has  been  rapid,  so  that 
before  the  end  of  the  first  year,  vision  appeared  to  be  perfect. 

Counter-irritation,  by  small  blisters  behind  the  ears,  has  sometimes  been 
useful  in  such  cases. 


1004 


CONGENITAL  AMAUROSIS. 


Congenital  amaurosis,  from  defective  development  of  some  portion  of  the 
optic  nervous  apparatus,  must  not  be  confounded  with  amaurosis  arising 
from  injury  to  the  head  of  the  child  in  instrumental  delivery. 

Case  416. — A  little  boy,  about  six  years  of  age,  was  brought  to  me  from  a  distance  for 
consultation.  I  was  informed  that  the  mother,  after  having  been  in  labor  for  thirty-six 
hours,  was  delivered  with  instruments,  by  which  the  child's  head,  just  above  the  ears, 
was  cut  on  both  sides.  During  the  first  four  weeks,  be  took  no  notice  of  anything,  not 
even  of  a  lighted  candle  brought  close  to  his  eyes.  About  the  end  of  the  fifth  week,  he 
began  to  take  a  little  notice  of  the  candle.  This  continued  for  a  week  or  two,  when  he 
began  to  take  notice  of  the  daylight.  He  continued  improving  till  he  was  six  months  old, 
taking  notice,  however,  only  of  strong  light.  The  improvement  went  on  gradually,  the 
child  taking  notice  of  objects  held  before  him,  if  placed  at  a  certain  distance  and  in  a  cer- 
tain position,  and  holding  out  his  hands  towards  them ;  but  he  never  seemed  to  fix  his 
eyes  directly  on  objects  of  bis  own  accord.  His  pupils,  when  I  saw  him,  dilated  and 
contracted  perfectly.  He  seemed  to  take  more  notice  of  people  when  in  the  open  air, 
than  when  within  doors. 


'  Langenbeck,  De  Retina  Ob.servationes  Ana- 
tomico-pathologicffi,  p.  148  ;  Gottingaj,  1836. 

^  Neue  Bibliothek  fiir  die  Chirurgie  und  Oph- 
thahnologie.  Band  iv.  p.  780;   Hannover,  1828. 

^  Traite  des  Maladies  des  Yeux,  p.  702  j 
Paris,  1847. 

*  Dictionnaire  des  Sciences  Medicales;  Tome 
xxxv.  p.  20  ;  Paris,  1819. 

'  Angiectasie,  p.  32;  Leipzig,  1808. 

'  Morbid  Anatomy  of  the  Human  Eye;  Vol. 
ii.  PI.  XV.  Fig.  1  ;  London,  1818. 

■■  Notes  to  Weller's  Manual;  Vol.  ii.  p.  79; 
Glasgow,  1821. 

*  On  Injuries  of  the  Brain,  in  the  14th  volume 
of  the  Medico-Chirurgical  Transactions. 

'  Transactions  of  a  Society  for  the  Improve- 
ment of  Medical  and  Chirurgical  Knowledge ; 
Vol.  iii.  p.  122;  London,  1812. 

'"  Ibid.,  p.  115. 

"  Pathological  and  Practical  Researches  on 
Diseases  of  the  Brain,  p.  461  ;  Edinburgh,  1829. 

'^  Cruveilhier,  Anatomie  Pathologique  du 
Corps  Humain  ;  8°>8  livraison,  PI.  3,  Figs.  1  <fc 
2;  Paris,  1830:  See  case  of  fibrous  tumor  of 
the  dura  mater,  by  Liell,  Edinburgh  Monthly 
Journal  of  Medical  Science,  Septeuiber,  1850, 
p.  201 ;  Cases  of  amaurosis  from  encephaloid 
tumor  of  skull  and  dura  mater,  by  Stanley, 
Lancet,  6  May,  1852,  p.  238. 

"  Bright,  Guy's  Hospital  Reports;  Vol.  i.  p. 
9;  London,  1836. 

'*  De  Morbis  Oculorum,  p.  75;  Gottingae, 
1746. 

"  Commentaries  on  Insanity,  p.  120;  Lon- 
don, 1828. 

"^  See  case  reported  by  I.  J.  Iken,  Lancet, 
January  9,  1836,  p.  569. 

' '  Medical  Facts  and  Observations ;  Vol.  v. 
p.  97;  London,  1794. 

"  Stevenson  on  Amaurosis,  p.  iv. :  London, 
1821. 

'"  Dublin  Journal  of  Medical  Science;  Vol. 
i.\.  p.  107;  Dublin,  1836. 

^''  Lee  on  the  Diseases  of  Women,  p.  169; 
London,  1832, 

"  Op.  eit.  p.  309. 

See  case  of  Jacob  Reutinger,  who  became 
blind  three  weeks  before  a  fatal  attack  of  apo- 
plexy, Wepferi  Historias  Apoplecticorum,  p.  14; 
Amstelajdami,  1724 :  Case  of  recovery  from 
apoplectic  amaurosis.  Portal  sur  la  Nature  et  le 


Traitement  de  I'Apoplexie,  p.  19  ;  Paris,  1811 : 
Case  of  John  Cunningham  Saunders,  Farre's 
Life  of  Saunders,  prefixed  to  a  Treatise  on  some 
practical  points  relating  to  the  Diseases  of  the 
Eye,  p.  xix. ;  London,  1811  :  Case  occurring  in 
typhus,  Armstrong's  Practical  Illustrations  of 
Typhus  Fever,  p.  29  ;  London,  1819. 

*^  Observations  on  the  Cataract  and  Gutta 
Serena,  p.  400  ;  London,  1812. 

"'  London  Medical  Repository  for  June,  1825, 
p.  443  :  See  case  by  Stilling,  Amuion's  Zeit- 
schrift  fiir  die  Ophthalmologie ;  Vol.  iii.  p.  465  ; 
Dresden,  1833. 

*'  Medical  Gazette,  February  7,1851,  p.  253. 

"  Ratio  Medendi,  Pars  C*",  p.  271 ;  Viennae, 
1763. 

''''  Ward,  London  Medical  Repository;  Vol. 
XX.  p.  217;  London,  1823  :  See  Powell,  Medi- 
cal Transactions ;  Vol.  v.  p.  223  ;  London,  1815  : 
Rayer,  Archives  Generales  de  Medecine;  Tome 
iii.  p.  350;  Paris,  1823. 

^'  Journal  de  Physiologie;  Tome  viii.  p.  28; 
Paris,  1 828. 

"'  Practical  Observations  in  Surgery  and 
Morbid  Anatomy,  by  John  Howship,  p.  121; 
London,  1816. 

"•  Ibid.,  p.  119. 

"  Inquiry  into  the  Human  Mind,  chap.  vi. 
sect.  12. 

^*  Larrey,  Recueil  de  Memoires  de  Chirurgie, 
p.  227;  Paris,  1821. 

^'  Collections  from  the  Unpublished  Writings 
of  C.  H.  Parry,  M.  D. ;  Vol.  i.  p.  561 ;  London, 
1825. 

'*  Travers's  Synopsis  of  the  Diseases  of  the 
Eye,  p.  166;  London,  1820. 

"  Allan's  System  of  Surgery;  Vol.  iii.  p. 
187;  Edinburgh,  1824:  See  case  of  Diseased 
Vision,  by  Mr.  Keir,  Lancet,  8  October,  1842, 
p.  60. 

'*  Traite  sur  les  Vers  Intestinaux,  traduit 
par  Grundler,  p.  370 ;  Paris,  1824. 

' '  Revue  Medicale  ;  Tome  iv.  p.  435 ;  Paria, 
1832. 

^°  Traite  Pratique  de  I'Amaurose,  p.  14  ; 
Paris,  1841. 

""  Cours  Complet  des  Maladies  des  Yeux,  p. 
378 ;  Paris,  1820. 

*°  Edinburgh  Medical  and  Surgical  Journal; 
Vol.  xxvi.  p.  279  ;  Edinburgh,  1826. 

*'  Abercrombie,  Op.  cit.  p.  143.   See  case  by 


CONGENITAL  AMAUROSIS. 


1005 


Pechlinus,  Observationes  Physico-Medicinae, 
Obs.  42,  p.  96 ;  Hamburg!,  1691 :  Case  by  De- 
val,  Traite  de  I'Amaurose,  p.  2 ;    Paris,  1851. 

"  Traite  des  Maladies  des  Yeux,  p.  703; 
Paris,  1847. 

''  Lehre  von  den  Augenkrankheiten ;  Band 
ii,  p.  444;  Wien,  1817. 

■■*  Osiander's  Nachrichten  von  "Wien,  p.  76 ; 
Tubingen,  1817. 

*'  Memoires  de  Cbirurgie,  par  J.  N.  Arra- 
chart,  p.  201 ;  Paris,  1805. 

"  Lancet,  April  28,  1838,  p.  173. 

*''  Howship,  Op.  cit.  p.  135. 

*'  See  case  by  Burton,  Medical  Gazette,  June 
16,  1848,  p.  1024:  Case  in  which  sulphate  of 
atropia  was  taken  internally,  Dublin  Medical 
Press,  November  13,  1850,  p.  310:  Two  cases 
by  Tufnell,  in  which  belladonna  berries  were 
swallowed  ;  Ibid.,  January  5,  1853,  p.  2. 

*'  Fatal  Effects  of  an  Over-dose  of  Stramo- 
nium, by  Duffin,  Medical  Gazette ;  Vol.  xv.  p. 
194. 

'°  See  eases,  by  Martin,  from  digitalis,  Edin- 
burgh Medical  and  Surgical  Journal ;  Vol.  Ixi. 
p.  355;  Edinburgh,  1844  :  Case  by  Devay,  from 
aconitum,  napellus.  Ibid.,  p.  496. 

"  Ogston,  Edinburgh  Medical  and  Surgical 
Journal ;  Vol.  xl.  p.  277. 

"  Pharmacologia ;  Vol.  ii.  p.  451 ;  London, 
1825. 

"  Nature  and  Treatment  of  Stomach  and 
Renal  Diseases,  p.  25  ;  London,  1840. 

''  Duplay,  Archives  Generales  de  Medecine  ; 
2«   Serie  ;  Tome  v.  p.  5  ;  Paris,  1834. 

"  Case  of  the  Effects  of  Tobacco,  by  Mar- 
shall Hall,  M.  D.;  Edinburgh  Medical  and  Sur- 
gical Journal ;  Vol.  xii.  p.  11 ;  Edinburgh,  1816. 

''  Zeitschrift  fur  Physiologie;  Vol.  i.  p.  271; 
Heidelberg,  1824. 

"  Trattato  delle  principal!  Malattie  degli 
Occhi ;  Vol.  ii.  p.  281 ;  Pavia,  1816. 

*'  Lancet,  November  3,  1838,  p.  228. 

*'  Abernethy's  Surgical  Observations  on  the 
Constitutional  Origin  and  Treatment  of  Local 
Diseases,  p.  91;  London,  1809. 

^^  Such  paroxysms  as  are  here  described  by 
Mr.  Lessey  are  generally  regarded  as  hyste- 
rical. In  a  female  who  had  long  been  subject 
to  such  fits  I  found,  on  dissection,  the  heart  of 
a  remarkably  small  size.  She  had  been  bled 
exceedingly  often  in  the  course  of  five  or  six 
years  preceding  her  death;  and  perhaps  to  this 
circumstance  the  smallness  of  the  heart  might 
be  owing. 

''  Edinburgh  Medical  and  Surgical  Journal; 
Vol.  XXV.  p.  319  ;  Edinburgh,  1826. 

^*  See  case,  by  O'Reilly,  from  hasmatesis, 
Lancet,  27  March,  1852,  p.  305  :  Case  from  loss 
of  blood  after  phlebotomy,  Esquirol,  Des  Mala- 
dies Mentales;  Tome  i.  p.  183;  Paris,  1838. 

'^^  Des  Pertes  Seminales  Involontaires;  Pa- 
ris, 1836. 

^'  Edinburgh  Medical  and  Surgical  Journal : 
Vol.  xliii.  p.  338. 

^^  Delpech,  Precis  61ementaire  des  Maladies 
reputees  Chirurgicales;  Tome  iii.  p.  238;  Paris, 
1816. 

"  Arrachart,  Op.  cit.  p.  209. 

^^  Caffo,  Resume  du  Compte-rendu  de  la  Cli- 
nique  Ophthalmologique  de  I'Hotel-Dieu,  p.  9; 
Paris,  1837. 


^*  Travers's  Synopsis  of  the  Diseases  of  the 
Eye,  p.  145 ;  London,  1820. 

"  Ibid. 

"  London  Medical  and  Surgical  Journal, 
November  3,  1832,  p.  431. 

^»  Ware's  Observations  on  the  Cataract  and 
Gutta  Serena,  p.  385  ;  London,  1812. 

^^  Guy's  Hospital  Reports;  Vol.  iv.  p.  1; 
London,  1839. 

"  Gazette  Medicale   de  Paris,  20   Octobre, 

1849,  p.  813. 

''  Howship,  Op.  cit.  p.  1. 

'"  Archives  Generales  de  Medecine;  Tome 
xxiii.  p.  261;  Paris,  1830. 

''"  London  Medical  Gazette ;  Vol.  xix.  p.  811. 

'''  Gooch's  Account  of  some  of  the  most  im- 
portant Diseases  peculiar  to  Women,  p.  355; 
London,  1829  :  Hall,  Medico-Chirurgical  Trans- 
actions ;  Vol.  xxiv.  p.  93 ;  London,  1841. 

''*  Observations  on  the  Dropsy  which  suc- 
ceeds Scarlet  Fever,  by  William  Charles  Wells, 
M.  D.,  Transactions  of  a  Society  for  the  Im- 
provement of  Medical  and  Chirurgical  Know- 
ledge ;  Vol.  iii.  p.  177;  London,  1812. 

'■'  Ibid.  p.  178. 

'°  Medico-Chirurgical  Transactions ;  Vol.  ii. 
p.  262;  London,  1823. 

"  Ibid.,  Vol.xiii.  p.  88;  London,  1825.  See 
Case  of  tumor  pressing  on  the  right  crus  cere- 
bri, right  half  of  pons  Varolii,  and  anterior 
surface  of  the  right  lobe  of  the  cerebellum,  pro- 
ducing amblyopia  of  right  eye,  and  complete 
amaurosis  of  left,  by  Boyer,  Archives  Generales 
de  Medecine,  ii®  Serie;  Tome  viii.  p.  91:  Hy- 
datids in  the  left  lateral  ventricle,  producing 
distressing  photopsia  and  complete  amaurosis, 
by  Johnson,  Medico-Chirurgical  Review,  Janu- 
ary, 1836,  p.  202  :  Tumor  pressing  on  corpora 
quadrigemina,  by  Kennion,  London  Medical 
Gazette ;  Vol.  xxii.  p.  894 :  Tumor  in  third 
ventricle,  Monro's  Morbid  Anatomy  of  the 
Brain;  Vol.  i.  p.  167;  Edinburgh,  1827:  Tu- 
mor in  posterior  part  of  cerebrum,  by  Bain- 
bridge,  Medical  Gazette,  April  10,  1840,  p.  119: 
Encephaloid  disease  of  brain,  lb. ;  Vol.  xx.xix. 
p.  1004:  Tumor  in  right  hemisphere  of  brain, 
productive  of  epilepsy  and  amaurosis.  Medical 
Times  and  Gazette,  August  13,  1853,  p.  166  : 
Tumor  below  third  ventricle,  rendering  first  one 
and  then  the  other  eye  amaurotic,  and  causing 
deafness,  by  Heath,  Ibid.,  September  10,  1853, 
p.  279  :  Cyst  in  brain,  by  Barncastle,  Lancet, 
12  December,  1846,  p.  635:  Tumor,  like  calf's- 
foot  jelly,  in  brain.  Ibid.,  29  April,  1848,  p.  468 : 
Fungous  hcematodes  in  brain.  Dublin  Medical 
Press,  11  October,  1848,  p.  230:  Case  of  amau- 
rosis of  one  eye,  and  exophthalmos,  by  Hibbert 
Taylor,  Medical  Gazette,  March,  1849,  p.  429  : 
Encephaloid  tumor  at  base  of  brain,  by  Erich- 
sen,  Ibid.;  Vol.  xlv.  p.  452:  Encephaloid  tumor 
in  optic  thalamus.  Medical  Times,  14  December, 

1850,  p.  622:  Tumor  of  cerebellum,  pressing  on 
pons  Varolii  and  fifth  nerve,  producing  amau- 
rosis and  paraplegia,  by  Beith,  Medical  Gazette, 
16  May,  1851,  p.  856:  Cyst  in  cerebellum,  by 
Reid,  Ibid.,  17  October,  1851,  p.  664:  Tubercu- 
lar tumor  of  cerebellum,  by  Bramwell,  Monthly 
Journal  of  Medical  Science,  November,  1851, 
p.  442  :  Hyperostosis  of  cranium,  with  tumoral 
basis  of  brain,  and  one  occupying  each  meatus 
auditorius  internus,  Himly,  De  Epostosi  Cranii 
rariore;  Gottingse,  1832. 


1006  ENTOZOA   IN   THE   ORGAN   OF   VISION, 


CHAPTER  XXVII. 


ENTOZOA   IN   THE  ORGAN  OF  VISION. 

Portal*  tells  ns,  that  he  found  hydatids  between  the  choroid  and  the 
retina.  From  so  meagre  a  statement,  it  is  impossible  to  determine  the  kind 
of  entozoon  which  he  saw  ;  indeed,  it  is  doubtful  whether  what  he  calls 
hydatids  were  entozoa  or  not. 
,  The  following  are  the  entozoa  which  have  been  met  with  in  the  human 
organ  of  vision  : — 

1.  Echinococcus  hominis,  in  the  areolar  tissue  of  the  orbit.  2.  Cysti- 
cercus  celltdosce,  in  the  areolar  tissue  of  the  eyelids,  under  the  conjunctiva,  in 
the  anterior  chamber,  and  in  the  cornea.  3.  Filaria  Medinensis,  under  the 
conjunctiva.  4.  Filaria  oculi  humani,  in  the  crystalline.  5.  Monostoma 
ocidi  humani,  in  the  crystalline.  6.  Distoma  oculi  humani,  in  the  crys- 
talline. 

§  1.   Echinococcus  hominis. 

The  term  hydatid,  which,  correctly  used,  comprehends  two  or  more  genera 
of  entozoa,  has  often  been  misapplied  to  common  encysted  tumors.  In  the 
following  cases,  however,  it  would  appear  that  a  number  of  echinococci  were 
contained  within  the  cavity  of  the  orbit. 

Case  417. — Charles  Rowell,  aged  forty-two,  was  admitted  into  the  London  Ophthalmic 
Infirmary,  under  the  care  of  Mr.  Lawrence,  on  the  3d  January,  1820,  with  protrusion  of 
the  globe  from  the  orbit  by  a  deep-seated  tumor,  which  had  been  growing  for  seven  years. 
He  had  applied  at  the  infirmary  at  an  earlier  period,  when  the  unnatural  prominence  of 
the  eyeball  was  distinctly  marked,  but  vision  had  not  become  impaired.  Mr.  L.,  at  that 
time,  felt  obscurely,  under  the  superciliary  arch,  a  small,  firm  protuberance,  which 
seemed  part  of  a  deep-seated  swelling,  and  considered  extirpation  as  afifording  the  only 
chance  of  relief.  The  patient  was  averse  to  this,  and  discontinued  his  attendance.  The 
complaint  had  slowly  increased,  its  progress  having  been  attended  with  great  pain,  which 
for  some  months  had  been  so  severe,  both  day  and  night,  as  to  cause  great  emaciation 
and  general  weakness. 

When  he  was  admitted  into  the  infirmary,  the  tumor  had  advanced  so  far  between  the 
upper  inner  portion  of  the  ball  and  the  eyelid,  as  to  thrust  the  globe  completely  out  of 
the  orbit.  The  upper  lid,  greatly  stretched  and  inflamed,  covered  the  ej-e  and  the 
tumor;  the  lower  lid  was  completely  everted,  and  its  membranous  lining  appeared  as  a 
thick  fleshy  mass.  The  conjunctiva  of  the  globe  was  thickened  by  chronic  inflamma- 
tion, the  consequence  of  exposure.  The  structure  of  the  eye  was  uninjured  ;  the  pupil 
of  a  middle  size,  circular  and  motionless ;  vision  destroyed.  The  tumor  was  firm,  and 
apparently  fixed  to  the  orbit,  aff'ording,  on  pressure,  an  obscure  sense  of  fluctuation. 

To  relieve  the  distension  and  pain,  and  acquire  some  further  insight  into  the  nature  of 
the  disease,  a  puncture  was  made  into  the  most  prominent  part  of  tlie  SAvelling,  when 
about  a  dessertspoonful  of  clear  watery  fluid  escaped.  Considerable  diminution  of  suf- 
fering ensued.  When  Mr.  Lawrence  examined  the  part  two  days  after,  he  found  a  soft 
white  substance  in  the  puncture,  which,  on  being  removed  with  a  pair  of  forceps,  proved 
a  hydatid.  A  few  others  escaped  when  pressure  was  made  on  the  swelling.  Some  more 
were  evacuated  next  day,  and  Mr.  L.  afterwards  cleared  out  the  whole  collection, 
amounting  to  half  a  teacupful,  by  enlarging  the  puncture,  and  injecting  water  forcibly 
into  the  cavity.  The  hydatids  varied  in  size,  from  that  of  a  filbert  to  that  of  a  small 
pea.  Some  were  entire,  others  collapsed.  Inflammation  and  suppuration  of  the  cyst 
followed,  without  much  pain ;  the  discharge  then  gradually  diminished,  and  the  opening 
closed  in  about  a  month.     The  eye  returned  to  its  natural  situation,  and  all  uneasiness 


ENTOZOA   IN   THE   ORGAN    OF   VISION.  lOOY 

ceased.  In  March,  the  only  traces  of  the  complaint  were  a  loose  and  wrinkled  state  of 
the  integuments  of  the  upper  lid,  and  eversion  of  the  lower,  A  little  motion  of  the  iris, 
and  slight  perception  of  light,  had  returned, 

Case  418. — James  Walker,  aged  twenty,  a  sail-maker,  was  admitted  into  the  Royal 
London  Ophthalmic  Hospital,  under  the  care  of  Mr.  Bowman,  August  10,  1852,  on 
account  of  a  tumor  within  the  left  orbit,  which  had  already  produced  disorganization  of 
the  globe.  At  its  inner  and  upper  parts  was  a  diffused  and  soft  swelling,  which  yielded 
to  the  finger  an  obscure  sense  of  fluctuation;  the  conjunctiva  of  the  lower  eyelid  was 
everted,  and  the  eye  itself  dislocated  forwards,  being  directed  also  somewhat  outwards 
and  downwards.  The  cornea  was  sunken,  flaccid,  and  half  opaque,  and  the  globe  par- 
tially collapsed.  At  first  sight  the  appearance  was  strongly  suggestive  of  the  existence 
of  some  malignant  growth  behind  the  eye ;  and  this  idea  was  confirmed  by  the  pale  and 
sallow  complexion  of  the  patient.  He  stated  that  three  years  previously  he  had  first 
noticed  the  undue  prominence  of  his  left  eye,  and  also  about  the  same  time  began  to 
suffer  a  severe  aching  pain  behind  it.  Both  these  symptoms  had  steadily  increased,  and, 
without  any  acute  inflammatory  affection  of  the  eye,  the  power  of  vision  had  gradually 
failed,  until  about  a  year  before  his  admission,  when  it  had  become  quite  extinct.  Ever 
since  the  commencement  of  the  disease  he  had  suffered  much  from  frontal  headache, 
■which  had  of  late  quite  prevented  him  from  sleeping ;  it  was,  indeed,  chiefly  the  severity 
of  this  symptom  which  had  induced  him  to  apply  for  advice.  He  had  been  under  much 
medical  treatment,  but  no  operative  procedure  had  been  adopted. 

August  27th.  Mr.  Bowman  determined  to  make  an  exploration  of  the  tumor,  and 
chose  for  examination  the  somewhat  elastic  part  which  was  at  the  upper  and  inner 
region,  under  cover  of  the  upper  lid.  The  lid  being  raised,  he  made  a  punctm-e  with  the 
point  of  a  knife,  and  immediately  a  quantity  of  perfectly  pellucid  water  escaped,  and  the 
swelling  sensibly  diminished.  He  now  immediately  enlarged  the  orifice  horizontally,  till 
it  was  large  enough  to  admit  his  finger,  which  he  introduced  into  a  large  cavity  extending 
doAvn  to  the  apex  of  the  orbit,  and  having  on  its  sides  the  textures  of  that  region  some- 
what thickened  and  obscured.  The  optic  nerve  and  some  of  the  recti  muscles  could, 
however,  be  felt,  as  it  were,  dissected  by  the  encroachment  of  the  cyst  in  their  inter- 
spaces. Search  was  expressly  made  for  hydatids  with  the  finger,  and  a  scoop  was  pressed 
down,  but  without  bringing  any  into  view;  and  it  was  concluded  that  the  cyst  was  a 
simple  aqueous  one,  surrounded  by  the  tissues  altered  by  its  pressure.  With  the  view  of 
obliterating  the  cyst,  a  piece  of  lint  was  inserted,  the  end  of  which  projected  from  the 
orifice  made,  and  the  patient  was  sent  to  bed  with  a  poultice  over  the  whole.  Con- 
siderable swelling  followed ;  and  at  the  end  of  about  a  week,  suppuration  being  esta- 
blished, three  hydatids  appeared  in  the  discharges,  two  of  them  being  as  big  as  large 
marbles,  and  the  third  about  half  that  size.  They  were  nearly  globular,  and  their  walls 
composed  of  a  thin  semi-pellucid  membrane. 

The  swelling  of  the  orbital  tissues  now  gradually  subsided ;  and,  at  the  beginning  of 
October,  the  parts  had  resumed  nearly  their  natural  dimensions,  the  remains  of  the 
eyeball  having  sunk  down  to  a  level  with  the  margin  of  the  orbit. 

AVithin  a  few  nights  after  the  emptying  of  the  cyst,  he  began  to  sleep  well,  the  tensive 
headache  from  which  he  had  previously  suffered  so  much  being  quite  removed.- 

§  2.    Cysticercus  telce  cellulosce. 

This  species  of  hydatid  has  been  met  with — 1.  In  the  areolar  tissue  of  the 
eyelids ;  2.  Under  the  conjunctiva ;  3.  In  the  anterior  chamber ;  and  4.  In 
the  cornea. 

Case  419. — A  lad  of  fourteen  years  of  age  was  brought  to  me  for  consultation,  with  a 
considerable  elevation  of  the  soft  parts  in  the  left  temple,  and  dilatation  of  the  zygoma. 
When  one  finger  was  placed  within  the  mouth,  and  pressure  was  made  Avith  another  finger 
externally,  the  swelling  was  perceived  to  fluctuate  obscurely.  The  antrum  was  sound. 
I  advised  a  puncture  to  be  made  into  the  swelling  within  the  mouth.  This  gave  issue  to 
a  great  number  of  hydatids,  mixed  with  glairy  fluid.  Gradually  the  swelling  fell,  and 
also  the  dilated  zygoma.  By  and  by  the  left  upper  eyelid  became  swollen  and  red.  In 
fact  it  suppurated  ;  and,  on  being  opened  with  the  lancet,  a  quantity  of  pus  was  dis- 
charged, with  six  or  eight  cysticerci  cellulosa3,  about  the  size  of  small  peas.  After  this, 
the  young  man  perfectly  recovered.* 

Case  420. — A  little  girl  of  six  years  of  age,  was  brought  to  the  Bristol  Eye  Dispensary, 
with  a  vesicular  tumor,  about  the  size  of  a  pea,  beneath  the  conjunctiva  sclerotica  of  the 
right  eye,  and  so  near  to  the  inner  canthus,  that  it  was  entirely  concealed  from  view, 
except  when  the  ej'e  was  turned  outwards.  It  was  accompanied  by  no  inflammation,  nor 
productive  of  any  inconvenience.     Neither  mother  nor  child  knew  how  long  it  had  existed. 

Mr.  Estlin  opened  the  tumor  with  a  cataract-knife,  and  a  thin  serous  fluid  escaping, 


1008  ENTOZOA  IN  THE   ORGAN   OF   VISION. 

the  distended  conjunctiva  became  immediately  flaccid.  Besides  the  clear  fluid  which  waa 
let  out,  Mr.  Estlin  observed  a  white  flat  substance,  which  he  supposed  to  be  a  flake  of 
coagulable  lymph,  or  some  caseous  matter  which  the  tumor  had  contained ;  it  was,  how- 
ever, of  a  firm  membranous  character.  On  being  immersed  in  water,  it  expanded,  and 
was  seen  to  be  a  little  bag,  which  had  been  opened,  and  which  had  attached  to  it  a  white, 
rather  solid  body,  a  line  and  a  half  in  length,  and  half  a  line  in  breadth.  The  bag  itself 
might  be  compared,  in  point  of  size,  with  the  skin  of  a  very  small  currant.  The  more 
solid  portion  appeared  within  the  cavity  of  the  bag. 

On  examining  the  substance  with  a  lens  of  an  inch  focus,  it  was  obvious  that  it  was 
the  cyst  of  a  hydatid,  the  projecting  part  being  the  head  and  neck  of  a  cysticercus  telse 
cellulose.  While  viewed  in  water,  the  four  suctorious  discs  were  observable  at  the  extre- 
mity of  the  head,  and  when  gently  compressed  between  the  glasses  of  an  aquatic  box, 
and  a  higher  power  employed,  the  double  circle  of  hooks  was  also  seen.  The  rugte  in 
the  neck  wer^  very  conspicuous.  The  head  and  neck  were  covered  with  minute  oval 
bodies,  supposed  to  be  gemmules.  On  the  head  they  were  not  very  numerous,  but  the 
neck  was  studded  with  them ;  they  were  not  only  upon  the  surface,  but  within  the  sub- 
stance of  the  neck  and  head.  Their  size  was  about  ^jj'^jj  inch.  Not  one  was  to  be  seen 
in  the  cystic  part  of  the  entozoon.  The  thick  neck,  covered  with  these  minute  oval 
bodies,  was  strongly  contrasted  with  the  fine  smooth  membrane  forming  the  globular  part 
of  the  entozoon.* 

The  following  is  the  earliest  known  instance  of  a  cysticercus  cellulosas  in 
the  anterior  chamber  of  the  human  eye.  It  occurred  in  the  practice  of  Dr. 
Schott,  and  was  published  by  Dr.  W.  Soemmerring,  in  Oken's  Isis  for  1830. 

Case  421. — In  the  left  anterior  chamber  of  a  healthy  girl  of  18  years  of  age,  a  living 
cysticercus  appeared  soon  after  an  ophthalmia ;  it  looked  like  a  little  bit  of  semi-opaque 
skin,  and  gradually  increased  in  size.  Two  months  after  its  first  appearance,  it  caused 
no  pain,  but  only  a  slightly  disagreeable  feelingwhen  it  moved  briskly;  it  impeded  vision 
only  when  it  came  directly  before  the  pupil ;  there  was  a  slight  redness  round  the  edge  of 
the  cornea.  The  cysticercus  generally  lay,  like  a  partially  dissolved  lenticular  cataract, 
at  the  bottom  of  the  anterior  chamber.  It  appeared  as  a  transparent  sphere,  presenting 
only  at  one  spot  a  milk-white,  opaque  projection.  When  the  eyelids  were  gently  rubbed, 
and  sometimes  spontaneously,  the  opaque  wrinkled  portion  of  the  sphere  became  pro- 
tuberant, and  the  slender  filiform  neck  was  slowly  pushed  out.  The  vesicular  body  of 
the  hydatid  changed,  sometimes  slowly,  sometimes  quickly,  its  spherical  form,  into  one 
which  was  broader,  oval,  or  pear-shaped.  It  commonly  lay  at  the  distance  of  from  half 
a  line  to  a  line  from  the  lower  edge  of  the  cornea,  as  the  angle  between  the  iris  and  the 
cornea  was  too  narrow  to  contain  it.  The  neck  hung  down  most  frequently  like  a  plum- 
met, and  swung  freely  towards  every  part  of  the  circumference  of  the  cornea,  according 
as  the  patient's  head  was  moved;  seldom  did  it  appear  to  take  hold  of  anything. 

After  remaining  for  seven  months  in  the  eye,  and  during  the  last  five  months  acquiring 
double  its  previous  size,  so  that  it  was  as  large  as  a  pea,  a  small  incision  into  the  cornea 
was  made  by  Dr.  Schott,  and  the  hydatid  extracted  alive,  with  Reisinger's  hook-forceps. 
Being  put  into  lukewarm  water,  it  continued  to  move  for  more  than  half  an  hour.  It 
then  became  gradually  opaque  and  white,  and,  with  the  microscope,  the  four  prominent 
suckers  surrounding  the  double  circle  of  hooks,  and  forming  the  head  of  the  animal,  were 
plainly  discerned.^ 

To  the  kindness  of  Mr.  Meikle,  of  Edinburgh,  I  owed  the  opportunity  of 
examining  the  case  of  cysticercus  in  the  anterior  chamber,  which  occurred  in 
the  practice  of  Mr.  Logan,  and  of  which  he  had  previously  published  an 
account."  The  patient,  a  lively,  healthy  girl,  of  seven  years  of  age,  was  pre- 
sent at  the  Glasgow  Eye  Infirmary,  on  the  3d  of  April,  1833,  and  the  accu- 
racy of  Mr.  Logan's  account  of  the  case  fully  recognized  by  a  great  number 
of  medical  practitioners. 

Case  422.— From  the  month  of  August,  1832,  till  about  the  middle  of  January,  1833, 
when  she  was  first  brought  to  Mr.  Logan,  the  child  had  suffered  repeated  attacks  of 
inflammation  in  the  left  eye.  Mr.  L.  found  the  cornea  so  nebulous,  and  the  ophthalmia 
so  severe,  that  he  dreaded  a  total  loss  of  sight.  He  treated  the  case  as  one  of  scrofulous 
ophthalmia ;  and  after  the  use  of  alterative  medicines  and  the  application  of  a  blister 
behind  the  ear,  the  inflammatory  symptoms  subsided,  leaving,  however,  a  slight  opacity 
of  the  lower  part  of  the  cornea.  After  a  week,  the  child  was  again  brought  to  Mr.  L., 
who,  on  examining  the  eye,  discovered,  to  his  great  surprise,  a  semi-transparent  body,  of 
about  two  lines  in  diameter,  floating  unattached  in  the  anterior  chamber.  This  body 
appeared  almost  perfectly  spherical,  except  that  there  proceeded  from  its  lower  edge  a 


ENTOZOA  IN  THE   ORGAN   OP  VISION. 


1009 


slender  process,  of  a  white  color,  with  a  slightly  bulbous  extremity,  not  unlike  the  pro- 
boscis of  a  common  fly.  This  process  Mr.  L.  observed  to  be  of  greater  specific  gravity 
than  the  spherical  or  cystic  portion,  so  that  it  always  turned  into  the  most  depending 
position.  He  also  remarked  that  it  was  projected  or  elongated  from  time  to  time,  and 
again  retracted,  so  as  to  be  completely  hid  within  the  cystic  portion,  while  this,  in  its 
turn,  assumed  various  changes  of  form,  explicable  only  on  the  supposition  of  the  whole 
constituting  a  living  hydatid. 

On  the  3d  April,  when  I  examined  the  case,  I  found  the  cornea  slightly  nebulous,  the 
eye  free  from  inflammation  and  pain,  and  the  appearances  and  movements  of  the  animal 
exactly  such  as  described  by  Mr.  Logan. 

When  the  patient  kept  her  head  at  rest,  as  she  sat  before  me,  in  a  moderate  light,  the 
animal  covered  the  two  lower  thirds  of  the  pupil.  Watching  it  carefully,  its  cystic  por- 
tion was  seen  to  become  more  or  less  spherical,  and  then  to  assume  a  flattened  form, 
while  at  one  moment  I  saw  it  thrust  its  bead  suddenly  down  to  the  bottom  of  the  anterior 
chamber  (Fig.  151),  and  at  the  next  draw  it  up  so  completely,  that  it  was  scarcely  visible 


Fig.  151. 


Fig.  152. 


(Fig.  152).  Mr.  Meikle  turned  the  child's  head  gently  back,  and  instantly  the  hydatid 
revolved  through  the  aqueous  humor,  so  that  the  head  fell  to  the  ujjper  edge  of  the  cor- 
nea, now  become  the  more  depending  part.  On  the  child  again  leaning  forwards,  it 
settled  like  a  little  balloon  in  its  former  position,  preventing  the  patient  from  seeing 
objects  directly  before  her,  or  below  the  level  of  the  eye,  but  permitting  the  vision  of 
such  as  were  placed  above. 

Mr.  Logan  had  observed  no  increase  of  size  in  the  animal  while  it  was  under  his  inspec- 
tion. Mr.  Meikle  had  watched  it  carefully  for  three  weeks,  without  observing  any  other 
change  than  a  slight  increase  in  the  opacity  of  the  cystic  portion. 

To  every  one  who  had  seen  or  heard  of  Mr.  Logan's  case,  the  question  naturally 
occurred.  Ought  not  this  animal  to  be  removed  from  the  eye  ?  Mr.  Logan  and  Mr.  Meikle 
appeared  to  have  deferred  employing  any  means  for  destroying  or  removing  it;  first, 
because  it  seemed  to  be  producing  no  mischief;  and,  secondly,  because  there  was  a 
probability  that  it  was  a  short-lived  animal,  and  likely,  therefore,  speedily  to  perish,  and 
shrink  away,  so  as  to  give  no  greater  irritation  than  a  shred  of  lenticular  capsule.  Va- 
rious means  naturally  suggested  themselves  for  killing  the  animal ;  such  as  passing  electric 
or  g.alvanic  shocks  through  the  eye,  rubbing  in  oil  of  turpentine  round  the  orbital  region, 
giving  this  medicine  internally  in  small  doses,  or  putting  the  child  on  a  course  of  sulphate 
of  quiua,  or  of  some  other  vegetable  bitter  known  to  be -inimical  to  the  life  of  the  entozoa. 
As  the  patient  appeared  to  be  in  perfect  health,  it  was  natural  to  suppose  that  the  other 
organs  were  free  from  hydatids,  and  that  change  of  diet  would  have  little  or  no  eff"ect 
upon  the  solitary  individual  in  the  aqueous  humor.  Had  she,  on  the  contrary,  presented 
a  cachectic  constitution,  with  pale  complexion,  tumid  belly,  debility,  and  fever,  none  of 
which  symptoms  were  present,  we  should  have  been  led  to  suspect  that  what  was  visible 
in  the  eye  was  but  a  sample  of  innumerable  hydatids  in  the  internal  parts  of  the  body, 
and  might  have  recommended  a  change  of  diet,  with  some  hopes  of  success. 

In  the  course  of  six  weeks  after  I  saw  the  patient,  the  cysticercus  having  enlarged  in 
size,  the  vessels  of  the  conjunctiva  and  sclerotica  become  turgid,  the  iris  changed  in  color, 
and  less  free  in  its  motions,  while  the  child  complained  much  of  pain  in  the  eye,  it  was 
decided  that  the  hydatid  should  be  extracted,  and  I  owe  to  Dr.  Robertson,  of  Edinbui'gh, 
who  operated,  the  communication  of  the  following  particulars. 

The  incision  of  the  cornea  was  performed  without  the  slightest  difiBculty,  but  no  per- 
suasion or  threats  could  induce  the  child  again  to  open  the  eye ;  she  became  perfectly 
unruly,  and  the  muscles  compressed  the  eyeball  so  powerfully,  that  the  lens  was  forced 
64 


1010  ENTOZOA  IN   THE   ORGAN   OF   VISION. 

out,  and  the  hydatid  ruptured.  The  patient  -was  put  to  bed  in  this  state.  In  the  evening, 
Dr.  R.  succeeded  in  getting  the  girl  to  open  the  eyelids,  when,  with  the  forceps,  he  ex- 
tracted from  the  lips  of  the  incision  the  remains  of  the  animal  in  shreds,  it  being  so  deli- 
cate as  scarcely  to  bear  the  slightest  touch.  A  portion  of  the  iris  remained  in  the  wound, 
which  nothing  would  induce  the  girl  to  allow  Dr.  R.  to  attempt  to  return. 

After  the  eye  healed,  the  cornea  remained  clear,  except  at  the  cicatrice,  where  it  was 
only  semi-transparent ;  the  pupil,  in  consequence  of  adhesion  to  the  cicatrice,  was  ellip- 
tical ;  and  the  opaque  capsule  of  the  lens  occupied  the  pupillary  aperture.  The  patient 
readily  recognized  the  presence  of  light. 

Case  423. — Elizabeth  Gordon,  aged  16  years,  applied  at  the  Glasgow  Eye  Infirmary,  on 
the  26tb  September,  1848,  on  account  of  obscurity  of  vision  in  her  left  eye.  In  the  an- 
terior chamber,  close  in  front  of  the  pupil,  which,  in  a  bright  light,  it  completely  covered, 
lay  a  spherical  body  about  \  inch  in  diameter,  semi-transparent,  and  having  a  good  deal 
the  appearance,  at  first  view,  of  the  nucleus  of  the  crystalline.  On  observing  it  for  some 
little  time,  it  was  evident  that  it  was  a  vesicle,  changing  occasionally  its  form  and  posi- 
tion, and  protruding  by  times  from  its  lower  edge  an  opaque  white  filament.  The  part 
first  mentioned  was,  in  fact,  the  tail-vesicle  of  a  cysticercus  cellulosos,  and  the  latter  its 
body  and  head.  The  head  was  seen  to  be  occasionally  thrust  down  nearly  to  the  bottom 
of  the  anterior  chamber,  and  then  drawn  up  completely  into  the  tail-vesicle. 

The  patient  stated,  that  about  the  middle  of  June  the  left  eye  had  been  afi'ected  with 
inflammation,  which  continued  for  about  three  weeks,  and  was  removed  after  the  applica- 
tion of  a  poultice  of  rotten  apples,  immediately  after  which  the  hydatid  was  noticed. 

She  seemed  in  good  health,  but  stated  that  she  had  never  been  robust,  and  when  a  child, 
had  been  troubled  with  ascarides  and  lumbrici. 

Objects  placed  in  a  direct  line  before  the  eye,  or  below  it,  she  saw  very  indistinctly ;  but 
when  the  light  was  moderated,  the  upper  part  of  the  pupil  expanded  past  the  obstruction 
of  the  hydatid,  leaving  the  two  lower  thirds  still  covered,  and  then  she  saw  distinctly 
objects  held  above  the  level  of  the  eye. 

From  the  1st  till  the  14th  of  October,  the  hydatid  was  an  object  of  curiosity  to  numerous 
medical  and  other  visitors. 

Sometimes  it  was  found  with  its  head  pointed  directly  towards  the  cornea,  sometimes 
with  it  turned  back  into  the  pupil.  In  both  positions,  the  opaque  white  color  of  the  body 
contrasted  strikingly  with  the  semi-pellucid  tail-vesicle.  I  tried  to  make  it  revolve  in  the 
anterior  chamber,  by  leaning  back  the  patient's  head,  but  did  not  succeed.  Its  movements 
were  observed  to  be  most  lively  in  the  morning,  or  when  the  patient  was  warm.  When 
the  patient  became  chilled,  it  moved  little,  and  retracted  its  body  into  the  tail-vesicle. 
The  extensibility  of  its  body,  neck,  and  four  lateral  suckers  was  very  great,  so  that  it  not 
only  reached  completely  to  the  bottom  of  the  anterior  chamber,  but  bent  its  head  to  one 
or  other  side  for  a  considerable  way  between  the  circumference  of  the  iris  and  that  of  the 
cornea.  (Plate  II.  Fig.  4.)  With  a  lens  of  half  an  inch  focus,  the  suckers  were  seen  elon- 
gated and  retracted  by  turns.  The  rostellum,  or  miildle  member  of  the  head,  was  also 
distinct,  but  the  cornea  of  claws  which  surrounds  this  part  could  not  be  made  out. 

In  general,  the  patient  made  no  complaint  of  pain.  Of  the  motions  of  the  hydatid  she 
was  quite  unconscious.  Once  or  twice  she  complained  of  pain  in  the  eye;  but  I  attributed 
this  rather  to  the  frequent  microscopic  examinations  to  which  the  eye  had  been  subjected, 
than  to  the  presence  of  the  cysticercus. 

Seeino-,  however,  that  vision  was  so  much  obstructed  by  it,  and  aware  that  its  presence 
in  the  eye  would  ultimately  bring  on  disorganization  of  the  textures  with  which  it  was  in 
contact,  it  was  resolved  that  it  should  be  exti-acted. 

On  the  14th  of  October,  the  patient  lying  supine,  and  her  left  eyelids  being  retracted 
by  the  fingers  of  the  assistant  and  the  operator,  I  made  a  puncture  with  Beer's  pyramidal 
knife,  at  the  temporal  edge  of  the  cornea  to  the  extent  of  ,3^  inch.  A  little  of  the  aqueous 
humor  escaping  as  I  withdrew  the  knife,  the  tail-vesfcle  of  the  hydatid  became  flattened 
and  much  expanded  between  the  iris  and  cornea.  I  immediately  passed  Schlagintweit's 
hook  through  the  wound,  seized  the  body  of  the  hydatid  with  it,  and  easily  withdrew  the 
animal  entire.  The  iris  protruded  somewhat  through  the  wound,  but  was  readily  reduced 
by  friction  through  the  medium  of  the'upper  eyelid,  so  that  the  pupil  resumed  its  natural 
form  and  place.  The  patient  was  sent  to  bed,  and  ordered  to  keep  her  eyes  shut,  and  the 
left  eye  covered  with  a  wet  rag. 

The  hydatid  was  received  into  a  teaspoonful  of  warm  blood-serum,  but  this  probably 
restrained  its  movements,  which  grew  moi-e  lively  on  its  being  transferred  into  tepid 
water.  It  continued  to  move  for  fully  forty  minutes  after  being  extracted  from  the  eye, 
but  very  feebly  for  the  latter  half  of  that  "time.  Viewed  with  a  compound  microscope, 
the  transparent  corona  of  claws  surrounding  the  rostellum  was  seen  distinctly,  the  claws 
numbering  fourteen.     The  corpuscles  scattered  over  the  neck,  and  which  by  some  have 


ENTOZOA  IN   THE   ORGAN   OF  YTSION.  1011 

been  taken  for  ova,  were  very  distinct,  as  well  as  the  four  lateral  suckers,  which  appeared 
as  if  covered,  each  of  them,  with  a  minute  enchased  cornea,  darkened  with  pigment. 

The  hydatid  is  preserved  in  the  Anatomical  Museum  of  Glasgow  College,  and  Plate  II. 
Fig.  6,  is  a  sketch  of  its  appearance  magnified  about  6  diameters,  which  I  owe  to  the  kind- 
ness of  Professor  Allen  Thomson. 

Next  day,  the  patient  felt  quite  well ;  the  eye  appeared  natural,  and  she  said  she  saw 
as  well  with  it  as  the  other.  No  reaction  followed,  and  she  was  dismissed  on  the  21st 
October. 

I  was  led  to  think  it  probable,  that  the  attack  of  ophthalmia  in  June,  immediately  pre- 
ceding the  appearance  of  the  hydatid,  was  owing  to  the  development  of  its  ovum  in  one  of 
the  bloodvessels  of  the  iris  or  choroid ;  and  that  the  inflammation  ceased  suddenly  as 
soon  as  the  hydatid  dropped  into  the  anterior  chamber,  where  it  lived  at  its  ease,  amply 
furnished  With  sustenance  from  the  aqueous  humor,  and  unrestrained  by  any  external  cyst, 
such  as  that  which  surrounds  the'  same  entozoon  when  lodged  among  the  muscles. 

As  it  was  resolved  to  extract  the  hydatid  by  an  incision  through  the  cornea,  I  tried  no 
application  to  the  eye  with  the  view  of  killing  it,  such  as  the  vapor  of  hydrocyanic  acid, 
which,  it  was  suggested,  might  perhaps  have  that  effect,  lest  the  entozoon,  being  killed, 
might  excite  inflammation,  which  it  had  evidently  not  commenced  to  do  since  assuming 
its  place  in  the  aqueous  humor ;  and  lest  the  very  means  used  to  dispatch  it  might  cause 
irritation  of  the  eye,  and  thereby  render  the  operation  more  hazardous. 

Had  the  patient  been  younger  and  not  very  staid,  I  should  have  put  her  under  the  in- 
fluence of  chloroform  before  proceeding  to  the  operation.  The  result  of  Mr.  Logan's  case, 
operated  on  by  Dr.  Robertson,  shows  the  danger  to  be  apprehended  from  restlessness  of 
the  patient,  under  similar  circumstances. 

Case  424. — Samuel  Byrne,  aged  28  years,  a  silk-dyer  from  Macclesfield,  was  admitted 
into  the  Glasgow  Eye  Infirmary,  22d  September  1850,  about  a  year  before  which  date  he 
had  observed  his  left  eye  become  intolerant  of  light,  and  the  sight  of  it  to  be  dim.  This 
was  followed,  in  about  a  fortnight,  by  the  appearance  of  an  opaque  object  in  the  anterior 
chamber,  and  this  about  eight  months  ago  was  recognized  to  be  a  cysticercus  cellulosae. 
The  eye  has  never  been  red  nor  painful.  The  hydatid  has  gradually  increased  in  size,  so 
that  the  tail-vesicle  completely  covers  the  pupil.  It  is  semi-transparent,  so  that  the  pupil 
is  seen  through  it;  it  is  observed  changing  its  figure  from  time  to  time.  The  neck  and 
head  are  greatly  developed,  being  nearly  half  an  inch  long,  and  fully  one-twentieth  of  an 
inch  thick.  The  neck  is  contracted  at  four  or  five  diS'erent  points;  the  head  is  apparently 
fixed  between  the  ii'is  and  the  cornea  at  their  temporal  edge.  (Plate  II.  Fig.  5.)  The 
hydatid  prevents  the  patient  from  seeing  any  object  with  the  left  eye,  which  is  merely 
sensible  to  light  and  shade. 

23d.  The  cysticercus,  and  especially  its  head,  more  lively.  Its  lateral  suckers  distinctly 
visible  with  the  ophthalmic  microscope,  and  from  the  centre  of  the  rostellum  a  minute 
conical  body  is  seen  to  be  darted  and  retracted  from  time  to  time.  The  tail-vesicle  is 
covered  with  white  striae.  Says  he  is  not  aware  of  ever  having  been  troubled  with  worms 
in  childhood.     Has  been  in  the  way  of  eating  wild  rabbits. 

27th.  In  presence  of  Professor  William  Thomson,  Professor  Allen  Thomson,  Mr.  Vaux, 
of  Macclesfield,  and  a  number  of  other  gentlemen,  I  proceeded  to  extract  the  hydatid,  as 
in  the  last  case.  Having  made  a  puncture  at  the  temporal  edge  of  the  cornea,  with  Beer's 
pyramidal  knife,  I  introduced  Schlagintweit's  hook,  and  seized  the  neck  of  the  hyatid 
close  to  the  head.  The  hyatid,  much  more  developed,  was  also  much  softer  than  in  Gor- 
don's case,  for,  on  attempting  to  withdraw  it,  the  head  broke  ofl^.  I  then  seized  the  neck 
nearer  to  the  tail-vesicle,  and  again  the  neck  broke  ofi".  Part  of  the  neck  projecting  from 
the  wound,  I  seized  it  with  a  small  forceps,  and  the  remainder  of  the  hydatid,  including 
the  whole  of  the  tail  vesicle,  readily  came  away.  No  protrusion  of  the  iris  took  place, 
so  that  the  pupil  retained  its  natui-al  place  and  size.  Strips  of  court  plaster  were  applied 
over  the  eyelids  of  both  eyes,  so  as  to  keep  the  eyelids  from  moving. 

3d  October.   He  has  been  up  and  going  about  for  three  days.     Eye  perfectly  well. 

The  portions  of  the  hydatid  were  carefully  put  together  by  Professor  Allen  Thomson, 
and  form  a  preparation  in  the  Anatomical  Museum  of  Glasgow  College.     Plate  II.  Fig.  7, . 
shows  the  appearance  of  the  head  and  neck,  magnified  about  12  diameters. 

Case  425. — Mr.  Canton  has  put  on  record^  the  case  of  a  boy,  about  ten  years  of  age, 
in  whom  a  gradual  diminution  of  the  vision  of  one  eye  having  occurred,  with  a  hydroph- 
thalmic  state  of  the  anterior  chamber,  and  of  such  haziness  of  the  cornea  as  completely 
to  obscure  the  ii-is  from  view,  the  eye  being  also  painful,  an  opening  was  made  through 
the  most  prominent  part  of  the  cornea  with  a  cataract-knife,  so  as  to  evacuate  a  small 
quantity  of  aqueous  humor,  along  with  what  was  suspected  to  be  the  lens  and  vitreous 
body,  but  which  turned  out,  on  being  examined  by  Mr.  Wharton  .Jones,  to  be  a  large 
cysticercus.     The  wound  healed  readily,  and  the  lad  was  released  from  his  suffering. 

Six  or  seven  months  from  this  period,  the  boy  again  applied  at  the  Royal  Westminster 


1012  ENTOZOA  IN  THE   ORGAN   OF   VISION. 

Ophthalmic  Hospital,  when  the  circumstances  of  the  case  appeared  to  require  the  eye  to 
be  again  punctured.  This  was  done,  when  a  substance  escaped,  which  some  took  for  a 
second  cysticercus,  but  which  Mr.  Canton  supposes  must  have  been  the  lens. 

The  operation  of  paracentesis  corneae  was  performed  a  third  time,  by  Mr.  Guthrie,  on 
account  of  pain  in  the  eye  and  around  the  orbit,  when  a  quantity  of  vitreous  humor  only 
was  discharged. 

The  case  appears  to  have  been  one  in  which  the  presence  of  a  cysticercus  not  having 
been  recognized  in  an  early  stage,  the  eye  was  lost  from  inflammation  of  the  cornea  and 
hydrophthalmia,  before  the  patient  applied  for  relief. 

Case.  426. — Dr.  Appia,  of  Geneva,  has  recorded^  the  case  of  a  woman,  aged  30  years, 
who  had  a  cysticercus  celluloste  between  the  lamelloe  of  her  left  cornea.  The  slow  move- 
ments of  the  hydatid  could  be  observed  by  another  person,  by  means  of  a  magnifying 
glass.  It  was  lodged  in  a  transparent  capsule  situated  within  the  lower  part  of  the  cor- 
nea, and  extended  upwards  a  little  beyond  the  edge  of  "the  pupil.  Its  size  was  that  of  a 
small  pea.  It  was  so  transparent  as  to  produce  merely  an  opaline  tinge  in  the  cornea. 
At  one  spot  a  whitish  point  was  discerned,  whence  the  animal  pushed  out  its  necli  sur- 
mounted by  a  little  head.  With  a  strong  lens,  four  openings  or  suckers  were  seen 
symmetrically  disposed  round  the  head,  and  at  its  extremity  a  double  corona  of  cilia. 
The  vesicle  was  seen  to  change  its  form,  being  sometimes  oval,  sometimes  spherical, 
according  as  the  animal  elongated  or  retracted  its  neck.  Although  its  size  was  sensibly 
increasing,  the  patient  felt  no  pain  from  it,  nor  any  particular  sensation,  except  that  the 
field  of  her  vision  became  a  little  obscured  whenever  the  animal  in  its  movements  came  to 
cover  the  edge  of  the  pupil. 

As  the  patient,  with  the  naked  eye  could  give  no  description  of  the  form  of  the  obstacle. 
Dr.  Appia  was  curious  to  try  whether  she  could  see  it  move  distinctly  with  the  aid  of  a 
lens.  He  therefore  placed  a  candle  on  the  ground  at  one  of  the  corners  of  the  room, 
and  held  a  strong  lens  before  the  eye  of  the  patient,  seated  at  the  opposite  corner.  She 
immediately  described  the  movements  of  the  hydatid,  and  could  tell  when,  by  its  succes- 
sive ascensions  and  retractions,  it  obscured  tlie  pupil  or  left  it  free. 

[Dr.  Yon  Graefe,^  of  Berlin,  has  been  enabled  by  the  aid  of  the  ophthalmo- 
scope, to  detect  cysticerci  adhering  to  the  retina  in  three  different  cases ;  and 
he  has  likewise  in  another  case  found  one  floating  in  the  vitreous  humor. — H.] 

It  appears  to  be  pretty  well  established,  that  the  cysticerci  are  only  imper- 
fect forms  of  toenia,  which,  so  long  as  they  are  in  the  encysted  or  confined 
condition,  do  not  reach  their  full  development.  Their  ova  or  embryoes  gain, 
no  doubt,  their  internal  situation  from  without ;  but  how  they  accomplish 
their  introduction  is  not  fully  known.  They  are  very  minute,  and,  being 
admitted  into  the  body  with  food  or  drink,  may  perhaps  be  carried  through 
the  capillary  vessels.  In  a  number  of  instances,  however,  the  embryoes  of 
small  entozoa  are  known  to  pierce  the  tissues  of  animals  with  great  apparent 
facility,  the  circlet  of  claws  with  which  their  head  is  provided  being  an  organ 
for  that  special  purpose.*" 

It  is  worthy  of  notice,  how  much  oftener  the  left  than  the  right  eye  has 
suffered  from  the  intrusion  of  cysticerci,  either  under  the  conjunctiva  or  into 
the  interior  of  the  or^au ;  and  how  frequently  the  appearance  of  these  entozoa 
has  been  preceded  either  by  some  slight  injury,  or  by  an  inflammatory  attack. 

§  3.   Fllaria  Medinensis. 

The  fllaria  Medinensis,  dracunculus,  or  Guinea-worm,  a  species  of  entozoon 
endemic  in  the  tropical  regions  of  Asia  and  Africa,  and  generally  developed 
in  the  sulx;utaneous  cellular  texture  of  the  lower  extremities,  and  sometimes 
of  the  scrotum,  has  occasionally  been  met  with  beneath  the  conjunctiva." 

Cast  427. — Dr.  Loney  met  with  two  cases,  both  patients  being  natives  of  Africa,  who 
applied  to  him  with  itching,  and  a  sensation  as  if  something  was  moving  about  in  the  eye. 
On  examination,  he  observed  a  worm  moving  round  and  round  the  cornea,  beneath  the 
conjunctiva,  causing  so  little  irritation  that  the  patients  appeared  unconscious  of  the 
presence  of  any  foreign  body.  Extraction  was  performed  without  any  difficulty  by  snip- 
ping off  a  small  portion  of  the  conjunctiva,  raised  on  a  tenaculum  over  the  centi-e  of  the 
worm.     Neither  worm,  when  extracted,  exceeded  two  inches  in  length.'^ 


ENTOZOA  IN  THE   ORGAN  OF  VISION. 


1013 


§  4.  Filaria  oculi  liumani. 

The  discovery  of  a  species  of  filaria  in  tlie  interior  of  the  human  eye,  we 
owe  to  Dr.  Nordmann,  of  Odessa.  On  examining  an  opaque  crystalline 
lens,  extracted  by  Grafe,  and  partially  covered  by  its  capsule,  Dr.  IST.  detected 
in  the  Morgagnian  fluid,  two  very  small  and  delicate  rings,  which,  with  the 
aid  of  the  microscope,  he  recognized  as  convoluted  filariae.  One  of  the  two 
had  been  wounded  in  the  middle,  probably  by  the  instrument  used  for  open- 
ing the  capsule,  so  that  the  intestines  protruded  from  the  body,  and  appeared 
like  fine  threads.  The  other  was  uninjured,  about  three-quarters  of  a  line 
long,  and  extremely  slender.  It  was  spirally  convoluted,  and  completely 
dead.  13 

In  a  lens  extracted  by  Dr.  Jiingken,  Dr.  Nordmann  afterwards  found  a 
living  filaria,  five  lines  and  a  half  long. 

§§  5,  6.  Monostoma  and  Distoma  oculi  Jiumani. 

In  an  extracted  lens,  Dr.  Nordmann  detected  eight  minute  individuals  of 
the  genus  monostoma;"  and  Drs.  Gescheidt  and  Ammon,  on  another  occa- 
sion, found  four  of  the  genus  distoma.^^ 


«  Cours  d'Anatomie  Medicale ;  Tome  iv.  p. 
418;  Paris,  1803. 

^  Medico-Chirurgical  Transactions;  Vol. xvii. 
p.  48  ;  London,  18.31. 

'  Medical  Times  and  Gazette,  November  6, 
1852,  p.  465. 

*  London  Medical  Gazette;  Vol.  xxii.  p.  839. 
See  a  second  case  by  Estlin,  Ibid.;  Vol.  xxvi. 
p.  5  :  Case  by  Baum,  Annales  de  I'Oculistique; 
Tome  ii.  p.  69 ;  Bruxelles,  1839  :  By  Hoering, 
Ibid.,  p.  71 :  By  Cunier,  Ibid.;  Tome  vi.  p.  271; 
Bruxelles,  1842 :  By  Canton,  Lancet,  April  22, 
1848,  p.  451 :  By  Bowman,  in  which  the  hyda- 
tid lay  between  the  external  rectus  and  the  la- 
chrymal gland,  Medical  Times  and  Gazette, 
November  6,  1852,  p.  466:  Cases  by  Sichel, 
Archives  d'Ophthalmologie ;  Tome  ii.  p.  238 ; 
Paris,  1854. 

*  Isis,  von  Oken;  1830;  Heft  vii.  p.  707  : 
Schmalz,  Tabulse  Anatomiam  Entozoorum  illus- 
trantes,  p.  11 ;  Dresdte,  1831 :  Advertisement 
appended  to  Schott's  Controverse  iiber  die  Ner- 
ven  des  Nabelstranges  und  seiner  Gef  assc ; 
Frankfurt  am  Main,  1836.  The  case  published 
by  Neumann  (Rust's  Magazin  fiir  die  gesammte 
Heilkunde;  Vol.  xxxiii.  p.  529 ;  Berlin,  1831) 
was  one  of  spontaneous  dislocation  of  the  lens, 
and  nut  a  hydatid.  His  figures,  as  well  as  his 
narrative,  show  this.     See  Edinburgh  Medical 


and  Surgical  Journal,  January,  1851,  p.  120. 
Alessi  (Delle  Elmintiasi  nelle  sue  relazioni  colla 
Oculistica,  p.  26 ;  Roma,  1850)  relates  a  case  as 
one  of  hydatid,  which  seems  to  have  been  one 
rather  of  eifused  lymph,  as,  under  the  influence 
of  calomel  and  blisters,  the  substance  seen  in 
the  eye  was  absorbed  and  disappeared. 

*  Case  of  Animalcule  in  the  eye  of  a  child, 
by  Robert  Logan;  1833. 

'  Lancet,  July,  22,  1848,  p.  n. 

'  Archives  d'Ophthalmologie;  Tome  i.  p.  58; 
Paris,  1853. 

'  [Archiv.  fiirOphthalmologie;  Vol.  i.  p. 457; 
containing  two  colored  figures  of  the  parasite, 
as  seen  within  the  eye. — H.] 

'°  Consult  Thomson,  Cyclopasdia  of  Anatomy 
and  Physiology;  Suppl.  pp.  25,40;  London, 
1862,  1854. 

"  Mongin,  Journal  de  Medecine  de  Paris, 
1770  ;  Tome  xxxii.  p.  338. 

'*  Lancet,  June  1,  1844,  p.  309. 

•^  Mikrographische  Beitrage  zur  Naturge- 
jchichte  der  wirbellosen  Thiere;  Heft  i.  p.  7; 
Berlin,  1832. 

'*  Ibid. ;  Heft  ii.  p.  ix. 

"  Zeitschrift  fUr  die  Ophthalmologie ;  VoL 
iii.  p.  75  ;  Dresden,  1833  :  On  Entozoa  in  the 
eyes  of  man  and  other  animals,  consult  Ge- 
scheidt, Ibid.,  p.  405. 


1014 


FORMULA. 


FORMULAE 


I.   INTERNAL  REMEDIES. 


1.  Emetkum  Tartratis  Antimonii. 
R.  Tartratis  Antimonii  et  Potassse  grana 

quatuor. 
Signa. — Dissolve  in  a  teacupful  of  water, 
and  give  a  teaspoonful  every  ten  minutes  till 
free  vomiting  is  produced. 

2.  Pulveres  Tartratis  Antimonii  et  Rhei. 
R.  Tartratis  Antimonii  et  Potasste  grana 

duo  ad  quatuor, 
Pulveris  Rhei  semidrachmam   ad  drach- 
mam.     Misce,  et  divide  in  Pulveres  sex. 
Signa. — One  to  be  taken  each  night. 

3.  Pulveres  DisuJphatis  Quinse. 
R.  Disulphatis  Quince, 

Amyli,  utriusque  grana  sex  ad  viginti 
quatuor. 
Misce,  terendo  in  mortaria,  et  divide  in 
pulveres  duodecim. 

Signa. — One  to  be  given  thrice  daily. 

4.  Pilulas  Calomelanos  et  Opii. 

R.  Chloridi  Hydrargyri  mitis  grana  tri- 
ginta  sex, 
Opii  desiccati  et  pulverisati  grana  no- 
vem. 
Misce,  terendo  in  mortario,  et  ope  paux- 
illi  aqufe,  fiat  massa,  in  pilulas  octodecim 
dividenda. 

Signa. — One  to  be  taken  every  eight  hours. 

5.  Pilulse  Minerales. 

R.  Arsenici  albi  grana  sex. 
Aloes  grana  nonaginta  sex, 
Opii  desiccati  et  pulverisati  grana  vi- 
ginti quatuor. 
Tere  simul,  adde  olei  menthse   piperitse 
guttas  sex,  et  ope  pauxilli  aquse,  fiat  massa, 
in  pilulas  centum  nonaginta  duo  dividenda. 
Signa. — Three  pills  to  be  taken  daily,  one 
after  each  meal. 

6.  Solutio  Persulpho-nitratis  Ferri. 

R.  Sulphatis  Ferri, 

Acidi  Nitrici,  utriusque  drachmas  tres. 
Tere  simul  per  horae  quadrantem,  adde 


aquffi  unciam  cum  semisse,  et  cola  per  char- 
tam. 

Signa. — Thrice  daily  mix  from  ten  to  thirty 
drops  in  a  wineglassful  of  water,  suck  them 
through  a  quill,  and  rinse  the  mouth  imme- 
diately afterwards  with  water. 

7.  Solutio  lodidi  Potassii. 
R.  lodidi     Potassii     semidrachmam    ad 
drachmas  duas, 
AquEe  uncias  duas. 
Solve. 

Signa. — A  teaspoonful  to  be  taken,  in  a 
wineglassful  of  water,  thrice  daily. 

8.   Tinctura  Belladonnse. 
R.  Extracti  Atropse  Belladonnae  unciam, 

Alcoholis  dilutions  libram. 
Digere  per  dies  septem,  et  cola  per  cbartam. 
Signa. — From  five  to  fifteen  drops  to  be 
taken  thrice  daily,  in  a  wineglassful  of  water. 

9.   Tinctura  Nucis  Vomicx. 
R.  Seminum  Nucis  Vomicae  rasorum  un- 
cias duas. 
Cocci  Cacti  scrupulum, 
Alcoholis  dilutions  uncias  octo, 
Olei   volatilis   Piorismarini    oflBcinalis 
drachmam. 
Digere  perdies  septem,  et  cola  per  cbartam. 
Signa. — Take  from  20  to  40  drops  thrice 
a  day,  in  a  wineglass  of  water. 

10.  Emulsio  Terebinthinse. 
R.  Olei  Terebinthinse  nurificati  unciam, 
Bicarbonatis  Sodas  grana  quindecim, 
Mucilaginis  gummi  Acacise  ArabiciB 
uncias  duas. 
jSIisce,  diligentur  terendo  in  mortario,  et 
adde  gradatim, 

Aquoe  Cinnamomi  uncias  tres, 
Aquoe  unciam, 
Syrupi  simplicis, 

Spiritus   Lavandulae  compositi,   utri- 
usque semiunciam. 
Signa. — Shake  the  phial,  and  take  a  table- 
spoonful  thrice  a  day. 


FOEMULiE. 


1015 


n.    EXTERNAL  REMEDIES. 


1.    Collyrium  Bichloridi  Hydrargyri. 
R.  Bichloridi  Hydrargyri  granum, 

Hj'drochloratis  Ammonia3  grana  sex, 
Cocci  Cacti,  granum  cum  semisse, 
Alcoholis  drachmam. 
Tere  simul,  adde  aquae  uncias  sex,  et  cola 
per  chartam. 

Signa. — Pour  out  half  a  tablespoonful  of 
this  fluid,  and  mix  it  with  as  much  boiling 
water  in  a  teacup  previously  warmed.  With 
a  piece  of  old  linen,  or  soft  sponge,  bathe 
the  eyelids  with  the  mixture,  for  a  few 
minutes ;  and  then,  by  leaning  back  the 
head,  allow  a  little  of  it  to  flow  in  upon  the 
eye.     Repeat  this  thrice  a  day. 

2.  Collyrium  Bichloridi  Hydrargyri  cum  Bel- 
ladonna, vel  Collyrium  Compositum. 
J(.  Bichloridi  Hydrargyri  granum, 

Hydrochloratis  Ammonia,  grana  sex, 
Extracti    Atropse   Belladonnas    grana 

decem, 
Cocci  cacti  granum  cum  semisse, 
Alcoholis,  ^j. 
Tere  simul,  adde  aquae  uncias  sex,  et  cola 
per  chartam. 

Signa. — As  for  No.  1. 

3.   Collyrium  Belladonnas  vel  Atropise. 
K..  Tincturse   Belladonnae  drachmam  ad 
drachmas  duas,  vel  Atropise  semi- 
granum  ad  granum, 
Aqute,  uncias  sex. 
Misce. 
Signa. — As  for  No.  1. 

4.   Collyrium  Frigidum. 
R.  Aceti  Aromatici  guttas  quinque, 
Spiritus  zEtheris  Nitrici  drachmam. 
Aquae   uncias   quinque  et   drachmas 

septem. 
Misce. 
Signa. — Pour  out  half  a  wineglassful  of 
this  fluid;  with  a  small  piece  of  clean  soft 
sponge  dipped  in  it,  and  gently  wrung, 
bathe  the  eyelids,  side  of  the  nose,  eyebrow, 
forehead  and  temple,  for  a  few  minutes ; 
and  then  allow  those  parts  to  dry  of  them- 
selves. Repeat  this  three  or  four  times 
daily,  or  as  often  as  the  eyes  feel  painful, 
hot,  or  weak  on  exposure  to  light.  The 
fluid  does  not  require  to  go  in  on  the  eye. 

5.  Solutio  Nitratis  Argenti. 
R.  Nitratis  Argenti  granas  duo  ad  decem. 
Aquae  destillataj  unciam. 
Solve,  et  cum  solutione  mitte  penicil- 
lum  parvum. 
Signa. — Pour  ten  or  twelve  drops  out  of 
the  phial  into  a  clean  wineglass.     Wash  the 
brush  with  a  little  cold  water,  and  wring  it 


gently ;  dip  it  into  the  wineglass  so  as  to 
take  up  the  drops ;  open  the  eye  and  touch 
the  inside  of  the  lower  eyelid  with  the 
brush,  so  as  to  let  the  drops  flow  in  upon 
the  eye.  Wash  the  brush,  and  keep  the 
phial  close  corked  and  standing  on  end,  till 
the  next  time  the  drops  are  to  be  used.  The 
drops  are  to  be  used  once  a  day,  or  oftener, 
if  so  directed. 

6.  Collyrium  Alkalinum. 

R.  Aquae    Potassae     semidrachmam    ad 
drachmas  duas, 
TincturiB  Catechu  scrupulum, 
Aquae  uncias  sex. 
Signa. — To  be  used  as  a  solution  for  bath- 
ing the  eye,  thrice  a  day.  Or, 

To  be  used  as  an  injection  into  the  la- 
chrymal passages. 

7.  Solutio  Lapidis  Divini. 
R.  ^Eruginis, 

Nitri  puri, 

Aluminis,  utriusque  pulverisati  uncias 
tres. 
Liquefiant  in  vase  vitreo  super  arenam 
calidam. 

Liquefactis  adde  Camphorse  tritae  drach- 
mam cum  semisse.  Misce.  Massa  refrige- 
rata  servetur  sub  nomine  Lajjidis  Divini. 

R.  Lapidis  Divini   grana   decem   ad  vi- 
ginti, 
Aquffi  Destillatse  semiunciam. 

Solve  et  cola. 

Colaturffi  adde  Vinii  Opii  drachmam  ad 
drachmas  duas. 

Aquae  Ro^rum  uncias  quatuor. 

Misce. 

Signa. — To  be  used  as  a  lotion  for  bathing 
the  eye  thrice  a  day.  Or, 

To  be  used  as  an  injection  into  the  lachry- 
mal sac. 

8.  Solutio  Belladonnas,  Aquosa. 
R.  Extracti   Atropte    Belladonnas  grana 
decem  ad  viginti, 
Aqute  unciam. 
Tere    simul    in    mortario,    et    cola    per 
chartam. 

Signa. — As  for  No.  5. 

9.  Solutio  Acetatis  Atropiae. 
R.  Atropite  granum, 

Acidi  Acetici  diluti  guttas  quinque, 

Aquae  semiunciam. 
Misce. 
Signa. — As  for  No.  5. 

10.    Unguentum  Praecipitati  Rubri. 
R.  Hydrargyri  Praecipitati  Rubri,  grana 
decem  ad  trigiuta. 


1016 


FORMULA. 


Tere  in  mortario  in  pulverem  subtilis- 
simum. 

Adde  Axungiae  unciam.  Misoe,  et  fiat 
unguentum. 

Siffna. — [In  Catarrhal  Ophthalmia.']  On 
going  to  bed,  melt  on  the  end  of  the  finger 
jfljbut  the  bulk  of  a  barleycorn  of  the  salve, 
and  anoint  with  it  the  edges  of  the  eyelids. 

[In  Opacity  of  the  Cornea.'\  Having  melted 
about  the  bulk  of  a  barleycorn  of  the  salve 
on  the  end  of  the  finger,  introduce  it  be- 
tween the  eyelids,  and,  if  possible,  beneath 
the  upper  eyelid.  Then  rub  gently,  for 
about  half  a  minute,  the  upper  eyelid  over 
the  eyeball,  so  that  the  salve  is  applied  to 
the  speck.  Repeat  this  each  night  at  bed- 
time. 

[/?i  Ophthalmia  Tarsi.'}  Having  carefully 
bathed  the  eyelids,  and  removed  with  the 
finger-nail  any  matter  which  may  be  stick- 
ing to  their  edges  or  the  eyelashes,  melt 
about  the  bulk  of  a  barleycorn  of  the  salvo 
on  the  end  of  the  finger,  and  rub  it  well 
into  the  roots  of  the  eyelashes,  and  along 
the  edges  of  the  eyelids.  Repeat  this  every 
night  at  bedtime. 


11.  Extr actum  Belladonnse. 

R.  Extracti  Atropse  Belladonnas,  drach- 
mas duas. 
Mitte  cum  extracto  penicillum  modicum. 

Siffna. — Having  fomented  the  eye  for  ten 
minutes  with  a  piece  of  flannel  wrung  out 
of  hot  water,  dip  the  brush  in  water,  and 
with  this  moisten  the  extract  till  it  becomes 
like  thick  paint ;  then  paint  it  upon  the 
eyebrow  and  outside  of  the  eyelids  morning 
and  evening. 

12.  Emplastrum  Antimoniale. 

Inducatur  linteum  idonese   formas   et 
amplitudinis     emplastro     resinoso. 
Dein  irroretur  oleo   tiglii  crotonis, 
margine  excepto.    Postea  saturetur 
oleum  pulvere  antimonii  tartarizati. 
Siffna. — Warm  the  plaster,  apply  it  to  the 
part  indicated  (behind  the  car,  to  the  tem- 
ple, &c.),  keep  it  on  for  three  days,  then 
remove  it;  apply  a  poultice  of  bread  and 
water  for  twenty-four  hours,  and  afterwards 
dress  the  part  morning  and  evening  with 
lard  or  resinous  ointment. 


INDEX 


ANATOMICAL   INTRODUCTION. 


Albino,  membrane  of  pigment  in,  xxix. 
Annulus  albidus,  xxvii. 
Anterior  chamber,  membrane  of,  xxvi. 
Aqueous  humor,  xxxiv. 

anterior  chamber  of,  ib. 

posterior  chamber  of,  ib. 
Arachnoidea  oculi,  xxvli. 
Arteries,  anterior  ciliary,  xxviii. 

long  ciliary  or  iridal,  ib. 

of  conjunctiva  and  cornea,  xxvi. 

short  or  posterior  ciliary,  xxviii. 
Artery,  central,  of  retina,  xxxv. 
Canal  of  Petit,  xxxiii. 
Canalis  hyaloideus,  ib. 
Capsule,  crystalline,  xxxii. 
Capsulo-pupillary  membrane,  xxxv. 
Choroid  coat,  xxvi. 
Ciliary  arteries,  anterior,  xxviii. 
long,  ib, 
short  or  posterior,  ib, 

body,  xxvii. 

ligament,  ib. 

muscle,  ib. 

nerves,  xxviii. 

processes,  xxvii. 
Conjunctiva  corneee,  xxv. 
Cornea,  xxiv. 

conjunctival  layer  or  epithelium  of,  xxv. 

lining  membranes  of,  xxvi. 

proper  substance  of,  xxiv. 
Corpus  ciliare,  xxvii. 

pars  plicata  of,  ib. 

pars  non-plicata  of,  ib. 
Crystalline  body,  xxxii. 

capsule,  ib. 

lens,  ib. 
Dioptric  parts  of  eye,  xxxi. 
Epithelium  of  cornea,  xxv. 
Eye,  as  an  optical  instrument,  parts  subsidiary 
to,  xxvii. 

dioptric  parts  of,  xxxi. 

lenses  of,  ib. 

specially  sensitive  parts  of,  xxix. 
Eyeball,  shape  of,  xxiii. 

tunics  of,  ib. 
Foramen  retinae  centrale,  xxx. 
Fossa  hyaloidea,  xxxi. 
Halo  signatus,  xxxiii. 

Horizontal  section  of  eye,  introduction  expla- 
natory of,  xxiii. 
Hyaloid  membrane,  xxxi. 


Iris,  xxvii. 

circular  venous  sinus  of,  xxviii. 
Jacob,  membrane  of,  xxx. 
Lamina  cribriformis,  xxix. 
Lens,  crystalline,  xxxii. 
Lenses  of  the  eye,  xxxi. 
Ligament,  ciliary,  xxvii. 
Limbus  luteus  foraminis  centralis,  xxx. 
Membrana  fusca,  xxvii. 
Membrane,  capsulo-pupillary,  xxxv. 

pupillary,  ib. 

of  anterior  chamber  of  aqueous  humor, xxvi. 
Descemet,  ib. 
Jacob,  xxx. 
pigment,  xxix. 

posterior  chamber  of  aqueous  humor, 
xxix. 
Nerve,  optic,  ib. 
Nerves,  ciliary,  xxi. 
Optic  nerve,  xxix. 

neurilemma  of,  ib. 

sheatli  of,  ib. 
Orbiculus  capsulo-ciliaris,  xxxiii. 
Papilla  conica,  xxx. 
Petit,  canal  of,  xxxiii. 
Pigment,  membrane  of,  xxix. 
Pigmentum  nigrum,  ib. 
Posterior  chamber,  membrane  of,  xxix. 
Pupil,  xxvii. 

Pupillary  membrane,  xxxv. 
Retina,  xxix. 

central  artery  of,  xxxv, 

stratum  bacillosum  of,  xxx. 
gangliosum  of,  xxxi. 
librillosum  of,  ib. 
granulosum  of,  ib. 

membrana  limitans  of,  ib. 

transparent  point  of,  xxx. 

fold  of,  ib. 

five  layers  of,  xxx. 

yellow  spot  of,  xxxi. 
Sclerotica,  xxiii. 
Section,  horizontal,  of  eye,  ib. 
Sinus  circularis  iridis,  xxviii. 
Tunics  of  eyeball,  xxiii. 
Uvea,  xxix. 
Vasa  vorticosa,  xxvi. 
Vitreous  body,  xxx. 

humor,  ib. 
Zonula  ciliaris,  vel  Zinnii,  xxxiii. 

lucida,  ib. 


INDEX 


DISEASES   OF   THE   EYE, 


Abscess  of  anterior  chamber,  604 
cornea,  602 
iris,  625,528,  535,540 
lachrymal  sac,  279,  2.83 
Meibomian  glands.  180 
orbit,  73,  74,75,  76,77,  79, 155,  311,313, 
319 
Abscission  of  iris,  809 

Absorption,  cure  of  cataract  by,  735,  770,  785 
of  iris,  52S,  635 

orbit  from  pressure,  93 
Accidental  colors,  877 

Acetate  of  lead  precipitated  on  ulcerated  con- 
junctiva, 261 
Adipose  substance,  protrusion  of  orbital,  325 
."Egilops,  282 

Albino  wants  pigmentum  nigrum,  389,  842 
Albugo,  612 

Albuminuria,  a  cause  of  amaurosis,  997 
Amaurosis,  646,  943 
apoplectic,  975 
hydrocephalic,  998 
causes  of,  946 
classifications  of,  961 
congenital,  1003 
consequent  to  scarlatina,  999 
definition  of,  943 
diagnosis  of,  703,  955 
diurnal,  926 
from  albuminuria,  997 

aneurism  of  central  artery  of  retina,  966 

apoplexy  of  retina,  965 

belladonna,  9S6 

blows  on  eye,  410 

cerebral  congestion,  972 

concussion  of  retina,  411 

or  other  injury  of  the  head,  980 
congestion  or  inflammation  of  nervous 
optic  apparatus,  981,  982,  983,984, 
986,  989, 
depressed  lens,  733,  743 
diarrhcEa,  993 
disease  in  antrum,  997 
of  frontal  sinus,  96 
lachrymal  organs,  285 
disordered  digestive  organs,  989 
dropsy  of  the  eye,  660,  662,  665 
encephalic  aneurism,  977 
enlarged  pituitary  gland,  978 
exostosis  of  orbit,  85 
fractured  cranium  with  depression,  968 


Amaurosis — continued. 

from  hffimorrhagy,  993 

hydrocephalus,  998,  999 

inflammation    of   brain    consequent    to 
scarlatina,  999 
orbital  areolar  tissue,  313 
retina,  555,  556,  558 

injuries  of  branches  of  fifth  nerve,  151 

intense  light,  981 

intoxication,  986 

irritation  of  branches  of  fifth  nerve,  997 

laceration  of  retina,  411 

leucorrhoea,  993 

lightning,  964 

loss  of  fluids,  993 

masturbation,  993 

morbid  changes  affecting  fifth  nerve,  940 
membranes  or  bones  of  cranium,  969 
in  optic  nerves,  966 
formations  in  brain,  1000 

onanism,  993 

ophthalmia3,  646 

over  exercise  of  sight,  981 

poisons,  986 

pressure  on  eye,  410 

ptyalism,  993 

sanguineous  extravasation  in  head,  975 

spermatorrhcca,  993 

suckling,  559,  993 

suppressed  menses,  983 
perspiration,  984 
purulent  discharge,  984 

tobacco,  9S7,  9S9  ' 

tumor  ori  crown  of  head,  997 

tumors  in  brain,  1000 
orbit,  326 

venery,  993 

worms,  982 

wounds  of  eye,  408,  412 

wounds  of  eyebrow  or  eyelids,  151 
general  account  of,  943 
hereditary,  947 
illustrations  of  species  of,  965 
lactantium,  559,  993 
nocturnal,  922 
prognosis  in,  956 
scrofulous  sclerotitis,  508 
seats  of,  944 

stages  and  degrees  of,  955 
symptoms  of,  949 
traumatica,  408,  410,  416 


INDEX. 


1019 


Amaurosis — continued. 
treatment  of,  956 
vaga,  953 
with  debility,  993 
Amblyopia,  911,  943 

An8esthesiaof  parts  supplied  by  fifth  nerve,  940 
Anchyloblepharon,  625 
Anchylops,  282 
Anel's  probes,  uses  of,  2S7 

syringe,  injections  with,  287 
Aneurism  by  anastomosis  in  orbit,  346 
of  eyelids,  188 
upper  maxillary  bone,  110 
of  central  artery  of  retina,  966 
cerebral  arteries,  a  cause  of  amaurosis,  977 
ophthalmic  artery,  344 
Anterior  chamber,  abscess  of,  604 

osseous  deposit  in,  647 
Antrum,  pressure  on  orbit  from,  100 

disease  of,  causing  amaurosis,  997 
Apoplexy,  amaurosis  from,  975 
of  eye,  667 
retina,  965 
Aqueous  chambers,  abolition  of,  637 
dropsy  of,  661 
evacuation  of,  426 
foreign  bodies  in,  397 
loss  of,  394 
Aquo-capsulitis,  546 
Arcus  senilis,  700 
Arthritic  ophthalmia,  541 
Artificial  eye,  652 
pupil,  797 

accidents  attending  formation  of,  827 
by  excision,  798,  800,  809,  818 
incision,  798,  806,  810 
separation,  798,  809,  821 
compound  operations  for,  826 
general  rules  regarding,  803 
.operations  for,  compared,  806 
states  of  eye  requiring,  800 
Asthenopia,  646,  908 
Astigmatism,  866 
Atresia  iridis,  519,  631 
Atrophy  of  eye,  633 

Beer's  artificial  pupil  by  incision,  812 

cataract  knife,  747 

classification  of  amaurosis,  961 
Belladonna,  amaurosis  from,  986 

uses  of,  428,  432,  465,  490,  522,  736-746 
777 
Blear  eyes,  173 
Blennorrhoea  of  excreting  lachrymal   organs, 

282 
Blepharitis  erysipelatosa,  154 

phlebitica,  157 

scrofulosa,  173 
Blepharospasm,  207 
Blood  effused  into  eye,  411,  667 

vessels,  arrangements  of,  in  ophthalmiae, 
433 

in  orbital  areolar  tissue,  312 
Blows  on  eye,  effects  of,  410 
Bonzel's  operation  for  artifical  pupil,  821 
Brain,  morbid  formations  in,  producing  amau- 
rosis, 1000 

partial  loss  of,  in  wounds  of  orbit,  67 
Buchhorn's  improvement  of  operation  for  cata- 
ract, 779 
Burns  of  conjunctiva  and  cornea,  258 

eyelids,  145 


Bursting  of  eye,  from  blows,  411 
Buzzi's  operation  for  artificial  pupil,  821 

Calculus,  lachrymal,  141,255,  308 

Meibomian,  180 
Callosity  of  eyelids,  174,  188 
Cancer,  epithelial,  165 

of  eyeball,  681 
eyelids,  165 

soft,  of  eyeball,  682 
Capsule,  aqueous,  inflammation  of,  546 

crystalline,  inflamed,  560 
injuries  of,  401 
Carbuncle  of  eyelids,  158 
Caruncula  lachrymalis,  inflammation  of,  273 

lithiasis  of,  275 

naevus  of,  274 

polypus  of,  274 

scirrhus  of,  275 
Caries  of  fossa  lachrymalis,  76 

orbit,  75,  236 

OS  unguis,  230,  295 
Cataracta  arborescens,  721 

cum  zonula,  718 

cystica,  405,  719 

fenestrata,  717 

fluido-dura,  715 

lymphatica,  619,  719 

pyramidata,  714,  720 

tremulans  vel  natatilis,  719 

traumatica,  401 
Cataract,  701 

anterior  capsular,  714 

black,  713 

bursal,  563,  719 

capsular,  714 

capsulo-lenticular,  716 

causes  of,  708 

central,  716 

classifications  of,  712,721 

complications  of,  723 

congenital,  836 

couching  of,  732 

cure  of,  by  absorption,  401,  735,  785 

cure  of,  by  operation,  727,  732 

definition  of,  701 

depression  of,  733,  735 

diagnosis  of,  703 

displacement  of,  733,  735,  788 

division  of,  735,  770,  785 

extraction  of,  734,  746,  786 

fibrinous,  719 

fluid,  722 

genera  and  species  of,  712 

glasses,  794 

green,722,  725,  838 

hard,  721 

history  of  pathology  of,  836 

lenticular,  713 

medical  treatment  of,  726 

mixed,  722 

Morgagnian,  715 

operations  for,  732,  785 

palliative  treatment  of,  726 

pigmentous,  721 

position  of  patient  in  operations  for,  729 

posterior  capsular,  714 

prognosis  in,  710 

purulent,  720 

reclination  of,  733,  735,  788 

sanguineous,  720 

secondary,  789 


1020 


INDEX. 


Cataract — continued. 

siliculose,  718,  765 

soft,  722 

spontaneous  displacement  of,  787 

tough, 722 

trabecular,  720 

treatment  of,  without  operation,  726 

questions  regarding  removal  of,  by  opera- 
tion, 727 
Cataracts  from  inflammation,  632,709 

spurious,  719 

true,  713 
Catarrhal  ophthalmia,  438 
Catarrho-rheumatic  ophthalmia,  500 
Cat's  eye,  847 

Catoptrical  examination  of  eye,  705 
Cavernous  sinus,  wound  of,  311 
Celsus  acquainted  with  operation  of  division, 

770 
Cerebral  congestion  causing  amaurosis,  972 
Chalazion,  182 
Chemosis,  434 
Cheselden's  operation  for  artificial  pupil,  798, 

811 
Chloroform,  use   in  ophthalmic  medicine  and 

surgery,  427,  697,  732,  877,  938 
Chloroma  of  lachrymal  gland,  130 

dura  mater,  969 

pericranium,  969 
Cholesterin  in  eye,  633 
Choroid  ossified,  648 

non-malignant  tumors  of,  674 

wounds  of,  408 
Choroiditis,  549 
Chrupsia,  872 
Cicatrices,  evcrsion  of  lids  from,  223 

of  cornea,  612 
Cirsophthalmia,  505 

Coarctation  of  retina,  506,  543,  663,  665 
Coloboma  palpebrx,  147 
Color-blindness,  881 
Colored  vision,  872 
Colors,  accidental,  877 

insensibility  to,  881 
Compound  ophthalmia;,  5S5 
Concussion  of  brain,  a  cause  of  amaurosis,  980 
Conical  cornea,  656- 
Conjunctiva,  atrophy  of,  623 

diseases  of,  250 

foreign  substances  adhering  to,  251 
in  sinuses  of,  255 

fungus  of,  269 

granular,  436,  445,  481,  617 

injuries  of,  256 

inflammation  of,  435,  438,  443,  461,  472, 
475,  476 

polypus  of,  268 

tumors  of,  270 

w-arts  of,  267 
Conjunctivitis  aphthosa,  475 

catarrhalis,  438 

contagiosa,  443 

Egyptiaca,  443 

erysipelatosa,  495 

gonorrhoica,  467 

leucorrhoica,  461 

morbillosa,  490 

phiegmonosa,  435 

phlyctenulosa,  476 

puro-mucous,  435 

pustulosa,  475 

scarlatinosa,  490 


Conj  uncti  vitis — continued. 

scrofulosa,  476 

variolosa,  491 
Conradi's  operation  for  cataract,  779 
Contagious  ophthalmia,  443 
Contusion  of  cornea,  391 

edge  of  orbit,  49 

eyebrow  and  eyelids,  142 
Convulsions  after  wounded  brain  through  orbit, 
56 

of  eyeball,  388,  390 
eyelids,  205 
Corectenia,  817 
Corectomia,  818 
Cornea,  abscess  of,  602 

burns  of,  258 

cicatrice  of,  612 

conical,  656 

contusion  of,  391 

dimple  of,  607 

dropsy  of,  660 

fistula  of,  394,  608 

foreign  substances  adhering  to,  251 
imbedded  in,  391 

hernia  of,  607 

incised  wounds  of,  394 

injuries  of,  391 

inflammation  of,  511 

lining  membrane  of,  inflamed,  546 

non-malignant  tumors  of,  672 

ossification  of,  647 

paracentesis  of,  426 

penetrating  wounds  of,  394 

punctured  wounds  of,  394 

rupture  of,  411,449,  839 

specks  or  opacities  of,  611,  801,  803 

transplantation  of,  829 

ulcer  of,  from  cholera,  60S 
debility,  608 

ulcers  of,  606 

and  iris,  staphyloma  of,  636 

vasculo-nebulous,  616,  6l9 

wounds  of,  394 
Corneitis,  511 

arthritica,  516 

postvariolosa,  493 

scrofulosa,  512 
Corodialysis,  821 
Corotomia,  810 
Couching,  732 

Counter-fractures  of  orbit,  52 
Crampton's  operation  for  entropium,  248 
Cranium,  membranes  or   bones  of,  producing 
amaurosis,  969 

pressure  on  orbit  from  cavity  of,  116 
Crystalline  capsule  ossified,  649 

lens  and  capsule,  injuries  of,  401 
Crystallino-capsulitis,  560 
Cyst  in  iris,  672 
Cysticercus  in  eyelid,  1007 

anterior  chamber,  1008 

cornea,  1009 

under  conjunctiva,  1008 
Cysts  in  parietes  of  orbit,  92 

Dacryocystitis  acuta,  278 

chronica,  282 
Dacryoliths,  141,  255,308 
Daviei's  operation  for  cataract,  746 
Day-blindness,  926 
Debility,  amaurosis  with,  839 
Deformation  of  orbit  from  pressure,  93 


INDEX. 


1021 


Delirium  tremens,  spectral  illusions  in,  907 
Depression  of  cataract,  733,  735,  788 

through  cornea,  736 
sclerotica,  736 
Diarrhoea,  chronic,  a  cause  of  amaurosis,  993 
Digestive  organs,  amaurosis  from  disordered, 

9S9 
Dilatation  of  orbit  from  pressure,  93 
Dimple  of  cornea,  606 
Diplochromatism  of  lens  in  glaucoma,  S35 
Diplopia,  353,  953 

unilocular,  S65 
Dislocation  of  eye,  59,  113,  416 

lens,  402 
Displacement  of  cataract,  733,  735,  788 

pupil,  502,  528 
Dissolution  of  vitreous  humor,  632 
Distichiasis,  237 
Distomain  crystalline,  1009 
Distortion  of  eyeball,  357,  387 
Division  of  cataract,  735,  770,  785 

through  cornea,  778 
sclerotica,  770 
Donegana's  operation  for  artificial  pupil,  826 
Double  vision  from  want  of  correspondence  in 
muscles  of  eyeball,  353 

with  one  eye,  865 
two  eyes,  353,  953 
Dropsy  of  aqueous  chambers,  661 

of  cornea,  660 

eye,  660 

vitreous  body,  665 

sub-choroid,  662 

sub-sclerotic,  662 
Dryness  ofeye,  121,623 
Duct  nasal,  exostosis  of,  307 

injuries  of,  277 

obliteration  of,  307 

obstruction  of,  303 
Ducts,  lachrymal,  encysted  tumor  in  vicinity  of, 
139 

injuries  of,  121 
Dura  mater,  fungus  of,  117,  946 

and    pericranium,  disease    of,    producing 
amaurosis,  946 
Dyschromatopsia,  881 

Earle's  instrument  for  extracting  cataract,  767 
Eblouissement,  9S9 
Ecchymosis  of  eyelids,  142 

under  conjunctiva,  262 
Echinococcus  in  orbit,  1006 
Ecthyma  cachecticum  affecting  iris,  533 
Ectropium,  219 

sarcomatosum,  219 
Effusion  of  blood  into  eye,  411,  667 
Effusions  into  eyeball,  656 
Egyptian  ophthalmia,  443 
Emphysema  of  eyelids,  203 

subconjunctival,  262 
Encanthis,  275 
Encysted  tumor  in  lachrymal  gland,  135 

tumors  in  orbit,  326 

in  vicinity  of  glandulae  congregatae 

and  lachrymal  ducts,  139 
of  frontal  sinus,  97 

eyelids  and  eyebrows,  185 
Enlargements  of  eyeball,  656 

of  lachrymal  gland,  125 
Entozoa  in  organ  of  vision,  1006 
Entropium,  243 
Epiphora,  123,  299,  478 


Epithelioma,  165 

Eruptions,  syphilitic,  affecting  eyelids,  165 
Erysipelas  of  eyelids,  154 
Erysipelatous  ophthalmia,  495 
Evacuation  of  aqueous  humor,  426 
Eversion  of  eyelids,  219 

puncta,  300 
Evulsion  of  eyeball,  417 
Excision,  artificial  pupil  by,  798.  808,  818 

of  upper  maxillary  bone,  105,107, 110,  111 
Excoriation,  eversion  of  eyelids  from,  221 
Excrescence  of  iris,  fungous,  673 
Exophthalmia,  135,  313,  320,508 

fungosa,  269 
Exophthalmos,  85 

anaemic,  323 

simple,  320 
Exostosis  between  nostril  and  orbit,  95 

of  frontal  sinus,  100 
maxillary  sinus,  112 
nasal  duct,  307 
orbit,  84 
Extirpation  of  eyeball,  697 

eyelids,  173 

lachrymal  gland,  132 

maxillary  fungus,  105 

orbital  tumors,  332,  335 

partial,  of  orbital  tumors,  330 
Extraction  of  cataract,  734,  746,  786 

through  semicircular  section  of  cornea,  746 
sclerotica,  767 

section  of  one-third  of  cornea,  764 
Eye,  adaptation  of  artificial,  652 

apoplexy  of,  667 

blows  on,  409,  410,  411 

dropsy  of,  660 

gunshot  wounds  of,  412 

modes  of  fixing,  during  operations,  729 

pressure  on,  410 

sanguineous  effusion  into,  411,  667,  966 
Eyeball,  atrophy  of,  633 

bursting  of,  406,  411,  416 

cancer  of,  681 

convulsions  of,  388,  390 

dislocated,  59,  113,  416 

encephaloid  tumor  of,  6S1 

enlargements  of,  656 

evulsion  of,  417 

extirpation  of,  697 

fungus  hsmatodes  of,  681 

inflammatory  diseases  of,  418 

injuries  of,  390 

malignant  affections  of,  680 

melanosis  of,  689 

oscillation  of,  388 

scirrhus  of,  681 

spongoid  or  medullary  tumor  of,  682 

tumors  within,  656 
Eyebrow,  injuries  of,  142 

tumors  in,  182 

wounds  of,  147,  150 
Eyelashes,  f^ilse,  237 

inversion  of,  237 
Eyelid,  upper,  falling  down  of,  213 

palsy  of,  215 
Eyelids,  albuminous  tumor  of,  184 

aneurism  by  anastomosis  of,  188 

anesthesia  of,  940 

burns  and  scalds  of,  145 

callosity  of,  173,  188 

cancer  of,  165 

carbuncle  of,  158 


1022 


INDEX. 


Eyelids — continued. 

contusion  and  ecchymosis  of,  142 

convulsion  of,  205 

emphysema  of,  203 

encysted  tumors  in,  185 

epithelial  cancer  of,  166 

erysipelatous  inflammation  of,  154 

eversion  of,  219 

extirpation  of,  171 

fibrinous  tumor  of,  182 

hydatids  in,  1007 

inflammation  of  edges  of,  173 

injuries  of,  142 

inversion  of,  243 

malignant  pustule  of,  159 

milium  of,  181 

naevus  maternus  of,  188 

neuralgia  of,  932 

oedema  of,  202 

palsy  of,  210,  215 

phlebitis  of,  157 

phlegmonous  inflammation  of,  153 

phlyctenula  of,  181 

poisoned  wounds  of,  144 

porrigo  larvalis  affecting,  179 

retraction  of,  218 

sarcomatous  tumor  of,  187 

scirrhus  of,  166 

spasm  of,  207 

Byphihtic  ulceration  of,  160 

eruptions  affecting,  165 
tumors  in,  182 

twitching  or  quivering  of,  205 
warts  on,  182 
wounds  of,  147 

Far-sightedness,  860 
Fever,  ophthalmitis  after,  579 
Fifth   nerve,  anesthesia  of  parts  supplied  by, 
940 
distribution  of,  932 
injuries  of  branches  of,  151 
irritation  of,  producing  amaurosis,  997 
morbid  changes  of,  producing   amaurosis, 

940 
neuralgia  of,  932 
Filaria  in  crystalline,  1013 

RIedinensis  under  conjunctiva,  1012 
Fistula  of  cornea,  394,  607 
lachrymal  sac,  2S3,  294 

spurious,  155,  157 
true  lachrymal,  140 
Foreign  bodies  in  aqueous  chambers,  397 
body  in  orbit,  58,  59,  311 
substances  adhering  to  conjunctiva,  251 
imbedded  in  cornea,  391 
in  vitreous  humor,  409 
Fossula  of  cornea,  607 
Fractured  cranium  with  depression,  producing 

amaurosis,  968 
Fractures  of  cranium,  51,  968 
edge  of  orbit,  50 
walls  of  orbit,  51,  52 
Frontal  sinus,  exostosis  of,  100 
encysted  tumors  of,  97 
inflammation  of,  96 
polypus  of,  99 
pressure  on  orbit  from,  96 
Fungus  hajmatodes  in  orbit,  342 

of  brain,  producing  amaurosis,  1000 
eyeball,  6S2 
optic  nerve,  342,  686,  691 


Fungus  hGematodes — continued. 
ofantrum,  102 

caruncula  lachrymalis,  274 
conjunctiva,  269 

from  foreign  bodies,  254 
iris,  673 

Gerontoxon,  700 

Gibson's  mode  of  extracting  soft  cataract,  765 
Gland,  lachrymal,  enlargement  or  scirrhus  of, 
126 

encysted  tumor  in,  135 

extirpation  of,  132 

inflammation  and  suppuration  of,  124 

injuries  of,  121 

scrofulous  enlargement  of,  125 
Glands  of  cilia,  inflammation  of,  173 
Glandula;  congregata;,  injuries  of,  121 

inflammation  of,  124 

encysted  tumor  in  vicinity  of,  139 
Glasses  for  cataract-patients,  794 

long-sightedness,  863 

short-sightedness,  856 

periscopic,  857,  863 
Glaucoma,  835 

acute,  549 

diplochromatism  of  lens  in,  835 

dissections  of  eyes  in  state  of,  840,  841 

its  diagnosis  from  cataract,  705 

to  be  distinguished  from  amaurosis,  943, 
955 

with  cataract,  838 
Gonorrhteal  ophthalmia,  461,  467 

conjunctivitis,  467 

iritis,  534 
Granular  conjunctiva,  436,  445,  451,  617 
Gunshot  wounds  of  orbit,  63 

eye, 412 
Gutta  opaca,  701 

serena,  943 

Haimophthalmos,  411,  667 
Half-vision,  928,  953 
Hemeralopia,  922,926 
Hemicrania,  938 
Hemiopia,  928 
Hemiplegia  facialis,  210 
Hernia  of  choroid,  505 

cornea,  478,  607 

iris,  478,  608 

lachrymal  sac,  296 
Herpes  of  eyelids,  179 

Himly's  operations  for  artificial  pupil,  809,  821 
Hordeolum,  ISl 
Hyaloid  membrane,  dissolved,  632,  840 

opacities  of,  632 

ossified,  649 
Hyaloiditis,  563 
Hyalonyxis,  770 
Hydatid  in  brain  producing  amaurosis,  1000 

of  frontal  sinus,  97 
lachrymal  gland,  135 
Hydatids  in  eyeball,  1006 

eyelids,  1007 

orbit,  1006 
Hydrocephalus,  amaurosis  from,  998,  999 
Hydrophthalmia,  660,  666 
Hydrops  of  lachrymal  sac,  298 
Hypaemia,  667 
Hyperaesthesia,  ocular,  874 
Hyperkeratosis,  656 
Hyperostosis  of  orbit,  83 


INDEX. 


102i 


Hypertrophia  lentis,  839 

Hypertrophy  of  glandulae  congregatse,  126 

lachrymal  gland,  126 
Hypochyma,  701,  720,  835 
Hypopium,  b04 

Illusions,  spectral,  906 

Incision,  artificial  pupil  by,  798,  806,  810 

through  cornea,  artificial  pupil  by,  812 
sclerr)tica,  artificial  pupil  by,  811 
Infiltration  of  orbital  cellular  membrane,  321 
Inflammation  of  aqueous  capsule,  549 

bones  of  orbit,  72 

caruncula  lachrymalis,  273 

choroid,  549 

conjunctiva,  251,  435 

cornea,  511 

crystalline  lens  and  capsule,  560 

eyelids,  erysipelatous,  154 
phlegmonous,  153 

edges  of  eyelids,  173 

excreting  lachrymal  organs,  acute,  278 
chronic,  282 

frontal  sinuses,  96 

hyaloid  membrane,  563 

internal  optic  apparatus,  a  cause  of  amau 
rosis,  981,  982,  983,  984,  986,  989 

iris,  517 

lachrymal  gland,  124 

Meibomian  follicles,  173 

ocular  capsule,  319 

orbital  cellular  membrane,  72,  154,  309 

periosteum  of  orbit,  72 

retina,  555,  559 

semilunar  membrane,  273 
Inflammations  of  eye  from  injuries,  586 

eyeball,  417 
Injections  of  lachrymal  passages,  287 
Injuries  of  branches  of  fifth  nerve,  150 

conjunctiva,  256 

cornea,  391 

crystalline  lens  and  capsule,  401 

eyeball,  390 

eyebrow  and  eyelids,  142 

head,  amaurosis  from,  968 

iris,  399 

lachrymal  canals,  276 

gland  and  ducts,  121 
sac,  277 

muscles  of  eyeball,  352 

nasal  duct,  277 

orbit,  49 

orbital  areolar  tissue,  310 
Inoculation,  cure  of  granular  conjunctiva  by, 

622 
Insensibility  to  certain  colors,  881 
Intermittent  ophthalmia,  599 
Intoxication  producing  amaurosis,  973,  986 
Inversion  of  eyelashes,  237 

eyelids,  243 
Iris,  absce?s  of,  525,  535 

abscission  of,  809 

absorption  of,  528,  635 

accidental    separation    of,   from    choroid, 
400 

cyst  in,  692 

fungous  excrescence  of,  673 

hernia  of,  478,608 

inflammation  of,  517 

injuries  of,  399 

non-malignant  tumors  of,  672 

paralysis  of,  830,  831 


Iris — continued. 

abnormal  states  of,  830 

prolnpsiis  of,  395,  758,  817 

staphyloma  of,  635,  759 

tremulous,  834 
Iritis,  517 

arthritica,  541 

from  ecthyma  cachecticum,  533 

gonorrhoica,  534 

idiopathica,  523 

pseudo-syphilitica,  533 

rheumatica,  523 

scrofulosa.  538 

syqjpathetica,  590 

syphilitica,  527 

traumatica,  586 

with  amaurosis  after  fever,  579 
Iridodonesis,  834 
Iridoncosis,  634 
Iridoncus,  634 
Iridoplegia,  830 
Irritation  of  fifth  nerve,  amaurosis  from,  997 

Jacob's  cataract  needle,  779 
Jaeger's  (C  )  operation  for  trichiasis,  240 
(F.)  operation  for  trichiasis,  241 
Janin's  ointment,  177 

operation  for  artificial  pupil,  813 

Kepler  explains  effects  of  glasses,  856 
Keratitis,  511 
Keratonyxis,  778 

Lachrymal  calculus,  141,  255,  276,  308 
canals,  injuries  of,  276 

obstruction  of,  301 
ducts,  encysted  tumor  in  vicinity  of,  139 
fistula,  true,  140 
gland  and  ducts,  injuries  of,  121 
chloroma  of,   130 

enlargement  or  scirrhus  of,  126,  131 
encysted  tumor  in,  135 
extirpation  of,  132 
hsmorrhagy  from,  141 
hypertrophy  of,  126 
inflammation  and  suppuration  of,  124 
scrofulous  enlargement  of,  125 
organs,  acute  inflammation  of  excreting, 
278 
chronic  inflammation  of  excreting,  282 
diseases  of  excreting,  276 
secreting,  121 
produce  amaurosis,  285 
puncta,  eversion  of,  300 
obstruction  of,  301 
relaxation  of,  299 
sac,  abscess  of,  279,  294 
blennorrhoea  of,  282 
fistula  of,  2S3,  294 
hernia  of,  296  ' 

hydrops  of,  298 
injuries  of,  277 
mucocele  of,  298 
polypus  of,  308 
relaxation  of,  297 
spurious  fistula  of,  283,  294 
varix  of,  298 
xeroma,  121 
Lachrymation,  sanguineous,  141 
Lactation,  a  cause  of  amaurosis,  559,  993 
Lagophthalmos,  81,  218 


1024 


INDEX. 


Langenbeck   improves  operation  for  artificial 

pupil,  810,821 
Larvas  of  insects  between  eyelids,  255 
Lens  and  capsule,  injuries  of,  401 

diplochromatic  in  glaucoma,  841 

dislocation  of,  402 

hypertrophy  of,  839 

opacity  of,  632,701 

ossified,  649 

regeneration  of,  756 
Lentitis,  560 
Leucoma,  61 1 

Leucorrhoea,  amaurosis  from,  993,  996 
Leucorrhffial  ophthalmia,  461 
Light,  amaurosis  from  intense,  981 

intolerance  of,  207,  478,  555,  874 
Lime,  effects  of,  thrown  into  eye,  258 
Lippitudo,  174,  435 
Lithiasis  of  caruncula  lachrymalis,  275 
Long-sightedness,  860 
Lunula,  602 
Lupus,  how  distinguished    from   cancer,  168, 

169 
Luscitas,  387 

Madarosis,  249 

Masturbation,  a  cause  of  amaurosis,  993 
Maunoir's  operation  for  artificial  pupil,  813 
Maxillary  bone,  tumors  of.  111 

sinus,  aneurism  by  anastomosis  of,  110 
dropsy  of,  100 
exostosis  of,  1 12 
fungus  or  polypus  of,  102 
pressure  on  orbit  from,  100 
pus  ill,  100 
Measles,  ophthalmia  from,  491 
Medullary  tumor  of  eyeball,  682 

lachrymal  gland,  125 
Meibomian  apertures,  obliteration  of,  175 
obstruction  of,  180 
glands,  abscess  of,  180 
calcului  of,  ISO 
Melanosis  in  orbit,  343 
of  conjunctiva,  272 
eyeball,  689 
eyelids,  187 
Menses  suppressed,  a  cause  of  amaurosis,  983 
Mercury  in  amaurosis,  957 
corneitis.  515 
iritis,  427,  521,  525.  531 
Milton,  blindness  of,  990 
Molluscum  of  eyelids,  1S4 
Monoblepsis,  354,  953 
Monostoma  in  crystalline,  1013 
Moon-blindness,  922 
Morbillous  ophthalmia,  491 
Mucocele  of  lachrymal  sac,  298 
Miisca;,  fixed,  900 

floating  SS7 
MuscK  volitanles,  S87 

Muscles  of  eyeball,  double  vision  from  want  of 
correspondence  in,  353 
injuries  of,  353 
palsy  of,  354 
Mydriasis,  831 
Mydriatics  428,  432 
Myccephalon,  477,  608 
Myodesopia,  bS7 
Myopia,  848 
Myosis,  830 


Nevus  maternus  of  caruncula  lachrymalis,  274 

conjunctiva,  268 

eyelids,  188 
Nasal  duct,  exostosis  of,  307 

injuries  of,  277 

obstruction  of,  303 
Near-sightedness,  848 
Nebula,  611 
Necrosis  of  orbit,  72 
Neuralgia  of  fifth  nerve,  932 
Newton's  hypothesis  regarding  arrangement  of 

optic  nerves,  929 
Nictitation,  morbid,  207 
Night-blindness,  922 

Nitrate  of  silver,  application  of,  to  ulcers  of 
cornea,  489,  609 

stains  conjunctiva,  260 

use  of,  430 
Nostril,  pressure  from,  on  orbit,  93 
Nyctalopia,  922 
Nystagmus,  390 

Obliteration  of  pupil,  519,  631 
Obstruction  of  lachrymal  canals,  301 

Meibomian  apertures,  180 

nasal  duct,  303 

puncta  lachrymalis,  301 
Ochlodes,  656 
Ocular  capsule,  diseases  of,  309 

intliunmation  of,  319  ' 

spectra,  877 
Oculus  purulentus,  604 
Q'^dema  of  eyelids,  202 

subconjunctival,  263 
Onyx,  602 
Opacities  of  cornea,  611 

hyaloid,  632 
Opacity  of  crystalline  capsule,  714,  716,  790 

lens,  713,716,  789 
Operation  for  anchyloblepharon,  627 

cataract,  choice  of  an,  785 

symblepharon,  628 
Operations  for  artificial  pupil,  797,  806 
compound,  826 

cataract,  general  account  of,  732,  785 
position  of  patient  during,  729 
indications  and   contra-indications  for, 

785 
preliminary  questions  regarding,  727 

eversion  of  eyelids,  219,  221,  223,  236 

inversion  of  eyelashes,  237 
eyelids,  243 
Ophthalmia,  aphthous,  475 

arthritic,  541,  843 

bellica,  443 

catarrhal,  438 

catarrho-rheumatic,  500 

contagious,  443 

Egyptian,  443 

epidemic,  443 

crysipelatosa,  495 

exantheinatous,  476 

from  absorption  of  pus,  571 

gonorrhoica,  467,  534 

interna,  555 

intermittent,  599 

leucorihoica,  461 

morbillosa,  491 

neonatorum,  461 

of  new-born  children,  461 

phlyctenulosa,  476 

post  febrem,  579 


INDEX. 


1025 


Ophthalmia — continued. 
pseudo-syphilitic,  533 
purulent,  438,  443 
purulenta  gravior,  443 
mitior,  438 
of  infants,  461 
pustular,  475 
rheumatic,  496 
scarlatinosa,  491 
scrofulous,  476 
strumous,  476 
sympatlietic,  590 
syphilitic,  527 
tarsi,  173 
variolosa,  491 
OphthalmiaB,  418 

arrangements  of  bloodvessels  in,  433 
artificial,  588 
classification  of,  421 
compound,  585 
diseases  consequent  to,  601 
kinds  of  pain  in,  434 
remedies  for,  423 
traumatic,  256,  586 
Ophthalmic  artery,  aneurism  of,  344 
Ophthalmitis,  phlebitic,  571 
phies;monosa,  565 
postfebrile,  579 
puerperal,  571 
reflexa,  590 
sympathetica,  590 
traumatic,  394,  586 
Ophthalmo-blennorrhoea,  435 
Ophthalmoplegia,  354 
Ophthalmoptosis,  321 
Ophthalmoscope,  564,  952 
Optic  nerve,  tumor  encircling,  338,  688 
nerves,  disposition  of,  928 
destruction  of,  966,  978 
morbid  changes  in,  producing  amaurosis, 

966 
semi-decussation  of,  928 
their  origin  and  connections,  944,  950 
Optometer,  application  of,  796,  857 
Orbicularis  palpebrarum,  palsy  of,  210 
Orbit,  abscess  of,  73,  74,  75,  76,  77,  155,  310, 
315 
absorption  of,  from  pressure,  93 
caries  of,  75,  236 
contusions  of  edge  of,  49 
counter-fractures  of,  52 
deformation  of,  from  pressure,  93 
dilatation  of,  from  pressure,  93 
diseases  of,  49 
exostosis  of,  84 
fractures  of,  50,  51,  52 
fungus  hajmatodes  in,  342 
gunshot  wounds  of,  63 
hydatids  in,  1006 
hyperostosis  of,  S3 
incised  wounds  of,  61 
injuries  of,  49 
melanosis  in,  343 
necrosis  of,  75 
osseous  tumor  in,  339 
ostco-sarcoma  of,  90 
ostitis  of,  72 

penetrating  wounds  of,  53 
periostitis  of,  72 
periostosis  of,  82 

pressure  on,  from  cavity  of  cranium,  116 
frontal  sinus,  96 

65 


Orbit — continued. 

pressure  on,  from  maxillary  sinus,  100 
nostril,  94 
sphenoid,  115 
within  orbit,  94 
tumors  in,  326 
Orbital  aneurisms,  344 

areolar  tissue,  effusion  of  blood  into,  312 
inflammation,  erysipelatous  of,  154 

phlegmonous  of,  312 
injuries  of,  310 
scirrhus  of,  340 
Oscillation  of  eyeball,  388 
Osseous  deposit  in  anterior  chamber,  647 

tumor  in  orbit,  339 
Ossification  in  different  parts  of  the  eye,  646 
of  choroid,  648 
cornea,  647 

crystalline  capsule,  649 
hyaloid  membrane,  649 
lens,  649 
retina,  648 
Os  unguis,  caries  of,  230,  295 
Osteo-sarcoma  of  orbit,  90 
Ostitis  of  orbit,  72 
Over-refraction,  848 

Pain,  kinds  of,  in  ophthalmiae,  434 
Palsy  from  penetrating  wound  of  orbit,  57 
of  abductor  oculi,  355 

levator  palpebrae  superioris,  215 
muscles  of  eyeball,  354 

face,  210 
portio  dura,  210 
third  nerve,  215,  354 
orbicularis  palpebrarum,  210 
upper  eyelid,  215 

frnm  wounds,  151,  214 
Pannus,  512,  616 

Paracentesis  cornese,  426,  459,  587 
Paralysis  of  iris,  830,  831 
Periostitis  of  orbit,  72 
Periostosis  of  orbit,  82 
Periscopic  glasses,  857,  863 
Perspiration,   suppressed,   causes    amaurosis, 

946 
Phimosis  palpebrarum,  249 
Phlebitis  of  eyelids,  157 
Phlebitic  ophthalmitis,  571 
Phlegmatia  dolens  of  eye,  505 
Phlegmon,  ocular,  565 

subconjunctival,  262 
Phlegmonous  inflammation  of  eyelids,  153 
Phlyctenula  of  eyelids,  181 
Phlyctenular  ophthalmia,  476 
Phosphene,  872 
Photophobia,  207,  478,  555,  874 

infantum  scrofulosa,  478 
Photopsia,  869 
Phthiriasis,  249 
Phthisis  oculi,  633 

pupillae,  631 
Pigmentum  nigrum,  amaurosis  from  deficiency 
of,  961 
congenitally  deficient  in  albino,  389,  842 
deficient  in  glaucoma,  841,  842 
Pinguecula,  267 
Pituitary  gland  enlarged  producing  amaurosis, 

978,  982 
Poisons,  amaurosis  from,  986 
Polypus  in  nose  pressing  on  orbit,  94 
of  caruncula  lachrymalis,  274 


1026 


INDEX. 


Polypus — continued. 

of  conjunctiva,  268 
frontal  sinus,  99 
lachrymal  sac,  308 
maxillary  sinus,  102 
Porrigo  larvalis  affecting  eyelids,  179 
Porta  compares  eye  to  camera  obscura,  857 
Position  of  patient  during  operations  for  cata- 
ract, 729 
Pott's  operation  for  cataract,  770 
Presbyopia,  860 
Preservers,  absurdity  of,  864 
Pressure  on  eye,  amaurosis  from,  410 
orbit,  effects  of,  54 

from  cavity  of  cranium,  116 
frontal  sinus,  96 
maxillary  sinus,  100 
nostril,  94 
sphenoid  sinus,  115 
within  orbit,  94 
Prolapsus  conjunctivae,  272 

of  iris,  395,  758 
Pseudo  syphilitic  iritis,  533 
Psorophthaltnia,  174 
Pterygium,  263 
pingue,  264 
Ptosis,  213 

Puerperal  ophthalmitis,  571 
Puncta  lachrymalia,  eversion  of,  300 
obstruction  of,  301 
relaxation  of,  299 
Pupil,  artificial,  797 

by  excision,  798,  809,  818 
incision,  79S,  806,  810 
separation,  798,  809,  821 
extension  of,  by  prolapsus,  800,  817 
morbid  contraction  of,  S30 

dilatation  of,  831 
displacement  of,  507 
obliteration  of,  631,  S02 
Pupils  contract  during  sleep,  522,  830 

their  occasional  mobility  in  amaurosis  ex- 
plained, 950 
Purkinje's  catoptrical  examination  of  eye,  705 
Puro-mucous  conjunctivitis,  435 
Pustular  ophlhaitnia,  475 
Pustule,  malignant,  of  eyelids,  159 

Quina,  use  of,  in  scrofulous  ophthalmia;,  178, 

428,432,483,515,539 
Quivering  of  eyelids,  205 

Read's  treatment  of  glandular  conjunctiva,  622 
Reclination  of  cataract,  732,  735,  788 

through  cornea,  736 
sclerotica,  736 
Reisinger's  instrument  for  artificial  pupil,  822 
Refraction,  diminished,  860 

irregular,  865 

abnormal,  848 
Relaxation  of  lachrymal  sac,  296 

puncta  lachrymalia  and  canaliculi,  299 
Retina,  aneurism  of  its  central  artery,  produces 
amaurosis,  966 

apoplexy  of,  965 

coarctation  of,  506,  543,  663,  665 

its  probable  structure,  944 

laceration  of,  410 

ossified,  648 

pressure  on,  by  depressed  lens,  733,  743 
Retinitis,  555 

lactantium,  559 


Retraction  of  eyelids,  210 
Rheumatic  iritis,  523 
ophthalmia,  496 
Rupture  of  cornea,  411,  449,  839 

Sanguineous  effusion  into  eye,  411,  667,  965 

Santerelli's  operation  for  cataract,  769 

Sarcosis  bulbi,  269 

Scarlatina,  amaurosis  attending,  999 

Scarlatinous  ophthalmia,  491 

Scarpa's  operation  for  artificial  pupil,  798 

Schmidt's  operations  for  artificial  pupil,  821 

Scirrhus  in  the  orbit,  340 

of  caruncula  lachrymalis,  275 
eyeball,  681 
eyelids,  165 
lachrymal  gland,  126 
Sclerectomia,  829 
Sclerotica,  extraction  through,  767 

non-malignant  tumors  of,  672 

wounds  of,  408 
Sclerotico-choroiditis,  504 
Sclerotitis  attenuans,  504 

idiopathica,  496 

scrofulosa,  504 
Scrofula  affecting  bones  of  orbit,  75 

conjunctiva,  476 

excreting  lachrymal  organs,  284 

eyelids,  173 

lachrymal  gland,  125 

OS  unguis,  295 
Scrofulous  corneitis,  512 

iritis,  538 

ophthalmia,  476 
Secondary  cataract,  789 
Semilunar  membrane,  inflammation  of.  273 
Separation,  artificial  pupil  by,  798,  809,  821 
Short-sightedness,  848 

Sight,  over-exercise  of,  a  cause  of  amaurosis 
981 

weakness  of,  645,  908 
Smallpox,  ophthahnia  from,  492 
Spasm  of  eyelids,  207 
t<peck,  vascular,  612,  614 
Specks  of  cornea,  61 1 

crystalline  capsule  and  lens,  632 
Spectra,  ocular,  877 
Spectacles,  concave,  856 

convex,  863 

periscopic,  857,  863 
Spectral  illusions,  906 

Sphenoid  sinus,  pressure  on  orbit  from,  115 
Spongoid  tumor  of  eyeball,  682 
Squinting,  357 
Staphyloma,  634 

conical,  639 

iridis,  635 

iridis  per  corneam,  635 

of  choroid  and  sclerotica,  505,  644 
cornea  and  iris,  636 

operation  for,  636,  642,  645 

partial,  638 

pellucidum,  656 

posticum,  644 

prevention  of,  640 

racemosum,  635 

sclerotic,  506,  644 

spherical,  639 

total,  644 

uveae,  634 
Stillicidium  lachrymarum,  123,  276,  299,^300 


INDEX. 


102'7 


Strabismus  activus,  357 

convergens,  359 

divergens,  359 

passivus,  3S7 
Stye,  181 

Style,  use  of  lachrymal,  289 
Suckling,  amaurosis  from,  559,  993 
Suffusio,  701,  836 

Sulphuric  acid,  effects  of,  thrown  into  eye,  259 
Suppressed  menses,  amaurosis  from,  983 

perspiration,  amaurosis  from,  984 

purulent  discharge,  amaurosis  from,  984 
Sycosis  of  edge  of  eyelid,  182 
Symblepharon,  625 
Synchysis,  632 

sparkling,  633 
Synechia  anterior,  630 

posterior,  630 
Synizesis,  631 
Syphilis  affecting  bones  of  orbit,  72,  82 

OS  unguis,  295 
Syphilitic  iritis,  527 

eruptions  affecting  eyelids  of  infants,  164 

ulceration  of  eyelids,  160 

Tarsal  ophthalmia,  174 
Tarsoraphia,  230 
Tears,  morbid,  140 
Tetanus  oculi,  388 
Tinea  palpebrarum,  174 
Tic  douloureux,  932 

non-douloureux,  205 
Tobacco  a  prolific  cause  of  amaurosis,  987 
Transplantation  of  cornea,  829 
Traumatic  ophthalmicE,  256,  586 
Tremulous  iris,  834 
Trichiasis,  237 
Trichosis  bulbi,  270 
Tumor,  albuminous,  in  eyelids,  184 
encysted,  in  eyelids,  185 
frontal  sinus,  97 
lachrymal  gland,  135 
vicinity  of  lachrymal  ducts,  139 
fibrinous,  in  eyelids,  182 
on  crown  of  head  producing  amaurosis,  997 
spongoid  or  medullary,  of  eyeball,  682 
Tumors,  conjunctival,  270 

in  eyebrow  and  eyelids,  182 

brain,  producing  amaurosis,  1000 
orbit,  326 
non-malignant,  in  vitreous  humor,  675 
of  choroid,  674 

cornea  and  sclerotica,  672 
eyeball,  671 
iris,  672 
subconjunctival,  270 
within  eyeball,  656 
Turpentine,  its  use  in  iritis,  522,  531 
Twitching  of  evelids,  205 
Tylosis,  167,  174,  188 


Ulcers  of  cornea,  394,  477,  606 
eyelids,  cancerous,  165 
scrofulous,  175 
syphilitic,  160 
legs,  discharge    from,  suppressed,  brings 
on  amaurosis,  984 
Unguis,  602 
Uvea,  staphyloma  of,  634 

Vaccination,  cure  of  nsevus  maternus  by,  191 

Varicositas  oculi,  505,  645 

Variolous  ophthalmia,  491 

Varix  of  lachrymal  sac,  298 

Venery,  a  cause  of  amaurosis,  993 

Vesication  of  cornea,  660 

Vision,  colored,  872 

abnormal,  various  states  of,  848 
Visus  defiguratus,  953 

dimidiatus,  953 

interruptus,  953 

lucidus,  869, 

nebulosus,  954 

obliquus,  953 

reticulatus,  954 
Vitiligo  of  eyelids,  ISO 
Vitreous  body,  dropsy  of,  665 

foreign  bodies  in,  409 

humor,  dissolution  of,  632 

non-malignant  tumors  in,  675 

Warts  on  eyelids,  1^2 

of  conjunc'.iva,  267 
Watery  eye,  282 
Weakness  of  sight,  90S 
Web,  263 

Wenzel's  operation  for  artificial  pupil,  798 
Willburg's  operation  for  cataract,  736 
WoUaston  on  senaidecussation  of  optic  nerves, 

931 
Woolhouss's  operation  for  closed  pupil,  632 
Worms,  amaurosis  from,  982 
Wound  of  cavernous  sinus,  311 
Wounds,  gunshot,  of  eye,  412 
orbit,  63 
incised  of  orbit,  61 
of  choroid,  408 

cornea,  penetrating,  394 

punctured,  394 
eyebrows  and  eyelids,  142,  147 
sclerotica,  408 
penetrating  orbit,  53 

Xeroma,  conjunctival,  623 

lachrymal,  121 
Xerophthalmia,  conjunctiva!,  623 

lachrymal,  121 

Zonula,  cataracta  cum,  718 


THE   END. 


EERATA. 

Page  243,  line  5  from  bottom,  for  surrounds  the  optic  nerve,  read  more  fully 
surrounds  the  optic  nerve. 
"    253,    "    8  from  bottom, /or  evulsion,  read  eversion. 


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classical  medical   literature   of  England. — £rirtsA    eases  is  made  more  complete,  and  is  kept  upon  a  level 

and  Foreign  Medico-Chir.  Review.  |  with  the  progress  of  modern  science.     It  is  the  best 

Dr.  Budd's  Treatise  on  Diseases  of  the  Liver  is  1  work  on  Diseases  of  the  Liver  in  any  language.— 


now  a  standard  work  in  Medical  literature,  and  dur- 
ing the  intervals  which  have  elapsed  between  the 
successive  editions,  the  author  has  incorporated  into 
the  text  the  most  striking  novelties  which  have  cha- 
racterized the  recent  progress  of  hepatic  physiology 
and  pathology;  so  thatalthougtithe  size  of  the  book 


London  Med.  Times  and  Gazette. 

This  work,  now  the  standard  book  of  reference  on 
the  diseases  of  which  it  treats,  has  been  carefully 
revised,  and  many  new  illustrations  of  the  views  of 
the  learned  author  added  in  the  present  edition. — 
Dublin  Quarterly  Journal. 


BY  THE  SAME  AUTHOR. 

ON  THE  ORGANIC  DISEASES  AND  FUNCTIONAL  DISORDERS  OF 

THE  STOMACH.    In  one  neat  octavo  volume,  extra  cloth.    $1  50. 


BUCKNILL  (J.  C),   M.  D.,  a.nd        DANIEL   H.   TUKE,    M.  D., 

Medical  Superintendent  of  the  Devon  Lunatic  Asylum.        Visiting  Medical  Officer  to  the  York  Retreat. 

A  MANUAL  OP   PSYCHOLOGICAL   MEDICINE;   containing  the  History, 

Nosology,  Defcripiion,  Statistics,  Diagnosis,  Pathology,  and  Trealmeul  of  INSANITY.     With 

a  Plate.     In  ote  handsome  octavo  volume,  of  536  pages.     £3  00. 

The  increase  ot  mental  disease  in  its  various  lorms,  and  the  difficult  questions  to  which  it  is 
constantly  giving  rise,  render  the  subject  one  of  daily  enhanced  interest,  requiring  on  the  part  of 
the  physician  a  constantly  greater  familiarity  with  this,  the  most  pierplexing  branch  of  his  profes- 
sion. At  the  same  time  there  has  been  for  some  years  no  work  accessible  in  this  country,  present- 
ing the  results  of  recent  investigations  in  the  Diagnosis  and  Prognosis  of  Insanity,  and  the  greatly 
improved  methods  of  treatment  which  have  done  so  much  in  alleviating  the  condition  or  restoring 
the  health  of  the  insane.  To  fill  this  vacancy  the  publishers  present  this  volume,  assured  that 
the  distinguished  reputation  and  experience  ol  the  authors  will  entitle  it  at  once  to  the  confidence 
of  both  student  and  practitioner.  Its  scope  may  be  gathered  from  the  declaration  of  the  authors 
that  "their  aim  has  Ijeen  to  supply  a  text  book  which  may  serve  as  a  guide  in  the  acquisition  of 
such  knowledge,  sutficiently  elementary  to  be  adapted  to  the  wants  of  the  student,  and  sulficienlly 
modern  in  its  views  and  explicit  in  its  teaching  to  sutBce  for  the  demands  of  the  practitioner." 


BENNETT   (HENRY),  M.D. 
A  PRACTICAL   TREATISE   ON  INFLAMMATION  OP  THE  UTERUS, 

ITS  CERVIX  AND  APPENDAGES,  and  on  its  connection  with  Uterine  Disease.  To  which 
is  added,  a  Review  of  the  present  stale  of  Uterine  Pathology.  Fifth  American,  from  the  third 
English  edition.     In  one  octavo  volume,  of  about  500  pages,  extra  cloth.  $2  00. 


BROWN    (ISAAC    BAKER), 

Surgeon- Accoucheur  to  St.  Mary's  Hospital,  &c. 

ON  SOME  DISEASES  OP  WOMEN  ADMITTING  OF  SURGICAL  TREAT- 

MENT.     With  handsome  illustrations.     One  vol.  8vo.,  extra  cloth,  pp.  27i3.     $1  60. 

Mr.  Brown  has  earned  for  himself  a  high  reputa-  ;  and  merit  the  careful  attention   of  every   surgeoa' 
tion  in  the  operative  treatment  of  sundry  diseases   accoucheur. — Association  Journal. 
and  injuries  to  which  females  are  peculiarly  subject.  I      .„    .  u     •.  ••  ■■       ^u      ■.     i 

We  can  truly  say  of  his  work  that  it  is  an  important '  ,  ^e  have  no  hesitation  in  recommending  this  bock 
addition  to  obstetrical  literature.  The  operative  to  t.ie  cnretul  at  ention  of  all  surgeons  who  make 
suggestions  and  contrivances  which  Mr.  Brown  de-  female  complaints  a  part  of  tUeir  study  and  practice. 
.crTbes,  exhibit  much  practical  sagacity  and  gkiH, ; -D«6'm  C^uarUr/y  Jo»r»ai. 

BOWMAN  (JOHN   E.),  M.D. 
PRACTICAL   HANDBOOK    OF    MEDICAL    CHEMISTRY.     Second  Ame- 

rican,from  the  third  and  revised  English  Edition.     In  one  neai  volume,  royal  12mo., extra  cloth, 
with  numerous  illustrations,     pp.  28S.     $1  25. 

BY  THE  SAME  AUTHOR. 

INTRODUCTION    TO    PRACTICAL    CHEMISTRY,    INCLUDING    ANA- 

LYSIS.    Second  American,  from  the  second  and  revised  London  edition.     With  numerous  illus- 
irations.    In  one  neai  vol.,  royall2mo.,  extra  cloth,    pp.350.    $125. 


BEALE  ON  THE  LAWS  OF  HEALTH  IN  RE- 
LATION TO  MIND  AND  BODY.  A  Series  of 
Letters  from  an  old  Practitioner  to  a  Patient.  In 
one  volume,  royal  12mo.,  extra  cloth,  pp.  296. 
80  cents. 

BUSHNAN'S  PHYSIOLOGY  OF  ANIMAL  AND 
VEGETABLE  LIFE ;  a  Popular  Treatise  on  the 
Functions  and  Phenomena  of  Organic  Life.  In 
ooe  hanusoine  royal  ]2mo.  volume,  extra  cloth, 
with  over  100  illastrations.    pp.234.    80  cents. 


I  BUCKLER  ON  THE  ETIOLOGY,  PATHOLOGY' 
AND  TREAT.MEXT  OF  FIBRO-BRONCHI- 
TIS  AND  RHEUMATIC  PNEU.MONIA.  In 
one  8vo.  volume,  extra  cloth,     pp.  150.    $1  25. 

BLOOD  AND  URINE  (MANUALS  ON).  BY 
JOHN  WILLIAM  GRIFFITH,  G.  OWEN 
REESE,  AND  ALFRED  MARKWICK.  One 
thick  volume,  royal  12mo.,  extra  cloth,  with 
plates,    pp.460.     81  25. 

BRODIE'S  CLINICAL  LECTURES  ON  SUR- 
GERY.   1  vol.  8vo.  cloth.    350  pp.     8125. 


AND   SCIENTIFIC    PUBLICATIONS. 


BUMSTEAD  (FREEMAN  J.)  M .  D., 

Lecturer  on  Venereal  Diseases  at  the  College  of  Pliysicians  and  Surgeons,  New  York,  &c. 

THE    PATHOLOGY   AND  TREATxMENT   OF  VENEREAL  DISEASES, 

including  the  results  of  recent  investigations  upon  the  subject.    With  illustrations  on  wood.     la 
one  very  handsome  octavo  volume,  of  nearly  700  pages,  extra  cloth;  $3  75.     {Now Ready.) 


By  far  the  most  valuable  contribution  to  this  par- 
ticular branch  of  practice  that  has  seen  the  light 
within  the  last  score  of  years.  His  clear  and  accu- 
rate descriptions  of  the  various  forms  of  venereal 
disease,  and  especially  the  methods  of  treatment  he 
proposes,  are  worthy  of  the  highest  encomium.  In 
these  respects  it  is  better  adapted  for  the  assistance 
of  the  every-day  practitioner  than  any  other  with 
which  we  are  acquainted.  In  variety  of  methods 
proposed,  in  minuteness  of  direction,  guided  by  care- 
lul  discrimination  of  varying  forms  and  complica- 
tions, we  write  down  the  book  as  unsurpassed.  It 
is  a  work  which  should  be  in  the  possession  of  every 
practitioner.— C/iicag-o  Med.  Journal.  Nov.  1861. 

Tne  foregoing  admirable  volume  comes  to  us,  em- 
bracing the  whole  subject  of  syphilology,  resolving 
many  a  doubt,  correcting  and  confirming  many  an 
entertained  opinion,  and  in  our  estimation  the  best, 
completest,  fullest  monograph  on  this  subject  in  our 
language.  As  far  as  the  author's  labors  themselves 
are  concerned,  ^ve  feel  it  a  duty  to  say  that  he  has 
not  only  exhausted  his  subject,  but  he  has  presented 
to  us,  without  the  slightest  hyperbole,  the  best  di- 
gested treatise  on  these  diseases  in  our  language. 
He  has  carried  its  literature  down  to  the  present 
moment,  and  has  achieved  his  task  in  a  manner 
which  cannot  but  redound  to  his  credit. — Britiih 
American  Journal,  Oct.  1861. 

We  believe  this  treatise  will  come  to  be  regarded 
as  high  authority  in  this  branch  of  medical  practice, 
and  we  cordially  commend  it  to  the  favorable  notice 
of  our  brethren  in  the  profession.  For  our  own  part, 
we  candidly  confess  that  we  have  received  aany 
new  idtas  from  its  perusal,  as  well  as  modified  many 
views  which  we  have  long,  and,  as  we  now  think, 
erroneously  entertained  on  the  subject  of  syphilis. 


To  sum  up  all  in  a  few  words,  this  book  isone  which 
no  practising  physician  or  medical  student  can  very 
well  afford  to  do  without. — American  Med.  Times, 
Nov.  2,  1861. 

The  whole  work  presents  a  complete  history  of 
venereal  diseases,  comprising  much  interesting  and 
valuable  material  that  has  been  spread  through  med- 
ical journals  within  the  last  twenty  years — the  pe- 
riod of  many  e.Kperiments  and  investigations  on  the 
subject — the  whole  carefully  digested  by  the  aid  of 
the  author's  extensive  personal  experience,  and 
ofTeied  to  the  profession  in  an  admirable  form.  Its 
completeness  is  secured  by  good  plates,  w^hich  are 
especially  full  in  the  anatomy  of  the  genital  organs. 
We  have  examined  it  with  great  satisfaction,  and 
congratulate  the  medical  profession  in  America  on 
the  nationality  of  a  work  that  may  fairly  be  called 
original. — Berkshire  Med.  Journal,  Dec.  1861. 

One  thing,  however,  we  are  impelled  to  say,  that 
we  have  met  with  no  other  book  on  syphilis,  in  the 
English  language,  which  gave  so  full,  clear,  and 
impartial  vie^s  of  the  important  subjects  on  which 
it  treats.  We  cannot,  however,  refrain  from  ex- 
pressing our  satisfaction  with  the  full  and  perspicu- 
ous manner  in  which  the  subject  has  been  presented, 
and  the  careful  attention  to  minute  details,  so  use- 
ful— not  to  say  indispensable — in  a  practical  treatise. 
In  conclusion,  if  we  may  be  pardoned  the  use  of  a 
phrase  now  become  stereotyped,  but  which  we  here 
employ  in  all  seriousness  and  sincerity,  we  do  not 
hesitate  to  express  the  opinion  that  Dr.  Bumstead's 
Treatise  on  Venereal  Diseases  is  a  ''  work  without 
which  no  medical  library  will  hereafter  be  consi- 
dered complete." — Boston  Med.  and  Surg.  Journal, 
Sept.  5,  1861. 


BARCLAY  (A.  W.),  M .  D., 

Assistant  Physician  to  St.  George's  Hospital,  &.c. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS ;   being  an  Analysis  of  the  Signs 

and  Symptoms  of  Disease.     Second  American  from  the  second  and  revised  London  edition.     In 
one  neat  octavo  volume,  extra  cloth,  of  451  pages.    $2  25.    {Now  ready.) 

The  demand  for  a  se^iond  edition  of  this  work  shows  that  the  vacancy  which  it  attempts  to  sup- 
ply has  been  recognized  by  the  profession,  and  that  the  e/Torls  of  the  author  to  meet  the  want  have 
been  successful.  The  revision  which  it  has  enjoyed  will  render  it  better  adapted  than  before  to 
afford  assistance  to  the  learner  in  the  prosecution  of  his  studies,  and  to  the  practitioner  who  requires 
a  convenient  and  accessible  manual  for  speedy  reference  in  the  exigencies  of  his  daily  duties.  For 
this  latter  purpose  its  complete  and  extensive  Index  renders  it  especially  valuable,  offering  facilities 
for  immediately  turning  to  any  class  of  symptoms,  or  any  variety  of  disease. 


The  task  of  composing  such  a  work  is  neither  an 
easy  nor  a  light  one ;  but  Dr.  Barclay  has  performed 
it  in  a  manner  which  meets  our  most  unqualified 
approbation.  He  is  no  mere  theorist;  he  knows  his 
work  thoroughly,  and  in  attempting  to  perform  it, 
has  not  exceeded  his  powers. — British  Med.  Journal. 

We  venture  to  predict  that  the  work  will  be  de- 
servedly popular,  and  soon  become,  like  Watson's 
Practice,  an  indispensable  necessity  to  the  practi- 
tioner.— iV.  A.  Med.  Journal. 

An  inestimable  work  of  reference  for  the  young 
practitioner  and  student. — Nashville  Med.  Journal. 


We  hope  the  volume  will  have  an  extensive  cir- 
culation, not  among  students  of  medicine  only,  but 
practitioners  also.  They  will  never  regret  a  faith- 
ful study  of  its  pages. —  CincinnatiLancet. 

An  important  acquisition  to  medical  literature. 
It  is  a  work  of  high  merit,  both  from  the  vast  im- 
portance of  the  subject  upon  which  it  treats,  and 
also  from  the  real  aDility  displayed  in  "^a  elabora- 
tion. In  conclusion,  let  us  bespeak  for  this  volume 
that  attention  of  every  student  of  our  art  which  it 
so  richly  deserves  —  that  place  in  every  medical 
library  which  it  can  so  well  adorn.- -i'eninfu/ar 
Medical  Journal. 


BARTLETT  (ELISHA),  M.  D. 
THE  HISTORY,  DIAGNOSIS,  AND  TREATMENT  OP  THE  FEVERS 

OF  THE  UNITED  STATES.  A  new  and  revised  edition.  By  Alonzo  Clark  ,  M.  D.,  Prof, 
of  Pathology  and  Praotical  Medicine  in  the  N.  Y.  College  of  Physicians  and  Surgeons,  &c.  In 
one  octavo  volume,  of  six  hundred  pages,  extra  cloth.    Price  $3  00. 


It  is  a  work  of  great  practical  value  and  interest, 
containing  much  that  is  new  relative  to  the  several 
diseases  of  which  it  treats,  and,  with  the  additions 
of  the  editor,  is  fully  up  to  the  times.  The  distinct- 
ive features  of  the  different  forms  of  fever  are  plainly 
and  forcibly  portrayed,  and  the  lines  of  demarcation 
carefully  and  accurately  drawn,  and  to  the  Ameri- 
can practitioner  is  a  more  valuable  and  safe  guide 
than  any  work  on  fever  extant. — Ohio  Med.  and 
Surg  Journal. 

This  excellent  monograph  on  febrile  disease,  has 


stood  deservedly  high  since  its  first  publication.  It 
will  be  seen  that  it  has  now  reached  its  fourth  edi- 
tion under  the  supervision  of  Prof.  A.  Clark,  a  gen- 
tleman w^ho,  from  the  nature  of  his  studies  and  pur- 
suits, is  well  calculated  to  appreciate  and  discuss 
the  many  intricate  and  difficult  questions  in  patho- 
logy. His  annotations  add  much  to  the  interest  of 
the  work,  and  have  brought  it  well  up  to  the  condi- 
tion of  the  science  as  it  exists  at  the  present  day 
in  regard  to  this  class  of  diseases. — Southern  Med. 
and  Surg.  Journal. 


JJLANCHARD  &  LEA'S   MEDICAL 


BARWELL  (RICHARD,)   F.  R.  C.  S., 

Assistant  Surgeon  Charing  Cross  Hospital,  &c. 

A  TREATISE  ON  DISEASES  OF  THE  JOINTS.  Illustrated  with  engrav- 
ings  on  wood.  la  one  very  handsome  octavo  volume,  of  about  500  pages,  extra  clotJi;  $3  GO. 
{Now  Ready.) 

"A  treatise  on  Diseases  of  the  Joints  equal  to,  or  rather  beyond  the  current  knowledge  of  the 
day,  has  long  been  required — my  professional  brethren  must  judge  whether  the  ensuing  pages  may 
supply  the  deficiency  No  author  is  fit  to  estimate  his  own  work  at  the  moment  ot  its  completion, 
but  it  may  be  permitted  me  to  say  that  the  study  of  joint  diseases  has  very  much  occupied  my  atten- 
tion, even  from  my  studentship,  and  that  for  the  last  six  or  eight  years  my  devotion  to  that  subject 

has  been  almost  unremitting The  real  weight  of  my  work  has  been  at  the  bedside, 

and  the  greatest  labor  devoted  to  interpreting  symptoms  and  remedying  their  cause." — Author's 
Preface. 

At  the  outset  we  may  state  that  the  work  is  to  be  of  much  use  to  the  practising  surgeon  who 
■worthy  of  much  praise,  and  bears  evidence  of  much  may  be  in  want  of  a  treatise  on  diseases  of  the  joints, 
thoughtful  und  careful  inquiry,  and  here  and  there  and  at  the  same  time  one  which  contains  the  latest 
of  no  slight  originality.  We  have  already  earned  '  information  on  articular  affections  and  the  opera- 
tfiis  notice  further  than  we  intended  to  do,  but  not  tions  for  their  cure. — Dublin  Med.  Press,  Feb.  27, 
to  the  extent  the  work  deserves.    We  can  only  add,  ;  1861. 

that  the  perusal  of  it  has  afforded  us  great  pleasure.  jhis  volume  will  be  welcomed,  both  by  the  pa- 
The  author  has  evidently  worked  very  hard  at  his  !  thologist  and  the  surgeon,  as  being  the  record  of 
subject,  and  his  investigations  into  the  Physiology  ;  ^„ci,  ,,j,„egj  research  and  careful  investigation  into 

1°  „„Jt'!iriffJ  fl:l?i"":!l*^^  11*°;1Y"^  f^°.'°.u  1  t'le  nature  and  treatment  of  a  most  important  class 
rv,„»„o.  «,   ,„     ^„».>  ^„     ,™  tn     «    ,„  «„.      „,,,.»,     Qf  jigQ[.(]grs.     We  cannot  conclude  this  notice  of  a 


manner  which  entitles  him  to  be  listened  to  with 
attention  and  respect.  We  must  not  omit  to  men- 
tion the  very  admirable  plates  with  which  the  vo- 
lume is  enriched.  AVe  seldom  meet  with  such  strik- 
ing and  faithful  delineations  of  disease. — London 
Med.  Times  and  Gazette,  Feb.  9,  la6l. 


valuable  and  ustful  book  without  calling  attention 
to  the  amount  of  bona  fide  work  it  contains.  In  che 
present  day  of  universal  book-making,  it  is  no  slight 
matter  for  a  volume  to  show  laborious  investiga- 
tion, and  at  the  same  time  original  thought,  (m  the 


We  cannot  take  leave,  however,  of  Mr.  Harwell,     part  of  its  author,  whom  we  may  congratulate  on 
without    congratulating    him    on    the    interesting    ttie  successful  completion  of  his  arduous  task. — 
amount  of  information  which  he  has  compressed     London  Lancet,  March  9,  1861. 
into  his  book.    The  work  appears  to  us  calculated  I 


CARPENTER  (WILLIAM    B.),   M.  D.,  F.  R.  S.,  &.C., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  applications  to 

Psychology,  Pathology,  Therapeutics,  Hygiene,  and  Forensic  Medicine.  A  new  American,  from 
the  last  and  revised  London  edition.  With  nearly  three  hundred  illustrations.  Edited,  with  addi- 
tions, by  Francis  Gurney  Smith,  M.  D.,  Profes.sor  of  the  Institutes  of  Medicine  in  the  Pennsyl- 
vania Medical  College,  &c.  In  one  very  large  and  beautiful  octavo  volume,  of  about  nine  hundred 
large  pages,  handsomely  printed  and  strongly  bound  in  leather,  with  raised  bands.    $4  25. 

In  the  preparation  of  this  new  edition,  the  author  has  spared  no  labor  to  render  it,  as  heretofore, 
a  complete  and  lucid  exposition  of  the  most  advanced  condition  of  its  important  subject.  The 
amount  of  the  additions  required  to  effect  this  object  thoroughly,  joined  to  the  former  large  size  of 
the  volume,  presenting  objections  arising  from  the  unwieldy  bulk  of  the  work,  he  has  omitted  all 
those  portions  not  bearing  directly  upon  Human  Physiology,  de^igning  to  incorporate  them  in 
his  forthcoming  Treatise  on  General  Physiology.  As  a  full  and  accurate  text-book  on  the  Phy- 
siology of  Man,  the  work  in  its  present  condition  therefore  presents  even  greater  claims  upon 
the  student  and  physician  than  those  which  have  heretofore  won  for  it  the  very  wide  and  distin- 
guished favor  which  it  has  so  long  enjoyed.  The  additions  of  Prof.  Smith  will  be  found  to  supply 
whatever  may  have  been  wanting  to  the  American  student,  while  the  introduction  of  many  new 
illustrations,  and  the  most  careful  mechanical  execution,  render  the  voliune  one  of  the  most  at- 
tractive as  yet  issued. 

For  upwards  of  thirteen  years  Dr.  Carpenter's]  To  eulogize  thisgreat  work  would  be  superfluous, 
work  has  been  considered  by  the  profession  gene- :  We  should  observe,  however,  that  in  this  edition 
rally,  both  in  this  country  and  England,  as  the  most  the  author  has  remodelled  a  large  portion  of  the 
valuable  compendium  on  the  subject  of  physiology    former,  and  the  editor  has  added  much  matter  of  in- 


in  our  language.  This  distinction  it  owes  to  the  high 
attainments  and  unwearied  industry  of  its  accom- 
plished author.  The  present  edition  (which,  like  the 
last  American  one,  was  prepared  by  the  author  him- 
self), is  the  result  of  such  extensive  revision,  that  it 
may  almost  be  considered  a  new  work.  We  need 
hardly  say,  in  concluding  this  brief  notice,  thatTvhile 
the  work  is  indispensable  to  every  student  of  medi- 
cine in  this  country,  it  ^vill  amply  repay  the  practi- 
tioner for  its  perusal  by  the  interest  and  value  of  its 
contents. — Boston  Med.  and  Surg.  Journal. 

This  is  a  standard  work — the  text-book  used  by  all 
medical  students  who  read  the  English  language. 
It  has  passed  through  several  editions  in  order  to 
keep  pace  with  the  rapidly  growing  science  of  Phy- 
siology. Nothing  need  be  said  in  its  praise,  for  its 
merits  are  universally  known  ;  we  have  nothing  to 
Bay  of  its  defects,  for  they  only  appear  where  the 
science  of  which  it  treats  is  incomplete. — Western 
Lancet. 

The  most  complete  exposition  of  physiology  which 
any  language  can  at  present  give. — Brit,  and  For. 
Med.'Chirurg.  Review. 

The  greatest,  the  most  reliable,  and  the  best  book 


terest,  especially  in  the  form  of  illustrations.  We 
may  confidently  recommend  it  as  the  most  complete 
work  on  Human  Physiology  in  our  language. — 
Southern  Med.  and  Surg.  Journal. 

The  most  complete  work  on  the  science  in  our 
language. — Am.  Med.  Journal. 

The  most  complete  work  now  extant  in  our  lan- 
guage.— iV.  O.  Med.  Register. 

The  best  text-book  in  the  language  on  this  ex- 
tensive  subject. — London  Med.  Times. 

A  complete  cyclopaedia  of  this  branch  of  science. 
—N.  Y.  Med.  Times. 

The  profession  of  this  country,  and  perhaps  also 
of  Europe,  have  aoxiously  and  for  some  time  awaited 
the  announcement  of  this  new  edition  of  Carpenter's 
Human  Physiology.  His  former  editions  have  for 
many  years  been  almost  the  only  text-book  on  Phy- 
siology in  all  our  medical  schools,  and  its  circula- 
tion among  the  profession  has  been  unsurpassed  by 
any  work  in  any  department  of  medical  science. 

It  is  quite  unnecessary  for  us  to  speak  of  this 
work  as  its  merits  would  justify.  The  mere  an- 
nouncement of  its  appearance  will  afford  the  highest 
pleasure  to  every  student  of  Physiology,  while  its 


on  the  subject  which  we  know  of  in  the  English '  perusal  will  be  of  infinite   service  in   advancing 
language. — Stethoscop*  |  physiological  science. — Okio  Med. and  Surg.  Journ. 


AND    SCIENTIFIC    PUBLICATIONS. 


CARPENTER  (WILLIAM  B.),   M.  D.,  F.  R.  S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

THE  MICROSCOPE  AND  ITS  REVELATIONS.      With  an  Appendix  eon- 

taining  the  Applications  of  the  Microscope  to  Clinical  Medicine,  &c.  By  F.  G.  Smith,  M.  D. 
Illustrated  by  four  hundred  and  thirty-four  beautiful  engravings  on  wood.  In  one  large  and  very 
handsome  octavo  volume,  of  724  pages,  extra  cloth,  $4  00  ;  leather,  $4  50. 

Dr.  Carpenter's  position  as  a  microscopist  and  physiologist,  and  his  great  experience  as  a  teacher, 
eminently  qualify  him  to  produce  what  has  long  been  wanted — a  good  text-book  on  the  practical 
use  of  the  microscope.  In  the  present  volume  his  object  has  been,  as  stated  in  his  Preface,  "  to 
combine,  within  a  moderate  compass,  that  information  with  regard  to  the  use  of  his  'tools,'  which 
is  most  essential  to  the  working  microscopist,  with  such  an  account  of  the  objects  best  fitted  for 
his  study,  as  might  qualify  him  to  comprehend  what  he  observes,  and  might  thus  prepare  him  to 
benefit  science,  whilst  expanding  and  refreshing  his  own  mind  "  That  he  has  succeeded  in  accom- 
plishing this,  no  one  acquainted  with  his  previous  labors  can  doubt. 

The  great  importance  of  the  microscope  as  a  means  of  diagnosis,  and  the  number  of  microsco- 
pists  who  are  also  physicians,  have  induced  the  American  publishers,  with  the  author's  approval,  to 
add  an  Appendix,  carefully  prepared  by  Professor  Smith,  on  the  applications  of  the  instrument  to 
clinical  medicine,  together  with  an  account  of  American  Microscopes,  their  modifications  and 
accessories.  This  portion  of  the  work  is  illustrated  with  nearly  one  hundred  wood-cuts,  and,  it  is 
hoped,  will  adapt  the  volume  more  particularly  to  the  use  of  the  American  student. 


Those  who  are  acquainted  with  Dr.  Carpenter's 
previous  writings  on  Animal  and  Vegetable  Physio- 
Kigy,  willfully  understand  how  vast  a  store  of  know- 
ledge he  is  able  to  bring  to  bear  upon  so  comprehen- 
sive a  subject  as  the  revelations  of  the  microscope  j 


medical  work,  the  additions  by  Prof.  Smith  give  it 
a  positive  claim  upon  the  profession,  for  which  we 
doubt  not  he  will  receive  their  sincere  thanks.  In- 
deed, we  know  not  where  the  student  of  medicine 
will  find  such  a  complete  and  satisfactory  collection 


and  even  those  who  have  no  previous  acquaintance  !  of  microscopic  facts  bearing  upon  physiology  and 
with  the  construction  or  uses  of  this  instrument,  !  practical  medicine  as  is  contained  in  Prof.  Smith's 
will  find  abundance  of  information  conveyed  in  clear  appendix;  and  this  of  itself,  it  seems  to  us,  is  fully 
and  simple  language. — Med.  Times  and  GazeiJe.  worth  the  cost  of  the  volume. — Louisville  Medical 
Although  originally  not  intended  as  a  strictly  \  •R«'''*««'. 


BY   THE   SAME   AUTHOR. 

ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO- 

LOGICAL  ANATOMY.    Second  American,  from  a  new  and  revised  London  edition.     With 

one  hundred  and  ninety  illustrations.    In  one  very  handsome  octavo  volume,  leather,    pp.  566. 

$3  00. 

In  publishing  the  first  edition  of  this  work,  its  title  was  altered  from  that  of  the  London  volume, 
by  the  substitution  of  the  word  "  Elements"  for  that  of  "  Manual,"  and  with  the  author's  sanction 
the  title  of  "  Elements"  is  still  retained  as  being  more  expressive  of  the  scope  of  the  treatise. 


To  say  that  it  is  the  best  manual  of  Physiology 
now  before  the  public ,  would  not  do  sufficient  justice 
to  the  author. — Buffalo  Medical  Journal. 

In  his  former  works  it  would  seem  that  he  had 
exhausted  the  subject  of  Physiology.  In  the  present, 
he  gives  the  essence,  as  it  were,  of  the  whole. — iV.  Y. 
Journal  of  Medicine. 


Those  who  have  occasion  for  an  elementary  trea- 
tise on  Physiology,  cannot  do  better  than  to  possess 

themselves  of  the  manual  of  Dr.  Carpenter Medical 

Examiner. 

The  best  and  most  complete  expos6  of  modern 
Physiology,  in  one  volume,  extant  in  the  English 
language. — St.  Louis  Medical  Journal. 


BY   THE   SAME   AUTHOR. 


PRINCIPLES  OP  COMPARATIVE   PHYSIOLOGY.     New  American,  from 

the  Fourth  and  Revised  London  edition.     In  one  large  and  handsome  octavo  volume,  with  over 
three  hundred  beautiful  illustrations,     pp.  752.    Extra  cloth,  $4  80 ;  leather,  raised  bands,  $5  25. 


This  book  should  not  only  be  read  but  thoroughly 
studied  by  every  member  of  the  profession.  None 
are  too  wise  or  old,  to  be  benefited  thereby.  But 
especially  to  the  younger  class  would  we  cordially 
commend  it  as  best  fitted  of  any  work  in  the  English 
language  to  qualify  them  for  the  reception  and  com- 
prehension of  those  truths  which  are  daibj' being  de- 
veloped in  physiology. — Medical  Counsellor. 

Without  pretending  to  it,  it  is  an  encyclopedia  of 
the  subject,  accurate  and  complete  in  all  respects — 
a  truthful  reflection  of  the  advanced  state  at  w^hich 
the  science  has  now  arrived. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  truly  magnificent  work — in  itself  a  perfect  phy- 
siological study. — Ranking^s  Abstract. 

This  work  stands  without  its  fellow.  It  is  one 
few  men  in  Europe  could  have  undertaken;  it  is  one 


no  man,  we  believe,  could  have  brought  to  so  suc- 
cessful an  issue  as  Dr.  Carpenter,  ft  required  for 
its  production  a  physiologist  at  once  deeply  read  in 
the  labors  of  others,  capable  of  taking  a  general, 
critical,  and  unprejudiced  view  of  those  labors,  and 
of  combining  the  varied,  heterogeneous  materials  at 
his  disposal,  so  as  to  form  an  harmonious  whole. 
We  feel  that  this  abstract  can  give  the  reader  a  very 
imperfect  idea  of  the  fulness  of  this  work,  and  no 
idea  of  its  unity,  of  the  admirable  marxier  in  which 
material  has  been  brought,  from  the  most  various 
sources,  to  conduce  to  its  completenesi,  of  the  lucid- 
ity of  the  reasoning  it  contains,  or  of  the  clearness 
of  language  in  which  the  whole  is  clothed.  Not  the 
profession  only,  but  the  scientific  world  at  large, 
must  feel  deeply  indebted  to  Dr.  Carpenter  for  this 
great  work.  It  must,  indeed,  add  largely  even  to 
his  high  reputation. — Medical  Times. 


BY  THE  SAME  AUTHOR.    (Preparing.) 

PRINCIPLES  OF   GENERAL   PHYSIOLOGY,   INCLUDING   ORGANIC 

CHEMISTRY  AND   HISTOLOGY.     With  a  General  Sketch  of  the  Vegetable  and  Animal 
Kingdom.    In  one  large  and  very  handsome  octavo  volume,  with  several  hundred  illustrations. 


BY  THE  SAME   AUTHOR. 


A  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN  HEALTH 

AND  DISEASE.    New  edition,  with  a  Preface  by  D.  F.  Condie,  M.  D.,  and  explanations  of 
scientific  words.    In  one  neat  12mo.  rolume,  extra  cloth,    pp.  178.    50  cents. 


BLANCHARD  &  LEA'S  MEDICAL 


CONOIE  (D.  FJ,  M.  D.,  &c. 
A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN.    Fifth 

edition,  revised  and  augmented.    In  one  large  volume,  8vo.,  leather,  of  over  750  pages.  $3  25. 

{J?tst  Issued,  1859.) 

In  presenting  a  new  and  revised  edition  of  this  favorite  work,  the  publishers  have  only  to  state 
that  the  author  has  endeavored  to  render  it  in  every  respect  "a  complete  and  faithful  exposition  of 
the  pathology  and  therapeutics  of  the  maladies  incident  to  the  earlier  stages  of  existence— ^a  full 
and  exact  account  of  the  diseases  of  infancy  and  childhood."  To  accomplish  this  he  has  subjected 
the  whole  work  to  a  careful  and  thorough  revision,  rewriting  a  considerable  portion,  and  adding 
several  new  chapters.  In  this  manner  it  is  hoped  that  any  deficiencies  which  may  have  previously 
existed  have  been  supplied,  that  the  recent  labors  of  practitioners  and  observers  have  been  tho- 
roughly incorporated,  and  that  in  every  point  the  work  will  be  found  to  maintain  the  high  reputation 
it  has  enjoyed  as  a  complete  and  thoroughly  practical  book  of  reference  in  infantile  affections. 

A  few  notices  of  previous  editions  are  subjoined. 

We  pronounced  the  first  edition  to  be  the  best 


Dr.  Condie's  schiilarship,  acumenj  industry,  and 
practical  sense  are  manifested  in  this,  as  in  all  his 
numerous  contributions  to  science. — Dr.  Holmes's 
Report  to  the  American  Medical  Association. 

Taken  as  a  whole,  in  our  judgment.  Dr.  Condie's 
Treatise  is  the  one  from  the  perusal  of  which  the 
practitioner  in  this  country  will  rise  with  the  great- 
est satisfaction. — Western  Journal  of  Medicine  and 
Surgery. 

One  of  the  best  works  upon  the  Diseases  of  Chil- 
dren in  the  English  language. — Western  Lancet. 

We  feel  assured  from  actual  experience  that  nc 
physician's  library  can  be  complete  without  a  copy 
of  this  work. — N.  Y.  Journal  of  Medicine. 

A  veritable  paediatric  encyclopaedia,  and  an  honoi 
to  American  medical  literature. — Ohio  Medical  and 
Surgical  Journal. 

We  feel  persuaded  that  the  American  medical  pro- 
fession will  soon  regard  it  not  only  as  a  very  goodj 
but  as  the  vkht  best  "Practical  Treatise  on  the 
Diseases  of  Children." — American  Medical  Journal 


work  on  the  diseases  of  children  in  the  English 
language,  and,  notwithstanding  all  that  has  been 
published,  we  still  regard  it  in  that  light. — Medical 
Examiner. 

The  value  of  works  by  native  authors  on  the  dis- 
eases which  the  physician  is  called  upon  to  combat, 
will  be  appreciated  by  all;  and  the  work  of  Dr.  Con- 
die  has  gained  for  itself  the  character  of  a  safe  guide 
for  students,  and  a  useful  work  for  consultation  by 
those  engaged  in  practice. — N.  Y.  Med.  Times. 

This  is  the  fourth  edition  of  this  deservedly  popu- 
lar treatise.  During  the  interval  since  the  last  edi- 
tion, it  has  been  subjected  to  a  thorough  revision 
by  the  author;  and  all  new  observations  in  the 
pathology  and  therapeutics  of  children  have  been 
included  in  the  present  volume.  As  we  said  btfore, 
we  do  not  know  of  a  better  book  on  diseases  of  chil- 
dren, and  to  a  large  part  of  its  recommendations  we 
yield  an  unhesitating  concurrence. — Buffalo  Med. 
Journal. 

Perhaps  the  most  full  and  complete  work  now  be- 


In  the  department  of  infantile  therapeutics,  the  Core  the  profession  ofthe  United  States;  indeed,  wa 
work  of  Dr.  Condie  is  considered  one  of  the  best  may  say  in  the  English  language.  It  is  vastly  supe- 
which  has  been  published  in  the  English  language,  rior  tomostof  Itspredecessors. — Transylvania  Med. 
—The  Stethoscope.  \  Journal. 


CHRISTISON  (ROBERT),  M.  D.,  V.  P.  R.  S.  E.,  «tc. 

A  DISPENSATORY;  or,  Commentary  on  the  Pharmacopoeias  of  Great  Britain 
and  the  United  States;  comprising  the  Natural  History,  Description,  Chemistry,  Pharmacy,  Ac- 
tions, Uses,  and  Doses  of  the  Articles  of  the  Materia  Medica.  Second  edition,  revised  and  im- 
proved, with  a  Supplement  containing  the  most  important  New  Remedies.  With  copious  Addi- 
tions, and  two  hundred  and  thirteen  large  wood-engravings.  By  R.  Eglesfeld  Griffith,  M.  D. 
In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  of  over  1000  pages.  $3  50. 

COOPER  (BRANSBY   B  )    F    R.  S> 

LECTURES  ON  THE   PRINCIPLES  AND  "  PRACTICE  OF   SURGERY. 

in  one  very  large  octavo  volume,  extra  cloth,  of  750  pages.    $3  00. 


COOPER  ON  DISLOCATIONS  AND  FRAC- 
TURES OF  THE  JOINTS  —Edited  by  Bkansbt 
B.  Cooper,  F.  R.S.,  *;c.  With  additional  Ob- 
servations by  Prof.  J.  C.  Wakren.  A  new  Ame- 
rican edition.  In  one  handsome  octavo  volume, 
extra  cloth,  of  about  500  pages,  with  numerous 
illustrations  on  wood.    $3  25. 

COOPER  ON  THE  ANATOMY  AND  DISEASES 
OF  THE  BREAST,  with  twenty-five  Miscellane- 
ous and  Surgical  Papers.  One  large  volume,  im- 
perial 8vo.,  extra  cloth,  with  252  figures,  on  36 
plates.    82  50. 

COOPER  ON  THE  STRUCTURE  AND  DIS- 
EASES OF  THE  TESTIS,  AND  ON  THE 
THYMUS  GLAND.  One  vol.  imperial  8vo.,  ex- 
tra cloth,  with  177  figures  on  29  plates.    $2  GO. 


COPLAND  ON  THE  CAUSES,  NATURE,  AND 
TREATMENT  OF  PALSY  AND  APOPLEXY. 
In  one  volume,  royal  12mo.,  extra  cloth,  pp.326. 
80  cents. 

CLYMER  ON  FEVERS;  THEIR  DIAGNOSIS, 
PATHOLOGY,  AND  TREATMENT  In  one 
octavo  volume,  leather,  of  600  pages.    $1  50. 

COLOMBAT  DE  L'ISERE  ON  THE  DISEASES 

OF  FEMALES,  and  on  the  special  Hygiene  of 
their  Sex.  Translated,  with  many  Notes  and  Ad- 
ditions, by  C.  D.  MkigSjM.D.  Second  edition, 
revised  and  improved.  In  one  large  volume,  oc- 
tavo, leather,  with  numerous  wood-cuts.  pp.  720. 
83  50. 


CARSON  (JOSEPH),  M.D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Pennsylvania. 

SYNOPSIS  OF  THE  COURSE  OF  LECTURES  ON  MATERIA  MEDICA 

AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.    Second  and  revised  edi- 
tion.   In  one  very  neat  octavo  volume,  extra  cloth,  of  208pige8.    $1  50. 


CURLING    (T.    B.),    F.R.S., 

Surgeon  to  the  London  Hospital,  President  of  the  Hunterian  Society,  &c. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  TESTIS,  SPERMA- 

TIC^CORD,  AND  SCROTUM.    Second  American,  from  the  second  and  enlarged  English  edi- 
tion.   In  one  handsome  octavo  volume,  extra  cloth,  with  numerous  illustrations,  pp.  420,  $2  00. 


AND   SCIENTIFIC   PUBLICATIONS. 


CHURCHILL  (FLEETWOOD),  M.  D.,  M.  R.  I.  A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.     A  new  American 

from  the  fourth  revised  and  enlarged  London  edition.  With  Notes  and  Additions,  by  D.  Francis 
UoNDiE,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Children,"  &c.  With  194 
illustrations  In  one  very  handsome  octavo  volume,  leather,  of  nearly  700  large  pages,  f  3  50. 
(Just  Issued.) 

This  work  has  been  so  long  an  established  favorite,  both  as  a  text-baok  for  the  learner  and  as  a 
reliable  aid  in  consultation  lor  the  practitioner,  that  in  presenting  a  new  edition  it  is  only  necessary 
to  call  attention  to  the  very  extended  improvements  which  it  has  received.  Having  had  the  benefit 
of  two  revisions  by  the  author  since  the  last  American  reprint,  it  has  been  materially  enlarged,  and 
Dr.  Churchill's  well-known  conscientious  industry  is  a  guarantee  that  every  portion  has  been  tho- 
roughly brought  up  with  the  latest  results  of  European  investigation  in  all  departments  of  the  sci- 
ence and  art  of  obstetrics.  The  recent  date  of  the  last  Dublin  edition  has  not  left  much  of  novelty 
for  the  American  editor  to  introduce,  but  he  has  endeavored  to  insert  whatever  has  since  appeared, 
together  with  such  matters  as  his  experience  has  shown  him  would  fee  desirable  for  the  American 
student,  including  a  large  number  of  illustrations.  With  the  sanction  of  the  author  he  has  added 
in  the  form  of  an  appendix,  some  chapters  from  a  little  "Manual  for  Midwives  and  Nurses,"  re- 
cently issued  by  Dr.  Churchill,  believing  that  the  details  there  presented  can  hardly  fail  to  prove  of 
advantage  to  the  junior  practitioner.  The  result  of  all  these  additions  is  that  the  work  now  con- 
tains fully  one-half  more  matter  than  the  last  American  edition,  with  nearly  one-half  more  illus- 
trations, so  that  notwithstanding  the  use  of  a  smaller  type,  the  volume  contains  almost  two  hundred 
pages  more  than  before. 

No  efibrt  has  been  spared  to  secure  an  improvement  in  the  mechanical  execution  of  the  work, 
equal  to  that  which  the  text  has  received,  and  the  volume  is  confidently  presented  as  one  of  the 
handsomest  that  has  thus  far  been  laid  before  the  American  profession;  while  the  very  low  price 
at  which  it  is  offered  should  secure  for  it  a  place  in  every  lecture-room  and  on  every  office  table. 


A  better  book  in  which  to  learn  these  important 
points  we  havenot  met  than  Dr.  Churchill's.  Every 
page  of  it  is  full  of  instruction;  the  opinion  of  all 
writers  of  authority  is  given  on  questions  of  diffi- 
culty, as  well  as  the  directions  and  advice  of  the 
learned  autnor  himself,  to  which  he  adds  the  result 
of  statistical  inquiry,  putting  statistics  in  their  pro 
per  place  and  giving  them  their  due  weight,  and  no 
more.  We  have  never  read  a  book  more  free  from 
professional  jealousy  than  Dr.  Churchill's.  It  ap- 
pears to  be  written  with  the  true  design  of  a  book  on 
medicine,  viz  :  to  give  all  that  is  known  on  the  sub- 
ject of  which  he  treats,  both  theoretically  and  prac- 
tically, and  to  advance  such  opinions  of  his  own  as 
he  believes  will  benefit  medical  science,  and  insure 
the  safety  of  the  patient.  We  have  said  enough  to 
convey  to  the  profession  that  this  book  of  Dr.  Chur- 
cliill's  is  admirably  suited  t"or  a  book  of  reference 
for  the  practitioner,  as  well  as  a  text-book  for  the 
student,  and  we  hope  it  may  be  extensively  pur- 
chased amongst  our  readers.  To  them  we  most 
strongly  recommend  it.  —  Dublin  Medical  Press, 
June  20,  1860. 

To  bestow  praise  on  a  book  that  has  received  such 
marked  approbation  would  be  superfluous.  We  need 
only  say,  therefore,  that  if  the  first  edition  was 
thought  worthy  of  a  favorable  reception  by  the 
medical  public,  we  can  confidently  affirm  that  this 
will  be  found  much  more  so.  The  lecturer,  the 
practitioner,  and  the  student,  may  all  have  recourse 
to  its  pages,  and  derive  from  their  perusal  much  in- 
terest and  instruction  in  everything  relating  to  theo- 
retical and  practical  midwifery. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  work  of  very  great  merit,  and  such  as  we  can 
confidently  recommend  to  the  study  of  every  obste- 
tric practitioner. — London  Medical  Gazette. 

This  is  certainly  the  most  perfect  system  extant. 
It  is  the  best  adapted  for  the  purposes  of  a  text- 
book, and  that  which  he  whose  necessities  confine 
him  to  one  book,  should  select  in  preference  to  all 
others. — Southern  Medical  and  Surgical  Journal. 

BY  THE  SAME  AUTHOR.    (Lately  Published.) 

ON  THE  DISEASES  OF  INFANTS  AND  CHILDREN.     Second  American 

Edition,  revised  and  enlarged  by  the  author.  Edited,  with  Notes,  by  W.  V.  Keating,  M.  D.  In 
one  large  and  handsome  volume,  extra  cloth,  of  over  700  pages.  $3  00,  or  in  leather,  f  3  25. 
In  preparing  this  work  a  second  time  for  the  American  profession,  the  author  has  spared  no 
labor  in  giving  it  a  very  thorough  revision,  introducing  several  new  chapters,  and  rewriting  others, 
while  every  portion  of  the  volume  has  been  subjected  to  a  severe  scrutiny.  The  efforts  of  the 
American  editor  have  been  directed  to  supplying  such  information  relative  to  matters  peculiar 
to  this  country  as  might  have  escaped  the  attention  of  the  author,  and  the  whole  may,  there- 
fore, be  safely  pronounced  one  of  the  most  complete  works  on  the  subject  accessible  to  the  Ame- 
rican Profession.  By  an  alteration  in  the  size  of  the  page,  these  very  extensive  additions  have 
been  accommodated  without  unduly  increasing  the  size  of  the  work. 

BY  THE  SAME   AUTHOR. 

ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DISEASES  PE- 
CULIAR TO  WOMEN.  Selected  from  the  writings  of  British  Authors  previous  to  the  close  of 
the  Eighteenth  Century.    In  one  neat  octavo  volume,  extra  cloth,  of  about  450  pages.    $2  50. 


The  most  popular  work  on  midwifery  ever  issued 
'rom  the  American  press. — Charleston  Med.  Journal. 

Were  we  reduced  to  the  necessity  of  having  but 
one  work  on  midwifery,  and  permitted  to  choose, 
we  would  unhesitatingly  take  Churchill. — Western 
Med.  and  Surg.  Journal. 

It  is  impossible  to  conceive  a  more  useful  and 
ilegant  manual  than  Dr.  Churchill's  Practice  of 
Midwifery. — Provincial  Medical  Journal. 

Certainly,  in  our  opinion,  the  very  best  work  on 
he  subject  which  exists. — N.  Y.  Annalist. 

No  work  holds  a  higher  position,  or  is  more  de- 
serving of  being  placed  in  the  hands  of  ttie  tyro, 
the  advanced  student,  or  the  practitioner. — Medical 
Examiner. 

Previous  editions,  under  the  editorial  supervision 
of  Prof.  R.  M.  Huston,  have  been  received  with 
marked  favor,  and  they  deserved  it;  but  this,  re- 
printed from  a  very  late  Dublin  edition,  carefully 
revised  and  brought  up  by  the  author  to  the  present 
time,  does  present  an  unusually  accurate  and  able 
exposition  of  every  important  particular  embraced 
in  the  department  of  midwifery.  *  *  The  clearness, 
directness,  and  precision  of  its  teachings,  together 
with  the  great  amount  of  statistical  research  which 
its  text  exhibits,  have  served  to  place  it  already  in 
the  foremost  rank  of  works  in  this  department  of  re 
medial  science. — N.  O.  Med.  and  Surg.  Journal. 

In  our  opinion,  it  forms  one  of  the  best  if  not  th 
very  best  text-book  and  epitome  of  obstetric  scienco 
which  we  at  present  possess  in  the  English  lan- 
guage.— Monthly  Journal  of  Medical  Science. 

The  clearness  and  precision  of  style  in  which  it  is 
written,  and  the  greatamount  of  statistical  research 
which  it  contains,  have  served  to  place  it  in  the  first 
rank  of  works  in  this  departmentof  medical  science. 
~N.  Y.  Journal  of  Medicine. 

Few  treatises  will  be  found  better  adapted  as  a 
text-book  for  the  student,  or  as  a  manual  for  th« 
frequent  consultation  of  the  young  practitioner. — 
American  Medical  Journal. 


10  BLANCHARD    &    LEA'S    MEDICAL 


CHURCHILL  (FLEETWOOD),    M .  D.,  M .  R.  I.  A.,    &c 
ON  THE  DISEASES  OP  WOMEN;  including  those  of  Pregnancy  and  Child- 
bed.   A  new  American  edition,  revised  by  the  Author.    With  Notes  and  Additions,  by  D  Fran- 
cis CoNDiE,  M.  D.,  author  ot  "A  Practical  Treatise  on  the  Diseases  of  Children."    With  nume- 
rous illustrations.    In  one  large  and  handsome  octavo  volume,  leather,  of  768  pages.   $3  00. 
This  edition  of  Dr.  Churchill's  very  popular  treatise  may  almost  be  termed  a  new  work    so 
thoroughly  has  he  revised  it  in  every  portion.     It  will  be  found  greativ  enlarged,  and  completely 
brought  up  to  the  most  recent  condition  of  the  subject,  while  the  very  hand.-ome  series  of  illustra- 
tions introduced,  representing  such  pathological  conditions  as  can  be  accurately  portrayed  present 
a  novel  feature,  and  afford  valuable  assistance  to  the  young  practitioner.     Such  addition's  as  ap- 
peared desirable  for  the  American  student  have  been  made  bv  the  editor,  Dr.  Condie,  while  a 
marked  improvement  in  the  mechanical  execution  keeps  pace  with  the  advance  in  all  other  respects 
which  the  volume  has  undergone,  while  the  price  has  been  kept  at  the  former  very  moderate  rate. 
It  comprises,  unquestionably,  one  of  the  most  ex-  ]  extent  that  Dr.  Churchill  does.     His,  indeed,  is  the 
act  and  comprehensive  expositi»ns  of  the  present    only  thorough  treatise  we  know  of  on  the  subject- 
state  of  medical  knowledge  in  respect  to  the  diseases    and  it  may  be  commended  to  practitioners  and  stu- 
of  women  that  has  yet  been  published.— ulw-JoMrn.  i  dents  as  a  masterpiece  in  its  particular  department 
Med.  Sciences.  —Tht  Western  Journal  of  Medicine  and  Surgery. 

This  work  is  the  most  reliable  which  we  possess  ,  as  a  comprehensive  manual  for  students,  or  a 
on  tins  subject;  and  is  deservedly  popular  with  the  i  work  of  reference  for  practitioners,  it  surpasses  any 
profession.— CAarJeiton  Med.  Journal,  July,  1857.        other  that  has  ever  issued  on  the  same  subject  from 

We  know  of  no  author  who  deserves  that  appro-  !  the  British  press. — Dublin  Quart.  Journal. 
bation,  on  "the  diseases  of  females,"  to  the  same  i 


DICKSON   (S.    H.),    M.  D., 

Professor  of  Practice  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

ELEMENTS  OF  MEDICINE;   a  Compendious  View  of  Pathology  and  Thera- 

peutics,  or  the  History  and  Treatment  of  Diseases.     Second  edition,  revised.    In  one  large  and 
handsome  octavo  volume   ot  750  pages,  leather.     $3  75.     (Just  Issued.) 

The  steady  demand  which  has  so  soon  exhausted  the  first  edition  of  this  work,  sufficiently  shows 
that  the  author  was  not  mistaken  in  supposing  that  a  volume  of  this  character  was  needed — an 
elementary  manual  of  practice,  which  should  present  the  leading  principles  of  medicine  with  the 
practical  results,  in  a  condensed  and  perspicuous  manner.  Disencumbered  of  unnecessary  detail 
and  fruitless  speculations,  it  embodies  what  is  most  requisite  for  the  student  to  learn,  and  at  the 
same  time  what  the  active  practitioner  wants  when  obliged,  in  the  daily  calls  of  his  profession,  to 
refresh  his  memory  on  special  points.  The  clear  and  attractive  style  of  the  author  renders  the 
whole  easy  of  comprehension,  while  his  long  experience  gives  to  his  teachings  an  authority  every- 
where acknowledged.  Few  physicians,  indeed,  have  had  wider  opportunities  for  observation  and 
experience,  and  few,  perhaps,  have  used  them  to  better  purpose.  As  the  result  of  a  long  life  de- 
voted to  study  and  practice,  the  present  edition,  revised  and  brought  up  to  the  date  of  publication, 
will  doubtless  maintain  the  reputation  already  acquired  as  a  condensed  and  convenient  American 
text-book  on  the  Practice  of  Medicine. 


DRUITT   (ROBERT),   M.R.C.S.,   &c. 
THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY.     A  new 

and  revised  American  from  the  eighth  enlarged  and  improved  London  edition.     Illustrated  with 

four  hundred  and  thirty-two  wood-engravings.    In  one  very  handsomely  printed  octavo  volume, 

leather,  of  nearly  700  large  pages.     $3  50.     {Just  Issued.)  , 

A  work  which  like  Druitt's  Surgery  has  for  so  many  years  maintained  the  position  of  a  lead- 
ing favorite  with  all  classes  of  the  profession,  needs  no  special  recommendation  to  attract  attention 
to  a  revised  edition.  It  is  only  necessary  to  state  that  the  author  has  spared  no  pains  to  keep  the 
work  up  to  its  well  earned  reputation  of  presenting  in  a  small  and  convenient  compass  the  latest 
condition  of  every  department  of  surgery,  considered  both  as  a  science  and  as  an  art;  and  that  the 
services  of  a  competent  American  editor  have  been  employed  to  introduce  whatever  novelties  may 
have  escaped  the  author's  attention,  or  may  prove  of  service  to  the  American  practitioner.  As 
several  editions  have  app)eared  in  London  since  the  issue  of  the  last  American  reprint,  the  volume 
has  had  the  benefit  of  repteated  revisions  by  the  author,  resulting  in  a  very  thorough  alteration  and 
improvement.  The  extent  of  these  additions  may  Ik?  estimated  from  the  fact  that  it  now  contains 
about  one-third  more  matter  than  the  previous  American  edition,  and  that  notwithstanding  the 
adoption  of  a  smaller  type,  the  pages  have  been  increased  by  about  one  hundred,  while  nearly  two 
hundred  and  fifty  wood-cuts  have  been  added  to  the  former  list  of  illustrations. 

A  marked  improvement  will  also  be  perceived  in  the  mechanical  and  artislical  execution  of  the 
work,  which,  printed  in  the  best  style,  on  new  type,  and  fine  paper,  leaves  little  to  be  desired  as 
regards  external  finish ;  while  at  the  very  low  price  afiixed  it  will  be  found  one  of  the  cheapest 
volumes  accessible  to  the  profession. 

This  popular  volume,  now  a  most  comprehensive  '  nothing  of  real  practical  importance  has  been  omit- 
work  on  surgery,  has  undergone  many  corrections,  ted  ;  it  presents  a  faithful  epitome  of  everything  re- 
improvements,  and  additions,  and  the  principles  and  lating  t )  surgery  up  to  the  present  hour.  It  is  de- 
the  practice  of  the  art  have  been  brought  down  to  servedly  a  popular  manual,  both  with  the  student 
the  latest  record  and  observation.  Of  the  operations  and  practitioner. — London  Lancet,  Nov.  19,  1859. 
in  surgery  it  is  impossible  to  speak  too  highly.     The!      ,,.,..■,,•  j 

descriptions  are  so  ckar  and  concise,  and  the  illus-  ,  In  closing  this  brief  notice,  we  recommend  as  cor- 
trations  so  accurate  and  numerous,  that  the  student  dially  as  ever  this  most  useful  and  comprehensive 
can  have  no  difficulty,  with  instrument  in  hand,  and  '  hand-book.  It  must  prove  a  vast  assistance,  not 
book  by  his  side,  over  the  dead  body,  in  obtaining    «"»ly  to  the  student  of  surgery,  but  also  to  the  busy 


a  proper  knowledge  and  sufficient  tact  in  this  much 
neglected  department  of  medical  education. — British 
and  Foreign  Medico-Chirurg.  Review,  Jan.  1860. 
In  the  present  edition  the  author  has  entirely  re 


practitioner  who  may  not  have  the  leisure  to  devote 
himself  to  the  study  of  more  lengthy  volumes. — 
London  Med.  Times  and  Gazette,  Oct  2*2,  1859. 


In  a  word,   this  eighth   edition   of  Dr._  Druitt's 
lanual  of  Surgery  is  all  that  the  sui 
r   practitioner  could  desire.  —  Dnb 
surgery.    On  carefully  going  over  it,  we  find  that    Journal  of  Med.  Sciences,  Nov.  1859. 


written  many  of  the  chapters,  and  has  incorporated    Manual  of  Surgery  is  all  that  the  surgical  student 
the  various  improvements  ana  additions  in  modern    or   practitioner  could  desire.  —  Dublin  Quarterly 


AND   SCIENTIFIC    PUBLICATIONS. 


11 


DALTON,  JR.  (J.   C),   M.  D. 

Professor  of  Physiology  in  the  College  of  Physicians,  New  York. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY,  designed  for  the  use  of  Students 

and  Practitioners  of  Medicine.     Second  edition,  revised  and  enlarged,  with  two  hundred  and 

seventy-one  illustrations  on  wood.    In  one  very  beautiful  octavo  volume,  of  700  pages,  extra 

cloth,  $4  00  ;  leather,  raised  bands,  $4  50.     {Just  Issued,  1861.) 

The  general  favor  which  has  so  soon  exhausted  an  edition  of  this  work  has  afforded  the  author 
an  opportunity  in  its  revision  of  supplying  the  deficiencies  which  existed  in  the  former  volume. 
This  has  caused  the  insertion  of  two  new  chapters — one  on  the  Special  Senses,  the  other  on  Im- 
bibition, Exhalation,  and  the  Functions  of  the  Lymphatic  System — besides  numerous  additions  of 
smaller  amount  scattered  through  the  work,  and  a  general  revision  designed  to  bring  it  thoroughly 
up  to  the  present  condition  of  the  science  with  regard  to  all  points  which  may  be  considered  as 
definitely  settled.  A  number  of  new  illustrations  has  been  introduced,  and  the  work,  it  is  hoped, 
in  its  improved  form,  may  continue  to  command  the  confidence  of  those  for  whose  use  it  is  in- 
tended. 

It  will  be  seen,  therefore,  that  Dr.  Dalton's  best  i  own  original  views  and  experiments,  together  with 
efforts  have  been  directed  towards  perfecting  his  i  a  desire  to  supply  what  he  considered  some  deficien- 
work.  The  additions  are  marked  by  the  same  fea-  cies  in  the  first  edition,  have  already  made  the  pre- 
tures  which  characterize  the  remainder  of  the  vol-  i  sent  one  a  necessity,  and  it  will  no  doubt  be  even 
unie,  and  render  it  by  far  the  most  desirable  text-  more  eagerly  sought  for  than  the  first.  That  it  is 
book  on  physiology  to  place  in  the  hands  of  the  not  merely  a  reprint,  will  be  seen  from  the  author's 
student  which,  so  far  as  we  are  aware,  exists  in  statement  of  the  following  principal  additions  and 
the  English  language,  or  perhaps  in  any  other.  We  i  alterations  which  he  has  made.  The  present,  like 
therefore  have  no  hesitation  in  recommending  Dr.  I  the  first  edition,  is  printed  in  the  highest  style  of  the 
Dalton's  book  for  the  classes  for  which  it  is  intend-  !  printer's  art,  and  the  illustrations  are  truly  admira- 
ed,  satisfied  as  we  are  that  it  is  better  adapted  to  ,  ble  tor  their  clearness  in  expressing  exactly  what 
their  use  than  any  other  work  of  the  kind  to  which  their  author  intended. — Boston  Medical  and  Surgi- 
they  have  access. — American  Journal  of  the  Med.  cal  Journal,  March  28,  1S61. 
Sciences,  April,  1861.  St.-  ^      •  ,.,,,,,.. 

]      It  IS  unnecessary  to  give  a  detail  of  the  additions  J 

It  is,  therefore,  no  disparagement  to  the  many  ■  suffice  it  to  say,  that  they  are  numerous  and  import- 
books  upon  physiology,  most  excellent  in  their  day,  ant,  and  such  as  will  render  the  work  still  more 
to  say  that  Dalton's  is  the  only  one  that  gives  us  the  valuable  and  acceptable  to  the  profession  as  a  learn- 
science  as  it  was  known  to  the  best  philosophers  i  ed  and  original  treatise  on  this  all-important  branch 
throughout  the  world,  at  the  beginning  of  the  cur-  1  of  medicine.  All  that  ^vas  said  in  commendation 
rent  year.  It  states  in  comprehensive  but  concise  j  of  the  getting  up  of  the  first  edition,  and  the  superior 
diction,  the  facts  established  by  experiment,  or  I  style  of  the  illustrations,  apply  with  equal  force  to 
other  method  of  demonstration,  and  details,  in  an  ''  this.  No  better  work  on  physiology  can  be  placed 
understandable  manner,  how  it  is  done,  but  abstains  [  in  the  hand  of  the  student. — St.  Louis  Medical  and 
from  thediscussionof  unsettled  or  theoretical  points.  '  Surgical  Journal,  May,  1861. 

Herein  it  is  unique ;  and  these  characteristics  ren  I  These  additions,  while  testifying  to  the  learning 
uer  It  a  text-book  without  a  rival,  for  those  who  \  ^nj  industry  of  the  author,  render  the  book  exceed- 
desire  to  study  physiological  science  as  it  is  known  j^giy  useful,  as  the  most  complete  expose  of  a  sci- 
to  Its  most  successful  cultivators.  And  it  isphysi-  e^ce,  of  which  Dr.  Dalton  is  doubtless  the  ablest 
ology  thus  presented  that  les  at  the  foundation  of  representative  on  this  side  of  the  Atlantic— ATew 
correct  pathologica  knowledge  ;  and  this  in  turn  is  Orleans  Med.  Times,  May,  1861. 
the  basis  of  rational  therapeutics ;  so  that  patholo-  1  j    j-  ■         ,    .•     ■ 

gy,  in  fact,  becomes  of  prime  importance  in  the  1  A  second  edition  of  this  deservedly  popular  work 
proper  discharge  of  our  every-day  practical  duties,  i  having  been  called  for  in  the  short  space  of  two 
—Cincinnati  Lancet,  May,  1861.  :  years,  the  author  has  supplied  deficiencies,  which 

I  existed  in  the  former  volume,  and  has  thus  more 

Dr.  Dalton  needs  no  word  of  praise  from  us.  He  completely  fulfilled  his  design  of  presenting  to  the 
is  universally  recognizeu  as  among  the  first,  if  not  profession  a  reliable  and  precise  text-book,  and  one 
the  very  fiist,  of  American  physiologistsnow  living,  which  we  consider  the  best  outline  on  the  subject 
The  first  edition  of  his  admirable  work  appeared  but  'of  which  it  treats,  in  any  language. — iV.  ATnerican 
two  years  since,  and  the  advance  of  science,  his    Medico-C hirurg .  Review,  May,  1861. 


DUNGLISON,   FORBES,   TWEEDIE,   AND  CONOLLY. 
THE  CYCLOPEDIA  OF  PRACTICAL  MEDICINE:  comprising  Treatises  on 

the  Nature  and  Treatment  of  Diseases,  JVIateria  Medica,  and  Therapeutics,  Diseases  of  Women 
and  Children,  JVIedical  Jurisprudence,  &c.  &c.  In  four  large  super-royal  octavo  volumes,  of 
3254  double-columned  pages,  strongly  and  handsomely  bound,  with  raised  bands.  $12  00. 
*JK:*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed  by 
eixty-eight  distinguished  physicians,  rendering  it  a  complete  library  of  reference  for  the  country 
practitioner. 

The  editors  are  practitioners  of  established  repu- 
tation, and  the  list  of  contributors  embraces  many 
of  the  most  eminent  professors  and  teachers  of  Lon- 
don, Edinburgh,  Dublin,  and  Glasgow.  It  is,  in- 
deed, the  great  merit  ol  this  work  that  the  principal 
articles  have  been  furnished  by  practitioners  who 
have  not  only  devoted  especial  attention  to  the  dis- 
eases about  which  they  have  written,  but  have 
also  enjoyed  opportunities  for  an  extensive  practi- 
cal acquaintance  with  them  and  whose  reputation 
carries  the  assurance  of  their  competency  justly  to 
appreciate  the  opinions  ol  others,  while  it  stamps 
their  own  doctrines  with  high  and  just  authority. — 
American  Medical  Journal. 


The  most  complete  work  on  Practical  Medicine 
extant;  or,  at  least,  in  our  language. — Buffalo 
Medical  and  Surgical  Journal, 

For  reference,  it  is  above  all  price  to  every  prac- 
titioner.— Western  Lancet. 

One  of  the  most  valuable  medical  publications  of 
the  day — as  a  work  of  reference  it  is  invaluable. — 
Western  Journal  oj  Medicine  and  Surgery. 

It  has  been  to  us,  both  as  learner  and  teacher,  a 
work  for  ready  and  frequent  reference,  one  in  whiqh 
modern  English  medicine  is  exhibited  in  the  most 
advantageous  light. — Medical  Examiner. 


DEWEES'S  COMPREHENSIVE  SYSTEM  OF 
MIDWIFERY.  Illustrated  by  occasional  cases 
and  many  engravings.  Twelfth  edition,  with  the 
author's  last  improvements  and  corrections.  In 
oneoctavovolume,  extracloth, of  600 pages.  $320. 

DEWEES'S  TREATISE  ON  THE  PHYSICAL 


AND  MEDICAL  TREATMENT  OF  CHILD 
REN.  The  last  edition.  In  one  volume,  octavo, 
extra  cloth,  548  pages.     $2  80 

DEWEES'S  TREATISE  ON  THE  DISEASES 
OF  FEMALES.  Tenth  edition.  In  one  volume, 
octavo  extra  cloth,  532  pages,  with  plates.  83  00 


12 


BLANCHARD   &    LEA'S    MEDICAL 


DUNGLISON    (ROBLEY),    M.  D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

NEW  AND  ENLARGED  EDITION. 

MEDICAL  LEXICON;   a  Dictionary  of  Medical  Science,  containing  a  concise 

Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathology,  Hygiene, 
Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  Jurisprudence,  Dentistry, 
&-C.  Notices  of  Climate  and  of  Mineral  Waters ;  Formulae  for  Otficinal,  Empirical,  and  Dietetic 
Preparations,  &c.  With  French  and  other  Synonymes.  Revised  and  very  greatly  enlarged. 
In  one  very  large  and  handsome  octavo  volume,  of  992  double-columned  pages,  ia  small  type; 
strongly  bound  in  leather,  with  raised  bands.    Price  $4  00. 

Especial  care  has  been  devoted  in  the  preparation  of  this  edition  to  render  it  in  every  respect 
worthy  a  continuance  of  the  very  remarkable  favor  which  it  has  hitherto  enjoyed.  The  rapid 
sale  of  Fifteen  large  editions,  and  the  constantly  increasing  demand,  show  that  it  is  regarded  by 
the  profession  as  the  standard  authority.  Stimulated  by  this  fact,  the  author  has  endeavored  in  the 
present  revision  to  introduce  whatever  might  be  necessary  "  to  make  it  a  satisfactory  and  desira- 
ble— if  not  indispensable — lexicon,  in  which  the  student  may  search  without  disappointment  for 
every  term  that  has  been  legitimated  in  the  nomenclature  of  the  science."  To  accomplish  this, 
large  additions  have  been  found  requisite,  and  the  extent  of  the  author's  labors  may  be  estimated 
from  the  fact  that  about  Six  Thousand  subjects  and  terms  have  been  introduced  throughout,  ren- 
dering the  whole  number  of  definitions  about  Sixty  Thousand,  to  accommodate  which,  the  num- 
ber of  pages  has  been  increased  by  nearly  a  hundred,  notwithstanding  an  enlargement  in  the  size 
of  the  page.  The  medical  press,  both  in  this  country  and  in  England,  has  pronounced  the  work  in- 
dispensable to  all  medical  students  and  practitioners,  and  the  present  improved  edition  will  not  lose 
that  enviable  reputation. 

The  publishers  have  endeavored  to  render  the  mechanical  execution  worthy  of  a  volume  of  such 
universal  use  in  daily  reference.  The  greatest  care  has  been  exercised  to  obtain  the  typographical 
accuracy  so  necessary  in  a  work  of  the  kind.  By  the  small  but  exceedingly  clear  type  employed, 
an  immense  amount  of  matter  is  condensed  in  its  thousand  ample  pages,  while  the  binding  will  be 
found  strong  and  durable.  With  all  these  improvements  and  enlargements,  the  price'has  been  kept 
at  the  former  very  moderate  rate,  placing  it  within  the  reach  of  all. 


This  work,  the  appearance  of  the  fifteenth  edition 
of  which,  it  has  become  our  duty  and  ple.isure  to 
announce,  is  perliaps  the  most  stupendous  monument 
of  labor  and  erudition  in  medical  literature.  One 
would  hardly  suppose  after  constant  use  of  the  pre- 
ceding editions,  where  we  have  never  failed  to  find 
a  sufficiently  full  explanation  of  everj  medical  term, 
that  in  this  edition  ^' about  six  thousand  subjects 
and  terms  have  been  added,"  with  a  careful  revision 
and  correction  of  the  entire  work.  It  is  only  neees-  I 
■  sary  to  announce  the  advent  of  this  edition  to  make 
it  occupy  the  place  of  the  preceding  one  on  the  table 
of  every  medical  man,  as  it  is  withoutdoubt  the  best 
and  most  comprehensive  work  of  the  kind  which  has  i 
ever  appeared. — Buffalo  Med.Joum.,  Jan.  1858.        < 

The  work  is  a  monument  of  patient  research.  ] 
skilful  judgment,  and  vast  physical  labor,  that  will 
perpetuate  the  name  of  the  author  more  effectually 
than  any  possible  device  of  stone  or   metal.     Dr.  | 
Dunglison  deserves  the  thanks  not  only  of  the  Ame-  j 
rican  profession,  but  of  the  whole  medic.il  world. — 
North  Am.  Medico-Chir.  Revieic,  Jan.  1859. 

A  Medical  Dictionary  better  adapted  for  the  wants  | 
of  the  profession  tlian  any  other  with  which  we  are 
acquainted,  and  of  a  character  which  places  it  far  j 
above  comparison  and   competition. — Am.  Journ. 
Med.  Sciences,  Jan.  1858. 

We  need  only  say,  that  the  addition  of  6,000  new  j 
terms,  with  their  accompanying  definitions,  may  be  i 
said  to  constitute  a  new  work,  by  itself.     We  have  I 
examined  the  Dictionary  attentively,  and  are  most  ' 
happy  to  pronounce  it  unrivalled  of  its  kind.     The  ; 
erudition  displayed,  and  the  extraordinary  industry  I 
which  must  have  been  demanded,  in  its  preparation 
and  perfection,  redound  to  the  lasting  credit  of  its 
author,  and  have  furnished  us  with  a  volume  indis- 
pensable  at  the  present  day,  to  all  who  would  find  ' 
themselves  au  niveau  with  the  highest  standards  of 
medical  information. — Boston  Medical  and  Surgical 
Journal,  Vec.^il,  18.57. 

Good  lexicons  and  encyclopedic  works  generally,  ' 
are  the  most  labor-saving  contrivances  which  lite-  , 
rary  men  enjoy;  and  the  labor  which  is  required  to  i 
produce  them  in  the  perfect  manner  of  this  example 
IB  something  appalling  to  contemplate.    The  author  [ 


tells  us  in  his  preface  that  he  has  added  about  six 
thousand  terms  and  subjects  to  this  edition,  which, 
before,  was  considered  universally  as  the  best  work 
of  the  kind  in  any  language. — StlHman^s  Journal, 
March,  1858. 

He  has  razed  his  gigantic  structure  to  the  founda- 
tions, and  remodellen  and  reconstructed  the  entire 
pile.  No  less  than  six  thousand  additional  subjects 
and  terms  are  illustrated  and  analyzed  in  this  new 
edition,  swelling  the  grand  aggregate  to  beyond 
sixty  thousand  !  Thus  is  placed  before  the  profes- 
sion a  complete  and  thorough  exponent  of  medical 
terrtiinology,  without  rival  or  possibility  of  rivalry. 
— Nashville  Journ.  of  Med.  and  Surg.,  Jan.  1858. 

It  is  universally  acknowledged,  we  believe,  that 
this  work  is  incomparably  the  best  and  most  com- 
plete Medical  Lexicon  in  the  English  language. 
The  amount  of  labor  which  the  distinguished  author 
has  bestowed  upon  it  is  truly  wonderful,  and  the 
learning  and  research  displayed  in  its  preparation 
are  equally  remarkable.  Comment  and  commenda- 
tion are  unnecessary,  as  no  one  at  the  present  day 
thinks  of  purchasing  any  other  Medical  Dictionary 
thnn  this. — St.  Louts  Med.  and  Surg.  Journ.,  Jan. 
1858. 

It  is  the  foundation  stone  of  a  good  medical  libra- 
ry, and  sliould  always  be  included  in  the  first  list  of 
books  purchased  by  the  medical  student. — Am.  Med. 
Monthly,  Jan.  1858. 

A  very  perfect  work  of  the  kind,  undoubtedly  the 
most  perfect  in  the  English  language. — Med.  and 
Surg.  Reporter,  Jan.  1858. 

It  is  now  emphatically  the  Medical  Dictionary  of 
the  English  language,  and  for  it  there  is  no  substi- 
tute.—iV.  H.  Med.  Journ.,  Jan.  1858. 

It  is  scarcely  necessary  to  remark  that  any  medi- 
cal library  wanting  a  copy  of  Dunglison's  Lexicon 
must  be  imperfect. — Cin.  Lancet,  Jan.  1858. 

We  have  ever  considered  it  thebestauthority  pub- 
lished, and  the  present  edition  we  may  safely  say  has 
no  equal  in  the  world. — Peninsular  Med.  Journal, 
Jan. 1858. 

The  most  complete  authority  on  the  subject  to  b« 
found  in  any  language.— Fa.  iVIed.  JoKrnai,  Feb.  '56. 


BY   THE  SAME   AUTHOR. 


THE  PRACTICE  OF  MEDICINE.    A  Treatise  on  Special  Pathology  and  The- 
rapeutics.   Third  Edition.    lu  two  large  octavo  volumes,  leather,  of  1,500  pages.    ?6  25. 


AND    SCIENTIFIC    PUBLICATIONS. 


13 


DUNGLISON    (ROBLEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College, .Philadelphia. 

HUMAN    PHYSIOLOaY.     Eighth  edition.     Thoroughly  revised  and  exten- 

sively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.    In  two  large  and 
handsomely  printed  octavo  volumes,  leather,  of  about  1500  pages.     $7  00. 

In  revising  this  work  for  its  eighth  appearance,  the  author  has  spared  no  labor  to  render  it  worthy 
a  continuance  of  the  very  great  favor  which  has  been  extended  to  it  by  the  profession.  The  whole 
contents  have  been  rearranged,  and  to  a  great  extent  remodelled  ;  the  investigations  which  of  late 
years  have  been  so  numerous  and  so  important,  have  been  carefully  examined  and  incorparated, 
and  the  work  in  every  respect  has  been  brought  up  to  a  level  with  the  present  state  of  the  subject. 
The  object  of  the  author  has  been  to  render  it  a  concise  but  comprehensive  treatise,  containing  the 
whole  body  of  physiological  science,  to  which  the  student  and  man  of  science  can  at  all  times  refer 
with  the  certainty  of  finding  whatever  they  are  in  search  of,  fully  presented  in  all  its  aspects;  and 
on  no  former  edition  has  the  author  bestowed  more  labor  to  secure  this  result. 

We  believe  that  it  can  truly  be  said,  no  more  com- 
plete repertory  of  facts  upon  the  subject  treated, 
can  anywhere  be  found.  The  author  lias,  moreover, 
that  enviable  tact  at  description  and  that  facility 
and  ease  of  expression  which  render  him  peculiarly 
acceptable  to  the  casual,  or  the  studious  reader. 
This  faculty,  so  requisite  in  setting  forth  many 
graver  and  less  attractive  subjects,  lends  additional 
cliarms  to  one  always  fascinating. — Boston  Med. 
and  Surg.  Journal. 

The  most  complete  and  satisfactory  system  of 
Physiology  in  the  English  language. — Amer.Med. 
Journal . 


The  best  work  of  the  kind  in  the  English  lan- 
guage.— SilliTnan's  Journal. 

The  present  edition  the  author  has  made  a  pcifcct 
mirror  of  the  science  as  it  is  at  the  present  hour. 
As  a  work  upon  physiology  proper,  the  science  of 
the  functions  performed  by  the  body,  the  student  will 
find  it  all  he  wishes. — Nashville  Journ.  of  Med. 

That  he  has  succeeded,  most  admirably  succeeded 
in  his  purpose,  is  apparent  from  the  appearance  of 
an  eighth  edition.  It  is  now  the  great  encyclopaedia 
on  the  subject,  and  worthy  of  a  place  in  every  phy- 
sician's library. — Western  Lancet. 


BY  THE  SAME  AUTHOR.     (A  new  edition.) 

GENERAL    THERAPEUTICS    AND    MATERIA  MEDIC  A;   adapted  for  a 

Medical  Text-book.  With  Indexes  of  Remedies  and  of  Diseases  and  their  Remedies.  Sixth 
Edition,  revised  and  improved.  With  one  hundred  and  ninety-three  illustrations.  In  two  large 
and  handsomely  printed  octavo  vols.,  leather,  of  about  1100  pages.    $6  00. 

In  announcing  a  new  edition  of  Dr.  Dunglison's 
General  Therapeutics  and  Materia  Medica,  we  have 
no  words  of  commendation  to  bestow  upon  a  work 
whose  merits  have  been  heretofore  so  often  and  so 
justly  extolled.  It  must  not  be  supposed,  however, 
that  the  present  is  a  mere  reprint  of  the  previous 
edition:  tiie  character  of  the  author  for  laborious 
research,  judicious  analysis,  and  clearness  of  ex- 
pression, is  fully  sustained  by  the  numerous  addi- 
tions he  has  made  to  the  work,  and  tbe  careful  re- 
vision to  which  he  has  subjected  the  whole. — N.  A. 
Medico-Chir.  Review,  Jan.  1858. 


The  work  will,  we  have  little  doubt,  be  bought 
and  read  by  the  majority  of  medical  students;  its 
size,  arrangement,  and  reliability  recommend  it  to 
all;  no  one,  we  venture  to  predict,  will  study  it 
without  profit,  and  there  are  few  to  whom  it  will 
not  be  in  some  measure  useful  as  a  work  of  refer- 
ence. The  young  practitioner,  more  especially,  will 
find  the  copious  indexes  appended  to  this  ediiion  of 
great  assistance  in  the  selection  and  preparation  of 
suitable  formulEe. — Charleston  Med.  Journ.  and  Re- 
view, Jan.  185S. 


BY  the  same  author.    (A  new  Edition.) 

NEW  REMEDIES,  WITH  FORMUL^^  FOR  THEIR  PREPARATION  AND 

ADMINISTRATION.     Seventh  edition,  with  extensive  Additions.    In  one  very  large  octavo 
volume,  leather,  of  770  pages.     $3  75. 

Another  edition  of  the  "New  Remedies"  having  been  called  for,  the  author  has  endeavored  to 
add  everythmg  of  moment  that  has  appeared  since  the  publication  of  the  last  edition. 

The  articles  treated  of  in  the  former  editions  will  be  found  to  have  undergone  considerable  ex- 
pansion in  this,  in  order  that  the  author  might  be  enabled  to  introduce,  as  far  as  practicable,  the 
results  of  the  sub.sequent  experience  of  others,  as  well  as  of  his  own  observation  and  reflection ; 
and  to  make  the  work  still  more  deserving  of  the  extended  circulation  with  which  the  preceding 
editions  have  been  favored  by  the  profession.  By  an  enlargement  of  the  page,  the  numerous  addi- 
tions have  been  incorporated  without  greatly  increasing  the  bulk  of  the  volume. — Preface. 


One  of  the  most  useful  of  the  author's  works. — 
Southern  Medical  and  Surgical  Journal. 

This  elaborate  and  useful  volume  should  be 
found  in  every  medical  library,  for  as  a  book  of  re- 
ference, for  physicians,  it  is  unsurpassed  by  any 
other  work  in  existence,  and  the  double  index  for 
diseases  and  for  remedies,  will  be  found  greatly  to 
•chance  its  value. — New  York  Med.  Gazette, 


The  great  learning  of  the  author,  and  his  remark- 
able industry  in  pushing  his  researches  into  every 
source  whence  information  is  derivable, have  enabled 
him  to  throw  together  an  extensive  mass  of  facts 
and  statements,  accompanied  by  full  reference  to 
authorities;  which  last  feature  renders  the  work 
practically  valuable  to  investigators  who  desire  te 
examine  the  original  papers. — The  ATnerican  Journal 
of  Pharmacy. 


ELLIS  (BENJAMIN),  M.D. 
THE   MEDICAL  FORMULARY :   being  a  Collectiou  of  Prescriptions,  derived 

from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America  and  Europe. 
Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poi.sons.  To  which  is  added 
an  Appendix,  on  the  Endermic  use  of  Medicines,  and  on  the  use  of  Ether  and  Chloroform.  The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Obserrations.  Eleventh  editioi  , 
revised  and  much  extended  by  Robert  P.  Thomas,  M.  D.,  Professor  of  Materia  Medica  in  the 
Philadelphia  College  of  Pharmacy.    {Preparing.) 


14 


BLANCHARD    &    LEA'S    MEDICAL 


ERICHSEN    (JOHN), 

Professor  of  Surgery  in  University  College,  London,  &c, 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Surgical 

Injuries,  Diseases,  and  Operations.    New  and  improved  American,  from  the  second  enlareed 

and  carefully  revised  London  edition.     Illustrated  with  over  four  hundred  engravings  on  wood. 

In  one  large  and   handsome  octavo  volume,  of  one  thousand  closely  printed  pages,  leather, 

raised  bands.     $4  50.     {Jrist  Issued.) 

The  very  distinguished  favor  with  which  this  work  has  been  received  on  both  sides  of  the  Atlan- 
tic has  stimulated  the  author  to  render  it  even  more  worthy  of  the  position  which  it  has  so  rapidly 
attained  as  a  standard  authority.  Every  portion  has  been  carefully  revised,  numerous  additions 
have  been  made,  and  the  most  watchful  care  has  been  exercised  to  render  it  a  complete  exponent 
of  the  most  advanced  condition  of  surgical  science.  In  this  manner  the  work  has  been  enlarged  by 
about  a  hundred  pages,  while  the  series  of  engravings  has  been  increased  by  more  than  a  hundred, 
rendering  it  one  of  the  most  thoroughly  illustrated  volumes  before  the  profession.  The  additions  of 
the  author  having  rendered  unnecessary  most  of  the  notes  of  the  former  American  editor,  but  little 
has  been  added  in  this  country;  some  few  notes  and  occasional  illustrations  have,  however,  been 
introduced  to  elucidate  American  modes  of  practice. 

It  is,  in  our  humble  judgtneni.  decidedly  the  best  i  step  of  the  operation,  and  not  deserting  him  until  the 
Book  of  the  kind  in  the  English  language.    Strange    final  issue  of  the  case  is  decided  — Sethoseope. 
thai  JHSl  such  books  are  noloflener  produced  by  pub-        Embracing,  as  will  be  perceived,  the  whole  surgi- 
Uc  teachers  of  surgery  in  tins  country  and  Great    gal  domain,  and  each  division  of  itself  almost  corn- 
Indeed,  his  a  matter  of  great  astonishment.  |  piete  and  perfect,  each  chapterfull  and  explicit,  each 


Britain 

but  no  less  true  than  astonishing,  that  of  the  many 
works  on  surgery  republished  in  this  country  within 
the  last  fifteen  or  twenty  years  as  text-books  for 
medical  students,  this  i>  the  only  one  that  even  ap- 
proximates to  the  fulfilment  of  the  peculiar  wants  of 
young  men  just  entering  upon  the  study  of  this  branch 
of  the  profession. —  WesUriiJour  .of  Med.  and  Surgery. 

Its  value  is  greatly  enhanced  by  a  very  copious 
well-arranged  index.  We  regard  this  as  one  of  the 
most  valuable  contributions  to  modern  surgery.  To 
one  entering  his  novitiate  of  practice,  we  regard  it 
the  most  serviceable  guide  which  he  can  consult.  He 
will  find  a  fulnessofdetaiileailinghim  through  every 


ubjpct  faithfully  exhibited,  we  can  only  express  oui 
estimate  of  it  in  the  aggregate.  We  consider  it  an 
excellent  contribution  to  surgery,  as  probably  the 
best  single  volume  now  extant  on  the  subject,  and 
with  great  pleasure  w?e  add  it  to  our  text-books. — 
NishHUe  Journal  of  Medicine  and  Surgery . 

Prof.  Erichsen's  work,  for  its  size,  has  not  been 
surpassed;  his  nine  hundred  and  eight  pages,  pro- 
fusely illustrated,  are  rich  in  physiological,  patholo- 
gical, and  operative  suggestions,  doctrines,  details, 
and  processes  ;  and  will  prove  a  reliable  resource 
for  information,  both  to  physician  and  surgeon,  in  the 
hour  of  peril.— iV.  0.  Med.  and  Surg.  Journal. 


FLINT  (AUSTIN),  M.  D., 

Professor  of  the  Theory  and  Practice  of  Medicine  in  the  University  of  Louisville,  tec. 

PHYSICAL  EXPLORATION  AND  DIAGNOSIS  OF  DISEASES  AFFECT- 
ING THE  RESPIRATORY  ORGANS.  In  one  large  and  handsome  octavo  volume,  extra 
cloth,  636  pages.  $3  00. 
We  regard  it,  in  point  both  of  arrangement  and  of 

the  marked  ability  of  its  treatment  of  the  subjects, 

as  destined  to  take  the  first  rank  in  works  of  this 

class.    So  far  as  our  information  extends,  it  has  at 

present  no  equal.     To  the  practitioner,  as  well  as 

the  student,  it  will  be  invaluable  in  clearing  up  the 

diagnosis  of  doubtful  cases,  and  in  shedding  light 

upon  difficult  phenomena. — Buffalo  Med.  Journal. 


A  work  oforiginal  observation  ofthe  highest  merit. 
We  recommend  the  treatise  to  every  one  who  wishes 
to  become  a  correct  anscultator.  Based  to  a  very 
large  extent  upon  eases  numerically  examined,  it 
carries  theevidtnce  of  careful  study  and  discrimina- 
tion upon  every  page.  It  does  credit  to  the  author, 
and,  through  him,  to  the  profession  in  this  country. 
It  is,  what  we  cannot  call  every  book  upon  auscul- 
tation, a  readable  book. — Am.  Jour.  Med.  Sciences. 

BY  THE  SAME  AUTHOR.     {Now  Ready.) 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY,  AND 

TREATJVIENT  OF  DISEASES  OF  THE  HEART.     In  one  neat  octavo  volume,  of  about 
500  pages,  extra  cloth.     $2  75. 


We  do  not  know  that  Dr.  Flint  has  written  any- 
thing which  is  not  first  rate  ;  but  this,  his  latest  con- 
tribution to  medical  literature,  in  our  opinion,  sur- 
passes all  the  others.  The  work  is  most  comprehen- 
sive in  its  scope,  and  most  sound  in  the  views  it  enun- 
ciatts.  The  descriptions  are  clear  and  methodical; 
the  statements  are  substantiated  by  facts,  and  are 
made  with  such  simplicity  and  sincerity,  that  with- 
out them  they  would  carry  conviction.  The  style 
is  admirably  clear,  direct,  and  free  from  dryness 
With  Dr.  Walshe's  excellent  treatise  before  us,  we 
have  no  hesitation  in  saying  that  Dr.  Flint's  book  is 
the  best  work  on  the  heart  in  the  English  language 
— Boston  Med.  and  Surg.  Journal. 

We  have  thus  endeavored  to  present  our  readers 
with  a  fair  analysis  of  this  remarkable  work.  Pre- 
ferring to  employ  the  very  words  of  thedistinguished 
author,  wherever  it  was  possible,  wfc  have  essayed 
to  condense  into  the  briefest  spacea  general  view  of 
his  observations  and  suggestions,  and  to  direct  the 
attention  of  our  brethren  to  the  abounding  stores  of 
valuable  matter  here  collected  and  arranged  for  their 
use  and  instruction.  No  medical  library  will  here 
after  be  considered  complete  without  this  volume; 
and  we  trust  it  will  promptly  find  its  way  into  the 
hands  of  every  American  student  and  physician. — 
N   Am.  Med.  Chir.  Revieio. 

This  last  work  of  Prof.  Flint  will  add  much  to 
bis  previous  well-earned  celebrity,  as  a  writer  ol 


great  forceand  beauty,  and,  with  his  previous  work, 
places  him  at  the  head  of  American  writers  upon 
diseases  of  the  chest.  We  have  adopted  his  work 
upon  the  heart  as  a  text- book,  believing  it  to  be 
more  valuable  for  that  purpose  than  any  work  of  the 
kind  that  has  yet  appeared. — Nashville  Med.Journ. 
With  more  than  pleasure  do  we  hail  the  advent  of 
this  work,  for  it  fills  a  wide  gap  on  the  list  v{  text- 
books for  our  schools,  and  is,  for  the  practitioner, 
the  most  valuable  practical  work  of  its  kind. — N.  O. 
Med.  News. 

In  regard  to  the  merits  of  the  work,  we  have  no 
hesitation  in  pronouncing  it  full,  accurate,  and  ju- 
dicious. C(msideriiig  the  present  state  of  science, 
such  a  work  was  much  needed.  It  should  be  in  the 
handsof  every  practitioner. — Chicago  Med.  Journal. 

But  these  are  very  trivial  spots,  and  in  nowise 
prevent  us  from  declaring  our  most  hearty  approval 
of  the  author's  ability,  industry,  and  conscientious- 
ness.— Dublin  Quarterly  Journal  of  Med.  Sciences. 

He  has  labored  on  wi'h  the  same  industry  and  care, 
and  his  place  among  the  Jirst  authors  of  our  country 
is  becoming  fully  esiablibhed.  To  this  end,  the  work 
whose  title  is  given  above,  contributes  in  no  small 
degree.  Our  spa?e  will  not  admit  of  »n  extended 
analysis,  and  we  will  close  this  orief  notice  by 
commending  it  without  reserve  to  every  class  of 
readers  in  the  profession. — Peninsular  Med.  Journ, 


AND    SCIENTIFIC    PUBLICATIONS, 


15 


FOWNES  (GEORGE),   PH.  D.,  &c. 
A  MANUAL  OF  ELExMENTARY  CHEMISTRY ;  Theoretical  and  Practical. 

From  the  seventh  revised  and  corrected  London  edition.     With  one  hundred  and  ninety-seven 

illustrations.     Edited  by  Robert  Bridges,  M.  D.    In  one  large  royal  12mo.  volume,  of  tiOO 

pag-es.     In  leather,  $1  65 ;  extra  cloth,  $1  50.     {Just  Issued.) 

The  death  of  the  author  having  placed  the  editorial  care  of  this  work  in  the  practised  hands  of 
Drs.  Bence  Jones  and  A.  W.  Hofiman,  everything  has  been  done  in  its  revision  which  experience 
could  suggest  to  keep  it  on  a  level  with  the  rapid  advance  of  chemical  science.  The  additions 
requisite  to  this  purpose  have  Hecess-ilated  an  enlargement  of  the  page,  notwithstanding  which  the 
work  has  been  increased  by  about  fifty  pages.  At  the  same  time  every  care  has  been  used  to 
maintain  its  distinctive  character  as  a  condensed  manual  for  the  student,  divested  of  all  unnecessary 
detail  or  mere  theoretical  speculation.  The  additions  have,  of  course,  been  mainly  in  the  depart- 
ment of  Organic  Chemistry,  which  has  made  such  rapid  progress  within  the  last  kw  years,  but 
yet  equal  attention  has  been  bestowed  on  the  other  branches  of  the  subject — Chemical  Physics  and 
Inorganic  Chemistry — to  present  all  investigations  and  discoveries  of  importance,  and  to  keep  up 
the  reputation  of  the  volume  as  a  complete  manual  of  the  whole  science,  admirably  adapted  for  the 
learner.  By  the  use  of  a  small  but  exceedingly  clear  type  the  matter  of  a  large  octavo  is  compressed 
within  the  convenient  and  portable  limits  of  a  moderate  sized  duodecimo,  and  at  the  very  low  price 
affixed,  it  is  oifered  as  one  of  the  cheapest  volumes  before  the  profession. 


Dr.  Fownes' excellent  work  has  been  universally 
recognized  everywhere  in  his  own  and  this  country, 
as  tlie  best  elementary  treatise  on  chemistry  in  the 
English  tongue,  and  is  very  generally  adopted,  we 
believe,  as  the  standard  text- bonk  in  alli  ur  colleges, 
both  literary  and  scientific. — Gkarleston  Med.Journ. 
and  Review. 

A  standard  manual,  which  has  long  enjoyed  the 
reputation  of  embodying  much  knowledge  in  a  small 
space.  The  author  has  achieved  the  difficult  task  of 
condensation  with  masterly  tact.  His  book  is  con- 
cise without  being  dry,  and  brief  without  being  too 
dogmatical  or  general. —  Virginia  Med.  and  Surgical 
Journal . 


The  work  of  Dr.  Fowiies  has  long  been  before 
the  public,  and  its  merits  have  been  fully  appreci- 
ated as  the  best  text-book  on  chemistry  now  in 
existence.  We  do  not,  of  course,  place  it  in  a  rank 
superior  to  the  works  of  Brande,  Graham,  Turner, 
Gregory,  or  Grnelin,  but  we  say  that,  as  a  work 
for  students,  it  is  preferable  to  any  of  them. — Lon- 
don Journal  of  Medicine. 

A  work  well  adapted  to  the  wants  of  the  student 
It  is  an  excellent  exposition  of  the  chief  doctrinea 
and  facts  of  modern  chemistry.  The  size  of  the  work, 
and  still  more  the  condensed  yet  perspicuous  style 
in  which  it  is  written,  absolve  it  from  the  charges 
very  properly  urged  against  most  manuals  termed 
popular. — Edinburgh  Journal  of  Medical  Scienct 


FISKE  FUND  PRIZE  ESSAYS  —  THE  EF- 
FECTS OF  CLIMATE  ON  TUBERCULOUS 
DISEASE.  By  Edwin  Lee,  M.  R.  C.  S  ,  London, 
and  THE  INFLUENCE  OF  PREGNANCY  ON 
THE  DEVELOPJMENT  OF  TUBERCLES     By 


Edward  Warren,  M.D,  of  Edenton,N.  C.  To- 
gether in  one  neat  8vo.  volume,  extra  cloth.  $1  00. 
FRICK  ON  RENAL  AFFECTIONS  I  their  Diag- 
nosis  and  Pathology.  With  illustrations.  One 
volume,  royal  r2mo.,  extra  cloth.    75  cents 


FERGUSSON  (WILLIAM),  F.  R.  S., 

Professor  of  Surgery  in  King's  College,  London,  &c. 

A  SYSTEM  OF  PRACTICAL  SURGERY.     Fourth  American,  from  the  third 

and  enlarged  London  edition.    In  one  large  and  beautifully  printed  octavo  volume,  of  about  700 
pages,  with  393  handsome  illustrations,  leather,     f  3  GO. 

GRAHAM  (THOMAS),  F.  R.  S. 
THE  ELEMENTS   OF   INORGANIC   CHEMISTRY,  including  the  Applica- 

lions  of  the  Science  in  the  Arts.   New  and  much  enlarged  edition,  by  Henry  Watts  and  Robert 

Bridges,  M.  D.     Complete  in  one  large  and  handsome  octavo  volume,  of  over  800  very  large 

pages,  with  two  hundred  and  thirty-two  wood-cuts,  extra  cloth.     $4  00. 

,fe*^  Part  II.,  completing  the  work  from  p.  431  to  end,  with  Index,  Title  Matter,  fee,  may  be 
had  separate,  cloth  backs  and  paper  sides.     Price  $2  50. 

From  Prof.  E.  N.  Horsford,  Harvard  College.      |  afford  to  be  without  this  edition  of  Prof.  Graham's 

It  has,  in  its  earlier  and  less  perfect  editions,  been  I  Elements.— Sill  iman's  Journal,  March,  1858. 
familiar  to  me,  and  the  excellence  of  its  plan  and  I     p^^^  p^^y  WoUott  Gibbs,  N.  Y.  Free  Academy. 
the  clearness  and  completeness  of  its  discussions,        _,  ,    .  ,.,..,. 

have  long  been  my  admiration.  .    The  work  is  an  admirable  one  in  all  respects,  and 

I  Its  republication  here  cannot  fail  to  exert  a  positive 

No  reader  of  English  works  on  this  science  can  '  influenceupon  the  progress  of  science  in  this  country. 


GRIFFITH  (ROBERT  E.),  M.  D.,  &c. 
A  UNIVERSAL  FORMULARY,  containing  the  methods  of  Preparing  and  Ad- 
ministering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceu- 
lists.  Second  Edition,  thoroughly  revised,  with  numerous  additions,  by  Robert  P.  Thomas, 
M.  D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large  and 
handsome  octavo  volume,  extra  cloth,  of  650  pages,  double  columns.     $3  00;  or  in  sheep,  $3  25. 


It  was  a  work  requiring  much  perseverance,  and 
when  published  was  looked  upon  as  by  far  the  best 
work  of  its  kind  that  had  issued  from  the  American 
press.  Prof  Thomas  has  certainly  "improved,"  as 
well  as  added  to  this  Formulary,  and  has  rendered  it 
addilionally  deserving  of  the  confidence  of  pharma- 
ceutists and  physicians.— jlm.  Journal  of  Pharmacy. 

We  are  happy  to  announce  a  new  and  improved 
edition  of  this,  one  of  the  most  valuable  and  useful 
works  that  have  emanated  from  an  American  pen. 
It  would  do  credit  to  any  country,  and  will  be  found 
of  daily  usefulness  to  practitioners  of  medicine;  ills 
better  adapted  to  their  purposes  than  the  dispensalo 
ries. — Soulhern  Med.  and  Surg.  Journal. 

It  is  one  of  the  most  useful  books  a  country  practi- 
tioner can  possibly  have. — Medical  Chioniclt. 


This  is  a  work  of  six  hundred  and  fifty-one  pages, 
^mhraeing  all  on  the  subject  of  preparing  and  admi- 
iiisleriiig  medicines  that  can  be  desired  by  the  physi- 
cian and  pharmaceutist. —  Western  Lancet. 

The  amountof  useful, every-day  matter, for  a  prac- 
ticing physician,  is  really  immense. — Boston  Med. 
and  Surg.  Journal. 

This  edition  has  been  greatly  improved  by  the  re- 
vision and  ample  additions  of  Dr  Thomas,  and  is 
now,  we  believe,  one  of  the  mosi  complete  works 
of  its  kind  in  any  language.  The  additions  amount 
to  about  seventy  pages,  and  no  effort  has  been  spared 
to  include  in  them  all  the  recent  improvements.  A 
work  of  this  kind  appears  to  us  indispensable  to  the 
physician,  and  there  is  none  we  can  more  cordially 
recommeiid.     N  Y  Journalof  Medicint. 


16 


BLANCHARD    &    LEA'S    MEDICAL 


GROSS  (SAMUEL  DJ,   M.  D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  4.C. 

Enlarged  Edition — Now  Keady,  January,  1862. 

A  SYSTEM  OP  SURGERY :  Pathological,  Diagnostic,  Therapeutic,  and  Opera- 

ti\'e.     lllustraied  by  Twelve  Hundred  and  Twenty-seven  Engravings.     Second   edition, 

nmoh  enlarged  and  carefully  revised.     In  two  large  and  beautifully  printed  octavo  volumes,  oi 

ubout  twenty-two  hundred  pages ;  strongly  bound  in  leather,  with  raised  bands.     Price  $12. 

The  exhaustion  in  little  more  than  two  years  of  a  large  edition  of  so  elaborate  and  comprehen- 
sive a  work  as  this  is  the  best  evidence  that  the  author  was  not  mistaken  in  his  estimate  of  the 
want  which  existed  of  a  complete  American  System  of  Surgery,  presenting  the  science  in  all  its 
necessary  deiails  and  in  all  its  branches.  That  he  has  succeeded  in  the  attempt  to  supply  this  want 
is  shown' not  only  by  the  rapid  sale  of  the  work,  but  also  by  the  very  favorable  manner  in  which  it 
ha*  been  received  by  the  organs  of  the  profesj'ion  in  this  country  and  in  Europe,  and  by  the  fact  that 
a  translation  is  now  preparing  in  Holland — a  mark  of  appreciation  not  often  bestowed  on  any  scien- 
tific work  so  extended  in  size. 

The  author  has  not  been  insensible  to  the  kindness  thus  bestowed  upon  his  labors,  and  in  revising 
the  work  for  a  new  edition  he  has  spared  no  pains  to  render  it  worthy  of  the  favor  with  which  \t 
has  been  received.  Every  portion  has  been  subjected  to  close  examination  and  revision  ;  any  defi- 
ciencies apparent  have  been  supplied,  and  the  results  of  recent  progress  in  the  science  and  art  ot 
surgery  have  been  everywhere  introduced;  while  the  series  of  illustrations  has  been  enlarged  by 
)he  addition  of  nearly  three  hundred  wood-cuts,  rendering  it  one  of  the  most  thoroughly  illustrated 
works  ever  laid  before  the  profession.  To  accommodate  these  very  extensive  additions,  the  work 
has  been  printed  upon  a  smaller  type,  so  that  notwithstanding  the  very  large  increase  in  the  matter 
and  value  of  the  book,  its  size  is  more  convenient  and  less  cumbrous  than  before.  Every  care  has 
been  taken  in  the  printing  to  render  the  typographical  execution  unexceptionable,  and  it  is  confi- 
dently presented  as  a  work  in  every  way  worthy  of  a  place  ia  eVea  the  most  limited  library  of  the 
p/aciitioner  or  student. 

A  few  testimonials  of  the  value  of  the  former  edition  are  appended. 

Has  Dr.  Gross  satisfactorily  fulfilled  this  object?  1  Of  Dr.  Gross's  treatise  on  Surgery  we  can  say 
A  careful  perusal  of  his  volumes  enables  us  to  give  '  no  more  than  that  it  is  the  most  elaborate  and  cora- 
an  answer  in  the  affirmative.  Not  only  has  he  given  •  plete  work  on  this  branch  of  the  liealiiig  art  which 
to  the  reader  an  elaborate  and  well-written  account  j  has  ever  been  published  in  any  country.  A  sys- 
of  his  osvn  vast  experience, but  he  has  not  failed  to  ;  tematic  work,  it  admits  of  no  analytical  review; 
embody  in  his  pages  the  opinions  and  practice  of  but,  did  our  space  permit,  we  should  gladly  give 
sureeons  in  this  and  other  countries  of  Europe.  The  ;  some  extracts  from  it,  to  enable  our  readers  to  judge 
result  has  been  a  work  of  such  completeness,  that  it  |  of  the  classical  style  of  the  author,  and  the  exhaust- 


has  nil  superior  in  the  systematic  treatises  on  sur 
gery  which  have  emanated  from  English  or  Conti- 
nental authors.  It  has  been  justly  objected  that 
these  have  been  far  from  complete  in  many  essential 
particulars,  inHny  of  them  havinir  been  deficient  in 
simie  of  the  most  important  points  which  should 
characterize  such  works.  Some  of  them  have  been 
elaborate — too  elnborate— with  respect  to  certain 
diseases,  while  they  have  merely  glanced  at,  or 


ing  way  in  which  eacli  subject  is  treated. — Dublin 
Quarterly  Journal  of  Med.  Science. 

The  work  is  so  superior  to  its  predecessors  in 
matter  and  extent,  as  well  as  in  illustrations  and 
style  of  publication,  that  we  can  honestly  recom- 
mend it  as  the  best  work  of  the  kind  to  be  taken 
home  by  the  young  practitioner. — Am.  Med.  Journ. 

With  pleasure  we  record  the  completion  of  this 
long-anticipated  work.     The  reputation  which  the 


Riven  an  unsatisfactory  account  of,  others  equally         .i"      i       V  .   =      i    u   .u     

important  to  the  surgeon.  Dr.  Gross  has  avoided  ,  aull'^r  ''"«  f""'  ""'."v-  years  sustained,  both  us  a  Pur- 
thiserror,  and  has  produced  the  most  complete  work  i  geon  and  as  a  writer,  had  prepared  us  to  expect  a 
that  has  yet  issued  from  the  press  on  the  science  and  i  treatise  of  great  excellence  and  originality ;  but  we 
practice  of  surgery.  It  is  not,  strictly  speaking,  a  <  confess  we  were  by  no  m^-uns  prepared  or  the  work 
Dictionary  of  Surgery,  but  it  gives  to  the  reader  all  ,  which  is  before  us-lhe  most  complete  treatise  upon 
the  inforination  that  he  mav  require  for  his  treatment  surgery  ever  publislied  either  in  this  or  any  ot.i.r 
of  surgical  diseases.  Ha  ving  said  so  much,  it  might  !  country,  and  we  might,  perhaps,  safely  say,  the 
appear  superfluous  to  add  another  w  .rd  ;  but  it  is  ,  """st  original.  There  is  no  subject  beloi.ging  pro- 
only  due  to  Dr.  Gross  to  state  that  he  has  embraced  ;  P'^r'V  '"  surgery  which  has  not  receive.l  from  the 
the  opportunity  of  transferring  to  his  pages  a  vast  :  ""thor  a  due  share  of  at  ention  Dr.  Grots  has  sup- 
number  o(  engravings  from  English  and  other  an-  Plied  a  want  in  surgical  literature  which  has  long 
taors,  illustnuive  of  the  pathology  and  treatment  of  ,  been  fe  t  by  practitioners;  he  has  furnishea  us  witFi 
surgical  diseases.  To  these  are  added  several  hun-  ^  complete  practical  treatise  up.m  surgery  in  all  its 
dred  original  wood-cnts  The  work  altogether  com-  i  departments  As  AmericH.s,  we  are  proud  of  the 
mends  itself  to  the  attention  of  Britibh  surgeons,  \«*"?T*'r.*'"i '  ^^  surgeons,  we  are  most  sincerely 
from  whom  it  cannot  fail  to  meet  with  extensive     thankful  to  him  for  Ins  extra.-rd  nary  labors  in  our 


patronage. — London  Laticet,  Sept.  1,  l&tiO. 


betialf. — N.  Y.  Monthly  Review  and  Buffalo  Med. 
Journal. 


BY  THE  SAME  AUTHOR. 

ELEMENTS  OF  PATHOLOGICAL  ANATOMY.     Third  edition,  thoroughly 

revised  and  greatly  improved.     In  one  large  and  very  handsome  octavo  volume,  with  about  three 
hundred  and  fifty  beautiful  illustrations,  of  which  a  large  number  are  from   original  drawings. 
Price  in  extra  cloth,  ?4  75;  leather,  raised  bauds,  $5  25.     [Lately  Published.) 
The  very  rapid  advances  in  the  Science  of  Pathological  Anatomy  during  the  last  few  years  have 
rendered  essential  a  thorough  modification  of  this  work,  with  a  view  of  making  it  a  correct  expo- 
nent of  the  present  state  of  the  subject.     The  very  careful  manner  in  which  this  task  has  been 
executed,  and  the  amount  of  alteration  which  it  has  undergone,  have  enabled  the  author  to  say  that 
"  with  the  many  changes  and  improvements  now  introduced,  the  work  may  be  regarded  almost  as 
a  new  treatise,"  while  the  efforts  of  the  author  have  been  seconded  as  regards  the  mechanical 
execution  of  the  volume,  rendering  it  one  of  the  handsomest  productions  of  the  American  press. 
We  most  sincerely  congratulate  the  author  on  the  ,      We  have  been  favoj;ably  impressed  with  the.  gene- 


successful  manner  in  which  he  has  accomplished  his 
proposed  object.  His  book  is  most  admirably  cal- 
culated to  fill  up  a  bhink  which  has  long  been  felt  to 
exist  in  this  department  of  medical  literature,  and 
as  such  must  become  very  widely  circulated  amongst 
all  classes  of  the  profession.  —  Dublin  Quarterly 
Journ.  of  Med.  Science,  Nov.  1857. 

BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE  AIR-PAS 

SAGES.    In  one  handsome  octavo  volume,  extra  cloth,  with  illustrations,    pp.  4f38.    $2  75. 


ral  manner  in  which  Dr.  Gross  has  executed  his  task 
of  affording  a  comprehensive  digest  of  the  present 
state  of  the  literature  of  Pathological  Anatomy,  and 
have  much  pleasure  in  recommending  his  work  to 
our  readers,  as  we  believe  one  well  deserving  of 
dili^rent  perusal  and  careful  study. — Montreal  Med. 
Ckron.,  Sept.  1857. 


AND    SCIENTIFIC  PU  BL.IC  ATIONS. 


17 


GROSS  (SAMUEL   D.),   M.  D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  &c. 

A.   PRACTICAL    TREATISE   ON   THE    DISEASES,    INJURIES,  AND 

MALFORMATIONS  OF  THE  URINARY  BLADDER,  THE  PROSTATE  GLAND,  AND 
THE  URETHRA.  Second  Edition,  revijied  and  mucli  enlarged,  with  one  hundred  and  eighty- 
four  illustrations.  In  one  large  and  very  handsome  octavo  volume,  of  over  nine  hundred  pages. 
In  leather,  raised  bands,  $5  25 ;  extra  cloth,  $4  75. 

Philosophical  in  its  design,  methodical  in  its  ar-  ]  agree  with  us,  that  there  is  no  work  in  the  English 
rasgeraent,  ample  and  sound  in  its  practical  details,  ;  language  which  can  make  any  just  pretensions  to 


it  may  in  truth  be  said  to  leave  scarcely  anything  to 
be  iesired  on  so  important  a  subject. — Boston  Med. 
and  Surg  Journal. 

Whoever  will  peruse  the  vast  amount  of  valuable 
practical  information  it  contains,  will,  we  think, 


be  its  equal. — iV.  Y.  Journal  of  Medicine . 

A  volume  replete  with  truths  and  principles  of  the 
utmost  value  in  the  investigation  of  these  diseases. — 
American  MedicalJournal . 


GRAY  (HENRY),   F.  R.  S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London,  &c. 

ANATOMY,  DESCRIPTIVE  AND   SURGICAL.      The  Drawings  by  H.  V. 

Carter,  M.  D.,  late  Demonstrator  on  Anatomy  at  St.  George's  Hospital ;  the  Dissections  jointly 
by  the  Author  and  Dr.  Carter.  Second  American,  from  the  second  revised  and  improved 
London  edition.  In  one  magnificent  imperial  octavo  volume,  of  over  800  pages,  with  3SS  large 
and  elaborate  engravings  on  wood.  Price  in  extra  cloth,  f6  25;  leather,  raised  bands,  $7  00. 
{Nolo  Ready,  1862.) 

The  speedy  exhaustion  of  a  large  edition  of  this  work  is  sufficient  evidence  that  its  plan  and  exe- 
cution have  been  found  to  present  superior  practical  advantages  in  facilitating  the  study  of  Anaio- 
mv.  In  presenting  it  to  the  profession  a  second  time,  the  author  has  availed  himself  of  the  oppor- 
tunity to  supply  any  deficiencies  which  experience  in  its  use  had  shown  to  exist,  and  to  correct 
a«y  errors  of  detail,  to  which  the  first  ediiion  of  a  scientific  work  on  so  extensive  and  complicated 
a  scieace  is  liable.  These  improvements  have  resulted  in  some  increase  in  the  size  of  the  volume, 
while  twenty-six  new  wood-cuts  have  been  added  to  the  beautiful  series  of  illustrations  which 
form  so  distinctive  a  feature  of  the  work.  The  American  edition  has  been  passed  through  the  press 
under  the  supervision  of  a  competent  p^ofes^io^al  man,  who  has  taken  every  care  to  render  it  in 
all  respects  accurate,  and  it  is  now  presented,  wiihout  any  increase  of  price,  as  fitted  to  maiutaia 
and  extend  the  popularity  which  it  has  everywhere  acquired. 

With  little  trouble,  the  busy  practitioner  whose  ,  to  exist  in  this  country.  Mr.  Gray  writes  fhrough- 
knowltdgeofanatoiny  may  have  become  obscured  by  |  out  with  both  branches  of  his  subject  in  view.  His 
want  of  practice,  may  now  resuscitate  his  former  I  description  of  each  particular  part  is  followed  by  a 
snatomical  lore,  and  be  ready  for  any  emergency.  |  notice  of  its  relations  to  trie  parts  with  which  it  is 
It  is  to  this  class  of  individuals,  and  not  to  the  stu-  1  connected,  and  this,  too,  sufficiently  ample  for  all 
dent  alone,  that  this  work  will  ultimately  tend  to  j  the  purposes  of  the  operative  surgeon.  After  de- 
be  of  most  incalculable  advantage,  and  we  feel  sat-  j  scribing  the  bones  and  muscles,  he  gives  a  concise 
isfied  that  the  library  of  the  medical  man  will  soon  i  statement  of  the  fractures  to  which  the  bones  of 
be  considered  incomplete  in  which  a  copy  of  this  !  the  extremities  are  most  liable,  together  with  the 


work  does  nut  exist.—  Madras  Quarterly  Journal 
of  Med.  Science,  July,  1861. 

This  edition  is  much  improved  and  enlarged,  and 
c<mtains  several  new  illustrations  by  Dr.  Wesfma- 
cott.  The  volume  is  a  complete  companion  to  the 
dissecting-room,  and  saves  the  necessity  of  the  stu 
dent  possessing  a  variety  of  "Manuals." — The  Lon- 
don Lancet,  Feb.  9,  1861. 

The  work  before  us  is  one  entitled  to  the  highest 
praise,  and  we  accordingly  welcome  it  as  a  valu- 


amount  and  direction  of  the  displacement  to  which 
the  fragments  are  subjected  by  muscular  action. 
The  section  on  arteries  is  remarkably  full  and  ac- 
curate. Not  only  is  the  surgical  anatomy  given  to 
every  important  vessel,  with  directions  for  its  liga- 
tion, but  at  the  end  of  the  description  of  each  arte- 
rial trunk  we  have  a  useful  summary  of  the  irregu- 
larities which  may  occur  in  its  origin,  course,  and 
termination. — N.  A.  Med.  Chir.  Review,  Mar.  1859. 

Mr.  Gray's  book,  in  excellency  of  arrangement 
able  addition  to  medical  literature.  Intermediate  |  and  completeness  of  execution,  exceeds  any  work 
in  fulness  of  detail  between  the  treatises  of  S.iar  j  on  anatomy  hitherto  published  in  the  English  lan- 
pey  and  of  Wilson,  its  characteristic  merit  lies  in  :  guage,  affording  a  complete  view  of  the  structure  of 
the  number  and  excellence  of  the  engravings  it  j  the  human  body,  with  especial  reference  to  practical 
contains.      Most  of  these  are  original,   of   much  j  surgery.  Thus  the  volume  constitutes  a  perfect  book 


larger  than  ordinary  size,  and  admirably  executed 
The  various  parts  are  also  lettered  after  the  plan 
adopted  in  Holden's  Osteology.  It  would  be  diffi- 
cult to  over-estimate  the  advantages  offered  by  this 
mode  of  pictorial  illusiration.  Bones,  ligaments, 
muscles,  bloodvessels,  and  nerves  are  each  in  turn 
figured,  and  marked  with  their  appropriate  names; 
tluisenabling  the  student  to  crmprehend,  at  a  glance, 
what  would  otherwise  often  be  ignored,  or  at  any 
rate,  acquired  only  by  prolonged  and  irksome  ap- 
plication. In  conclusion,  w^e  heartily  commend  the 
■work  of  Mr.  Gray  to  the  attention  of  the  medical 
professiim,  feeling  certain  tuat  it  should  be  regarded 
as  one  of  the  most  valuable  contributitms  ever  made 
to  educational  literature. — iV.  Y.  Monthly  Review. 
Dec.  1859. 

In  this  view,  we  regard  the  work  of  Mr.  Gray  as 
far  belter  adapted  to  the  wants  of  the  profession, 
and  especially  of  the  student,  than  any  treatise  on 
anatomy  yet  published  in  this  country .  1 1  is  destined, 
we  believe,  to  supersede  ill  others,  both  as  a  manual 
of  dissecticms,  and  a  standard  of  reference  to  tlie 
student  of  general  or  relative  anatomy.  —  N.  Y. 
Journal  of  Medicine,  Nov.  1859. 

For  this  truly  admirable  work  the  profession  is 
indebted  to  the  distinguished  author  of  "  Gray  on 
the  Spleen."    The  vacancy  it  fills  has  been  long  felt 


of  reference  for  the  practitioner,  demanding  a  place 
in  even  the  most  limited  library  of  the  physician  or 
surgeon,  and  a  work  of  necessity  for  the  student  to 
fix  in  his  mind  what  he  has  learned  by  the  dissecting 
knife  from  the  book  of  nature. — The  Dublin  Quar- 
terly Journal  of  Med.  Sciences,  Nov.  1858. 

In  our  judgment,  the  mode  of  illustration  adopted 
in  the  present  volume  cannot  but  present  many  ad- 
vantages to  the  studentof  anatomy.  To  the  zealous 
disciple  of  Vesalius,  earnestly  desirous  of  real  im- 
provement, the  book  will  certainly  be  of  immense 
value;  but,  at  the  same  time,  we  must  also  ccmfess 
that  to  those  simply  desirous  of  "cramming"  it 
will  be  an  undoubted  godsend.  The  peculiar  value 
of  Mr.  Gray's  mode  of  illustration  is  nowhere  more 
markedly  evident  than  in  the  chapter  on  osteology, 
and  especially  in  those  portions  which  treat  of  the 
bones  of  the  head  and  of  thair  development.  The 
study  of  these  parts  is  thus  made  one  of  comparative 
ertse,  if  not  of  positive  pleasure ;  and  those  bugbears 
of  the  student,  the  temporal  and  sphenoid  bones,  are 
shorn  of  half  their  terrors.  It  is,  in  our  estimation, 
an  admirable  and  complete  text-book  for  the  student, 
and  a  useful  work  of  reference  for  the  practitioner; 
its  pictorial  character  forming  a  novel  element,  to 
which  we  have  already  sufficiently  alluded. — Am, 
Journ.  Med.  Sci.,  July,  1859. 


18 


BLANCHARD    &    LEA'S    MEDICAL 


GIBSON'S  INSTITUTES  AND  PRACTICE  OF 
SURGERY.  Eighth  edition,  improved  and  al- 
tered. With  thirty-fourplates.  In  two  handsome 
octavo  volumes,  containing  about  1,000  pages, 
leather,  raised  bandi.     S6  50. 

GARDNER'S  MEDICAL  CHEMISTRY,  for  the 
use  of  Students  and  the  Profession.  In  one  royal 
l2mo.  vol.,  cloth,  pp.  396,  with  wood  cuts.     $1. 

GLUGE'S  ATLAS  OF  PATHOLOGICAL  HIS- 
TOLOGY.     Translated,  with   Notes  and  Addi- 


tions by  Joseph  Leidy,  M.  D.  In  one  volume, 
very  large  iraperia'  quarto,  extra  cloth,  with  320 
copper  plate  figures,  plain  and  colored,    S5  00. 

HUGHES'  INTRODUCTION  TO  THE  PRAC- 
TICE OF  AUSCULTAriON  AND  OTHER 
MODES  OF  PHYSICAL  DIAGNOSIS.  IN  DIS- 
EASES OF  THE  LUNGS  AND  HEART.  Se- 
cond edition  1  vol.  royal  12mo.,  ex.  cloth,  pp. 
304.    «1  00. 


HAMILTON  (FRANK    H.),   M.   D., 

Professor  of  Surgery  in  the  Long  Island  College  Hospital. 

A  PRACTICAL  TREATISE  ON  FRACTURES  AND  DISLOCATIONS.    In 

one  large  and  handsome  octavo  volume,  ol  over  750  pages,  witli  289  illustrations.   $4  25.    (Now 
Ready,  January,  18G0.) 

I  opinion  may  be  gathered  as  to  its  value. — Boston 

Medical  and  Surgical  Journal,  March  1,  1660. 
I      The  work  is  concise,  judicious,  and  accurate,  and 
I  adapted  to  the  wants  of  the  student,  practitcner, 
and  investigator,  hont)rabIe  to  the  author  and  :o  the 
profession. — Chicago  Mtd.  .Journal,  March,  1560. 

We  regard  this  work  as  an  honor  not  only  to  its 
author,  but  to  the  profession  of  our  country.  Were 
we  to  review  it  thoroughly,  we  could  not  convey  to 
the  mind  of  the  reader  more  forcibly  our  ."lonest 
opinion  expressed  in  the  few  words — we  think  it  the 
best  book  ol  its  kind  extant.  Every  man  interested 
in  surgery  will  soon  have  this  work  on  his  desk. 
He  who  does  not,  will  be  the  loser. — New  Orleans 
Medical  Newx,  March,  1860. 

Now  that  it  is  before  us,  we  feel  bound  to  say  that 
much  as  was  expected  from  it,  and  onerous  as  was 
the  undertaking,  it  has  surpassed  expectation,  and 
achieved  more  than  was  pledged  in  its  behalf;  for 
its  title  does  not  express  in  full  the  richness  of  its 
contents.  On  the  whole,  we  are  prouder  of  this 
work  than  of  any  which  has  for  years  emanated 
from  the  American  medical  press;  its  sale  will  cer- 
tainly be  very  large  in  this  country,  and  we  antici- 
pate its  eliciting  much  attention  in  Europe. — Nash- 
ville Medical  Record,  Mar.  1S60. 

Every  surgeon,  young  and  old,  should  possess 
himself  of  it,  and  give  it  a  careful  perusal,  in  doing 
which  he  will  be  richly  repaid. — St.  Louis  Med. 
and  Surg.  Journal,  March,  1860. 

Dr.  Hamilton  is  fortunate  in  having  succeeded  in 
filling  tlie  void,  so  long  I'elt,  with  what  cannot  fail 
tube  atonceacceptedas  a  model  monograph  in  some 
respects,  aud  a  work  of  classicil  authority.  We 
sincerely  congratulate  the  profession  of  the  United 
States  on  the  appearance  of  such  a  publication  from 
one  of  their  number.  We  have  reason  to  be  proud 
of  it  as  an  original  work,  both  in  a  literary  and  sfi- 
entific  point  of  view,  and  to  esteem  it  as  a  valuable 
guide  in  a  most  difficult  and  important  branch  of 
study  and  practice.  On  every  arcotint,  therefore, 
we  hope  that  it  may  soon  be  widely  known  abroad 
as  an  evidence  of  genuine  progress  on  this  side  of 
the  Atlantic,  and  further,  that  it  may  be  still  more 
widely  known  at  home  as  an  authoritative  teacher 
from  which  every  one  may  profitably  learn,  and  as 
affording  an  example  of  honest,  well-directed,  and 
untiring  industry  in  authorship  which  every  surgeon 
may  eniulate.-  Am.  Med.  Journal,  April,  1860. 


Among  themanygood  workers  at  surgery  of  whom 
America  may  now  boast  rot  theleafit  is  Frank  Hast- 
ings Hamilton;  and  the  volume  before  us  isfwe  say 
it  wi'h  a  pang  of  wounded  patriotism)  the  best  and 
handiest  book  on  the  subject  in  the  Erglish  lan- 
guage. It  is  in  vain  to  attempt  a  review  of  it; 
nearly  as  vain  to  seek  for  any  sins,  either  of  com- 
mission or  omission.  AVe  have  seen  no  work  on 
practical  surgery  which  we  would  sooner  recom- 
mend to  our  brother  surgeons,  especially  those  of 
'« the  services,"  i  r  those  whose  practice  lies  in  dis- 
tricts where  a  man  has  necessarily  to  rely  on  his 
own  unaided  resources.  The  practitioner  will  find 
in  t  directions  for  nearly  every  possible  acndent, 
easily  found  and  comprehended  ;  and  much  pleasant 
reading  for  him  to  muse  over  in  the  after  considera- 
tion of  his  Cisee.—Erlinbursh  Med.  Jovrn  Feb.  1861. 
This  is  a  valuable  contribution  to  the  surgery  of 
most  important  affections,  and  is  the  more  welcome, 
inasmuch  as  at  the  present  time  we  do  not  possess 
a  single  complete  treatise  on  Fractures  and  Dislo- 
cations in  the  English  language.  It  has  remained  for 
our  American  brother  to  produce  a  complete  treatise 
upim  the  subject,  and  bring  together  in  a  convenient 
form  those  alterations  and  improvements  that  have 
been  made  from  time  to  time  in  the  treatment  of  these 
affections.  One  great  and  valuable  feature  in  the  , 
work  before  us  is  the  fact  that  it  comprises  all  the  j 
Jmprovements  introduced  into  the  practice  of  both  j 
English  and  American  surgery,  and  though  tar  from  j 
omitting  mention  of  our  continental  neighbors,  the  | 
author  by  no  means  tncourages  the  notion — but  too  i 
prevalent  in  some  quarters— that  nothing  is  good 
unless  imported  from  France  or  Germany.  Tlie 
latter  half  of  the  work  is  devoted  to  the  considera- 
tion of  the  vari(>u8  dislocations  and  their  appropri-  ; 
ate  treatment,  and  its  merit  is  fully  equal  to  that  of 

the  preceding  portion The  London  i.a«ce«.  May  5,  1 

1360. 

It  is  emphatically  the  book  upon  the  subjects  of 
which  it  treats,  and  we  cannot  doubt  that  it  will  i 
continue  so  to  be  for  an  indefinite  period  of  time. ' 
When  we  say,  however,  that  we  believe  it  will  at 
once  take  its  place  as  the  best  book  for  consultation 
by  the  practitioner ;  and  that  it  will  form  the  most 
complete,  available,  aud  reliable  guide  in  emergen- 
cies of  every  nature  connected  with  its  subjects;  and  , 
also  that  the  student  of  surgery  may  make  it  his  text-  j 
book  with  entire  confidence,  and  with  pleasure  also, 
from  Its  agreeable  aud  easy  style — we  think  our  own  1 


HOBLYN  (RICHARD  D.),  M.  D. 
A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND  THE 

COLLATERAL  SCIENCES.  A  new  American  edition.  Revised,  with  numerous  Additions, 
by  Isaac  Hays,  M.  D.,  editor  of  the  "  American  Journal  of  the  Medical  Sciences."  In  one  large 
royal  12mo.  volume,  leather,  of  over  500  double  columned  pages.     $1  50. 

To  both  practitioner  and  student,  we  recommend  use  ;  embracing  every  department  of  medical  science 
this  dictionary  as  being  convenient  in  size,  accurate  I  down  to  the  very  latest  date. — Western  Lancet. 
in  definition,  and  sufficiently  lull  and  complete  for  j      Hoblyn's  Dictionary  has  long  been  a  favorite  with 
ordinary  consultation. -r/iaWe.««on  Med.  Joum.  [  ^^      ^^\^  ^^^  best  book  of  definitions  we  have,  and 

AVe  know  of  no  dictionary  better  arranged  and    ought  always   to   be   upon   the    student's  table. — 
adapted.  Itisnotencumbered  with  theobsoleteterms  ■  Southern  Med.  and  Surg.  Journal. 
of  a  bygone  age,  but  it  contains  all  that  are  now  in  ! 


HOLLAND'S  MEDICAL  NOTES  AND  RE- 
FLECTIONS. From  the  third  London  edition. 
In  one  handsome  octavo  volume,  extra  cloth.  $3. 

HORNER'S   SPECIAL   ANATOMY  AND   HIS- 


TOLOGY. Eighth  edition.  Extensivly  revised 
and  modified.  In  two  large  octavo  voli-.mes,  ex- 
tra cloth,  of  more  than  1000  pages,  with  over  300 
illustrations.    $6  00. 


AND    SCIENTIFIC    PUBLICATIONS. 


19 


HODGE  (HUGH    L.),   M.D., 
Professor  of  Midwifery  and  the  Diseases  of  Women  and  Children  in  the  University  of  Pennsylvania,  &c. 

ON   DISEASES   PECULIAR   TO  WOMEN,  including  Displacements  of  the 

Uterus.    With  original  illustrations.     In  one  beautifully  printed  octavo  volume,  of  nearly  500 

pages,  extra  clot  it.     $3  25.     {Now  Ready.) 

priate  management — his  ample  experience,  his  ma- 
tured judgment,  and  his  perfect  conscientiousness — 
invest  this  publication  with  an  interest  and  value  to 
which  few  of  the  medical  treatises  of  a  recent  date 
can  lay  a  stronger,  if,  perchance,  an  equal  claim. — 
Am.  Journ.  Med.  Sciences,  Jan.  1861. 

Indeed ,  although  no  part  of  the  volume  is  not  emi- 
nently deserving  of  perusal  and  study,  we  think  that 
the  nine  chapters  devoted  to  this  suhject,  are  espe- 
cially so,  and  we  know  of  no  more  valuable  mono- 
graph upon  the  symptoms,  prognosis,  and  manage- 
ment of  these  annoying  maladies  than  is  constituted 
by  this  part  of  the  work.  We  cannot  but  regard  it 
as  one  of  the  most  original  and  m  ist  practical  works 
of  the  day  ;  one  which  every  accoucheur  and  physi- 
cian should  most  carefully  reid;  for  we  are  per- 
suaded that  he  will  arise  from  its  perusal  with  new 
ideas,  which  will  induct  him  into  a  more  rational 
practice  in  regard  to  many  a  suffering  femile,  who 
may  have  placed  her  health  in  his  hands. — British 
American  Journal,  Feb.  1661. 

Of  the  many  excellences  of  the  work  we  will  not 
speak  at  length.  We  advise  all  who  would  acquire 
a  knowledge  of  the  proper  management  of  the  mala- 
dies of  which  it  treats,  to  study  it  with  care.  The 
second  part  is  of  itself  a  most  valuable  contribution 
to  the  practice  of  our  art. — Am.  Med.  Monthly  and 
New  York  Revieto,  Feb.  1861. 


We  will  say  at  once  that  the  work  fulfils  its  object 
capitally  well  j  and  we  will  moreover  venture  the 
issertion  that  it  will  inaugurate  an  improved  prac- 
tice throughout  this  whole  country.  The  secrets  of 
tae  author's  success  are  so  clearly  revealed  that  the 
attentive  student  cannot  fail  to  insure  a  goodly  por- 
tion of  similar  success  m  his  own  practice.  It  is  a 
credit  to  all  medical  literature;  and  we  add,  that 
th«  physician  who  does  not  place  it  in  his  library, 
ani  who  does  not  faithfully  con  its  pages,  will  lose 
a  vast  deal  of  knowledge  that  would  be  most  useful 
to  kimself  and  beneficial  to  his  patients.  It  is  a 
practical  work  of  the  highest  order  of  merit;  and  it 
will  take  rank  as  such  immediately. — Maryland  and 
Virginia  Medical  Journal,  Feb.  i&61. 

This  contribution  towards  the  elucidation  of  the 
pathology  and  treatment  of  some  of  the  diseases 
peculiar  to  women,  cannot  fail  to  meet  with  a  favor- 
able reception  from  the  medical  profession.  The 
charapter  of  the  particular  maladies  of  which  the 
work  before  us  treats;  their  frequency,  variety, and 
oi)scuiity ;  the  amount  of  malaise  and  even  of  actual 
suffering  by  which  they  are  invariably  attended; 
their  obstinacy,  the  diiRculty  with  which  they  are 
overcome,  and  their  disposition  again  and  again  to 
leeur — these,  taken  in  connection  with  the  entire 
competency  of  the  author  to  render  a  correct  ac- 
count of  their  nature^  their  causes,  and  their  appro- 


Tiie  illustrations,  which  are  all  original,  are  drawn  to  a  uniform  scale  of  one-half  the  natural  size. 


HABERSHON  (S.  O.),  M.  D., 

Assistant  Physician  to  and  Lecturer  on  Materia  Medica  and  Therapeutics  at  Guy's  Hospital,  &c. 

PATHOLOGICAL  AND   PRACTICAL  OBSERVATIONS  ON  DISE/^SES 

OF  THE  ALIMENTARY  CANAL,  CESOPHAGUS,  STOMACH,  C^CUM,  AND  INTES- 
TINES. With  illustrations  on  wood.  In  one  handsome  octavo  volume  of  312  pages,  extra 
clnth     $1  75.     (Now  Ready.) 


JONES  (T.   WHARTON),   F.  R.  S., 

Professor  of  Ophthalmic  Medicine  and  Surgery  in  University  College,  London,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OF   OPHTHALMIC    MEDICINE 

AND  SURGERY.  With  one  hundred  and  ten  illustrations.  Second  American  from  the  second 
and  revised  London  edition,  with  additions  by  Edward  Hartshorne,  M.  D.,  Surgeon  to  Wills' 
Hospital,  &c.     In  one  large,  handsome  royal  12mo.  volume,  extra  cloth,  of  500  pages.     $1  50. 


JONES  (C.  HANDFIELD),  F.  R.  S.,  &.  EDWARD  H.  SIEVEKING,   M.D., 

Assistant  Physicians  and  Lecturers  in  St.  Mary's  Hospital,  London. 

A  MANUAL  OF  PATHOLOGICAL  ANATOMY.    First  American  Edition, 

Revised.    With  three  hundred  and  ninety-seven  handsome  wood  engravings.     In  one  large  and 
beautiful  octavo  volume  of  nearly  750  pages,  leather.     $3  75. 
As  a  concise  text-book,  containing,  in  a  condensed 


form,  a  complete  outline  of  what  is  known  in  the 
domain  of  Pathological  Anatomy,  it  is  perhaps  the 
best  work  in  the  English  language.  Its  great  merit 
consists  in  its  completeness  and  brevity,  and  in  this 
respect  it  supplies  a  great  desideratum  in  our  lite- 
rature.   Heretofore  the  student  of  pathology  was 


obliged  to  glean  from  a  great  number  of  monographs, 
and  the  field  was  so  extensive  that  but  few  cultivated 
it  with  any  degree  of  success.  As  a  simple  work 
of  reference,  therefore,  it  is  of  great  value  to  the 
student  of  pathological  anatomy,  and  should  be  in 
every  physician's  library. — Western  Lancet. 


KIRKES  (WILLIAM   SENHOUSE),   M.  D., 

Demonstrator  of  Morbid  Anatomy  at  St.  Bartholomew's  Hospital,  &c. 

A    MANUAL    OF    PHYSIOLOGY.      A  new  American,  from  the   third  and 

improved  London  edition.     With  two  hundred  illustrations.     In  one  large  and  handsome  royal 
12mo.  volume,  leather,     pp.  586.     $2  00.     {Lately  Published.) 


This  is  a  new  and  very  much  improved  edition  of 
Dr.  Kirkes'  well-known  Handbook  of  Physiology. 
It  combines  conciseness  with  completeness,  and  is, 
therefore,  admirably  adapted  for  consultation  by  the 
busy  practitioner. — Dublin  Quarterly  Journal. 

One  of  the  very  best  handbooks  of  Physiology  wt 
possess — presenting  just  such  an  outline  of  the  sci- 
ence as  the  student  requires  during  his  attendance 
upon  a  course  of  lectures,  or  for  reference  whilst 
preparing  for  examination.— jl?n.  Medical  Journal 

Its  excellence  is  in  its  compactness,  its  clearness. 


and  its  carefully  cited  authorities.  It  is  the  most 
convenient  of  text-books.  These  gentlemen,  Messrs. 
Kirkes  and  Paget,  have  the  gift  of  telling  us  what 
we  want  to  know,  w^ithout  thinking  it  necessary 
to  tell  us  all  they  know. — Boston  Med  and  Surg. 
Journal. 

For  the  student  beginning  this  study,  and  the 
practitioner  who  has  but  leisure  to  refresh  his 
memory,  this  book  is  invaluable,  as  it  contains  all 
that  it  is  important  to  know. — Charleston  Med. 
Journal, 


20  BLANCHARD  &   LEA'S   MEDICAL 


KNAPP'S  TECHNOLOGY ;  or,  Chemistry  applied 
to  ttie  Arts  and  to  Manufactures.  Edited  by  Dr. 
Ronalds,  Dr.  Richardson,  and  Prof.  W.  R. 
Johnson.  In  two  handsome  8vo.  vols.,  with  about 
500  wood- engravings.    $6  00. 


LAYCOCK'S  LECTURES  ON  THE  PRINCI- 
PLES AND  METHODS  OF  MEDICAL  OB- 
SERVATION AND  RESEARCH.  For  the  Use 
of  Advanced  Students  and  Junior  Practitioners. 
In  one  royal  l'2mo.  volume,  extra  cloth.  Price $1. 


LALLEMAND  AND  WILSON. 
A    PRACTICAL    TREATISE    ON    THE    CAUSES,    SYMPTOMS,    AND 

TREATMENT  OF  SPERMATORRHCEA.     By  M.  Lallemand.     Translated  and  edited  by 

Henry  J   McDougall.     Third  American  edition.     To  which  is  added ON  DISEASES 

OF  THE  VESICUL^  SEMINALES;  and  their  associated  organs.  With  special  refer- 
ence to  the  Morbid  Secretions  of  the  Prostatic  and  Urethral  Mucous  Membrane.  By  Maeris 
Wilson,  M.  D.    In  one  neat  octavo  volume,  of  about  400  pp.,  extra  cloth.  $2  00.  (Just  Issved.) 


LA   ROCHE  (R.),   M.  D.,  Stc. 
YELLOW  FEVER,  considered  in  its  Historical,  Pathological,  Etiological,  and 

Therapeutical  Relations.  Including  a  Sketch  of  the  Disease  as  it  has  occurred  in  Philadelphia 
from  1699  to  1854,  with  an  examination  of  the  connections  between  it  and  the  fevers  known  under 
the  same  name  in  other  parts  of  temperate  as  well  as  in  tropical  regions.  In  two  large  and 
handsome  octavo  volumes  of  nearly  1500  pages,  extra  cloth.     $7  00. 


Frotn  Professor  S.  H.  Dickson,  Charleston,  S.  C, 
September  18,  1855. 
A  monument  of  intelligent  and  well  applied  re- 
search, almost  without  example.    It  is,  indeed,  in 
itself,  a  large  library,  and  is  destined  to  constitute 
the  special  resort  as  a  book   of  reference,  in  the 


nant  and  unmanageable  disease  of  modern  times, 
has  for  several  years  been  prevailing  in  our  country 
to  a  greater  extent  than  ever  before;  that  it  is  no 
longer  confined  to  either  large  or  email  cities,  but 
penetrates  country  villages,  plantations,  and  farm- 
houses; that  it  is  treated  with  scarcely  better  suo- 


Bubject  of  which  it  treats,  to  all  future  time.  j  cess  now  than  thirty  or  forty  years  ago;  that  there 

We  have  not  time  at  present,  engaged  as  we  are,  isyastiniscliiefdonebyignorantpretenders  to  know- 
by  day  and  by  night,  in  the  work  (Vf  Combating  this  'ed?e  in  regard  to  the  disease,  and  m  view  of  the  pro- 
very  disease,  now  prevailing  in  our  city,  to  do  more  !  bability  that  a  majority  of  southern  physicians  will 
tlian  give  this  cursory  notice  of  what  we  consider  be  called  upon  to  treat  the  disense,  we  trust  that  this 
as  undoubtedly  the  most  able  and  erudite  medical  !  able  and  c.mprehensive  treatise  will  be  very  gene- 
publication  our  country  has  yet  produced.  But  in  '^^^V  ^^^'^  '"  ^^^  eo^xth.— Memphis  Med.  Recorder. 
view  of  the  startling  fact,  that  this,  the  most  malig-  I 

BY  THE  SAME  AUTHOR. 

PNEUMONIA ;  its  Supposed  Connection,  Pathological  and  Etiological,  with  Au- 
tumnal Fevers,  including  an  Impiiry  into  the  Existence  and  Morbid  Agency  of  Malaria.  In  one 
handsome  octavo  volume,  extra  cloth,  of  500  pages.    $3  00. 


LAWRENCE  (W.),   F.  R.  S.,  8cc. 
A  TREATISE    ON    DISEASES    OF    THE    EYE.     A    new  edition,  edited, 

with  numerous  additions,  and  243  illustrations,  by  Isaac  Hays,  M.  D.,  Surgeon  to  Will's  Hospi- 
tal, &c.  In  one  very  large  and  handsome  octavo  volume,  of  950  pages,  strongly  bound  in  leather 
with  raised  bands.    $5  00. 

LUDLOW  (J.  L.),   M.  D. 
A  MANUAL   OF    EXAMINATIONS   upon   Anatomy,   Physiology,   Surgery, 

Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and  Therapeutics.     To 
which  is  added  a  Medical  Formulary.     Third  edition,  thoroughly  revised  and  greatly  extended 
and  enlarged.    With  370  illustrations.    In  one  handsome  royal  12mo.  volume,  leather,  of  81  ti 
large  pages.     $2  50. 
We  know  "f  no  better  companion  for  the  student     trammed  into  his  head  by  the  various  professors  to 

during  the  hours  spent  in  the  lecture  room,  or  to  re-     whom  he  is  compelled  to  listen. — Western  Lancet, 

fresh,  at  a  glance,  his  memory  of  the  various  topics     .May,  1857. 


LEHMANN   (C.  G.) 
PHYSIOLOGICAL    CHEMISTRY.      Tran.slated  from  the"  second   edition   by 

George  E.  Day,  M.  D.,  F.  R.  S.,  &c.,  edited  by  R.  E.  Rogers,  M.  D.,  Professor  of  Chemistry 
in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustrations  selected  from 
Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  ot  plates.  Complete  in  two  large 
and  handsome  octavo  volumes,  extra  cloth,  containing  1200  pages,  with  nearly  two  hundred  illus- 
trations.    $6  00. 


The  most  important  contribution  ns  yet  made  to 
Physiological  Chemistry. — Am.  Journal  Med.  Sci- 
ences, Jan.  1856. 


The  work  of  Lehmann  stands  unrivalled  as  the 
most  comprehensive  book  of  reference  and  informa- 
tion extant  on  every  branch  of  the  subject  on  which 
it  treats. — Edinburgh  Journal  of  Medical  Science. 

BY  THE  SAME  AUTHOR.     [Lately  Published.) 

MANUAL  OF  CHEMICAL   PHYSIOLOGY.      Translated  from  the  German, 

with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  Introductory  Essay  on  Vital 
Force,  by  Professor  Samuel  Jackson,  M.  D.,  of  the  University  of  Pennsylvania.  With  illus- 
trations on  wood.     In  one  very  handsome  octavo  volume,  extra  cloth,  of  336  pages.     $2  25, 

Frotn  Prof.  Jackson^s  Introductory  Essay. 
In  adopting  the  handbook  of  Dr.  Lehmann  as  a  manual  of  Organic  Chemistry  for  the  use  of  the 
Students  of  the  University,  and  in  recommending  his  original  work  of  Physiological  Chemistry 
for  their  more  mature  studies,  the  high  value  of  his  researches,  and  the  great  weigtit  of  his  autho- 
rity in  that  important  department  of  medical  science  are  fully  recognized. 


AND    SCIENTIFIC    PUBLICATIONS. 


21 


LYONS  (ROBERT   D.),    K.  C.  C, 

Late  Pathologist  in-chief  to  the  British  Army  in  the  Crimea,  &c. 

A  TKEATISE  ON"  FEVER;  or.  selections  from  a  course  of  Lectures  on  Fever. 

Being  part  of  a  cour«e  of  Theory  and  Practice  of  Medicine.     lu  one  neat  octavo  volume,  of  362 
pages,  extra  cloth;  $2  00.     (^Noio  Ready .) 

From  the  Aitthor's  Preface. 

"lam  induced  to  publish  this  -work  on  Fever  with  a  view  to  bring  within  the  reach  of  the 
student  and  junior  practitioner,  in  a  convenient  form,  the  more  recent  results  of  inquiries  into  the 
Pathology  and  Therapeutics  of  this  formidable  class  of  diseases. 

"The  works  of  the  great  writers  on  Fever  are  so  numerous,  and  in  the  present  day  are  scattered 
in  so  many  languages,  that  they  are  difficult  of  access,  not  only  to  students  but  also  to  practitioners. 
I  shall  deem  myself  fortunate  if  I  can  in  any  measure  supply  the  want  which  is  felt  in  this  respect. 


We  have  great  pleasure  in  recommending  Dr. 
Lyons'  work  on  Fever  to  the  attention  of  the  pro- 
fession. It  is  a  wrork  which  cannot  fail  to  enhance 
the  author's  previous  well-earned  reputation,  as  a 
diligent,  careful,  and  accurate  observer. — British 
Med.  .Journal,  March  2,  1661. 

Taken  a<?  a  whole  we  can  rcommend  it  in  the 
highest  terms  as  well  worthy  the  careful  perusal 
and  study  of  every  student  and  practitioner  of  medi- 


cine. We  consider  the  work  a  most  valuable  addi- 
tion to  medical  literature,  and  one  destined  to  wield 
no  little  influence  over  the  mind  of  the  profession. — 
Med. and  Sure.  Reporter,  May  4,  1861. 

This  is  an  admirable  work  upon  the  most  remark- 
able and  most  important  class  of  diseases  to  which 
mankind  are  liable.— Jlfei.  Journ.  of  N.  Carolina, 
May,  1861. 


MEIGS(CHARLES   D.),  M.  D., 

Professor  of  Obstetrics,  &c.  in  the  JefTerson  Medical  College,  Philadelphia. 

OBSTETRICS:   THE   SCIENCE   AND  THE   ART.     Third  edition,  revised 

and  improved.    With  one  hundred  and  twenty-nine  illustrations.  In  one  beautifully  printed  octavo 
volume,  leather,  of  seven  hundred  and  fifty-two  large  pages.    $3  15. 


Though  the  work  has  received  only  five  pages  of 
enlargement,  its  chapters  throughout  weaf  the  im- 
press of  careful  revision.  Expunging  and  rewriting, 
remodelling  its  sentences,  with  occasional  new  ma- 
terial, all  evince  a  lively  desire  that  it  shall  deserve 
to  be  regarded  as  improved  in  jtianner  as  well  as 
matter.  In  the  matter,  every  stroke  of  the  pen  has 
increased  the  value  of  the  book,  both  in  expungings 
and  additions  — Western  Lancet,  Jan.  1857. 


The  best  American  work  on  Midwifery  that  is 
accessible  to  the  student  and  practitioner — N.  W. 
Med.  and  Surg.  Journal,  Jan.  1857. 

This  is  a  standard  work  by  a  great  American  Ob- 
stetrician. It  is  the  third  and  last  edition,  and,  in 
the  language  of  the  preface,  the  author  has  "brought 
the  subject  up  to  the  latest  dates  of  real  improve- 
ment in  our  art  and  Science." — Nashville  Journ.  of 
Med.  and  Surg.,  May,  1857. 


BY   THE  SAME  AUTHOR.      (Jllst  Issued.) 

WOMAN :  HER  DISEASES  AND  THEIR  REMEDIES.  A  Series  of  Lec- 
tures to  his  Class.  Fourth  and  Improved  edition.  In  one  large  and  beautifully  printed  octav© 
volume,  leather,  of  over  700  pages.     $3  60. 


In  other  respects,  in  our  estimation,  too  much  can- 
not be  said  in  praise  of  this  work.  It  abounds  with 
beautiful  passages,  and  for  conciseness,  for  origin- 
ality, and  for  all  that  is  commendable  in  a  work  on 
the  diseases  of  females,  it  is  not  excelled,  and  pro- 
fa  ibly  not  equalled  in  the  English  language.  On  the 
whole,  we  know  of  no  work  on  the  diseases  of  wo- 
men which  we  can  so  cordially  commend  to  the 
student  imd  practitioneras  the  one  before  us. — Ohio 
Med.  and  Surg.  Journal. 

The  body  of  the  book  is  worthy  of  attentive  con- 
sideration, and  is  evidently  the  production  of  a 
clever,  thoughtful,  and  sagacious  physician.  Dr. 
Meigs's  letters  on  the  diseases  of  the  external  or- 
gans, contain  many  interesting  and  rare  cases,  and 
°f ^^'  i"^'.''"<='>v«  observations.     We  take  our  leave    the""cle'arne8"8  'with  "which  Vhe"7nforma'tion'''is  'pre-' 


which  cannot  fail  to  recommend  the  volume  to  the 
attention  of  the  reader. — Banking's  Abstract. 

It  contains  a  vast  amount  of  practical  knowledge. 
by  one  who  hag  accurately  observed  and  retained 
the  experience  of  many  years. — Dublin  Quarterly 
Journal. 

Full  of  important  matter,  conveyed  in  a  ready  and 
agreeable  manner. — St.  Louis  Med.  and  Surg.  Jour. 

There  is  an  off-hand  fervor,  a  glow,  and  a  warm- 
heartedness infecting  the  effort  of  Dr.  Meigs,  which 
is  entirely  captivating,  and  which  absolutely  hur- 
ries the  reader  through  from  beginning  to  end.  Be- 
sides, the  book  teems  with  solid  instruction,  and 
it  shows  the  very  highest  evidence  oT  ability,  viz., 


of  Dr.  Meigs,  with  a  high  opinion  of  his  talents  and 
originality.— TAe  British  and  Foreign  Medico-Chi- 
TUrgical  Review. 

Everj*  chapter  is  replete  with  practical  instruc- 
tion, and  bears  the  impress  of  being  the  composition 
of  an  acute  and  experienced  mind.  There  is  a  terse- 
ness, and  at  the  same  time  an  accuracy  in  his  de- 
scription of  symptoms,  and  in  the  rules  for  diagnosis. 


aented.  We  know  of  no  better  test  of  one's  under- 
standing a  subject  than  the  evidence  of  the  power 
of  lucidly  explaining  it.  The  most  elementary,  as 
well  as  the  obscurest  subjects,  under  the  pencil  of 
Prof.  Meigs,  are  isolated  and  made  to  stand  out  in 
such  bold  relief,  as  to  produce  distinct  impressions 
upon  the  mind  and  memory  of  the  reader. —  Tht 
Charleston  Med.  Journal.  v 


BY   THE  SAME  AUTHOR. 


ON    THE    NATURE,    SIGNS,    AND    TREATMENT    OP    CHILDBED 

FEVER.    In  a  Series  of  Letters  addressed  to  the  Students  of  his  Class.    In  one  handsome 
octavo  volume,  extra  cloth,  of  365  pages.    $2  50. 

lectable  book.  *    *    *  This  treatise  upon  child- 


The  instructive  and  interesting  author  of  this 
work,  whose  previous  labors  have  placed  his  coun- 
trymen under  deep  and  abiding  obligations,  again 
challenges  their  admiration  in  the  fresh  and  vigor- 
ous, attractive  and  racy  pages  before  us.   it  is  a  de- 


bed  fevers  will  have  an  extensive  sale,  being  des- 
tined, as  it  deserves,  to  find  a  place  in  the  library 
of  every  practitioner  who  scorns  to  lag  in  the  rear.— ■ 
Nashville  Journal  of  Medicine  and  Surgery. 


BY   THE  SAME   AUTHOR  ;   WITH  COLORED  PLATES. 

A  TREATISE  ON  ACUTE  AND  CHRONIC  DISEASES  OF  THE  NECK 

OF  THE  UTERUS.    With  numerous  plates,  drawn  and  colored  from  nature  in  the  highest 
style  of  art.    In  one  handsome  octavo  volume,  extra  cloth.    $4  50. 


22 


BLANCHARD   &   LEA'S    MEDICAL 


MACLISE   (JOSEPH),    SURGEON. 
SURGrlCAL  ANATOMY.     Forming  one  volume,   very  large  imperial  quarto. 

With  sixty-eight  large  and  splendid  Plates,  drawn  in  the  best  style  and  beautifully  colored.    Con- 
taining one  hundred  and  ninety  Figures,  many  of  them  the  size  of  life.     Together  with  copious 
and  explanatory  letter-presg.     Strongly  and  handsomely  bound  in  extra  cloth,  being  one  of  the 
cheapest  and  best  executed  Surgical  works  as  yet  issued  in  this  country.    $11  00. 
*^*  The  size  of  this  work  prevents  its  transmission  through  the  post-office  as  a  whole,  but  those 

who  desire  to  have  copies  forwarded  by  mail,  can  receive  them  in  five  parts,  done  up  in  stout 

wrappers.     Price  $9  00. 


One  of  the  greatest  artistic  triumphs  of  the  age 
in  Surgical  Anatomy. — British  American  Medical 
Journal. 

No  practitioner  whose  means  will  admit  should 
fail  to  possess  it. — Ranking^s  Abstract. 

Too  much  cannot  be  said  in  its  praise;  indeed, 
we  have  not  language  to  do  it  justice. — Ohio  Medi- 
cal and  Surgical  Journal. 

The  most  accurately  engraved  and  beautifully 
colored  plates  we  have  ever  seen  in  an  American 
book — one  of  the  best  and  cheapest  surgical  works 
ever  published. — Buffalo  Medical  Journal. 

It  is  very  rare  that  so  elegantly  printed,  so  well 
illustrated,  and  so  useful  a  work,  is  offered  at  so 
moderate  a  price. — Charleston  Medical  Journal. 

Its  plates  can  boast  a  superiority  which  places 
them  almost  beyond  the  reach  of  competition. — Medi- 
cal Examiner. 

Country  practitioners  will  find  these  plates  of  im- 
mense value. — N.  Y.  Medical  Gazette. 


A  work  which  has  no  parallel  in  point  of  accu- 
racy and  cheapness  in  the  English  language. — N.  Y. 
Journal  of  Medicine. 

We  are  extremely  gratified  to  announce  to  th« 
profession  the  completion  of  this  truly  magnificent 
work,  which,  as  a  whole,  certainly  stands  unri- 
valled, both  for  accuracy  of  drawing,  beauty  of 
coloring,  and  all  the  requisite  explanations  of  the 
subject  in  hand. — Tht  Nei*  Orleans  Medical  and 
Surgical  Journal. 

This  is  by  far  the  ablest  work  on  Surgical  Ana- 
tomy that  has  come  under  our  observation.  We 
know  of  no  otlier  work  that  would  justify  a  stu- 
dent, in  any  degree,  for  neglect  of  actual  dissec- 
tion. In  those  sudden  emergencies  that  so  often 
arise,  and  which  require  the  instantaneous  command 
of  minute  anatomical  knowledge,  a  work  of  this  kind 
keeps  the  details  of  the  dissecting-room  perpetually 
fresh  in  the  memory. — The  Western  Journal  of  Medi- 
cine and  Surgery. 


MILLER  (HENRY),  M.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  University  of  Louisville. 

PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS,  &c. ;  including  the  Treat- 

ment  of  Chronic  Inflammation  of  the  Cervix  and  Body  of  the  Uterus  considered  as  a  frequent 
cause  of  Abortion.  With  about  one  hundred  illustrations  on  wood.  In  one  very  handsome  oc- 
tavo volume,  of  over  600  pages.     {Lately  FuUislied.)     $3  75. 


We  congratulate  the  author  that  the  task  is  done. 
We  congratulate  him  that  he  hasgiven  to  the  medi- 
cal public  a  work  which  will  secure  for  him  a  high 
and  permanent  position  among  the  standard  autho- 
rities on  the  principles  and  practice  of  obstetrics. 
Congratulaticms  are  not  less  due  to  the  medical  pro- 


tion  to  which  its  merits  justly  entitle  it.  The  style 
is  such  that  the  descriptionsare  clear,  and  each  sub- 
ject is  discussed  and  eluiidaled  with  due  regard  to 
its  practical  bearings,  which  cannot  fail  to  make  it 
acceptable  and  valuable  to  both  students  and  prac- 
titioners.     We  cannot,  however,  close  this  brief 


fession  of  this  country,  on  the  acquisition  of  a  trea-  |  notice  without  congratulating  the  author  and  the 
tise  embodying  the  results  of  the  studies,  reflections,  profession  on  the  production  of  such  an  excellent 
and  jBxperience  of  Prof.  Miller.  Few  men,  if  any,  |  treatise.  The  author  is  a  western  man  of  whom  we 
in  this  country,  are  more  competent  than  he  to  write  i  feel  proud,  and  we  cannot  but  think  that  his  book 
on  thisdepartment  of  medicine.  Engaged  for  thirty-  will  find  many  readers  and  warm  admirers  wherever 
five  years  in  an  extended  practice  of  obstetrics,  for  j  obstetrics  is  taught  and  studied  as  a  science  and  an 
many  years  a  teacher  of  tliis  branch  of  instruction    art. — The  Cincinnati  Lancetand  Observer. 


in  one  of  the  largest  of  our  institutions,  a  diligent 
student  as  well  as  a  careful  observer,  an  original  and 
independent  thinker,  wedded  to  no  hobbies,  ever 
ready  to  ccmsider  without  prejudice  new  views,  and 
to  adopt  innovations  if  they  are  really  improvements, 
and  withal  a  clear,  agreeable  writer,  a  practical 
treatise  from  his  pen  could  not  fail  to  possess  great 
value. — Buffalo  Med  Journal. 

In  fact,  this  volume  must  take  its  place  among  the 
standard  systematic  treatises  on  obstetrics  ;  a  posi- 


A  most  respectable  and  valuable  addition  to  our 
home  medical  literature,  and  one  reflecting  credit 
alike  on  the  author  and  the  institution  to  which  he 
is  attached.  The  student  will  find  in  this  work  a 
most  useful  guide  to  his  studies;  the  country  prac- 
titioner, rusty  in  his  reading,  can  obtain  from  its 
pages  a  fair  resume  of  the  modern  literature  of  the 
science;  and  we  hope  to  see  this  American  produc- 
tion generally  consulted  by  the  profession. —  Va. 
Med.  Journal. 


MACKENZIE   (W.),    M.D., 

Surgeon  Oculist  in  Scotland  in  ordinary  to  Her  Majesty,  A.c.  A;c. 

A  PRACTICAL   TREATISE  ON   DISEASES   AND  INJURIES  OF   THE 

EYE.  To  which  is  prefixed  an  Anatomical  Introduction  explanatory  of  a  Horizontal  Section  of 
the  Human  Eyeball,  by  Thomas  Wharton  Jones,  F.  R.  S.  From  the  Fourth  Revised  and  En- 
larged London  Edition.  With  Notes  and  Additions  by  Addinell  Hewson,  M.  D.,  Surgeon  to 
Wills  Hospital,  &c.  &c.  In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  with 
plates  and  numerous  wood-cuts.    $5  25. 


The  treatise  of  Dr.  Mackenzie  indisputably  holds 
the  firstplace,  and  forms,  in  respect  of  learning  and 
research,  an  Encyclopaedia  unequalled  in  extent  by 
any  other  work  of  the  kind,  either  English  or  foreign. 
— Dixon  on  Diseases  of  the  Eye. 

Few  modern  books  on  any  department  of  medicine 
or  surgery  have  met  with  such  extended  circulation, 
or  have  procured  for  their  authors  a  like  amount  of 
European  celebrity.  The  immense  research  which 
it  displayed,  the  thorough  acquaintance  with  the 
subject,  practically  as  well  as  theoretically,  and  the 


able  manner  in  which  the  author's  stores  of  learning 
and  experience  were  rendered  available  for  general 
use,  at  once  procured  for  the  first  edition,  as  well  on 
the  continent  as  in  this  country,  that  high  position 
as  a  standard  work  which  each  successive  edition 
has  more  firmly  established.  We  consider  it  the 
duty  of  every  one  who  has  the  love  of  his  profession 
and  the  welfare  of  his  patient  at  heart,  to  make  him- 
self familiar  with  this  the  most  complete  work  in 
the  English  language  upon  the  diseases  of  the  eye. 
— Med.  Times  and  Gazette. 


MAVNE'S  DISPENSATORY  AND  THERA- 
PEUTICAL REMEMBRANCER.  With  every 
Practical  Formula  contained  in  the  three  British 
Pharmacopccias.  Edited,  with  the  addition  of  the 
Formulae  of  the  U.  S.  Pharmacopoeia,  by  R.  E. 
GkiffitHjM.D    1  12mo. vol. ex. cl. ,300pp.  75c. 


MALGAIGNE'S  OPERATIVE  SURGERY,  based 
on  Normal  and  Pathological  Anatomy.  Trans- 
lated from  the  French  by  Frederick  Brittan, 
A.  B.,M.D.  WithnumerouE  illustrations  on  wood. 
In  one  handsome  octavo  volume,  extra  cloth,  of 
nearly  six  hundred  pages.    9'2  25, 


AND    SCIENTIFIC    PUBLICATIONS. 


23 


MILLER  (JAMES),   F.  R.  S.  E., 

Professor  of  Surgery  in  the  Univergity  of  Edinburgh,  Ice. 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and  revised 

Edinburgh  edition.    In  one  large  and  very  beautiful  volume,  leather,  of  700  pages,  with  two 
hundred  and  forty  illustrations  on  wood.     $3  75. 


Tlie  work  of  Mr.  Miller  is  too  well  and  too  favor- 
ably known  among  us,  as  one  of  our  best  text-books, 
to  render  any  further  notice  of  it  necessary  than  the 
announeement  of  a  ne'w  edition,  the  fourth  in  our 
country,  a  proof  of  its  extensive  circulation  among 
us.    As  a  concise  and  reliable  exposition  of  the  sei- 


The  work  takes  rank  with  Watson's  Practice  of 
Physic;  it  certainly  does  not  fall  behind  that  great 
work  in  soundness  of  principle  or  depth  of  reason- 
ing and  research  Vo  physician  who  values  his  re- 
putation, or  seeks  the  interests  of  his  clients,  can 
acquit  himself  before  his  God  and  the  world  without 


ence  of  modern  surgery,  it  stands  deservedly  high —  I  making  himself  familiar  with  the  sound  and  philo- 

we  know  not  its  superior Boston  Med.  and  Surg,  j  sophical  views  developed  in  the  foregoing  book. — 

Journal.  \  New  Orleans  Med.  and  Surg.  Journal. 

BY  THE  SAME  AUTHOR.     {Just  Issued.) 

THE    PRACTICE   OF   SURGERY.      Fourth   American  from  the  last  Edin- 

burgh  edition.     Revised  by  the  American  editor.     Illustrated  by  three  hundred  and  sixty-four 

engravings  on  wood.     In  one  large  octavo  volume,  leather,  of  nearly  700  pages.     $3  7.5. 

No  encomium  of  ours  could  add  to  the  popularity  i  his  works,  both  on  the  principles  and  practice  of 

of  Miller's  Surgery.    Its  reputation  in  this  country    surgery  have  been  assigned  the  highest  rank.     If  we 

is  unsurpassed  by  that  of  any  other  work,  and,  when    were  limited  to  but  one  work  on  surgery,  that  one 


taken  in  connection  with  the  author's  Principles  of 
Surgery,  constitutes  a  ^vhole,  without  reference  to 
which  no  conscientious  surgeon  would  be  willing  to 
practice  his  art. — Southern  Med.  and  Surg.  Journal. 
It  is  seldom  that  two  volumes  have  ever  made  so 
profound  an  impression  in  so  short  a  time  as  the 
"  Principles"  and  the  "  Practice"  of  Surgery  by 
Mr.  Miller — or  so  richly  merited  the  reputation  they 
have  acquired.  The  author  is  an  eminently  sensi- 
ble, practical,  and  well-informed  man,  who  knows 
exactly  what  he  is  talking  about  and  exactly  how  to 
talk  it. — Kentucky  Medical  Recorder. 

By  the  almost  unanimous  voice  of  the  profession, 


should  be  Miller's,  as  we  regard  it  as  superior  to  all 
others. — St.  Louis  Med.  and  Surg.  Journal. 

The  author  has  in  this  and  his  "  Principles,"  pre- 
sented to  the  profession  one  of  the  most  complete  and 
reliable  systems  of  Surgery  extant.  His  style  of 
writing  is  original,  impressive,  and  engaging,  ener- 
getic, concise,  and  lucid.  Few  have  the  faculty  of 
condensing  so  much  in  small  space,  and  at  the  same 
time  so  persistently  holding  theattention.  Whether 
as  a  text-book  for  students  or  a  book  of  reference 
for  practitioners,  it  cannot  be  too  strongly  recom- 
mended.— Southern  Journal  of  Med.  and  Physical 
Sciences. 


MORLAND  (W.  WJ,   M.   D., 

Fellow  of  the  Massachusetts  Medical  Society,  &c. 

DISEASES  OF  THE  URINARY  ORGANS;  a  Compendium  of  their  Diagnosis, 

Pathology,  and  Treatment.     With  illustrations.     In  one  large  and  handsome  octavo  volume,  of 
about  600  pages,  extra  cloth.     (Just  Issued.)     $3  50. 


refer.  This  desideratum  has  been  supplied  by  Dr. 
Morland,  and  it  lias  been  ably  done.  He  has  placed 
before  us  a  full,  judicious,  and  reliable  digest. 
Each  subject  is  treated  with  sufficient  minuteness, 
yet  in  a  succinct,  narrational  style,  such  as  to  render 
the  woric  one  of  great  interest,  and  one  which  will 
prove  in  the  highest  degree  useful  to  the  general 
practitioner. — iV.  Y.  Journ.  of  Medicine, 


Taken  as  a  whole,  we  can  recommend  Dr.  Mor- 
land's  compendium  as  a  very  desirable  addition  to 
the  library  of  every  medical  or  surgical  practi- 
tioner,— Brit. and  For.  Med.-Chir.  Rev.,  April,  1859. 

Every  medical  practitioner  whose  attention  has 
been  to  any  extent  attracted  towards  the  class  of 
diseases  to  which  this  treatise  relates,  must  have 
often  and  sorely  experienced  the  want  of  some  fu41, 
yet  concise  recent  compendium  to  which  he  could 

BY  THE  SAME  AUTHOR — {Now  Ready.) 

THE  MORBID  EFFECTS  OF  THE   RETENTION  IN  THE   BLOOD  OF 

THE  ELEMENTS  OF  THE  URINARY"  SECRETION.  Being  the  Dissertation  to  which  the 
Fiske  Fund  Prize  was  awarded,  July  11,  1861.  In  one  small  octavo  volume,  S3  pages,  extra 
cloth.    75  cents. 


MONTGOMERY  (W.  F.),   M.  D.,   M.  R.  I.  A.,  &.C., 

Professor  of  Midwifery  in  the  King  and  Queen's  College  of  Physicians  in  Ireland,  &;c. 

AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

With  some  other  Papers  on  Subjects  connected  with  Midw'ifery.  From  the  second  and  enlarged 
English  edition.  With  two  exquisite  colored  plates,  and  numerous  wood-cuts.  In  one  very 
handsome  octavo  volume,  extra  cloth,  of  nearly  600  pages.     (Lately  Published.)     $3  75. 


A  book  unusually  rich  in  practical  suggestions. — 
Am  Journal  Med.  Sciences,  Jan.  1857. 

These  several  subjects  so  interesting  in  them- 
selves, and  so  important,  every  one  of  them,  to  the 
most  delicate  and  precious  of  social  relations,  con- 
trolling often  the  honor  and  domestic  peace  of  a 
family,  the  legitimacy  of  offspring,  or  the  life  of  its 
parent,  are  all  treated  with  an  elegance  of  diction, 
fulness  of  illustrations,  acutenessand  justice  of  rea- 
soning, unparalleled  in  obstetrics,  and  unsurpassed  in 
medicine.    The  reader's  interest  can  never  flag,  so 


fresh,  and  vigorous,  and  classical  is  our  author's 
style;  and  one  forgets,  in  the  renewed  charm  of 
every  page,  that  it,  and  every  line,  and  every  word 
has  been  weighed  and  reweighed  through  years  of 
preparation  ;  that  this  is  of  all  others  the  book  of 
Obstetric  Law,  on  each  of  its  several  topics;  on  all 
points  connected  with  pregnancy,  to  be  everywhere 
received  as  a  manual  of  special  jurigprudence^  at 
once  announcing  fact,  afTonling argument,  establish- 
ing precedent,  and  governing  alike  the  juryman,  ad- 
vocate, and  judge.  —  N.  A.  Med.-Chir.  Review. 


MOHR  (FRANCIS),  PH.  D.,  AND  REDWOOD  (TH  EOPHI  LUS). 
PRACTICAL   PHARMACY.     Comprising  the  Arrangements,  Apparatus,  and 

JVIanipulations  of  the  Pharmaceutical  Shop  and  Laboratory.  Edited,  with  extensive  Additions, 
by  Prof  William  Procter,  of  the  Philadelphia  College  of  Pharmacy.  In  one  handsomely 
printed  octavo  voliune,  extra  cloth,  of  570  pages,  with  over  500  engravings  oa  wood.    $2  75, 


24 


BLANCHARD    &   LEA'S    MEDICAL 


NEILL  (JOHN),   M.  D., 

Surgeon  to  thePennsylvaniaHospital,&c.;  and 

FRANCIS  QURNEY   SMITH,   M.D., 

Professor  of  Institutes  of  Medicine  in  the  Pennsylvania  Medical  College. 

AN  ANALYTICAL   COMPENDIUM    OF   THE   VARIOUS   BRANCHES 

OF  MEDICAL  SCIENCE ;  for  the  Use  and  Examination  of  Students.    A  new  edition,  revised 
and  improved.     In  one  very  large  and  handsomely  printed  royal  12mo.  volume,  of  about  one 
thousand  pages,  with  374  wood-cuts.     Strongly  bound  in  leather,  with  raised  bands.     $3  00. 
The  very  flattering  reception  which  has  been  accorded  to  this  work,  and  the  high  estimate  placed 
upon  it  by  the  profession,  as  evinced  by  the  constaat  and  increasing  demand  which  has  rapidly  ex- 
hausted two  large  editions,  have  stimulated  the  authors  to  render  the  volume  in  its  present  revision 
more  worthy  ol  .the  success  which  has  attended  it.     It  has  accordingly  been  thoroughly  examined, 
and  such  errors  as  had  on  former  occasions  escaped  observation  have  been  corrected,  and  whatever 
additions  were  necessary  to  maintain  it  on  a  level  with  the  advance  of  science  have  been  introduced. 
The  extended  series  of  illustrations  has  been  still  further  increased  and  much  improved,  while,  by 
a  slight  enlargement  of  the  page,  these  various  additions  have  been  incorporated  without  increasing 
the  bulk  of  the  volume. 

The  work  is,  therefore,  again  presented  as  eminently  worthy  of  the  favor  with  which  it  has  hitherto 
been  received.  As  a  book  for  daily  reference  by  the  student  requiring  a  guide  to  his  more  elaborate 
text-books,  as  a  manual  for  preceptors  desiring  to  stimulate  (heir  students  by  frequent  and  accurate 
examination,  or  as  a  source  from  which  the  practitioners  of  older  date  may  easily  and  cheaply  acquire 
a  knowledge  of  the  changes  and  improvement  in  professional  science,  its  reputation  is  permanently 
established. 


The  best  work  of  the  kind  with  which  we  are 
acquainted. — Med.  Examiner. 

Having  made  free  use  uf  this  volume  in  our  ex- 
aminations of  pupils,  we  can  speak  from  experi- 
ence in  recommending  it  as  an  admirable  compend 
for  students,  and  as  especially  useful  to  preceptors 
who  examine  their  pupils.  It  wilt  save  the  teacher 
much  labor  by  enabling  him  readily  to  recall  all  of 
the  points  upon  which  his  pupils  should  be  ex- 
amined. A  work  of  this  sort  should  be  in  the  aands 
of  every  one  who  takes  pupils  into  his  office  with  a 
viewof  ex.imining  them  ;  and  this  is  unquestionably 
the  best  of  Its  class. — Transylvania  Med.  Journal 

In  the  rapid  course  of  lectures,  where  work  for 


the  students  is  heavy,  and  review  necessary  for  an 
examination,  a  compeud  is  not  only  valuable,  but 
it  is  almost  a  5ine  9ua  non.  The  one  before  us  is, 
in  most  of  the  divisions,  the  most  unexceptionable 
of  all  books  of  the  kind  that  we  know  of.  The 
newest  and  soundest  doctrines  and  the  latest  im- 
provements and  discoveries  are  explicitly,  though 
concisely,  laid  before  the  student.  There  is  a  elasB 
to  whom  we  very  sincerely  commend  this  cheap  book 
as  worth  its  weight  in  silver — that  class  is  the  gradu- 
ates in  medicine  of  more  than  ten  years'  standing, 
who  have  not  studied  medicine  since.  They  will 
perhaps  find  out  from  it  that  the  science  is  not  exactly 
now  what  it  was  when  they  left  it  off. — Tht  Stetko- 
icopt. 


NELIGAN  (J.    MOORE),  M.  D.,  M.  R.  I.  A.,  &.C. 

ATLAS  OF  CUTANEOUS  DISEASES.  In  one  beautiful  quarto  volume,  extra 
cloth,  with  splendid  colored  plates,  presenting  nearly  one  himdred  elaborate  representations  of 
disease.    $4  50. 

This  beautiful  volume  is  intended  as  a  complete  and  accurate  representation  of  all  the  varieties 
of  Diseases  of  the  Skin.  While  it  can  be  consulted  in  conjunction  with  any  work  on  Practice,  it  has 
especial  reference  to  the  author's  "  Treatise  on  Diseases  of  the  Skin,"  so  favorably  received  by  the 
profession  some  years  since.  The  publishers  feel  justified  in  saying  that  few  more  beautifully  exe- 
cuted plates  have  ever  been  presented  to  the  profession  of  this  country. 

Neligan's  Atlas  of  Cutaneous  Diseases  Bupplie»«  I  give,  at  a  coup  d^ail,  the  remarkable  peculiarities 
long  existent  desideratum  niucli  felt  by  the  largest  ,  of  each  individual  variety.  And  while  thus  the  dis 
class  of  our  profession.  It  presents,  in  quarto  size.  '  ease  is  rendered  more  definable,  there  is  yet  no  loss 
16  plates,  each  containing  from  3  to  6  ngures,  ana  of  proportion  incurred  by  the  necessary'  concenfra- 
forming  in  all  a  total  of  90  distin'"t  representations  i  tion.  Each  figure  is  highly  colored,  and  so  truthful 
of  the  different  species  of  skin  affections,  grouped  has  the  artist  been  that  the  mostfastid  ous  observer 
together  in  genera  or  families.  The  illustrations  ;  could  not  justly  take  exception  to  the  correctness  of 
have  been  taken  from  nature,  and  have  been  copied  |  the  execution  of  the  pictures  under  his  scrutiny.— 
with  such  fidelity  that  they  present  a  striking  picture  Montreal  Med.  Chronicle. 
of  life  J  in  which  the  reduced  scale  aptly  serves  to  I 

BY  THE  SAME  AUTHOR. 

A    PRACTICAL   TREATISE.  ON    DISEASES   OF  THE   SKIN. 

American  edition.    In  one  neat  royal  12mo.  volume,  extra  cloth,  of  334  pages.    $1  00. 
The  two  volumes  will  be  sent  by  mail  on  receipt  of  Five  Dollars. 


Third 


OWEN  ON  THE  DIFFERENT  FORMS  OF 
THE  SKELKTON,  AND   OF  THE  TEETH. 


One  vol.  royal  12mo.,  extra  cloth  with  numerous 
illustrations.    SI  '25 


PIRRIE  (WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE    PRINCIPLES  AND  PRACTICE  OF  SURGERY.    Edited  by  John 

Neill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  tothe  Pennsylvania 
Hospital,  &c.  In  one  very  handsome  octavo  volume,  leather,  of  780  pages,  with  316  illustrations. 
$3  75. 


We  know  of  no  other  surgical  work  of  a  reason- 
able size,  wherein  there  is  so  much  theory  and  prac- 
tice, or  where  subjects  are  more  soundly  or  clearly 
taught. — The  Stethoscope. 

Prof.  Pirrie,  in  the  work  before  us,  has  elabo- 


rately discussed  the  principles  of  surgery,  and  a 
safe  and  effectual  practice  predicated  upon  them. 
Perhaps  no  work  upon  this  subject  heretofore  issued 
is  so  full  upon  the  science  of  the  art  of  surgery.— 
Nashville  Journal  of  Medicine  and  Surgery. 


AND   SCIENTIFIC    PUBLICATIONS. 


25 


PARRISH    (EDWARD), 

Lecturer  on  Practical  Pharmacy  and  Materia  Medica  in  the  Pennsylvania  Academy  of  Medicine,  &c. 

AN  INTRODUCTION  TO  PRACTICAL  PHARMACY.    Designed  as  a  Text- 

Book  for  the  Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  For- 
mulas and  Prescriptions.  Second  edition,  greatly  enlarged  and  improved.  In  one  handsome 
octavo  volume  of  720  pages,  with  several  hundred  Illustrations,  extra  cloth.  $3  50.  {Just 
Issued.) 

During  the  short  time  in  which  this  work  ha*  been  before  the  profession,  it  has  been  received 
with  very  great  favor,  and  in  assuming  the  position  of  a  standard  authority,  it  has  filled  a  vacancy 
which  had  been  severely  felt.  Stimulated  by  this  encouragement,  the  author,  in  availing  himself 
of  the  opportunity  of  revision,  has  spared  no  pains  to  render  it  more  worthy  of  the  confidence  be- 
stowed upon  it,  and  his  assiduous  labors  have  made  it  rather  a  new  book  than  a  new  edition,  many 
portions  having  been  rewritten,  and  much  new  and  important  matter  added.  These  alterations  and 
improvements  have  been  rendered  necessary  by  the  rapid  progress  made  by  pharmaceutical  science 
during  the  last  few  years,  and  by  the  additional  experience  obtained  in  the  practical  use  of  the 
volume  as  a  text-book  and  work  of  reference.  To  accommodate  these  improvements,  the  size  of 
the  page  has  been  materially  enlarged,  and  the  number  of  pages  considerably  increased,  presenting 
in  all  nearly  one-half  more  matter  than  the  last  edition.  The  work  is  therefore  now  presented  as  a 
complete  exponent  of  the  subject  in  its  most  advanced  condition.  From  the  most  ordinary  matters 
in  the  dispensing  office,  to  the  most  complicated  details  of  the  vegetable  alkaloids,  it  is  hoped  that 
everything  requisite  to  the  practismg  physician,  and  to  the  apothecary,  will  be  found  fully  and 
clearly  set  forth,  and  that  the  new  matter  alone  will  be  worth  more  than  the  very  moderate  cost  of 
the  work  to  those  who  have  been  consulting  the  previous  edition. 

will  -find  all  that  they  desire  to  know,  and  should 


That  Edward  Parrish,  in  writing  a  book  upon 
practical  Pharmacy  some  few  years  ago — one  emi- 
nently original  and  unique — did  the  medical  and 
pharmaceutical  profeseiims  a  great  and  valuable  ser- 
vice, no  one,  we  think,  who  has  had  access  to  its 
pages  will  deny ;  doubly  welcome,  then,  is  this  new 
edition,  containing  the  added  results  of  his  recent 
and  rich  experience  as  an  observer,  teacher,  and 
practicil  operator  in  thepharmaceutical  laboratory. 
The  excellent  plan  of  the  first  is  more  thoroughly, 
and  in  detail,  carried  out  in  this  edition. — Peninsular 
Med.  Journal,  Jan.  1860. 

Of  course,  all  apothecaries  who  have  not  already 
a  copy  of  the  first  edition  will  procure  one  of  this; 
it  is,  therefore,  to  physicians  residing  in  the  country 
and  in  small  towns,  who  cannot  avail  themselves  of 
the  skill  of  an  educated  pharmaceutist,  that  we 
would  especially  commend  this  work.     In  it  they 


know,  but  very  little  of  which  they  do  really  Know 
in  reference  to  this  important  collateral  branch  of 
their  profession;  for  it  is  a  well  established  fact, 
that,  in  the  education  of  physicians,  while  the  sci- 
ence of  medicine  is  generally  well  taught,  very 
little  attention  is  paid  to  the  art  of  preparing  them 
for  use,  and  we  know  not  how  this  defect  can  be  so 
well  remedied  as  by  procuring  and  consulting  Dr. 
Parrish's  excellent  work.— St.  Louis  Med.  Journal. 
Jan.  1860. 

We  know  of  no  work  on  the  subject  which  would 
be  more  indispensable  to  the  physician  or  student 
desiring  information  on  the  subject  of  which  it  treats. 
With  Griffith's  "  Medical  Formulary"  and  this,  the 
practising  physician  would  be  supplied  with  nearly 
or  quite  all  the  most  useful  inforntiation  on  the  sub- 
ject.— Charleston  Med.  Jour,  and  Review,  Jan.  1S60 


PEA-SLEE  (E.  R.),  M.  D., 

Professor  of  Physiology  and  General  Pathology  in  the  New  York  Medical  College. 

HUMAN  HISTOLOGY,  in  its  relations  to  Anatomy,  Physiology,  and  Pathology; 

for  the  use  of  Medical  Students.    With  four  hundred  and  thirty- four  illustrations.    In  one  hand- 
some octavo  volume,  of  over  600  pages.     (Lately  Published.)    $3  75. 

We  would  recommend  it  to  the  medical  student 
and  practitioner,  as  containing  a  summary  of  all  that 
is  known  of  the  important  subjects  which  it  treats  ; 
of  all  that  is  contained  in  the  great  works  of  Simon 
and  Lehmann,  and  the  organic  chemists  in  general. 
Master  this  one  volume,  we  would  say  to  the  medical 
student  and  practitioner — master  this  book  and  you 
know  all  that  is  known  of  the  great  fundamental 
principles  of  medicine,  and  we  have  no  hesitation 
in  saying  that  it  is  an  honor  to  the  American  medi- 
cal profession  that  one  of  its  members  should  have 
produced  it. — St.  Louis  Med.  and  Surg.  Journal. 


It  embraces  a  library  upon  the  topics  discussed 
within  itself,  andis  just  what  the  teacher  and  learner 
need.  Another  advantage,  by  no  means  to  be  over- 
looked, everything  of  real  value  in  the  wide  range 
which  it  embraces,  is  with  great  skill  compressed 
into  an  octavo  volume  of  but  little  more  than  six 
hundred  pages.  We  have  not  only  the  whole  sub- 
ject of  Histology,  interesting  in  itself, ably  and  fully 
discussed,  but  what  is  of  infinitely  greater  interest 
to  the  student,  because  of  greater  practical  value, 
are  its  relations  to  Anatomy,  Physiology,  and  Pa- 
thology, which  are  here  fully  and  satisfactorily  set 
foTtk.— Nashville  Journ.  of  Med.  and  Surgery. 


PEREIRA  (JONATHAN),  M.  D.,  F.  R.  5.,  AND  L.  S. 
THE    ELEMENTS    OF   MATERIA    MEDICA    AND    THERAPEUTICS. 

Third  American  edition,  enlarged  and  improved  by  the  author;  including  Notices  of  most  of  the 
Medicinal  Substances  in  use  in  the  civilized  world,  and  forming  an  Encyclopaedia  of  Materia 
Medica.  Edited,  with  Additions,  by  Joseph  Carson,  M.  D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.  In  two  very  large  octavo  volumes  of  2100  pages, 
on  small  type,  with  about  500  illustrations  on  stone  and  wood,  strongly  bound  in  leather,  with 
raised  bands.  $9  00. 
^*^  Vol.  II.  will  no  longer  be  sold  separate. 

PARKER   (LANGSTON), 

Surgeon  to  the  Queen's  Hospital,  Birmingham. 

THE  MODERN  TREATMENT  OF  SYPHILITIC  DISEASES,  BOTH  PRI- 

MARY  AND  SECONDARY;  comprisingtheTreatmentof  Constitutional  and  Confirmed  Syphi- 
lis, by  a  safe  and  successful  method.  With  numerous  Cases,  Formulae,  and  Clinical  Observa- 
tions. From  the  Third  and  entirely  rewritten  London  edition.  In  one  neat  octavo  volume, 
extra  cloth,  of  316  pages.    $1  75. 

ROYLE'S   MATERIA   MEDICA   AND   THERAPEUTICS;   including  the 

Preparations  of  the  Pharmacopoeias  of  London,  Edinburgh,  Dublin,  and  of  the  United  States. 
With  many  new  medicines.  Edited  by  Joseph  Carson,  M.  D.  With  ninety-eight  illustrations. 
la  onelargeoctavo  volume,  extra  cloth,  of  about  700  pages.    $3  00. 


26 


BLANCHARD    Ae    LEA'S    MEDICAL 


RAMSBOTHAM  (FRANCIS  H.),  M.D. 
THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDICINE  AND 

SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly 
revised  by  the  Author.  With  Additionsby  W.  V.  Keating, M.  D.,  Professor  of  Obstetrics,  &:c.,  in 
the  Jefferson  Medical  College,  Philadelphia.  In  one  large  and  handsome  imperial  octavo  volume, 
of  650  pages,  strongly  bound  in  leather,  with  raised  bands;  with  sixty- four  beautiful  Plates,  and 
numerous  Wood-cuts  in  the  text,  containing  in  all  nearly  200  large  and  beautiful  figures.    $5  00. 

From  Prof.  Hodge,  of  the  University  of  Pa. 

To  the  American  public,  it  is  most  valuable,  from  its  intringic  undoubted  excellence,  and  as  bemg 
the  best  authorized  exponent  of  British  Midwifery.  Its  circulation  will,  I  trust,  be  extensive  throughout 
our  country. 

It  is  unnecessary  to  say  anything  in  regard  to  the  i  truly  elegant  style  in  which  they  have  brought  it 
utility  of  this  work.  It  is  already  appreciated  in  our  out,  excelling  themselves  in  its  production,  espe- 
country  for  the  value  of  the  matter,  the  clearness  of    eially  in  its  plates.     It  is  dedicated  to  Prof.  Meigs 


Its  style,  and  the  fulness  of  its  illustrations.  To  the 
physician's  library  it  is  indispen.-5able,  while  to  the 
student  as  a  text-book,  from  which  to  extract  the 
material  for  laying  the  foundation  of  an  education  on 
obstetrical  science,  it  has  no  superior. — Ohio  Med 
and  Surg,  Journal. 

The  publishers  have  secured  its  success  by  the 


and  has  the  emphatic  endorsement  of  Prof.  Hodge, 
as  the  best  exponent  of  British  Midwifery.  We 
kni.w  of  no  text-book  which  deserves  in  all  respects 
to  be  more  highly  recommended  to  students,  and  we 
could  wish  to  see  it  in  the  handsof  every  practitioner, 
for  they  will  find  it  invaluable  for  reference. — Med. 
Gazette. 


RfCORD  (P.),   M.  D. 
A  TREATISE  ON  THE  VENEREAL  DISEASE.     By  John  Hunter,  F.  R.  S. 

With  copious  Additions,  by  Ph  Ricord,  M.D.    Translated  and  Edited,  with  Notes,  by  Freeman 
J.  BuMSTEAD.  M.D,  Lecturer  on  Venereal  at  the  College  of  Physicians  and  Surgeons,  New  York. 
Second  edition,  revised,  containing  a  resume  of  Ricord's  Recent  Lectures  on  Chancre.    In 
one  handsome  octavo  volume,  extra  cloth,  of  550  pages,  with  eight  plates.    $3  25.   (Just  Issued.) 
In  revising  this  work,  the  editor  has  endeavored  to  introduce  whatever  matter  of  interest  the  re- 
cent investigations  of  syphilographers  have  added  to  our  knowledge  of  the  subject.     The  principal 
source  from  which  this  has  been  derived  is  the  volume  of  "Lectures  on  Chancre,"  published  a  few 
months  since  by  M.  Ricord,  which  affords  a  large  amount  of  new  and  instructive  material  on  many 
controverted  points.     In  the  previous  edition,  M.  Ricord's  additions  amounted  to  nearly  one-third 
of  the  whole,  and  with  the  mailer  now  introduced,  the  work  may  be  considered  to  present  his  views 
and  experience  more  thoroughly  and  completely  than  any  other. 

Kvery  one  will  recognize  the  auractiveness  and  i  secretaries,  sometimes  accredited  and  sometimes  not. 
value  which  this  work  derives  from  thus  presenting  In  the  notes  to  Hunter,  the  master  subslilules  him- 
the  opinion?  of  these  two  masters  side  by  side.  Bui,  selfforhis  interpreters,  and  gives  hisoriginal  thoughts 
it  must  be  admitted,  what  has  made  the  fortune  of  to  the  world  in  a  lucid  and  perfectly  intelligible  man- 
Ihe  book,  is  the  fact  that  it  contains  the  "most  com-  ner.  In  conclusion  we  can  say  that  this  is  incon- 
plele  embodiment  of  the  veritable  doctrines  of  the  i  tesiably  the  besureali.-e  on  syphilis  with  which  we 
Hopital  du  Alidi,"  which  has  ever  been  made  public,  are  acquainted,  and,  as  we  do  not  often  employ  the 
The  doctrinal  ideas  of  M.  Ricord.  ideas  which,  if  not  phrase,  we  may  be  excused  for  expressing  the  hope 
universally  adopted. are  incontestably  dominant,  have  that  it  may  find  a  place  in  the  library  of  every  phy- 
hereioforeonlybeen  interpretedby  moreorlessskilful  jsician. —  Virginia  Med.  and  Surg.  Journal. 

BY   THE  SAME   AUTHOR. 

RICORD'S  LETTERS  ON  SYPHILIS.   Translated  by  W.  P.  Lattimore,  M.  D. 
In  one  neat  octavo  volume,  of  270  pages,  extra  cloth.    $2  00. 


ROKITANSKY   (CARL),    M.D., 

Curator  of  the  Imperial  Pathological  Museum,  and  Professor  at  the  University  of  Vienna,  Ac. 

MANUAL   OF  PATHOLOGICAL    ANATOMY.     Four  volumes,   octavo, 


bound  in  two,  extra  cloth,  of  about  1200  pages. 

king,  C.  H.  Moore,  and  G.  E.  Day.     $5  50. 

The  profession  is  too  well  acquainted  with  the  re- 
putation of  Rokitansky's  work  to  need  our  assur- 
ance that  this  is  one  of  the  mostprofound.  thorough, 
and  valuable  books  ever  issued  from  the  medical 
press.  It  is  sui  generis,  and  has  no  standard  of  com- 
parison. It  is  only  necessary  to  announce  that  it  is 
issued  in  a  form  as  cheap  as  is  compatible  with  its 
size  and  preservation,  and  its  sale  follows  as  a 
matter  of  course.  No  library  can  be  called  com- 
plete without  it.— Buffalo  Med.  Journal. 

An  attempt  to  give  our  readers  any  adequate  idea 
of  the  vast  amount  of  instruction  accumulated  in 
these  volumes,  would  be  feeble  and  hopeless.  The 
effort  of  the  distinguished  author  to  concentrate 
in  a  small  space  his  great  fund  of  knowledge,  has 


Translated  by  W.  E.  Swaine,  Edward  Sievk- 

BO  charged  his  text  with  valuable  truths,  that  any 
attempt  of  a  reviewer  to  epitomize  is  at  once  para- 
lyzed, and  must  end  in  a  failure. —  Western  Lancet. 

As  this  is  the  highest  source  of  knowledge  upon 
the  important  subject  of  which  it  treats,  no  real 
student  can  afford  to  be  without  it.  The  American 
publishers  have  entitled  themselves  to  the  thanks  of 
the  profession  of  their  country,  for  this  timeous  and 
beautiful  edition. — Naskville  Journal  of  Medicine. 

As  a  book  of  reference,  therefore,  this  work  must 
prove  of  inestimable  value,  and  we  cannot  too  highly 
recommend  it  to  the  profession. — Charleston  Med. 
Journal  and  Review. 

This  book  is  a  necessity  to  every  practitioner. — 
Am.  Med.  Monthly. 


RIGBY   (EDWARD),    M.  D., 

Senior  Physician  to  the  General  Lying-in  Hospital,  &c. 

A    SYSTEM    OF    MIDWIFERY.     With  Notes  and  Additional  Illustrations. 

Second  American  Edition.    One  volume  octavo,  extra  cloth,  422  pages.    $2  50. 

BY  THE  SAME  AUTHOR.     {Lately  Published.) 

ON  THE  CONSTITUTIONAL  TREATMENT  OF  FEMALE  DISEASES. 

In  one  neat  royal  12mo.  volume,  extra  cloth,  of  about  250  pages.    $1  00. 


AND    SCIENTIFIC    PUBLICATIONS. 


27 


STILLE  (ALFRED),    M.  D. 
THERAPEUTICS  AND  MATERIA  MEDIC  A;  a  Systematic  Treatise  od  the 

Action  and  Uses  of  Medicinal  Agent?,  including  their  Description  and  History.    In  two  large 

and  handsome  octavo  volumes,  of  1789  pages.     (Just  Issued.)    $S  00. 

This  work  is  designed  especially  for  the  student  and  practitioner  of  medicine,  and  treats  the  various 
articles  of  the  Materia  Medica  from  the  point  of  view  of  the  bedside,  and  not  of  the  shop  or  of  the 
lecture-room.  While  thus  endeavoring  to  give  all  practical  information  likely  to  be  useful  with 
respect  to  the  employment  of  special  remedies  in  special  afiections,  and  the  results  to  be  anticipated 
from  their  administration,  a  copious  Index  of  Diseases  and  their  Remedies  renders  the  work  emi- 
nently fitted  for  reference  by  showing  at  a  glance  ihe  different  means  which  have  been  employed, 
and  enabling  the  practitioner  to  extend  his  resources  in  difficult  ca«es  with  all  that  tlie  experience 
of  the  profession  has  suggested. 

Rarely,  indeed,  have  we  had  Bubmitted  to  us  a  ,  fied  us  that  we  were  not  mistaken  in  our  anticipa- 
work  on  medicine  so  ponderous  in  its  dimensions    tions. — New  Orleans  Medical  News,  March,  ISGO. 


as  that  now  before  us,  and  yet  so  fascinating  in  its 
contents.  It  is,  therefore,  with  a  peculiar  gratifi- 
cation that  we  recognize  in  Dr.  Stille  the  posses- 
sion of  many  of  those  more  distinguished  qualifica- 
tions which  entitle  him  to  approbation,  and  which 
justify  him  in  coming  before  his  medical  brethren 
as  an  instructor.  A  comprehensive  knowledge, 
tested  by  a  sound  and  penetrating  judgment,  joined 
to  a  love  of  progress  — which  a  discriminating  spirit 
of  inquiry  has  tempered  so  as  to  accept  nothing  new 
because  it  is  new,  and  abandon  nothing  old  because 
it  is  old,  but  which  estimates  either  accorcing  to  its 
relations  to  a  just  logic  and  experience — manifests 
itself  everywhere,  and  gives  to  the  guidance  of  the 
author  all  the  assurance  of  safety  which  the  diffi- 
culties of  his  subject  can  allow.  In  conclusion,  we 
earnestly  advise  our  readers  to  ascertain  for  them- 
selves, by  a  study  of  Dr.  Stille's  volumes,  the  great 
value  and  interest  of  the  stores  of  knowledge  they 
present.  We  have  pleasure  in  referring  rather  to 
the  ample  treasury  of  undoubted  truths,  the  real  and 
assured  conquest  of  medicine,  accumulated  by  Dr. 
Stille  in  his  pnges  ;  and  commend  the  sum  of  his  la- 
bors to  the  attention  of  our  readers,  as  alike  honor- 
able to  our  science,  and  creditable  to  the  zeal,  the 
candor,  and  the  judgment  of  him  who  has  garnered 
the  whole  so  carefully. — Edinburgh  Med.  Journal. 

Our  expectations  of  the  value  of  this  work  were 
based  on  the  well-known  reputation  and  character 
of  the  author  as  a  man  of  scholarly  attainments,  an 
elegant  writer,  a  candid  inquirer  after  truth,  and  a 
philosophical  thinker  ;  we  knew  that  the  task  would 
be  conscientiously  performed,  and  that  few,  if  any, 
among  the  distinguished  medical  teachers  in  this 
country  are  better  qualified  than  he  to  prepare  a 
systematic  treatise  on  therapeutics  in  accordance 
with  the  present  requirements  of  medical  science. 
Our  preliminary  examination  of  the  work  has  satis- 


The  most  recent  authority  is  the  one  last  men- 
tioned, Stillfe.  His  great  work  on  "  Materia  Medi- 
ca and  Therapeutics,"  published  last  year,  in  two 
octavo  volumes,  of  some  sixteen  hundred  pages, 
while  it  embodies  the  results  of  the  labor  of  others 
up  to  the  time  of  publication,  is  enriched  with  a 
great  amount  of  original  observation  and  research. 
We  would  draw  attention,  by  the  way,  to  the  very 
convenient  mode  in  which  the  Index  is  arranged  in 
this  work.  There  is  first  an  "  Index  of  Remedies;" 
next  an  "Index  of  Diseases  and  their  Remedies." 
Such  an  arrangement  of  the  Indices,  in  our  opinion, 
greatly  enhances  the  practical  value  of  books  of  this 
kind.  In  tedious,  obstinate  cases  of  disease,  where 
we  have  to  try  one  remedy  after  another  until  our 
stock  is  pretty  nearly  exhausted,  and  we  are  almost 
driven  to  our  wit's  end,  such  an  index  as  the  second 
of  the  two  just  mentioned,  is  precisely  what  we 
want. — London  Med.  Times  and  Gazette,  A\iTil,  1861. 

We  think  this  work  will  do  much  to  Obviate  the 
reluctance  to  a  thorough  investigation  of  this  branch 
of  scientific  study,  for  in  the  wide  range  of  medical 
literature  treasured  in  the  English  tongue,  we  shall 
hardly  find  a  work  written  in  a  style  more  clear  and 
simple,  conveying  forcibly  the  facts  taught,  and  yet 
free  from  turgidity  and  redundancy.  There  is  a  fas- 
cination in  its  pages  that  will  insure  to  it  a  wide 
popularity  and  attentive  perusal,  and  a  degree  of 
usefulness  not  often  attained  through  the  influence 
of  a  single  work.  The  author  has  much  enhanced 
the  practical  utility  of  his  book  by  passing  briefly 
over  the  physical,  botanieal,  and  commercial  history 
of  medicines,  and  directing  attention  chiefly  to  their 
physiological  action,  and  their  application  for  the 
amelioration  or  cure  of  disease.  He  ignores  hypothe- 
sis and  theory  which  are  so  alluring  to  many  medical 
writers,  and  so  liable  to  lead  them  astray,  and  con- 
fines himself  to  such  facts  as  have  been  tried  in  the 
crucible  of  experience. — Chicago  Medical  Journal. 


SMITH   (HENRY    H.),  M.  D.    .AND    HORNER  (WILLIAM    E.),  M.  D. 
AN  ANATOMICAL  ATLAS,  illustrative  of  the  Structure  of  the  Human  Body. 

In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred  and  fifty  beautiful 

figures.    $3  00. 

These  figures  are  well  selected,  and  present  a -late  the  student  upon  the  completion  of  this  Atlas 
complete  and  accurate  representation  of  that  won-  as  it  is  the  most  convenient  work  of  the  kind  that 
derful  fabric,  the  human  body.  The  plan  of  this  has  yet  appeared  ;  and  we  must  add,  the  very  beau- 
Atlas,  which  renders  it  so  peculiarly  convenient  tiful  manner  in  which  it  is  "  got  up"  is  so  creditabU 
for  the  student,  and  its  superb  artistical  execution,  to  the  country  as  to  be  flattering  to  our  national 
have  been  already  pointed  out.    We  must  congratu-    pride. — American  Medical  Journal. 


SHARPEY  (WILLIAM),   M.D.,   JONES   QUAIN,   M.D.,   AND 

RICHARD  QUAIN,   F.  R.  S.,  &.C. 

HUMAN  ANATOMY.     Revised,  with  Notes  and  Additions,  by  Joseph  Leidt, 

M.  D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.  Complete  in  two  large  octavo 
volumes,  leather,  of  about  thirteen  hundred  pages.  Beautifully  illustrated  with  over  five  hundred 
engravings  on  wood.    $6  00. 

SIMPSON  (J.  Y.  ,   M.  D., 

Professor  of  Midwifery,  &c.,  in  the  University  of  Edinburgh,  &c. 

CLINICAL  LECTURES  ON  THE  DISEASES  OF  FEMALES.     With  nume- 

rous  illustrations. 

This  valuable  series  of  practical  Lectures  is  now  appearing  in  the  "Medical  News  and 
Library"  for  1860,  1861,  and  1862,  and  can  thus  be  had  without  cost  by  subscribers  to  the 
"American  Journal  of  the  Medical  Sciences."    See  p.  2. 


SOLLY  ON  THE  HUMAN  BRAIN;  its  Structure, 
Physiology,  and  Diseases.  From  the  Second  and 
much  enlarged  London  edition.  In  one  octavo 
volume,  extra  cloth,  of  500  pages,  with  120  wood- 
cuts.   $2  00. 

SKEY'S  OPERATIVE  SURGERY.    In  one  very 


handsome  octavo  volume,  extra  cloth,  of  over  650 
pages,  with  about  one  hundred  wood-cuts.  $3  25. 
SIMON'S  GENERAL,  PATHOLOGY,  as  conduc- 
ive to  the  Establishment  of  Rational  Principles 
for  the  prevention  and  Cure  of  Disease.  In  one 
octavo  volume,  extra  cloth,  of  212  pages.    SI  25. 


28  BLANCHARD    &   LEA'S    MEDICAL 

SARGENT  (F.  W.),   M.  D. 
ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SURGERY. 

New  edition,  wiili  an  additional  chapter  on  Military  Surgery.  One  handsome  royal  12mo.  vol., 
of  nearly  400  pages,  with  184  wood  cuts.  Leather,  $1  50.  (Now  Ready.) 
The  value  of  this  work  as  a  handy  and  convenient  manual  for  surgeons  engaged  in  active  duty  in 
the  field  and  hospital,  has  induced  the  publishers  to  render  it  more  complete  for  those  purposes  by 
the  addition  of  a  chapter  on  gun-shot  wounds  and  other  matters  peculiar  to  military  surgery.  In 
its  present  form,  therefore,  with  no  increase  in  price,  it  will  be  found  a  very  cheap  and  convenient 
vade-mecum  lor  consultation  and  relerence  in  Ihe  daily  exigencies  of  military  as  well  as  civil 
practice. 


AVe  have  read  Bourgerie's  Minor  Surgery  with 
pleasure  and  profit,  but  in  many  respects  the  volume 
now  belore  us  immeasurably  transcends  it.  We 
consider  that  no  better  boolt  could  be  placed  in  Ihe 
hands  of  an  hospital  dresser,  or  the  young  surgeon, 
whose  education  in  this  respect  has  not  been  per- 
fected. We  most  cordially  commend  this  volume 
as  one  which  the  medical  student  should  most  close- 
ly study,  to  perfect  himself  m  these  minor  surgical 
operations  in  which  neatness  and  dexterity  are  so 
much  required,  and  on  which  a  great  portion  of  his 
rtputatlon  as  a  future  surgeon  must  evidently  rest. 
Atid  to  the  surgeon  in  practice  it  must  prove  itself 
a  valuable  volume,  as  instructive  on  many  points 
which  he  may  have  forgotten. — British  American 
Journal.  May,  1862. 


The  instruction  given  upon  the  subject  of  Ban- 
daging., is  alone  of  great  value,  and  while  the  author 
modestly  proposes  to  instruct  the  students  of  medi- 
cine, and  the  younger  physicians,  we  will  say  that 
experienced  physicians  will  obtain  many  exceed- 
ingly valuable  suggestions  by  its  perusal.  With- 
out attempting  to  particularize  further,  we  will 
conclude  our  brief  notice  by  saying,  liiat  it  will  be 
found  one  of  the  most  satisfactory  inunuuls  for  refer- 
ence in  the  field,  or  hospital  yet  published;  thor- 
oughly adapted  to  the  wants  of  Military  surgeons, 
and  at  the  same  time  equally  useful  for  ready  and 
convenient  reference  by  surgeons  everywhere. — 
Buffalo  Med.  and  Surg.  Journal,  June,  1862. 


SMITH   (W.   TYLER),  M.  D., 

Physician  Accoucheur  to  St.  Mary's  Hospital,  &c. 

ON   PARTURITION,   AND   THE   PRINCIPLES   AND   PRACTICE    OF 

OBSTETRICS.    In  one  royal  r2mo.  volume,  extra  cloth,  of  400  pages.    $1  25. 

BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PATHOLOGY  AND  TREATMENT 

OF  LEUCORRHCEA.    With  numerous  illustrations.    In  one  very  handsome  octavo  volume, 
extra  cloth,  of  about  250  pages.    $1  50. 

TANNER   (T.    HJ,    M.  D., 

Physician  to  the  Hospital  for  Women,  &c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS. 

To  which   is  added  The  Code   of  Ethics   of   the  American    Medical  Association.     Second 
American  Edition.     In  one  neat  volume,  small  12mo.,  extra  cloth,  87i  cents. 


TAYLOR  (ALFRED  SJ,  M.  D.,  F.  R.  S., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDENCE.     Fifth  American,  from  the  seventh  improved 

and  enlarged  London  edition.  With  Notes  and  References  to  American  Decisions,  by  Edward 
Hartshorne,M.  D.  InonelargeSvo.  volume,  leather,  of  over  700  pages.  {Now  Ready.)  $3  25. 
This  standard  work  having  had  the  advantage  of  two  revisions  at  the  hands  of  the  auihor  since 
the  appearance  of  the  last  American  edition,  will  be  found  thoroughly  revised  and  brought  up  com- 
pletely to  the  present  stale  of  the  science.  As  a  work  of  authoniy,  it  must  therefore  maintain  its 
position,  both  as  a  text-book  for  the  student,  and  a  compendious  treatise  to  which  the  practitioner 
can  at  all  times  relier  in  cases  of  doubt  or  difficulty. 

No  work  upon  the  subject  can  be  put  into  the  American  and  British  legal  medicine.  It  should  be 
hands  of  students  either  of  law  or  medicine  which  in  the  possession  of  every  physician,  as  the  subject 
will  engage  them  more  closely  or  profitably;  and  ;  is  one  of  great  and  increasing  importance  to  the 
none  could  be  oflered  to  the  busy  practitioner  of  public  as  well  as  to  the  profession. — St.  Louts  Med. 
either  calling,  for  the  purpose  of  casual  or  hasty  and  Surg.  Journal. 
reference,  that  would  be  more  likely  toafford  the  aid  ,     /•  t^     m     , 

desired.  We  therefore  recommend  itas  the  best  and  This  work  of  Dr.  Taylor's  is  generally  acknow- 
safeat  manual  for  daily  MBC—Amtrican  Journal  oj  \  'edged  to  be  one  of  the  ablest  extant  on  the  subject 
Medical  Sciences.  *'•  •neU'C'il  jurisprudence.     It  is  certainly  out  of  the 

,    .  ,  »u   »  »u         1  1  most  attractive  books  that  we  have  met  with ;  sun- 

It  18  not  excess  of  praise  to  say  that  the  volume       j  ^^  .^^^^  ^^^j,  j„  ■  .nstruc  ,  tSat 

before  us  is  the  ve_ry_best_Ueat.se_extant_^on  Med^caj  .  ^^>  ^S^^t  1,^^^^^^^  j„  ^(ji„„  ^^^^  ^^^^^  having'once 


DC  conceaea  uiai  i^y^'r 's  superior  »u  any lunig  lua.     jhat  is  recent  of  Chemical,  Microscopical,  and  Va- 
bHS  preceded  it.-N.W.  Medical  and  Surg.  Journal      tin,iog,cal   research,   besides  papers   on   numerous 


It  is  at  once  comprehensive  and  eminently  prac-  subjects  never  before  published. — Charleston  Med. 
tical,  and  by  universal  consent  EtanUs  at  the  head  of    Journal  and  Jieview. 

BY    THE   SAME   AUTHOR. 

ON  POISONS,  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.    Second  American,  from  a  second  and  revised  Loudon  edition,     la  one  large 

octavo  volume,  of  765  pages,  leather.    $3  50. 

Mr.  Taylor's  position  as  the  leading  medical  jurist  of  England,  has  conferred  on  him  extraordi- 
nary advantages  in  acquiring  experience  on  these  subjects,  nearly  all  cases  of  moment  being 
referred  to  him  for  examination,  as  an  expert  whose  testimony  is  generally  accepted  as  final. 
The  results  of  his  labors,  therefore,  as  gathered  together  in  this  volume,  carefully  weighed  and 
sifted,  and  presented  in  the  clear  and  intelligible  style  for  which  he  is  noted,  may  be  received 
as  aa  acknowledged  authority,  and  as  a  guide  to  be  followed  with  implicit  confidence. 


AND    SCIENTIFIC    PUBLICATIONS. 


29 


TODD  (ROBERT  BENTLEY),  M.  D.,  F.  R.  S., 

Professor  of  Physiology  in  King's  College,  London;  and 
WILLIAM  BOWMAN,  F.  R.  S., 

Demonstrator  of  Anatomy  in  King's  College,  London. 

THE  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF  MAN.    With 

about  three  hundred  large  and  beautiful  illustrations  on  wood.     Complete  in  one  large  ociavo 

volume,  of  950  pages,  leather.     Price  $4  50. 

K^  Gentlemen  who  have  received  portions  ol'  this  work,  as  published  in  the  "  Medical  News 
AND  Library,"  can  now  complete  their  copies,  if  immediate  application  be  made.  It  will  be  fur- 
nished as  follows,  free  by  mail,  in  paper  covers,  with  cloth  backs. 

Parts  1.,  II.,  III.  (pp.  25  to  552),  $2  50. 

Part  IV.  (pp.  553  to  end,  with  Title,  Preface,  Contents,  &c.),  $2  00. 

Or,  Part  IV.,  Section  II.  (pp.  725  to  end,  with  Title,  Preface,  Contents,  fee),  $1  25. 


A  magnificent  contribution  to  British  medicine, 
and  the  American  physician  w^ho  shall  fail  to  peruse 
it,  will  have  failed  to  read  one  of  the  most  instruc- 
tive books  of  the  nineteenth  century. — N.  O.  Med 
and  Surg.  Journal. 

1 1  is  more  concise  than  Carpenter's  Principles,  and 
more  modern  than  the  accessible  edition  of  iVI tiller's 
Elements;  its  details  are  brief,  but  sufficient;  its 
descriptions  vivid;  its  illustrations  exact  and  copi- 
ous ;  and  its  language  terse  and  perspicuous. — 
Charleston  Med.  Journal. 

We  know  of  no  work  on  the  subject  of  physiology 


so  well  adapted  to  the  wants  of  the  medical  student. 
Its  completion  has  been  thus  long  delayed,  that  the 
authors  might  secure  accuracy  by  personal  observa- 
tion.— St.  Louis  Med.  and  Surg.  Journal. 

Our  notice,  though  it  conveys  but  a  very  feeble 
and  imperfect  idea  of  the  magnitude  and  importance 
of  the  work  now  under  consideration,  already  tran- 
scends our  limits  ;  and,  with  the  indulgence  of  our 
readers,  and  the  hope  that  they  will  peruse  the  book 
for  themselves,  as  we  feel  we  can  with  confidence 
recommend  it,  we  leave  it  in  their  hands.  —  Tin 
Northwestern  Med.  and  Surg.  Journal. 


TODD  (R.   B.)     M.  D.,    F.  R.  S.,   Sic. 
CLINICAL  LECTURES  ON  CERTAIN  DISEASES  OF  THE  URINARY 

ORG-ANS  AND  ON  DROPSIES.    In  one  octavo  volume,  284  pages.    $1  50. 

BY  THE  SAME  AUTHOR.      (iV»W  Ready.) 

CLINICAL  LECTURES  ON  CERTAIN  ACUTE  DISEASES.     In  one  neat 

octavo  volume,  of  320  pages,  extra  cloth,     f  1  75. 


TOYNBEE  (JOSEPH),   F.  R.  S., 

Aural  Surgeon  to,  and  Lecturer  on  Surgery  at,  St.  Mary's  HospitaL 

A  PRACTICAL  TREATISE  ON  DISEASES   OF   THE   EAR;   their  Diag- 

nosis.  Pathology,  and  Treatment,     lilustrated  with  one  hundred  engravings  on  wood.     In  one 

very  handsome  ociavo  volume,  extra  cloth,  $3  00.     {Just  Issued.) 

The  work,  as  was  stated  at  the  outset  of  our  no-  [  ment,  and  with  a  sincere  and  unbiassed  judgment. 


tice,  is  a  model  of  its  kind,  and  every  page  and  para- 
graph o[  it  are  \vorthy  of  tha  most  thorough  study. 
Considered  all  in  all — as  an  original  work,  well 
written,  philosophically  elaborated,  and  happily  il- 
lustrated with  cases  and  drawings — it  is  by  far  the 
ablest  mimograph  that  has  ever  appeared  on  the 
anatomy  and  diseases  of  the  ear,  and  one  of  the  most 
valuable  contributions  to  the  art  and  science  of  sur- 
gery in  the  nineteenth  century. — N.  Amer.  Medico- 
^Chirurg   Review^  Sept.  1860. 

To  recommend  such  a  work,  even  after  the  mere 
hint  we  have  given  of  its  original  excellence  and 
value,  would  be  a  work  of  supererogation.  We  are 
E|)eakiug  within  the  limits  of  modest  acknowledg- 


when  we  affirm  that  as  a  treatise  on  Aural  Surgery, 
it  is  without  a  rivhl  in  our  language  or  any  other. — 
Charleston  Mtd.  Journ.  and  Review,  Sept.  1S60. 

The  work  of  Mr.  Toynbee  is  undoubtedly,  upon 
the  whole,  the  most  valuable  production  of  tne  kind 
in  any  language.  The  author  has  long  been  known 
by  his  numerous  monographs  upon  subjects  con- 
nected with  diseases  of  the  ear,  and  is  now  regarded 
as  the  highest  authority  on  most  points  in  his  de- 
partment of  science.  Mr.  Toynbee's  work,  as  we 
have  already  said,  is  undoubtedly  the  most  reliable 
guide  for  the  study  of  the  diseases  of  the  tar  in  any 
language,  and  should  be  in  the  library  of  every  phy- 
sician.—  Chicago  Med.  Journal,  July,  1860. 


WILLIAMS  (C.   J.   B.),    M.D.,    F.  R.  S., 

Professor  of  Clmieal  Medicine  in  University  College,  London,  &c. 

PRINCIPLES  OP  MEDICINE.     An  Elementaiy  View  of  the  Causes,  Nature, 

Treatment,  Diagnosis,  and  Prognosis  of  Disease;  with  briel  remarks  on  Hygienics,  or  the  pre- 
servation of  health.    A  new  American,  from  the  third  and  revised  Loudon  edition.     In  one  octavo 
volume,  leather,  of  about  500  pages.     $2  50.     (Just  Issued.) 
We  find  that  the  deeply-interesting  matter  and 

style  of  this  book  have  so  far  fascinated  us,  that  we 

have  unconsciously  hung  upon  its  pages,  not   too 


long,  indeed,  for  our  own  profit,  but  longer  than  re- 
viewers can  be  permitted  to  indulge.  We  leave  the 
further  analysis  to  the  student  and  practitioner.  Our 
judgment  of  the  work  has  already  been  sufficiently 


expressed.     It  is  a  judgment  of  almost  unqualified 
praise. — London,  Lancet. 

A  text-book  to  which  no  other  in  our  language  is 
comparable. — Charleston  Medical  Journal. 

No  work  has  ever  achieved  or  maintained  a  more 
deserved  reputation. —  Va.  Med.  anil  Surg.  Journal. 


WHAT   TO   OBSERVE 
AT    THE    BEDSIDE    AND    AFTER   DEATH,   IN    MEDICAL   CASES. 

Published  under  the  authority  of  the  London  Society  for  Medical  Observation.    A  new  American, 

from  the  second  and  revised  London  edition.    In  one  very  handsome  volume,  royal  I2mo.,  extra 

cloth.    $1  00. 

To  the  observer  who  prefers  accuracy  to  blunders  I  One  of  the  finest  aids  to  a  young  practitioner  wa 
and  precision  to  carelessness,  this  little  book  is  ;«-  have  ever  seen. — Ptninsular  Journal  of  Mtdieitu. 
valuable. — N.  H.  Journal  of  Medicint,  \ 


30  BLANCHARD    &   LEA'S   MEDICAL 

New  and  much  enlarged  edition — (Just  Issued.) 

WATSON   (THOMAS),    M.D.,    tU-c, 

Late  Physician  to  the  Middlesex  Hospital,  &c. 

LECTUEES    ON    THE   PRINCIPLES    AND    PRACTICE   OP   PHYSIO. 

Delivered  at  King's  College,  London.     A  new  American,  from  the  last  revised  and  enlarged 

English  edition,  with  Additions,  by  D.  Francis  Condie,  M.  D.,  author  of  "A  Practical  Treatise 

on  the  Diseases  of  Children,"  &c.     With  one  hundred  and  eighty. five  illustrations  on  wood.     In 

one  very  large  and  handsome  volume,  imperial  octavo,  of  over  1200  closely  printed  pages  in 

small  type ;  the  whole  strongly  bound  in  leather,  with  raised  bands.     Price  $4  25. 

That  the  high  reputation  of  this  work  might  be  fully  maintained,  the  author  has  subjected  it  to  a 

thorough  revision;  every  portion  has  been  examined  with  the  aid  of  the  most  recent  researches 

in  pathology,  and  the  results  of  modern  investigations  in  both  theoretical  and  practical  subjects 

have  been  carefully  weighed  and  embodied  throughout  its  pages.     The  watchful  scrutiny  of  the 

editor  has  likewise  introduced  whatever  possesses  immediate  importance  to  the  American  physician 

in  relation  to  diseases  incident  to  our  climate  which  are  little  known  in  England,  as  well  as  those 

points  in  which  experience  here  has  led  to  different  modes  of  practice  ;  and  he  has  also  added  largely 

to  the  series  of  illustrations,  believing  that  in  this  manner  valuable  assistance  may  be  conveyed  to 

llie  student  in  elucidating  the  text.     The  work  will,  therefore,  be  found  thoroughly  on  a  level  with 

the  most  advanced  state  of  medical  science  on  both  sides  of  the  Atlantic. 

The  additions  which  the  work  has  received  are  shown  by  the  tact  that  notwithstanding  an  en- 
largement in  the  size  of  the  page,  more  than  two  hundred  additional  pages  have  been  necessary 
to  accommodate  the  two  large  volumes  of  the  London  edition  (which  sells  at  ten  dollars),  within 
the  compass  of  a  single  volume,  and  in  its  present  form  it  contains  the  matter  ol  at  least  three 
ordinary  octavos.  Believing  it  to  be  a  work  which  should  lie  on  the  table  of  every  physician,  and 
be  in  the  hands  of  every  student,  the  publishers  have  put  it  at  a  price  within  the  reach  of  all,  making 
it  one  of  the  cheapest  books  as  yet  presented  to  the  American  profession,  while  at  the  same  time 
the  beauty  ol  its  mechanical  execution  renders  it  an  exceedingly  attractive  volume. 

The  fourth  edition  now  appears,  so  carefully  re-  j      The  lecturer's  skill,  his  wisdom,  his  learning, are 

equalled  by  the  ease  of  his  graceful  diction,  his  elo- 
quence, and  the  far  higher  qualities  of  candor,  of 
courtesy,  of  modesty,  and  of  generous  appreciation 
of  merit  in  others. — N.  A.  Med  -Chir  Review. 

Watson's  unrivalled,  perhaps  unapproachable 
work  on  Practice — the  copious  addiiions  made  to 
which  (the  fourth  edition)  have  given  it  all  the  no- 
velty and  much  of  the  interest  of  a  new  book. — 
Charleston  Med.  Journal. 

Lecturers,  practitioners,  and  students  of  medicine 
will  equally  hail  the  reappearance  of  the  work  of 
Dr.  Watson  in  theform  of  anew — afourth — edition. 
We  merely  do  justice  to  our  own  feelings,  and,  we 
are  sure,  of  the  whole  profession,  if  we  thank  him 
for  having,  in  the  trouble  and   turmoil  of  a  lai^e 


vised,  as  to  add  considerably  to  the  value  of  a  book 
already  acknowledged,  wherever  the  English  lan- 
guage is  read,  to  be  beyond  all  comparison  the  best 
systematic  work  on  the  Principles  and  Practice  of 
Physic  in  the  whole  range  of  medical  literature. 
Every  lecture  contains  proof  of  the  extreme  anxiety 
of  the  author  to  keep  pace  wiih  :he  advancing  know- 
ledge of  the  day,  and  to  bring  the  results  of  the 
labors,  not  only  of  physicians,  but  of  chemists  and 
histologists,  before  his  readers,  wherever  they  can 
be  turned  to  useful  account.  One  scarcely  knows 
whether  to  admire  most  the  pure,  simple,  forcible 
English — the  vast  amount  of  aseful  practical  in- 
formation condensed  into  the  Lectures — or  the  man- 
ly, kind-hearted,  unassuming  character  of  the  lec- 
turer shining  through  his  work.— Lonrf.  Med.  Times. 

Thus  tUese  admirable  volumes  come  before  the  I  practice,  made  leisure  to  supply  the  hiatus  caused 
profession  in  their  fourth  edition,  abounding  in  those  by  the  exhaustion  of  the  pulilisher's  stock  of  the 
distinguished  attributes  of  moderation,  judgment,  third  edition,  which  ha's  been  severely  felt  for  the 
erudite  cultivation,  clearness,  and  eloquence,  with  i  last  three  years.     For  Dr.  Watson  has  not  merely 


which  they  were  from  the  first  invested,  but  yet 
richer  than  before  in  the  results  of  more  prolonged 
observation,  and  in  the  able  appreciation  of  the 
latest  advances  in  pathology  and  medicine  by  one 
of  the  most  profound  medical  thinkers  of  the  day. — 
London  Lancet. 


caused  the  lectures  to  be  reprinted,  but  scattered 
through  the  whole  work  we  find  additiims  or  altera- 
tions which  prove  that  the  author  has  in  every  way 
sought  to  bring  up  his  teaching  to  the  level  of  .lie 
most  recent  acquisitions  in  science. — Brit,  and  For. 
Medico-Chir.  Review. 


WALSHE  (W.   H.),   M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London,  &c. 

A  PRACTLCxVL  TREATISE  ON  DISEASES  OF  THE  LUNGS;  including 

the  Principles  of  Physical  Diagnosis.    A  new  American,  from  the  third  revised  and  much  en- 
larged Loncon  edition.     In  one  vol.  octavo,  of  468  pages.     $2  2.5. 

The  present  edition  has  been  carefully  revised  and  much  enlarged,  and  may  be  said  in  the  main 
to  be  rewritten.  Descriptions  of  several  diseases,  previously  omitted,  are  now  introduced ;  the 
causes  and  mode  of  production  of  the  more  important  affections,  so  tar  as  they  possess  direct  prac- 
tical significance,  are  succinctly  inquired  into;  an  effort  has  been  made  to  bring  the  description  ol 
anatomical  characters  to  the  level  of  the  wants  of  the  practical  physician  ;  and  the  diagnosis  and 
prognosis  of  each  complaint  are  more  completely  considered.  The  sections  on  Treatment  and 
the  Appendix  (concerning  the  influence  of  climate  on  pulmonary  disorders),  have,  especially,  been 
largely  extended. — Author^s  Preface. 

BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  THE  HEART  AND 

GREAT  VESSELS,  including  the  Principles  of  Physical  Diagnosis.     Third  American,  from  the 

third  revised  and  much  enlarged  London  edition.     In  one  handsome  octavo  volume  of  420  pages, 

extra  cloth.     $2  25.     (Just  Ready.) 

From  the  Author'' s  Prefacs. 

The  present  edition  has  been  carefully  revised  ;  much  new  matter  has  been  added,  and  the  entire 
work  in  a  measure  remodelled.  Numerous  facts  and  discussions,  more  or  less  completely  novel, 
will  be  found  in  the  description  of  the  principles  of  physical  diagnosis;  but  the  chief  additions  have 
been  made  in  the  practical  portions  of  the  book.  Several  affections,  of  which  little  or  no  account 
had  been  given  in  the  previous  editions,  are  now  treated  of  in  detail.  Functional  disorders  ot  the 
heart,  the  frequency  ol  which  is  almost  rivalled  by  the  misery  they  inflict,  have  been  closely  recon- 
sidered ;  more  especially  an  attempt  has  been  made  to  render  their  essential  nature  clearer,  and 
consequently  their  treatment  more  successful,  by  an  analysis  of  their  dynamic  elements. 


AND    SCIENTIFIC    PUBLICATIONS 


31 


New^  and  much  enlarged  edition — (Just  Issued.) 

WILSON    (ERASMUS),  F.  R.  S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  Oeneral  and  Special.     A  new  and  re- 

vised  American,  from  the  last  and  enlarged  English  Edition.  Edited  by  W.  H.  Gobrecht,  M.  D., 
Professor  of  Anatomy  in  the  Pennsylvania  Medical  College,  &c.  Illustrated  with  three  hundred 
and  ninety-seven  engravings  on  wood.  In  one  large  and  exquisitely  printed  octavo  volume,  of 
over  600  large  pages;  leather.     $3  25. 

The  publishers  trust  that  the  well  earned  reputation  so  long  enjoyed  by  this  work  will  be  more 
than  maintained  by  the  present  edition.  Besides  a  very  thorough  revision  by  the  author,  it  has  been 
most  carefully  examined  by  the  editor,  and  the  efforts  of  both  have  been  directed  to  introducing 
everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it  a  complete 
text-book  for  those  seeking  to  obtain  or  to  renew  an  acquaintance  with  Human  Anatomy.  The 
amount  of  additions  whicli  it  has  thus  received  may  be  estimated  from  the  fact  that  the  present 
edition  ctmtains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type  and  an  enlarged 
page  requisite  to  keep  the  volume  within  a  convenient  size.  The  editor  has  exercised  the  utmost 
caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased  the  number  of  illustra- 
tions, of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition  than  in  the  last,  thus 
bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or  importance. 


It  may  be  recommended  to  the  student  as  no  less 
distinguished  by  its  accuracy  and  clearness  of  de- 
scription thiin  by  its  typographical  elegance.  The 
wood-cuts  are  exquisite. — Brit,  and  For.  Medical 
Review. 

An  elegant  edition  of  one  of  the  most  useful  and 
accurate  systems  of  anatomical  science  which  has 
been  issued  from  the  press  The  illustrations  are 
really  beautiful.  In  its  style  the  work  is  extremely 
concise  and  intelligible.  JVo  one  can  possibly  take 
up  this  volume  without  being  struck  with  the  great 


beauty  of  its  mechanical  execution,  and  the  clear- 
ness of  the  descriptions  w^hich  it  contains  is  equally 
evident.  Let  students,  by  all  means  examine  ttie 
claims  of  this  work  on  their  notice,  before  they  pur- 
chase a  text-book  of  the  vitally  important  science 
which  this  volume  so  fully  and  easily  unfolds.— 
Lancet. 

We  regard  it  as  the  best  system  now  extant  for 
students. — Western  Lancet. 

It  therefore  receives  our  highest  commendation.— 
Southern  Med.  and  Surg.  Journal. 


BY  THE  SAME  AUTHOR.      (Just  IsSUed.) 

ON  DISEASES  OF  THE  SKIN.     Fourth  and  enlarged  American,  from  the  last 

and  improved  London  edition.     In  one  large  octavo  volume,  of  6.50  pages,  extra  cloth,  $2  75. 


The  writings  of  Wilson,  upondiseasesof  the  skin, 
are  by  far  the  most  scientific  and  practical  that 
have  ever  been  presented  to  the  medical  world  on 
this  subject.  The  present  edition  is  a  great  improve- 
ment on  all  its  predecessors.  To  dwell  upon  all  the 
great  merits  and  high  chums  of  the  work  before  us, 
seriatim^  would  indt-ed  be  an  agreeable  service ;  it 
would  be  a  mental  homage  which  we  could  freely 
offer,  but  we  should  thus  occupy  an  undue  amount 
of  space  in  this  Journal.    We  will,  howtver,  look 


at  some  of  the  more  salient  points  with  which  it 
abounds,  and  wh  ich  make  itincomparauiy  superior  in 
excellence  to  all  other  treatises  on  the  subject  of  der- 
mutology.  No  mere  speculative  views  are  allowed 
a  place  in  this  volume,  wliich,  without  a  doubt,  will, 
for  a  very  long  period,  be  acknowledged  as  the  chief 
standard  work  on  dermatology.  Tlie  principles  of 
an  enlightened  and  rational  therapeia  are  introduced 
on  every  appropriate  occasion. — Am.  Jour.  Med. 
Science,  Oct.  1857. 


ALSO,  NOW  READY, 

A  SERIES  OF  PLATES  ILLUSTRATING  WILSON  ON  DISEASES  OF 

THE  SKIN  ;  consisting  of  nineteen  beautifully  executed  plates,  of  which  twelve  are  exquisitely 
colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin,  and  containing  accurate  re- 
presentations of  about  one  hundred  varieties  of  disease,  most  of  them  the  size  of  nature.  Price 
in  cloth  $4  25. 

In  beauty  of  drawing  and  accuracy  and  finish  of  coloring  these  plates  will  be  found  equal  to 
anything  of  the  kind  as  yet  issued  in  this  country. 


The  plates  by  which  this  edition  is  accompanied 
leave  nothing  to  be  desired,  so  far  as  excellence  of 
delineation  and  perfect  accuracy  of  illustration  are 
concerned. — Medico-Cfiirurgical  Review. 

Of  these  plates  it  is  impossible  to  speak  too  highly. 
The  representations  of  the  various  forms  of  cutane- 
ous disease  are  singularly  accurate,  and  the  color- 
ing exceeds  almost  anything  we  have  met  with  in 
point  of  delicacy  and  hnish.— British  and  Foreign 
Medical  Review. 


We  have  already  expressed  our  high  appreciation 
of  Mr.  Wilson's  treatise  on  Diseases  of  the  Skin. 
The  plates  are  comprised  in  a  separate  volume, 
which  we  counsel  all  those  who  possess  the  text  to 
purchase.  It  is  a  beautiful  specimen  of  color  print- 
ing, and  the  representations  of  the  various  forms  of 
skin  disease  are  as  faithful  as  is  possible  in  plates 
of  the  sizt.— Boston  Med.  and  Surg.  Journal,  April 
8,  1858. 


BY   THE  SAME  AUTHOR. 

ON    CONSTITUTIONAL    AND    HEREDITARY    SYPHILIS,   AND    ON 

SYPHILITIC  ERUPTIONS.  In  one  small  octavo  volume,  extra  cloth,  beautifully  printed,  with 
four  exquisite  colored  plates,  presenting  more  than  thirty  varieties  of  syphilitic  eruptions.  $2  25, 

BY   THE  SAME   AUTHOR. 

HEALTHY  SKIN;  A  Popular  Treatise  on  the  Skin  and  Hair,  their  Preserva- 
tion and  Management.  Second  American,  from  the  fourth  London  edition.  One  neat  volume, 
'royal  12mo. 5  extra  cloth,  of  about  300  pages,  with  numerous  illustrations.  $1  00;  paper  cover, 
75  cents. 

BY  THE  SAME  AUTHOR. 

THE    DISSECTOR'S  MANUAL;  or,  Practical  and  Surgical  Anatomy.     Third 

American,  from  the  last  revised  and  enlarged  English  edition.  JModified  and  rearranged,  by 
William  Hunt,  M.  D.,  Demonstrator  of  Anatomy  in  the  University  of  Pennsylvania.  In  one 
large  and  handsome  royal  i2mo.  volume,  leather,  of  582  pages,  with  154  illustrations.    $2  00. 


32 


BLANCHARD    &    LEA'S    MEDICAL    PUBLICATIONS. 


WINSLOW    (FORBES),  M.D.,    D.  C.  L.,  &.C. 
ON  OBSCURE  DISEASES  OF  THE  BRATN  AND  DISORDERS  OF  THE 


MIND;  their  incipient  Symptom?,  Pathology, 
handsome  octavo  volume,  of  nearly  600  pages, 

We  close  this  brief  and  necessarily  very  imperfect 
notice  of  Dr.  Winslow'a  great  and  classical  work, 
by  expressing  our  conviction  that  it  is  long  since  so 
important  and  beautifully  written  a  volume  has  is- 
Bued  from  the  British  medical  press — Dublin  Med. 
J-ress,  July  25,  iSCO. 

We  honestly  believe  this  to  be  the  best  book  of  the 
season. —  Hanking'i  Abstract,  July,  1660. 

It  ca"  cU  us  back  to  our  old  days  of  novel  reading, 
it  kep'.  us  from  our  diLner,  from  our  business,  and 
fri  11.  our  slumbers;  in  short,  we  laid  it  down  only 
wpen  we  had  got  to  the  end  of  the  last  paragraph, 
and  even  then  turned  back  to  the  repeiusal  of  several 
passages  which  we  had  marked  as  requiring  further 
study  We  have  failed  entirely  in  the  above  notice 
to  give  an  adequate  acknowledgment  of  the  profit 
and  pleasure  witli  which  we  have  perused  the  above 
work.    We  can  only  say  to  our  readers,  study  it 


Diagnosis,  Treatment,  and  Prophylaxis.     In  one 
jj7(st  Issued.)     $3  00. 

yourselves ;  and  we  extend  the  invitation  to  unpro- 
fessional as  well  as  professional  men,  believing  that 
it  contains  matter  deeply  interesting  not  to  physi- 
cians alone,  but  to  all  who  appreciate  the  trutti  that; 
"  The  proper  study  of  mankind  is  man."^A'aiA«i//e 
Medical  Record,  July,  le60. 

Tlie  'atter  portion  of  Dr.  Winslow's  work  is  ea- 
clusively  devoted  to  the  consideration  of  Cerebral 
Pathology.  It  completely  exhausts  the  subject,  in 
the  same  manner  as  the  previous  seventeen  chapters 
relating  to  morbid  psychical  phenomena  left  nothing 
unnoticed  in  reference  to  the  mental  symptoms  pre- 
monitory of  cerebral  disease.  It  is  impossible  oo 
overrate  the  benefits  likely  to  result  from  a  general 
perusal  of  Dr.  Winslow's  valuaile  and  deeply  in- 
teresting work  — London  Lancet,  June  23,  1&60. 

It  contains  an  immense  mass  of  information.-— 
Brit,  anil  For.  Med.-Chir.  Review,  Oct.  1£60. 


WEST  (CHARLES),    M.  D., 

Accoucheur  to  and  Lecturer  on  Midwifery  at  St.  Bartholomew's  Hospital,  Physician  to  the  Hospital  for 

Sick  Children,  &c. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.    Second  American,  from  the 

f-econd  London   edition.     In  one   liandsome  octavo  volume,  extra  cloth,  ol  about  500  pages ; 

price  $2  50.     (Now  Ready,  July,  1861.) 
*,)(.*  Gentlemen  who  received  the  first  portion,  as  issued  in  the  "  Medical  News  and  Library,"  can 

now  complete  their  copies  by  procuring  Part  II,  being  page  309  to  end,  with  Index,  Title  matter, 

&c.,  Svo.,  clotb,  price  $1. 

We  mustnow  conclude  this  hastily  written  sketch  i  tion  In  easy  garments;  combining  pleasure  with 
with  the  confident  assurance  to  our  readers  that  the  profit,  he  leads  his  pupils,  in  spile  of  the  ancient 
work  will  well  repay  perusal.  The  conscientious,  proverb,  along  a  royal  road  to  learning.  His  work 
painstaking,  practical  physician  isapparent  on  ever)  |  is  one  which  will  not  satisfy  the  extreme  on  either 


page. — N.  Y.  Journal  of  Medicine,  March,  1S58. 

We  know  of  no  treatise  of  the  kind  so  complete 
and  yet  so  compact. — Chicago  Med.  Jour.  Jan.  1858. 

A  fairer,  more  honest,  more  earnest,  and  more  re- 
liable investigator  of  the  many  diseases  of  women 
and  children  is  not  to  be  found  in  any  country.— 
Southern  Med.  and  Surg.  Journal,  January  185S. 

We  gladly  recommend  his  Lectures  as  in  the  high- 
est degree  instructive  to  all  who  are  interested  in 
obstetric  practice. — London  Lancet. 

We  have  to  say  of  it,  briefly  and  decidedly,  that 
it  is  the  best  work  on  the  subject  in  any  language ; 
and  that  it  stamps  Dr.  West  as  the  facile  princeps 
of  British  obstetric  authors. — Edinb.  Med.  Journ. 

As  a  writer,  Dr.  West  stands,  in  our  opinion,  sec- 
ona  only  to  Watson,  the  "  Macaulay  of  .Medicine  ;" 
he  possesses  that  happy  faculty  of  clothing  instruc- 


side,  but  it  is  one  that  will  please  the  great  majority 
who  are  seeking  truth,  and  one  that  will  convince 
the  student  that  he  has  committed  himself  to  a  can- 
did, safe, and  valuable  guide. — ^V.  A.  Med.-Chirurg. 
Review,  July,  1858. 

Happy  in  his  simplicity  of  manner,  and  moderate 
in  his  expression  of  opinion,  the  author  is  a  sound 
reasoner  and  a  good  practititmer,  and  his  book  is 
worthy  of  the  handsome  garb  in  which  it  has  ap- 
peared.—  Virginia  Med.  Journal. 

We  must  take  leave  of  Dr.  West's  very  nseful 
work,  with  our  commendation  of  the  clearness  of 
its  style,  and  the  incustry  and  sobriety  of  judgment 
of  which  It  gives  evidence. — London  Med   Times. 

Sound  judgment  and  gocid  sense  pervade  every 
chapter  of  the  book.  From  its  perusal  we  have  de- 
rived unmixed  satisfaction. — Dublin  Quart.  Juurn. 


BY  THE  SAME  At;THoa.    (Just  Issued.) 

LECTURES   ON   THE   DISEASES    OF  INFANCY  AND  CHILDHOOD. 

Third  American,  from  the  fourth  enlarged  and  improved  London  edition.     In  one  handsome 
octavo  volume,  extra  cloth,  of  about  six  hundred  and  fifty  pages.     %i  75. 


The  three  former  editions  of  the  work  now  before 
us  have  placed  the  author  in  the  foremost  rank  of 
those  physicians  who  have  devoted  special  attention 
to  the  diseases  of  early  life.  We  attempt  no  ana- 
1)  sis  of  this  edition,  but  may  refer  the  reader  to  some 
of  the  chapters  to  which  the  largest  additions  have 
been  made — those  on  Diphtheria,  Disorders  of  the 
Mind,  and  Idiocy,  for  instance — as  a  prool  that  the 
work  is  really  a  new  edition;  not  a  mere  reprint. 
In  its  present  shape  it  will  be  found  of  the  greatest 
possible  service  in  the  every-day  practice  of  nine- 
tenths  of  the  profession. — Med.  Times  and  Gazette, 
London,  Dec.  10,  1859. 

All  things  considfred,  this  book  of  Dr.  West  is 
by  far  the  best  treatise  in  our  language  upon  such 
modifications  of  morbid  action  and  diseise  as  are 
witnessed  when  we  have  to  deal  with  infancy  and 
childhood.  It  is  true  that  it  confines  itself  to  such 
disorders  as  come  wichin  the  proviace  of  the  phy- 
tician,  and  even  with  respect  to  these  it  is  unequal 
as  regards  minutentss  of  consideration,  and  some 


diseases  it  omits  to  notice  altogether.  But  those 
who  know  anything  of  the  present  condition  of 
paediatrics  will  readily  admit  that  it  would  be  next 
to  impossible  to  efl^ect  more,  or  effect  it  better,  than 
the  accoucheur  of  St.  Bartholomew's  has  done  in  a 
single  volume.  The  lecture  (XVI.)  upon  Disorotrs 
of  the  Mind  in  children  is  an  admirable  specimen  of 
the  value  of  the  later  information  convejed  m  the 
Lectures  of  Dr.  Charles  West. — London  Lancet, 
Oct.  22,  1S59. 

Since  the  appearance  of  the  first  edition,  about 
eleven  years  ago,  the  experience  of  the  author  has 
doubled  ;  so  that,  whereas  the  lectures  at  first  wer« 
founded  on  six  hundred  observations,  and  one  hun- 
dred and  eighty  dissections  made  among  nearly  four- 
teen thousand  children,  they  now  embody  the  results 
of  nine  hundred  observations,  and  two  hundred  and 
eighty-eightpost-mortem  examinations  made  aitiong 
nearly  thirty  thousand  children,  who,  during  tne 
past  twenty  years,  have  been  under  his  care. — 
British  Med.  Journal,  Oct.  1,  1859. 


BY  THE  SAME  AUTHOR. 


AN  ENQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE  OF  ULOEB- 

ATION  OF  THE  OS  UTERI.    In  one  neat  octavo  volume,  extra  cloth.    $1  00. 


WHITEHEAD  ON  THE  CAUSES  AND  TREAT- 
MENT OF    ABORTION    AND  STERILITY. 


Second  American  Edition.    In  one  volume,  >>«ta- 
vo  extra  cloth,  pp.  308.    81    75. 


.^^£^Mi£&  i 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


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